Sleep Maintenance Insomnia: Why You Wake Up at 3am and Can't Fall Back Asleep
Once again it’s 2 A.M., pitch dark and quiet, but you’re awake for seemingly no reason. No anxious thoughts, or Sunday Scaries keeping you awake, you just cannot fall back asleep. If this nightly dread sounds familiar, you might be experiencing sleep maintenance insomnia, a common, but less well-known, symptom of insomnia. 50-70% of people who experience insomnia struggle with sleep maintenance insomnia, the inability to stay asleep (National Institute of Health). While persistent and annoying, Cognitive Behavioral Therapy for Insomnia (CBT-I) utilizes evidence-based practices to help you fall asleep and stay asleep.
Sleep Maintenance Insomnia vs. Sleep Onset Insomnia — What's the Difference?
Sleep Onset Insomnia: is the inability to fall asleep
what people typically think of when they hear the word insomnia,
Sleep Maintenance Insomnia: is difficulty staying asleep, often waking up in the middle of the night or too early and struggling to fall back asleep
While many people have both forms of insomnia, sleep maintenance struggles are distinct and have different targeted treatments.
Professionals who utilize CBT-I teach strategies for both falling asleep and staying asleep. Identifying which one is the main struggle is helpful to focus on the right treatment.
Why Does This Keep Happening? The Science Behind Middle-of-the-Night Waking
Natural sleep architecture
Throughout the night, your body is cycling through different sleep cycles, some of them lighter and some of them deeper sleep. Lighter sleep stages are longer, later at night
Short awakenings are normal in between sleep cycles, most people roll over and go back to sleep without noticing
For those with sleep maintenance insomnia, the brain has difficulty transitioning from one sleep cycle to another during light sleep
Hyperarousal: the core mechanism
Hyperarousal is when the brain becomes over-reactive and is chronically alert, even while sleeping
This leads to higher cortisol levels, faster heart rate and a quicker reaction time from the mind. So when it senses the body waking up, it becomes instantly alert.
This underlying neurological symptom is the main target of CBT-I for sleep maintenance insomnia
Middle of the Night Spirals
Once awake, the over-active mind floods with thoughts and worries
This cycle creates a pattern in the brain, connecting nighttime waking with an alert mind
Anxiety over not being able to sleep seeps in, even if anxiety was not the initial reason you could not sleep
What Makes It Worse (Common Culprits)
Aging
Alcohol
Laying in bed too long
Anxiety and Depression
Watching the Clock
What CBT-I Does Differently for Sleep Maintenance Insomnia
Stimulus control
Do not continue lying in bed if you have been awake longer than 15 minutes, change scenery and go to another room. Do a calming and quiet activity (no screens) until sleepy again. Breaking the connection between the bed and being awake is a big focus for CBT-I and is entirely evidence-based. This teaches your brain the bed is for sleeping, other rooms are for alertness.
Sleep consolidation (sleep restriction)
This is best done with a trained clinician guiding the process and advising schedules based on data collected about sleep. The idea is to shorten the amount of time you aim to sleep at night, thus increasing sleep pressure (drowsiness) and making it less likely you will wake up.
Cognitive restructuring for 3am thoughts
Name and reframe the anxious thoughts that start up when you wake up in the middle of the night, yet again. “Something is wrong with me” becomes “My body is having a hard time but I will be okay”. Spiraling, negative thoughts amplify the mind’s arousal and contribute to alertness. Stopping them in their tracks and replacing them with helpful, calming thoughts calms the brain.
Relaxation and mindfulness strategies
Multiple mindfulness strategies can ease the body back into rest - muscle relaxation, deep breathing and body scans do not instantly bring sleep, but they calm the body from its alert and over-reactive state.
The cycle of 3 a.m. wakings, anxious thoughts and dreading nighttime is exhausting, frustrating and can lead to more severe anxiety and depression. Sleep maintenance insomnia is extremely common, but because it is less talked about the strategies are not as well known. CBT-I utilizes evidence-based treatment to target middle of the night waking and the overactive nervous system without medication.
If you are tired and want proven strategies for better sleep, reach out to our expertly trained CBT-I specialists.