Help Me Sleep: Ways to Sleep Better Tonight

By Brandon Peters, MD

It seems like sleep should come naturally, but when it doesn't, you might quickly find yourself pleading, "Help me sleep!" It can be a frustrating, unnerving experience to have difficulty falling or staying asleep. When you awaken without feeling refreshed, this problem quickly becomes a drag on the rest of your life and health. What are reasons why you can't sleep? Are there tried and true ways to sleep better tonight? What should you do if you have tried everything and it just isn't working? Let's explore these issues and discover the help you need to sleep.

What Is Wrong with My Sleep?

We have an expectation of perfect sleep; that we will crawl into bed, fall asleep within minutes, sleep without interruption, and awaken fully refreshed and ready to start our day. But is this a reasonable standard?

Children are often hailed as a model of perfect sleep because (for the most part) they are able to do just what we've described. As we mature, our bodies change and our sleep seems to likewise deviate from the ideals of childhood. Life, in a sense, gets complicated. There are new time pressures, our sleep is disrupted by others (including bed partners and our own children), and other health problems (such as nocturia, heartburn, and even pain) compromise our sleep.

As a result, we may not enjoy the sleep we knew in your youth. Indeed, even the timing of our sleep may shift. Those who are in the twilight of their lives may more often find themselves waking early, unable to stay asleep as they once did.

Some of our expectations regarding our sleep may be slightly misguided. As an example, the thought that we will fall asleep almost immediately upon retiring to our beds may be improper. In fact, people who fall asleep in less than 5 minutes may be "pathologically sleepy". This means that they are so sleepy that they fall asleep quicker than might be normal. In some cases, this ability to fall asleep quickly -- and enter rapid eye movement (REM) sleep quickly -- can be seen in excessive daytime sleepiness that might occur in sleep deprivation or narcolepsy.

Some sleep researchers believe that it might be normal to be awake some during the night. The fact that you sleep straight through the night without budging may again be a sign of inadequate time spent sleeping. This phenomenon is called "quiet wakefulness" and is often observed when the sleep habits of other non-Western cultures are studied. When people sleep in a group in close quarters, there is more time spent awake during the night. This makes sleep a more fluid concept. Time may be spent chatting, eating a snack, or engaging others around you. In history, fragmented sleep with periods of wakefulness in the middle of the night were common, reflected in the midnight adventures seen in the plays of Shakespeare, for example.

When we find ourselves waking in the night, no matter the cause, we may conclude that something is wrong. If there are no consequences in daytime function, however, this may not be the case. (Waking to go to the bathroom is so common as we get older that you would be hard-pressed to call it "abnormal".) The problem begins when our poor sleep compromises our lives. If difficulty falling or staying asleep at night begins to have consequences, there is a motivation to seek the cause.

Common Causes of Difficulty Sleeping

When we find ourselves lying awake, watching the minutes tick past in the red light of our alarm clocks, the desperation to sleep quickly escalates. There are many reasons this could occur and getting to the bottom of it may require some reflection on your situation. 

The most common reason why you can't sleep is also the most obvious: you are not tired. Your desire to sleep will be greatly diminished if you are trying to sleep at the wrong time. Imagine lying down three hours before your normal bedtime. The chance of you being able to fall right to sleep is pretty slim. This has to do with the circadian rhythm of our bodies. This system helps to coordinate our activities, including our desire for food and sleep, to the external environment. Problems with the timing of sleep may occur in the circadian rhythm sleep disorders as well as in temporary conditions like jet lag. If you spend more time in bed than required by your sleep needs, you will also be subject to long periods of wakefulness. Another reason you might be diminishing your desire to sleep at night is because of naps you take during the day.

A very common cause of difficulty sleeping relates to stress and the intrusion of stimulating substances and activities. You may have trouble falling asleep the night before a big test or presentation. In periods of emotional stress, such as after the death of a loved one, you may also have trouble sleeping. This is called acute insomnia. It usually passes when these stressors resolve. Similarly, stimulants such as caffeine and even nicotine can disrupt your sleep. You may be surprised to learn that exposure to light at night -- such as from a television or computer screen -- may make it difficult for some people to fall asleep. Additionally, late-night exercise may rev you up and provoke insomnia. For those who have chronic insomnia, the bedroom space may become a trigger for insomnia through conditioning.

The sleep environment is meant to be comfortable and facilitate sleep.

It should be cool, quiet, and free of distractions. Ideally you would not allow a television or pets in your bedroom. Bed partners may be disruptive and some people choose to maintain separate sleep spaces for this reason.

Another common cause of difficulty falling asleep is the activities that precede your bedtime. If you eat or drink too late, you may suffer from heartburn or frequent nighttime trips to the bathroom. There are general guidelines to improve sleep and many of these are meant to reinforce positive sleep habits. You should go to bed and get up the same time every day. Irregular sleep schedules may set you up for sleep disruption. You should follow a bedtime routine, including quiet, relaxing activities to help transition to sleep. If you fail to unwind prior to bed, you may find yourself struggling to drift off to sleep.

Finally, there are medical conditions that may keep you from sleeping well at night. These may be common problems such as heartburn or pain, but there are also multiple sleep disorders that might cause difficulty sleeping. Some of these include:

• Insomnia

• Sleep apnea

• Restless legs syndrome

• Circadian rhythm sleep disorders

Whether you suffer from one of these conditions or not, you may be interested in learning about some of the treatment options if you find yourself struggling to sleep at night.

Home Remedies When You Can't Sleep

The first task to sleep better at night is to improve your sleep hygiene, which refers to following the guidelines for better sleep. These steps may initially seem straightforward but because they involve modifying your behaviors in relation to your sleep, this can be challenging. If you have mastered these changes, you may be compelled to look at other options.

For those who have difficulty with insomnia, there are a handful of options to help you sleep. One treatment option is sleep restriction. This involves limiting the amount of time that you spend in bed, so that the time you are there you are more likely to spend asleep. It can also be useful to make a behavioral change called stimulus control. Stimulus control helps to break the association between not being able to sleep and your bedroom.

There are other non-medication options that might be helpful. Some people find benefit with the use of aromatherapy. Various relaxation techniques, including the use of biofeedback, may also establish a connection between your mind and body. This can be incorporated into your bedtime rituals and make it easier to relax and transition into sleep.

Finally, you may find yourself turning to over-the-counter medications to help your sleep. One of the most common is the naturally occurring hormone called melatonin. It is sold in many pharmacies and herbal supplement stores. It can be highly effective if you have insomnia related to a poorly timed circadian rhythm. As it has a low risk of major side effects (the most frequent is sleepiness), it might be an option to consider. Other herbal supplements (such as valerian root) do not have a lot of research supporting their efficacy.

If you still struggle to sleep, you may be compelled to look at other options.

Serious Help for Difficulty Sleeping

For those who still need help sleeping after exhausting changes in your sleep routine and at-home remedies, it may be necessary to turn to a professional. You may want to start by discussing the matter with your primary health care provider, but you may also choose a sleep doctor.

There are diagnostic tests that can be helpful for assessing your sleep problems, with special tests for insomnia. It may be helpful to keep a sleep log or use an actigraph to track your sleep patterns. Further testing with a home sleep apnea test or an overnight sleep study called a polysomnogram can also be helpful to identify sleep apnea or leg movements related to restless legs syndrome.

The other benefit of speaking with a health care professional is that you can discuss the use of sleeping pills. In addition, you can ask for a referral to a psychologist who might be able to teach you cognitive behavioral therapy for insomnia (CBTI) techniques to help your sleep.

This is a very serious matter, as the consequences of poor sleep can undermine your health and may even lead to your death. There are serious symptoms and physical effects of sleep deprivation, including hallucinations. For all these reasons – and more – it is absolutely worthwhile to get the help that you need in order to sleep well and wake refreshed.

What Causes Early Morning Awakenings?

By Brandon Peters, MD

There is something disappointing about waking up earlier than is necessary. It may be nice to doze in and out of sleep in the early morning hours, but it is especially upsetting if you cannot fall back asleep. What might cause someone to wake up before the alarm clock goes off? There are specific conditions, including a fair number of sleep and mood disorders, which might cause early morning awakenings.  By understanding these potential causes, you may be able to find a treatment that will keep you asleep until your desired wake time.

The Role of Insomnia

The most important cause of difficulty staying asleep near morning is insomnia. Insomnia is defined as difficulty falling or staying asleep or sleep that is simply not refreshing. These awakenings may occur throughout the night, but they tend to be more frequent in the second half of the night. This is due to a diminishing ability to sleep toward the morning hours.

The ability to sleep is linked to two processes, one called the homeostatic sleep drive and the other being the circadian rhythm (which will be discussed more later). The homeostatic sleep drive is the gradual desire for sleep that builds the longer a person stays awake. It relates to the gradual accumulation of a chemical within the brain called adenosine. This “sleepiness signal” eventually helps to initiate sleep. During sleep, it is cleared away, so that midway through the night, the desire for sleep is depleted. By morning, it should be completely gone.

If a person awakes in the night, especially if this awakening occurs toward morning, the ability to return to sleep will be compromised due to the lower levels of adenosine. Sleep may be greatly delayed, fragmented, or disrupted in insomnia, but awakenings near morning can be especially troublesome.

Anxiety and Depression May Provoke Awakenings

Any of the mood disorders, most notably anxiety and depression, can provoke awakenings. These typically occur in the several hours before the intended awakening. For example, if the alarm is set for 6 AM, someone with depression may start waking at 4 AM for no good reason. How can this be addressed?

As with insomnia, it is important to address the underlying contributing factors that lead to these awakenings. In the setting of psychiatric distress, these problems can persist. It is therefore necessary to treat any coexisting depression or anxiety. This may require the use of medications or counseling with the assistance of a psychologist or psychiatrist. Studies have shown that both, used in combination, are the most effective. Insomnia is especially well-treated with cognitive behavioral therapy for insomnia (CBTi).

It is clear that sleep can undermine mood. Conversely, mood problems can greatly affect sleep. By working on both issues together, the complexity of this relationship can be unraveled.

The Unexpected Influence of Sleep Apnea

It may seem peculiar to imagine that a breathing disorder such as obstructive sleep apnea may contribute to early morning awakenings. To better understand this relationship, it is necessary to carefully consider the structure of sleep.

It is artificial (but useful) to divide the night in half when considering the stages of sleep. In the first half of the night, slow-wave sleep more frequently occurs, especially among young people. In the second half, rapid eye movement (REM) sleep makes a more frequent appearance. Though the cycles of sleep occur regularly through the night, REM sleep becomes more prolonged towards morning. Therefore, we are more likely to awaken from it near morning and recall the vivid dreams that are associated with the state.

Sleep apnea is also more likely to occur during REM sleep. The muscles of the body are actively paralyzed during this stage, so that we are unable to act our dreams out. (If this does not occur, a condition called REM behavior disorder may result.) Muscles lining the upper airway are also paralyzed. This makes the airway more collapsible and when collapse occurs, it manifests as disrupted breathing and sleep apnea. Sleep apnea is often worsened during REM for this reason.

Therefore, morning awakenings may occur in the setting of sleep apnea that is worsened during the periods of REM that become more frequent and prolonged towards morning.

Morning Larks, Circadian Rhythms, and How Sleep Changes in Aging

The last major contributor to early morning awakenings is the class of conditions that are collectively known as circadian rhythm disorders. These include the natural tendency to wake early in the morning (so-called early birds or morning larks), advanced sleep phase syndrome, and natural changes that occur in sleep ability as we get older.

There are some who are just naturally morning people. They may prefer to fall asleep earlier (such as at 9 PM) and wake earlier (by 5 or 6 AM). This may be a lifelong preference. It isn’t necessarily abnormal, but it may lead to morning awakenings. If a sufficient amount of sleep is obtained before getting up for the day, then there is no reason to give it a second thought.

As we get older, our ability to maintain a continuous, uninterrupted period of sleep diminishes. The “machinery” of sleep (whatever we might conceive this to be) isn’t working as well as it used to. Sleep may become more fragmented. There may be more time spent awake in the transition to falling asleep and during the night. Slow-wave sleep diminishes. The total sleep time may be reduced. As part of this, early morning awakenings may occur.

In some cases, a condition called advanced sleep phase syndrome may become apparent. In this circadian rhythm disorder, the onset and offset of sleep moves forward by several hours. If it is disruptive to social life, it may be treated with the use of properly timed melatonin and light exposure at night.

If you suffer from morning awakenings, you should reflect on your situation and consider what might be contributing to the occurrence. If there is evidence for mood disorders, these should be addressed by a doctor. When a clear explanation cannot be identified, it may be useful to speak with a sleep specialist who may be able to provide additional insight. 

What Factors Lead to Insomnia?

By Brandon Peters, MD

It’s 1 a.m. again. You can’t sleep. You have been lying awake for hours. Just when sleep seems within your grasp, you are cruelly pulled back to wakefulness. How are you going to function tomorrow? Why can’t you get to sleep? If you find yourself struggling to fall and stay asleep, learn how you can master the factors that lead to your insomnia and get the rest that you need.

Sleep Depends on Drive and Circadian Rhythms

There are certain factors working in your favor that should help you get to sleep at night. When these are corrupted, however, they may quickly start working against you and lead to insomnia. To better understand how this may occur, it is important to first consider the patterns that lead to sleep and why some people can’t sleep at night.

Sleep depends on two independent processes: sleep drive and circadian rhythm. Sleep drive is the desire for sleep that builds gradually during wakefulness. Put simply, the longer you are awake, the more you want to sleep. This is thought to be due to the gradual accumulation of a chemical within the brain called adenosine, one of the neurotransmitters. Sleep is a time to clear adenosine away, and when you are awake it piles up and leads to increased sleepiness. A poorly timed nap during the day will diffuse the chemical and diminish your ability to sleep at night.

The other factor that determines when (and whether) you can sleep is something called the circadian rhythm. Our bodies respond to the natural daily patterns of light and darkness, linking certain biological processes to these rhythms. One of these processes is sleep.

There are certain factors that affect these circadian rhythms. Melatonin is a hormone that has a key role in regulating sleep patterns. Exposure to light exerts the most powerful influence, however. Taken together, the circadian rhythm encourages the specific timing of sleep and wakefulness. Sleep that is attempted counter to our natural desires is often ineffectual. Moreover, a prolonged shift in the timing of sleep may represent a circadian rhythm sleep disorder.

What Factors Cause Insomnia?

Insomnia is defined as difficulty falling asleep, staying asleep, or sleep that is simply not refreshing. How this happens is best understood by considering a theoretical model of what causes someone to have insomnia. According to Dr. Arthur Spielman’s model, there seem to be three considerations, summarized as predisposing, provocative, and precipitating factors.

First, it seems that some people have a predisposition towards insomnia. The threshold for developing insomnia will vary for each person. Believe it or not, there are people who rarely or never develop trouble sleeping at night. On the other hand, some people may be unlucky and are simply predisposed to have insomnia. This likely relates to genetic factors (insomnia often runs in families), age, sex (more often women), substance use, and other medical and psychiatric conditions.

Insomnia may also be attributed to an increased alerting signal. This relates to the sympathetic nervous system, which is responsible for the so-called “fight or flight” response. Some people may have an increased sympathetic drive, meaning they are primed to respond to an external threat. This signal can keep you awake during the day – but it also keeps insomniacs up at night. Some have described this as being “tired but wired”.

Even though you might have a predisposition towards insomnia, it has to be triggered. These triggers are called provocative factors. Insomnia might occur transiently and be secondary to stress, a cup of coffee, or an uncomfortable sleep environment. About 25 percent of people cannot identify the trigger for their insomnia. If you hadn’t encountered the trigger, however, you might continue to sleep without difficulty. Instead, you find yourself in the throes of acute insomnia. In time, this may resolve. But sometimes it doesn’t.

The final components that transform a passing difficulty sleeping into chronic insomnia are the precipitating factors. These are the elements that perpetuate the difficulty sleeping. These can best be understood by considering an example.

Let’s imagine that you lie awake several hours in the middle of the night, a common occurrence in insomnia. You recognize that you need 8 hours of sleep and by lying awake you are cutting into this time. You decide to start going to bed 2 hours earlier to compensate. This helps some, but now that you are going to bed extra early it is taking you more time to fall asleep. As you lie awake more of the night, your frustration increases and you compound your initial insomnia.

There are a variety of choices that might perpetuate your insomnia. Some people choose to limit their daytime activities because of sleepiness. This avoidance may reduce your physical activity. Since you are less tired, you may be less able to sleep. You may start working on your computer in bed to make the most of your time spent awake. This light and activity may worsen your ability to sleep. In addition, you may start napping during the day to get some sleep, and this could undermine your sleep drive and ability to sleep at night. All told, perpetuating factors are going to prolong your battle with insomnia.

How to Get to Sleep

Now that you understand the factors that might lead you to have difficulty sleeping at night, you no doubt wonder how you are going to get to sleep. In general, you can follow these simple rules:

1.    Build up your sleep drive through sleep restriction.

Work to make yourself tired by limiting your time in bed with sleep restriction. Avoid naps that may diminish your ability to sleep at night. Do not sleep in divided periods. If you find you cannot sleep, do not allow yourself prolonged wakefulness in bed, but observe stimulus control. These interventions can increase the quality of your sleep.

2. Respect your circadian rhythm, and sleep at the right time for you.

Acknowledge your body’s desired timing of sleep. If you are a night owl, don’t go to bed too early and lie awake. If you wake early, allow yourself adequate sleep time by going to bed early as well. There are ways to adjust the timing of your sleep, but start by sleeping when your body desires.

3.    Avoid triggers that can precipitate insomnia.

If you can identify the causes of your insomnia, do your best to avoid these triggers. Start by eliminating caffeine, especially after noon. Consider other ways that you may be ruining your sleep. Don’t forget about treating other sleep disorders, as these can also trigger difficulty falling or staying asleep.

4.    For those with chronic insomnia, seek professional help.

Finally, if you are suffering from chronic insomnia, lasting more than 3 months, you may need to seek professional help. When insomnia becomes prolonged, it is necessary to pursue other interventions. Sleeping pills may help in the short term, but other treatments are preferred for chronic insomnia. It can be very helpful to address the beliefs, thoughts, and feelings that surround your insomnia with a treatment called cognitive behavioral therapy.

If you suffer from insomnia, start by considering the factors that underlie your difficulty. Then talk with your doctor and if appropriate ask for a referral to a sleep specialist.

Sources:

Kryger, MH et al. "Principles and Practice of Sleep Medicine." ExpertConsult, 5th edition, 2011.

Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987;10(4):541-553.

Are Light Therapy Glasses Right for Me?

By Brandon Peters, MD

They look a little futuristic, casting a blue light over the eyes and onto the face. In some ways, they are. Light therapy delivered via glasses also relies on science that is as old as time. The use of light therapy glasses may be helpful to manage circadian mood and sleep disorders like seasonal affective disorder (SAD), insomnia, and jet lag. They may offer a boost of energy on a winter morning. How do light glasses work and are they right for you? Learn about phototherapy, circadian rhythms, and the usefulness of artificial light delivered via glasses for several conditions.

What is Light Therapy?

Light therapy, or phototherapy, is the use of light to treat a medical condition. It may be helpful to treat problems that occur when the internal circadian rhythm is misaligned to the natural patterns of light and darkness. This may impact the ability to sleep, the release of hormones including melatonin, and even mood and energy levels.

Light therapy may be done by properly timed exposure to sunlight. Unfortunately, living at northern latitudes may make this more difficult in the winter months. In some cases, an artificial source of light may be needed.

There are certain medical conditions that respond extremely well to this treatment, but how is it delivered?

Light Boxes Versus Light Glasses

Historically, light boxes were used to artificially deliver phototherapy. Initially quite large, the technology has become more portable. In fact, there are now several brands of light glasses that are capable of performing the task:

Ayo

The smallest glasses are available for $299 from Ayo. With a well-integrated app, it is possible to personalize the program by providing information on sleep habits and lifestyle. The light intensity, timing, and duration varies based on the mode and purpose. Boost energy, optimize the sleep-wake cycle, or even beat jet lag and adjust to the new time zone faster. There is some built-in flexibility in the timing of their use. The glasses are comfortable, with a sleek visor-like design that is unobtrusive. It is easy to charge the glasses by placing them in a pill-shaped pod that connects to a computer with a USB cable.

Luminette

For a lower price point, consider the light therapy glasses offered by Luminette. For $199 to buy, or $39 for a trial, similar technology is used to deliver the light therapy directly into the eyes. Unlike a light box, which may require 10,000 lux to be effective, the blue light directed into the eye accomplishes the same treatment with a lesser intensity. There are 3 intensity levels offered: 500, 1000, and 1500. The glasses themselves are larger, broadly situated above the eyes. It is recommended that they be used for 30 minutes daily for best effect.

Re-Timer

Similarly priced, at $199, Re-Timer delivers blue-green light into the eyes for the purposes of phototherapy. Designed to frame the eyes, these glasses were developed at a university based on 25 years of research. It is recommended that the glasses be used for 60 minutes daily, the longest recommended usage of the three models.

Conditions That Respond to Light

The circadian rhythms of the body are mostly affected by exposure to blue light. This part of the light spectrum is present in full-spectrum sunlight. It can also be isolated and delivered at a lower intensity with equivalent effectiveness. What conditions respond best to light therapy delivered via light glasses?

Seasonal affective disorder

Also known as winter depression, it occurs seasonally when the lack of light availability leads to a deterioration of mood. It may be associated with increased sleeping, lack of initiative and social isolation, and changes in appetite and weight gain.

Insomnia

Difficulty falling asleep may be especially responsive to the use of phototherapy. Artificial light exposure in the evening may be a problem, but using light glasses in the morning upon awakening may help to realign the circadian rhythm.

Delayed sleep phase syndrome

Night owls experience this condition that leads to both difficulty falling asleep at a conventional time as well as difficulty waking in the morning at an earlier time. Bedtimes may be at 2 a.m. or later and waking may naturally occur mid-morning or even mid-day. Though it does not necessarily have to be associated with insomnia, it often does when social pressures require sleep-wake timing that is not consistent with this genetic tendency.

Morning sleepiness

Difficulty getting out of bed in the morning due to sleepiness may be relieved with phototherapy. Light naturally wakes us. It initiates the circadian alerting signal. Consistent use in the morning may help to align sleep’s place to the darkness of the night.

Jet lag

In the modern age, jet travel allows a rapid misalignment of the body’s circadian rhythms to the patterns of light and darkness in the environment. It may take one day to adjust to each time zone crossed, but light therapy may make this adjustment occur more quickly. 

Cautions and Side Effects

Phototherapy is generally well tolerated. If it is bothersome, it should be discontinued. Any perceived side effects should resolve once the light glasses are no longer being used. In some cases, the following side effects may occur:

Headaches

Artificial light therapy may trigger headaches or migraines in those predisposed. In this case, a lower light intensity for a more prolonged period may be useful.

Insomnia

Light at the wrong time may lead to difficult sleeping. For example, using light glasses at bedtime may cause a shift in the timing of sleep later. This will make it hard to fall asleep, and hard to wake. Avoid this by following the instructions associated with the light glasses program.

Photophobia

Sensitivity to light may occur. This may lead to pain or simply an aversion to exposure characterized by squinting. It will go away when the light stimulus is removed.

Fatigue

Rarely, fatigue may occur with phototherapy. This may have to do with the changes that occur in the sleep-wake schedule. Following the directions of the program should help to minimize this risk.

Hypomania

For those who have a history of bipolar disorder, light therapy needs to be used with caution. There is a risk that the light may lead to a state of hypomania. This may be associated with an elevated mood, increased productivity, hypersexuality, or other symptoms.

Irritability

Although mood would typically improve with light therapy, in some cases it may lead to irritability. Like the other side effects, it should resolve by stopping the use of the light therapy glasses.

Importantly, there is no ultraviolet (UV) light exposure with the use of light therapy glasses. Therefore, the risks associated with this—such as damage to the eye or cancer—would not be present.

Conclusion

If you are interested in learning more about your sleep, consider evaluation by a board-certified sleep physician. In some cases, consultation with this specialist may optimize your response to the light therapy glasses. Should you experience any problems with their use, seek further assistance by an expert.

Sources:

Peters, BR. “Irregular Bedtimes and Awakenings.” Evaluation of Sleep Complaints. Sleep Med Clinic. 9(2014)481-489.

Reid, KJ and Zee, PC. “Circadian disorders of the sleep-wake cycle,” in Principles and Practices of Sleep Medicine. Edited by Kryger MH, Roth T, Dement WC. St. Louis, Missouri, Elsevier Saunders, 2011, pp. 470-482.

What Causes Sunday Night Insomnia and What Can Help?

By Brandon Peters, MD

It’s been a great weekend and now it’s time to settle into bed to get a good night of sleep before the busy week ahead. After waiting for a few minutes, you start to get a little anxious: you aren’t falling asleep. You start to worry about your function the next day. Then you realize that trouble falling asleep seems to occur every Sunday night. What causes Sunday night insomnia? Learn about some of the contributing factors, including sleeping in, taking naps, caffeine or alcohol use, and anxiety about the week ahead. By identifying and resolving some of the causes, you can finally get to sleep on Sunday nights easily without feeling dread for Monday morning.

Anticipating the Week of Ahead May Provoke Anxiety

What makes Sunday night so special? Of all the nights of the week, it seems to be mostly commonly associated with difficulty falling asleep that characterizes insomnia. Insomnia is defined as trouble falling or staying asleep. When it takes more than 20 to 30 minutes to drift off, this may be a sign of a problem.

There are lots of potential causes of insomnia. When it occurs, anxiety may make it worse. Pressure to fall asleep, or even the slightest focus on it, makes it nearly impossible to doze off. Sunday night may be the time that you start to think about the week ahead. If you hate your job, or if it is stressful, you may approach the week with dread. You might think about the coworkers who drive you crazy. You might ruminate on the projects that seem overwhelming. You might ponder the biggest stressors that you face in the week ahead. None of these thoughts will be conducive to falling asleep.

It may be helpful to use scheduled worry time or relaxation techniques to relieve this stress. You may be able to distract yourself from these thoughts, and fall asleep more easily. If you have persistent anxiety, you may need further help with the use of medication or psychotherapy from a counselor.

Weekend Sleep Patterns May Worsen Sleep Initiation

There is also good evidence that changes in the sleep patterns of the weekend may make it harder to fall asleep on Sunday night. It is very common to be sleep deprived during the week. You may get to bed too late or you may have to wake early. Getting the children ready for school, or making the commute to work, may prompt an earlier wake time. You may get to bed to late due to projects that delay your bedtime. As a result, you may note meet your individual sleep needs during the week. Each night, you may short yourself a little. Night after night, your desire for sleep grows stronger. When Saturday morning rolls around, you may sleep in. You “catch up” on lost sleep and pay off the accumulated sleep debt. If you don’t get up early Sunday morning, the same indulgence may recur. How does this impact sleep?

Our sleep is enhanced through two processes: homeostatic sleep drive and circadian rhythm. The sleep drive is the desire for sleep that builds the longer we stay awake. If you were to stay awake for 30 hours, at the end of 30 hours you would be very sleepy, and fall asleep very quickly. You would probably sleep longer and deeper than you normally would. All wakefulness builds this desire for sleep. Conversely, if you sleep, you diminish the sleep drive. By sleeping in, there is a delay in starting to build the desire for sleep. It is almost like going to bed early. If you sleep in 2 or 3 hours on the weekend, it’s like going to bed that much earlier. If your bedtime is normally at 11 PM, but you crawl into bed at 8 PM, is it any wonder that you can’t fall asleep?

Another contribution to poor sleep on Sunday night is our circadian rhythm. We have a natural tendency toward sleep that is synchronized to the day-night patterns of light and darkness. This is reinforced by our genetics as well as morning light exposure. By delaying the wake time, and getting light to our suprachiasmatic nucleus in the brain a little later, the pattern shifts. It makes it harder for us to wake up and harder for us to fall asleep.

Our bodies respond best to regular patterns, and this includes the pattern of sleep and wakefulness. Keep a regular wake time (with an alarm, if needed), even on the weekends. Go to bed when you feel sleepy, but try to get 7 to 8 hours of sleep through the week to meet your sleep needs. Try to avoid catching up on sleep on the weekend; get enough sleep every night to feel rested.

Afternoon Naps May Diminish Your Ability to Fall Asleep

Weekends are when we can most easily indulge in a nap. Though these don’t usually occur in the morning, they may frequently interrupt the afternoon. Imagine how often you have seen someone dozing on a lazy Sunday afternoon! Sports, movies, and reading seem perfectly paired for dozing on the weekends. Unfortunately, naps can diminish the drive for sleep.

Try to avoid taking prolonged naps, especially if you have difficulty falling asleep at night. Naps lasting 2 hours or more are especially problematic. (These naps may also be sign of a sleep disorder, such as sleep apnea.) As much as possible limit naps to shorter periods, perhaps 15 to 20 minutes. These can be refreshing, without impacting sleep at night. In addition, try to time the naps to mid-afternoon and avoid sleeping in the late afternoon or evening. Falling asleep in the hours before bedtime will make it especially difficult to get to sleep.

If your insomnia is especially entrenched, cut out the naps completely until your sleep improves.

Selecting a Bedtime and Going to Bed Sleepy

As noted above, try to keep a regular sleep schedule, including week nights and weekend nights. By going to bed at the same time every night, you will fall asleep more easily. It is also important to listen to your body and go to bed when you are feeling sleepy.

Sleepiness or drowsiness is different that fatigue, tiredness, or exhaustion. One can feel exhausted, and not fall asleep. Sleepiness is the strong desire for sleep that immediately precedes its onset. It may be associated with heavy eyelids, a warm sensation in the body, and loss of focus in vision.

Go to bed when you feel sleepy, including on the weekends. Don’t choose an optimistic bedtime based on when you would like to fall asleep. If you need to adjust your schedule, it is actually easier to change your wake time with an alarm. Subsequently adjust your bedtime earlier to correspond with when you are feeling sleepy. Insomnia is more likely to occur if you crawl into bed too early to get enough sleep to start your week.

If you are not falling asleep, observe stimulus control. Get up after 15 minutes, do something else relaxing, and come back to bed when you are feeling more sleepy.

Decreased Physical Activity and Consumption of Alcohol and Caffeine

There are other things that can impact your ability to fall asleep. These include changes in physical activity and the varying consumption of alcohol and caffeine.

Some people have very physical jobs. The weekends might be their opportunity to recover and rest. Decreased physical activity, including exercise, on the weekend may make it heard to fall asleep. As much as possible, try to maintain similar levels of exercise on the weekend (or even increase them, if possible).

Alcohol may enhance adenosine levels and increase the desire for sleep. Unfortunately, it is metabolized very quickly. The levels drop, and the desire for sleep disappears. Avoid alcohol intake in the hours before bedtime. Importantly, do not use alcohol as a nightcap.

Caffeine consumption can also impair our ability to sleep. Some people are very sensitive, and caffeine found in coffee, tea, soda pop, energy drinks, or chocolate should be avoided after noon. In others, reducing intake after mid-afternoon may be sufficient. If you have insomnia, try eliminating late consumption of caffeine to learn if it is impacting you.

Final Considerations for Sunday Night Insomnia

When difficulty falling asleep persists, consider other potential causes of Sunday night insomnia. Are you reluctant to go to bed because it means ending the weekend? Are you avoiding the stress of the work week? Is it time to make serious changes in your life to relieve stress?

If your insomnia persists, consider speaking with a sleep specialist about treatment options that may be helpful, including cognitive behavioral therapy for insomnia (CBTI). In rare cases, the use a sleeping pill on Sunday nights may be helpful.

You can sleep normally, even on Sunday nights.

Turning the Alarm Clock May Help with Insomnia

By Brandon Peters, MD

What is the first thing you do when you wake up at night? If it’s look at what time it is, you might consider how turning your alarm clock around may actually help your insomnia. Learn how checking the clock may provoke emotional reactions that disrupt sleep even further and how a simple solution may help you to sleep better.

Insomnia is defined as difficulty falling or staying asleep. For many people, it manifests by taking a long time to fall asleep initially or by frequently waking up in the night with trouble returning to sleep. There are multiple causes of insomnia, but paying attention to what time it is can actually make the condition worse.

If you wake up at night and immediately check the clock, there may be consequences to this seemingly innocent action. First, looking to the clock can become a habit. Every time you briefly return to consciousness in the night, rather than simply letting yourself fall back asleep, you may instead wake even further to look to the clock. Depending on what you find, you may put yourself into an emotional state in which returning to sleep becomes even more difficult.

Let’s take an example in which you check the clock and it’s 3 AM. This piece of information may be rather harmless if noted in isolation. It really shouldn’t matter what time of the night it is. However, in the context of your difficulties sleeping, it is a loaded experience. “Oh great,” you might promptly think, “I’m wide awake again.” This may incite a negative reaction, causing you to feel upset, angry, frustrated, or even despondent. How likely is it, when experiencing those feelings, that you will be able to calmly and easily fall back asleep? Quite the contrary, you are more likely to be worked up, aroused further, and stay awake even longer.

To counter this tendency, set your alarm for the time you wish to wake up in the morning. Then, turn the clock around so you can’t see the time. When you awake in the night, you may check it a few times until you remember that you can’t see it any longer. If you awake, tell yourself that you do not hear your alarm blaring, therefore, no matter what time it is, you can return back to sleep. Whether you awake early or late in the night, this will help you to doze off more easily. There will no longer be emotional reactions that can further disrupt your sleep.

There is no reason to keep track of the time at night. It only will further your difficulty returning to sleep. Instead of checking the hour, allow yourself to remain quiet and comfortable until sleep resumes. It is normal to wake up at night – to change positions, adjust the covers, even roll over – but it becomes a problem when this wakefulness persists. Use relaxation techniques such as breathing, muscle relaxation, or guided imagery to distract yourself from any effort related to falling back asleep.

If you find yourself checking your alarm clock at night, the simple step of turning it around may allow you to ease yourself back into sleep. This step can be an important part of other interventions offered by cognitive behavioral therapy for insomnia (CBTI). For those with persistent insomnia, you may wish to speak to a sleep specialist about your treatment options.

Are You a Night Owl? Delayed Sleep Phase Syndrome Overview

By Brandon Peters, MD

Night owls rule the evening roost. What explains the natural desire to stay up late and sleep in, especially in teenagers? With this overview, discover the causes, symptoms, diagnostic testing, and treatments of delayed sleep phase syndrome. Consider the consequences, including insomnia and sleep deprivation, and what can be done to keep the condition in check.

What Is a Night Owl?

First, how is a night owl defined? Anyone who stays up later than most may be viewed as a potential suspect. However, those with delayed sleep phase syndrome may be birds of a different feather.

If the natural tendency to fall asleep is delayed by at least several hours compared to the average person, with a sleep onset closer to 1 to 3 a.m., this fits the bill. In some cases, the delay may be even more extreme, with a night owl going to sleep closer to sunrise.

The desire to wake up is similarly delayed by at least several hours. Someone who is characterized as a night owl may not desire to wake until 10 a.m. or later. With a sleep onset closer to sunrise, the affected person may not desire to wake until into the early afternoon.

How Common Is Delayed Sleep Phase Syndrome?

It is estimated that 10 percent of the population could be characterized as night owls with delayed sleep phase syndrome. It may be more common among teenagers, who are susceptible to a slight delay in their sleep timing, but it can persist throughout life. There are many retired people who experience the condition once the alarm clock is silenced!

What Causes a Delayed Sleep Phase?

There seems to be a genetic predisposition towards developing delayed sleep phase syndrome. Some of this science is understood. For example, a mutation in the CRY1 gene alters the human circadian clock, delaying sleep by 2 to 2 1/2 hours compared to non-carriers. There will likely be more genes identified that have a role. 

Approximately 40 percent of people with delayed sleep phase syndrome report a family history of the condition.

Beyond genetic programming, there are environmental factors that may unmask the condition. Most importantly, light has powerful effects on the timing of the circadian system. It may provoke the delay in sleep timing, and may also be used to correct the condition.

Understanding the Circadian System and Sleep

Sleep is dependent on two processes: sleep drive and the circadian alerting system. If isolated in a constant environment, like a cave, the genetically determined circadian timing will become evident. It is controlled by the suprachiasmatic nucleus, a region of cells in the hypothalamus of the brain, and highly influenced by light exposure. Every cell, and organ, in the body follows a circadian pattern.

For most people, this internal clock is programmed to run a little long, perhaps resetting every 24 1/2 hours. In the cave, without exposure to light variance, an isolated person would naturally fall asleep and wake 30 minutes later, shifting later each and every day. In a week, the timing of sleep would move 3 1/2 hours. In a month, it would shift 14 hours, so that the person would want to sleep during the natural day and be awake in the natural night. This natural drift in the circadian timing is reset with morning sunlight.

Exposure to natural light in the early morning hours is a signal to the brain for wakefulness. It makes it easier to wake. It also slightly shifts the timing of sleep earlier, making it easier to fall asleep. This helps to align the desire for sleep to the natural period of darkness overnight. Without it, significant problems can develop with sleep and health.

What Are the Symptoms of Delayed Sleep Phase Syndrome?

People with delayed sleep phase syndrome will generally experience two symptoms: insomnia and sleepiness. Why would these seemingly contradictory symptoms occur in the same person? Again, it comes back to a question of when—it comes back to timing. 

Insomnia

Most night owls will experience significant insomnia if they attempt to go to bed earlier than their natural desire for sleep onset. Crawling into bed at 10 p.m. may result in hours of lying awake, tossing and turning. This can provoke anxiety, frustration, and anger—feelings that make the insomnia worse. When left to stay up late on weekends or during vacation breaks, it suddenly becomes much easier to fall asleep.

Morning sleepiness

In the early morning hours, it can be difficult to wake a night owl. It’s like trying to wake the dead. Teenagers have to be dragged out of bed, splashed with water, or roused with threats from despondent parents. This morning sleepiness can be profound. Depending on the hour, it is akin to waking someone with normal sleep timing in the middle of the night. It is extremely difficult to wake and function. By midday, however, the sleepiness abates. When the late evening rolls around, the night owl feels very awake, repeating the cycle again.

Social Pressure Leads to Sleep Deprivation

Unfortunately, night owls are not typically allowed to sleep and wake when their bodies tell them to. If they could always go to bed at 2 a.m. and wake at 10 a.m., there would be no sleep problem. They would fall asleep easily, without insomnia, and wake easily without conflict. Unfortunately, pressure from the rest of society—parents, spouses, bosses, school systems—may be quite disruptive. Without accommodation, chronic tardiness and absenteeism can lead to educational and professional dysfunction.

If someone does not naturally fall asleep until 2 a.m., but has to wake at 6 a.m. to be to work on time, sleep deprivation inevitably results. Unfortunately, 4 hours of sleep is not enough to meet even basic sleep needs. This can have profound effects on health and well-being. Consider some of the symptoms associated with sleep deprivation:

• Sleepiness

• Fatigue

• Difficulty concentrating

• Memory problems

• Mood changes (depression, anxiety, or irritability)

• Errors or accidents

• Physical pain

• Hallucinations

• Paranoia

There is some evidence this can be fatal. This is likely due to the chronic effects of sleep deprivation. One study suggests that people with delayed sleep phase syndrome have a 10 percent higher risk of dying compared to controls.

How Is Delayed Sleep Phase Diagnosed?

With proper education, it becomes fairly easy to recognize night owls who are likely experiencing delayed sleep phase syndrome. It may be a lifelong affliction, starting in adolescence and persisting for decades. How can it be diagnosed?

Fortunately, testing is not required to reach a diagnosis. A careful history by a board-certified sleep physician can typically identify the condition. In some cases, sleep logs kept over weeks may aid the recognition. Rarely is testing with actigraphy needed.

In research settings, the measurement of melatonin levels can help to identify the circadian timing. In particular, the dim light melatonin onset (DLMO) measured via blood or saliva can establish the pattern. Unfortunately, the repeated sampling requires a carefully controlled laboratory environment. This is virtually never done in a clinical practice. More recently, a blood test called TimeSignature has been developed, but it is not widely available.

Treatments of Delayed Sleep Phase Syndrome: Light, Melatonin, and More

If a condition is genetically determined, and potentially lifelong, it may seem like a life sentence. Fortunately, for delayed sleep phase syndrome, this is not the case! There are some effective ways to keep the timing of sleep in a normal phase. It may require a little extra effort, but consider these potential helpful interventions:

Sleep schedule consistency

There is good evidence that night owls can maintain a socially acceptable sleep timing. This requires consistency, especially in regard to the wake time. Get up at the same time every day, including weekends. Do not sleep in. Go to bed feeling sleepy, even if this initially requires a delay in the preferred bedtime. This will make it easier to fall asleep faster, relieve pressure to sleep, and reinforce the sleep quality.

Morning sunlight

It is especially important to reset the timing of sleep with morning sunlight. This is most effective immediately upon awakening. Try to go outside for 15 to 30 minutes upon awakening. Wake with an alarm, throw on clothes, and immediately get outside. Take a walk. Read the newspaper in the garden. Check social media while facing the sunrise. Light should hit the eyes, but don’t stare directly into the sun. Even a cloudy or rainy day, try to stick to the routine. In winter months, a light box may be necessary for phototherapy. The effects may take up to 1 month to become evident.

Avoid light at night

Artificial screen light should be minimized at night, especially in the hours preceding bedtime. It may shift the timing of sleep to occur later, causing insomnia and morning sleepiness. Devices may be switched to night mode, cutting out the blue light that can shift sleep timing. Blue blocker sunglasses (with an amber tint) or screen covers may be employed. Best yet, simply shut down the electronics in the 2 hours before bedtime. The buffer zone before the goal bedtime should be spent relaxing.

Melatonin

Melatonin is a hormone produced overnight by the pineal gland in the brain. It can be an external signal to the circadian system, most effective among the blind. If taken up to 6 hours before the desired bedtime, it may help night owls to fall asleep earlier. The effects may be somewhat weak, and certainly overpowered by the effects of light.

Cognitive behavioral therapy for insomnia (CBTI)

This effective treatment helps to improve the patterns of sleep and one’s relationship to it. Sleep consolidation, stimulus control, mindfulness, and relaxation techniques may be integrated into a program. It may be guided with help from a psychologist, class, online course, or book.\

Chronotherapy

Rarely, it may be necessary to adjust the timing of sleep incrementally in a structured environment. It is difficult to carry out at home and may require hospitalization. Over successive days, the sleep period may be delayed by 1 to 2 hours until the desired timing of sleep is achieved. Poorly timed light may complicate the efforts, and strict adherence to the final schedule must be observed.

Prescription medications

Sleeping pills and stimulant medication to enhance alertness have a limited role in this condition. Generally, they will be weakly effective. As a result, they may be overused and even abused. The risk of overdose in night owls, especially when these medications are used in combination with alcohol, is high. Instead of masking symptoms with a drug, the underlying timing of the circadian rhythm should be corrected.

Social awareness

Education may help parents to appreciate what their teenager is experiencing, to know that it is not laziness or defiance. High schools should continue to accommodate this natural timing among their students by shifting the school day. Later school start times enhance academic performance, reduce tardiness and truancy, and even diminish car accidents among teens. 

Conclusion

Sleep deprivation can have serious impacts on health and well-being. If you are struggling with delayed sleep phase syndrome, consider seeking the guidance of a board-certified sleep physician. Start with some simple advice: Go to bed feeling sleepy (even if later), keep a consistent wake time, and get sunlight upon awakening. If more help is needed, seek it out.

Why Does Insomnia Happen?

By Brandon Peters, MD

There are few things more frustrating than an inability to sleep. Insomnia may undermine your night’s rest, leading to important daytime consequences. Why does insomnia happen? Learn about the factors that may lead to an inability to sleep at night and consider what you might do about them.

Insomnia is defined as the inability to fall or stay asleep or sleep that is unrefreshing in the absence of another sleep disorder (such as sleep apnea). It is the most common of all the various sleep disorders, and it may be a significant problem in about 1 in 4 people. Nearly everyone has experienced some degree of insomnia, even if only transiently, but why does this occur?

Spielman’s theoretical model of insomnia underpins our current understanding of the disorder. This theory suggests that three things contribute to the development of chronic insomnia, including: predisposing, precipitating, and perpetuating factors.

Predisposition: The Threshold for Insomnia

It is believed that everyone has the capacity to develop difficult sleeping at night. This predisposition is likely genetically determined. Some of the contributions to it likely include our individual circadian rhythm, homeostatic sleep drive, and level of arousal. The circadian rhythm directs the timing of our sleep, and it may be either advanced or delayed in some people. The homeostatic sleep drive is dependent on the build of sleep-promoting chemicals, including the compound called adenosine. The longer we stay awake, the sleepier we become, due in part to these chemicals. Finally, the baseline level of arousal also is factored in. Some people are more “wired” – also likely due to varying levels of neurotransmitters that promote wakefulness – and this may make sleep disruption more likely.

The predisposition towards insomnia can be thought of as a threshold. Below the threshold at which insomnia will develop, you sleep fine. Given the proper scenario, however, and the balance tips toward sleep disruption. The things that provoke the development of insomnia are known as the precipitating factors.

The Precipitating Factors for Insomnia

What might cause insomnia? There will be some variability in what provokes insomnia in you. Triggers for insomnia may not be the same for every person. Something that is particularly disruptive to your sleep may have no effect on someone else’s. This varying sensitivity is normal, and it shouldn’t be a source of additional distress.

Some of the most common triggers for insomnia include stress, mood disorders, pain, substance use, and poor sleep environment. Stress of every imaginable type is highly likely to make it difficult to sleep. The night before a big examination or presentation at work may be fitful. Major life events such as moving, the loss of a job, relationship problems including divorce, or the death of a close friend or relative may also lead to insomnia. If these problems lead to anxiety or depression, the risk of insomnia may be compounded.

There are other causes of insomnia as well. In particular, chronic medical conditions, especially those that cause pain, may disrupt sleep. Sleep is usually an anesthetic state, in which pain is not sensed, but nevertheless pain can make it hard to fall asleep. There are certain substances that may contribute to difficulty falling or staying asleep as well. The most common, caffeine, is notorious for sleep disruption. Nicotine is another stimulating substance that disrupts sleep. Alcohol may cause drowsiness initially, but when it starts to wear off, sleep becomes fragmented. Other medications and drugs can also undermine sleep.

Finally, the sleep environment can also make it hard to sleep. If your bedroom is too warm or too cold, too bright, or too noisy, sleep may be fleeting. An uncomfortable bed, or none at all, may also cause insomnia. If someone is snoring nearby, or a baby cries out to be fed, sleep becomes light and fragmented. Studies have also shown that environmental noise, such as may be present in a busy city, can also disrupt sleep.

It should also be noted that working against your natural ability to sleep can also cause insomnia. If you try to sleep at a time that your body expects you to be awake (contradicting your circadian rhythm), you will likely lie awake. If you took a prolonged nap in the afternoon, your desire for sleep will be diminished due to a weakened sleep drive. In addition, if you are wound up after a fight with your spouse (with increased arousal), insomnia will likewise result.

Perpetuating an Inability to Sleep

Once your threshold for insomnia has been crossed, incited by one of the precipitating factors, you will find yourself lying awake at night. This may quickly pass, as occurs in acute insomnia. If you had insomnia due to an examination that has come and gone, for example, the difficulty sleeping goes away with it. However, there are scenarios where insomnia will persist, and unintentional behavioral or cognitive changes may actually make things worse.

If the precipitating factor has not resolved, it is very likely that it will continue to disrupt your sleep. It is possible to adapt to some of these triggers, depending on the nature of the disruption, but this may not always happen. Therefore, it can be important to identify the cause of the insomnia and try to resolve it. This will require a careful self-assessment of the factors that are important to your situation.

Unfortunately, some triggers are not easily remedied. It may require a tincture of time to grieve a death. A mood disorder may require medication or psychotherapy. A new baby may take months to sleep through the night. Focus on what you have control over, and avoid making things worse.

Many people with insomnia unintentionally make their insomnia more sustained. Several bad nights of sleep (or dozens, for that matter) may lead you to change your pattern of sleep. This can be particularly true if you find yourself waking and lying awake in the night. You may think, “I am not sleeping well, so I am going to go to bed earlier to try to get enough sleep.” By extending your time in bed, you have introduced a new problem: you are now going to bed earlier than your body wants you to. If your body says you will get sleepy at 11 PM, but you crawl into bed at 9 PM, guess what happens? You will now have trouble falling asleep as well.

There can be a lot of emotions and thoughts that become associated with insomnia. Chronic insomnia is deeply frustrating. Feelings of distress, hopelessness, inadequacy, and failure become part of the scenario. People who sleep well do not wake in the morning and assess how well they slept. Insomniacs often do. Sleep becomes a focus in insomnia, and when it does, it becomes a challenge. There can also be an element of catastrophization, in which the worst possible scenario is imagined during the periods of wakefulness: “If I don’t get enough sleep, I’m going to get fired.” Many of these thoughts and feelings must be defused, and cognitive behavioral therapy for insomnia (CBTI) can be very helpful in this regard.

It is clear that insomnia can happen for multiple reasons, as detailed above. Everyone has a specific threshold at which insomnia will develop. The precipitating factors will vary for each person, but there are common triggers related to stress, mood, pain, and substance use. Acute insomnia becomes chronic when behaviors, thoughts, and emotions change surrounding sleep. If you find yourself stuck in the pattern of insomnia, it can be helpful to speak to a sleep specialist to begin to make changes that can correct the problem. Insomnia can be treated effectively, so reach out to get the help that you need.

Source:

Kryger, MH et al. “Principles and Practice of Sleep Medicine.” Elsevier, 5th edition. 2011.

How to Take Melatonin

By Brandon Peters, MD

Melatonin is a naturally occurring hormone that is often taken in a pill form as an over-the-counter supplement to aid sleep. It is most helpful in circadian rhythm sleep disorders, but it is frequently taken to alleviate difficulty falling or staying asleep (characteristic symptoms of insomnia). If you are interested in using melatonin to help you to sleep, you may wonder how to take melatonin, as well as the appropriate dose and timing.

What Dose of Melatonin Should I Take?

Melatonin is believed to be relatively safe and it is therefore available over-the-counter at many pharmacies and health supplement stores. It may be compounded in multiple different ways, and it is sometimes even added to other products meant to aid sleep. Pure melatonin is most often sold as a pill or capsule, but you can also buy it in a liquid or even spray form.

The advertised strength of the melatonin dose may range from 1 mg up to 10 mg or more. It is important to remember that melatonin is not regulated by the Food and Drug Administration (FDA). As such, production and quality standards are not enforced, so the dose may actual vary from the listed strength.

Research suggests that even quite low doses of melatonin may be effective, especially in circadian rhythm disorders. The relationship between the dose and the perceived effect -- a so-called dose-response relationship – does not appear to exist for melatonin. Therefore, it is difficult to determine the optimal dose for an individual. Given these limitations, it is probably best if you take the lowest possible effective dose. (This would mean taking 1 mg or 2 mg to aid sleep.) If you take too much, you may actually flood your system and the benefits will be counteracted. The timing of the dose is very important and high blood levels at the wrong times may be a problem.

When Should I Take Melatonin?

The role of melatonin in regulating our biological clock, or circadian rhythm, appears to be critical. Therefore, the timing of when you actually take it is just as important. It is normally produced in part of the brain called the pineal gland and is released during the period of darkness from sundown to sunrise. When taken as an oral supplement, it reaches a maximum concentration in your blood after 30 minutes. However, the timing of administration may not be quite so simple.

Most people should take melatonin in the evening before going to bed, but -- curiously -- there are others who should actually take it in the morning. How do you know when you should take it? If you have trouble falling asleep (especially if you want to stay asleep in the morning), you should take it at night. However, if you have no trouble falling asleep but you awaken too early in the morning, you should actually take it in the morning. (As an aside, you should also ensure that you have ample light exposure at the opposite time from when you take your melatonin.)

Now that you have figured out whether to take it in the morning or at night, how close should you take it to your desired bedtime (or after awakening)? If you decide to take it at night, you should take it 3 hours before your desired bedtime. Conversely, if you are falling asleep and awakening too early, you may take it 3 hours after waking.

Is It Safe to Take Melatonin Every Night?

As described above, melatonin is extremely safe. It is a hormone that your body makes naturally. Its use in a supplement form is also believed to be quite safe. It is not habit forming and you will not become “addicted” or dependent upon it. Therefore, if you find it to be helpful in improving your sleep, you may use it on a nightly basis without fear of adverse consequences.

Source:

Kryger, MH et al. "Principles and Practice of Sleep Medicine." Elsevier, 5th edition, pp. 916-920.

What Is Jet Lag?

By Brandon Peters, MD

Jet lag is a circadian disorder that transiently occurs after rapid travel across multiple time zones. It may be associated with other physical symptoms, including disturbed sleep. Learn about this common condition, its symptoms, and potential treatments.

If you have ever flown across a few time zones, you are undoubtedly familiar with the struggles of adjusting your sleep to the new hours. Why is jet lag, as it is called, so hard to tolerate and is there anything to be done?

First, it should be recognized that your body wishes to keep a regular sleep schedule. Certainly we are creatures of habit, and our bodies like when we go to bed and get up at the same time every day. Our biological clock, which is controlled by part of the brain called the suprachiasmatic nucleus, helps us to keep a regular schedule by releasing hormones on a regular pattern. This pattern is called a circadian—or “near day”—rhythm. Our sleep follows this same regular pattern.

When we disrupt the regularity of these cycles, our body treats us unkindly by making us sleepy or alert when we don’t wish to be. For example, if you were to go to bed three hours early tonight, you would have great difficulty falling asleep. However, if you fly from California to New York and crawl into bed at your normal bedtime, you are effectively attempting the same thing.

Causes

Rapid travel across multiple time zones leaves the circadian rhythms out of sync with the destination’s light-dark cycles. These rhythms affect sleep and wakefulness as well as metabolism, body temperature, and hormone release. It can take time for the internal circadian rhythm to be re-synchronized to external time cues. Jet lag is sometimes called desynchronosis, referring to the misaligned sense of time.

As a general rule, it is possible to adapt at an average rate of 1 hour per day. For someone who lives in California to fly to New York and cross three time zones, it would usually take 3 days to adjust to the new time zone. It is generally easier to travel westward and harder to travel eastward for most people.

Social jet lag may cause less intense symptoms and occurs in people who delay their bedtime and wake time by 1 to 2 hours on weekends and then have to correct as the work week resumes on Monday. This shift in the circadian timing may affect the start of the work week for several days.

Significance

In the new location, circadian signals may conflict with environmental and social cues in the context of jet lag. This may lead to a constellation of symptoms, including:

• Excessive daytime sleepiness

• Fatigue

• Insomnia

• Irritability

• Poor concentration

• Digestive problems (dyspepsia)

• Malaise (feeling unwell)

These symptoms may be disruptive and may be exacerbated by sleep deprivation, dehydration, sleep environment changes, and stress associated with travel.

Testing

The presence of the typical symptoms in the context of jet travel confirms the diagnosis without the need for further testing. In research, it is possible to measure an individual’s circadian pattern with tests that detect melatonin levels, often sampled from repeated saliva measurements. There are new blood tests also coming into clinical use that may identify the circadian rhythm.

Associated Conditions

Jet lag is most commonly associated with insomnia, defined as difficulty falling asleep or returning to sleep after waking. If insomnia occurs for less than 3 months, it is termed acute insomnia. As most people would be taking trips of a shorter duration than this, it could be grouped with other briefer disturbances of sleep. In some cases, jet lag may trigger a disruption that may evolve into a chronic form of insomnia.

Treatment

How can we counter our circadian rhythm when we travel? There are several techniques to reduce the effects of jet lag.

One solution would be to keep the same hours as our original time zone, going to bed and getting up based on the times at home.  his may not be the best way to enjoy our travels, especially if we fly great distances. An alternative would be to slowly adapt to the new time zone prior to leaving.

It may be possible to prepare the body gradually prior to departure by slowing adjusting bedtime and wake time to match the destination’s time. This can be done by adjusting our sleep by an hour for a week at a time. If we are crossing two time zones, the change can occur over two weeks. If traveling west, we would go to bed and get up an hour later for one full week. During the second week we would repeat the same, going to bed and getting up another hour later. If traveling east, we would go to bed and get up an hour earlier each week. If we can slowly adapt to the change, we will tolerate it better.  Unfortunately, unless the trip is quite lengthy, we wouldn’t be able to adjust the other way for our return home.This adjustment may be enhanced with properly time light exposure.

Light is one of the primary synchronizers of the circadian rhythm in sighted individuals. It may advance the timing of sleep earlier if the light exposure occurs in the 2 hours prior to the normal wake time or immediately upon awakening. Sunlight is best, but the use of light boxes or light therapy boxes may also have a role.

Beyond light, it may be important to address the symptoms that occur. Caffeine or strategic napping may relieve sleepiness. Other stimulant medications could also have a role. It may also be helpful to use hypnotic medications to aid sleep, including over-the-counter melatonin or prescription pills, such as:

• Zolpidem (Ambien)

• Eszopiclone (Lunesta)

• Zaleplon (Sonata)

• Ramelteon (Rozerem)

These medications to aid both wakefulness and sleep may ease the transition to a new time zone.

Conclusion

If you have a big trip coming up, you might plan ahead in how you can adjust your circadian pattern of sleep and wakefulness with some of the interventions outlined. This may help to optimize your experience while traveling to avoid the symptoms of jet lag.

Sources: 

Drake CL and Wright KP. Shift Work, Shift-Work Disorder, and Jet Lag. Principles and Practice of Sleep Medicine, 6thed., Philadelphia, Elsevier, 2017. pp.714-725.

American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed. Darien, IL: American Academy of Sleep Medicine, 2014.

Gooley JJ. Treatment of circadian rhythm sleep disorders with light. Annals of the Academy of Medicine, Singapore. 37(8):669-76, 2008 Aug.

Sack RL. The pathophysiology of jet lag. Travel Medicine & Infectious Disease. 2009 Mar;7(2):102-10.

Sack RL. Circadian rhythm sleep disorders: part I, basic principles, shift work and jet lag disorders. Sleep. 30(11):1460-83, 2007 Nov 1.

Srinivasan V, et al. Jet lag: therapeutic use of melatonin and possible application of melatonin analogs. Travel Medicine & Infectious Disease. 6(1-2):17-28, 2008 Jan-Mar.

How Long Should You Wait Between Screen Light Exposure and Going to Bed?

By Brandon Peters, MD

There is some concern that light exposure at night may affect sleep. What is the evidence that artificial light from screens contributes to insomnia? How long should you wait between screen light exposure and going to bed? Explore this relationship and some of the science behind the rationale.

The Science of Sleep

When considering how optimal sleep occurs, it is important to understand the two primary contributors: homeostatic sleep drive and circadian rhythm. Sleep drive is the fact that the longer you stay awake, the sleepier you will become. This is due to a chemical that gradually builds in the brain with prolonged wakefulness. This chemical is called adenosine. High levels of adenosine contribute to the onset of sleep. Sleep, at least in part, is a process of clearing this chemical away until consciousness is restored. Interestingly, caffeine blocks this signal and alcohol enhances it.

The circadian rhythm is the complement to this system. It is predominately an alerting signal that strengthens during the daytime and is largely absent overnight. It becomes strongest in the late evening hours, when we would expect to feel fairly sleepy. There is a lull in the mid-afternoon, which can contribute to a desire to take a nap then.  The circadian rhythm is based in our genetics, persisting without external influences. It contributes to sleep-wake propensity, hormone release, and metabolism. These processes are linked to the day-night cycle of light and darkness via the eyes.

How Light Changes Sleep

A simple anatomy lesson reveals the importance of light exposure to sleep. The eyes perceive light via the retina and pass this information along the optic nerves, extensions of the brain itself. These optic nerves receive input from each eye and cross at a location called the optic chiasm. Just above this is an area of the brain called the hypothalamus, a functional area that is integral to the control of the processes described above.

Within the hypothalamus lies the suprachiasmatic nucleus. This is the control center of the body’s circadian rhythm. It is the central pacemaker, coordinating the activities of all the body’s organs, tissues, and cells. Therefore, light input can be directly linked to the influence of many of the body’s processes.

In particular, light exposure can suppress the desire for sleep. Morning sunlight exposure may help to wake us, initiating the circadian alerting signal. In the same way, artificial light at night may affect the timing of sleep. It may contribute to insomnia in susceptible individuals, especially among those with a tendency towards being a night owl (called delayed sleep phase syndrome).

Preserving Darkness in the Night

What impact did Thomas Edison have on sleep in inventing the light bulb? As society has evolved, the potential disturbances have only expanded. With electricity, our evenings are filled with activity: televisions, computers, tablets, e-books, and phones that flicker light into our eyes. Moreover, the activity itself may keep us awake, shorten our total sleep time, and interfere with a relaxing buffer zone before bedtime. There is some evidence that light at night may adversely affect sleep.

Research has demonstrated that in the spectrum that we perceive as light, the blue wavelength is the one that can change our circadian rhythms. Therefore, industries have developed to supply filters and glasses that block the blue light. It seems that even short bursts of light, especially when of higher intensity, can impact sleep’s timing.

The sun is much more powerful in intensity compared to light from bulbs or screens. Full sunlight may be 100,000 lux in intensity while overhead lights may be just 1,000 lux. Therefore, a blast of sunlight at night could profoundly impact sleep. For susceptible individuals, artificial light may also negatively impact sleep onset and contribute to insomnia.

As a result, it is recommended that people who have difficult falling asleep may benefit from reduced light exposure prior to bedtime. Preserve the last 1 hour, and perhaps longer in highly sensitive individuals, as an electronics-free zone. Power off your screens, especially those that are closer to your eyes. It is also advisable to keep your bedroom free of electronics to preserve sleep. This is especially important advice for teens and children.

Why might some people not be bothered by light at night? The complement system, characterized by sleep drive and building levels of adenosine, could counteract these effects. If you are sleepy enough, you may not be bothered by the light. If you struggle with persisting insomnia, consider speaking with a sleep specialist to help determine ways for you to improve your sleep.

How Long Should You Wait Between Exercising and Going to Bed?

By Brandon Peters, MD

If you exercise late and have trouble falling or staying asleep, symptoms that characterize insomnia, you might wonder: How long should I wait between exercising and going to bed? Learn how much time should elapse after your exercise before bedtime and what symptoms you might experience if you don’t wait long enough before going to sleep.

The Relationship Between Exercise and Sleep

There are some theoretical impacts of exercise on sleep that you might take into consideration. Vigorous, aerobic exercise may increase your body temperature. An elevated body temperature may make it harder to fall asleep, as most of us prefer to sleep in a slightly cool environment. Fortunately, your body temperature is well regulated by sweating and once you are no longer sweating, it is likely mostly normalized.

In addition, exercise can release hormones such as cortisol and adrenaline (also called epinephrine). These hormones may rev you up, making it slightly harder to fall asleep. The good news is that they are likely not too disruptive and may actually enhance your sleep. In fact, when you are more active during the day, most people report sleeping better at night.

How Long to Wait Between Exercise and Bedtime?

In the past, sleep experts recommended avoiding exercise for 4 hours before going to sleep. Recently, this recommendation has changed. For many people who work, no exercise in the 4 hours before bedtime led too often to simply no exercise. Given the health implications, this is no longer suggested.

Instead, it is recommended that you stay active and exercise every day. It is not necessary to avoid exercising before bedtime. If you find that you are having difficulty getting to sleep on the nights you exercise right before bedtime, you might consider changing the timing of your exercise or your activity. In general, low-impact stretching and walking are great ways to unwind and may be done in the last few hours of the night without negative impacts on sleep.

If you continue to have difficult falling or staying asleep, speak with a sleep specialist about ways to help you to sleep better.

How Long Should You Wait Between Drinking Alcohol and Going to Bed?

By Brandon Peters, MD

If you drink alcohol late and have trouble falling or staying asleep, symptoms that characterize insomnia, you might wonder: How long should I wait between my last alcoholic drink and going to bed? Whether it is beer, wine, or hard liquors, learn how much time should elapse after your last drink before bedtime and what symptoms you might experience if you don’t wait long enough before going to sleep.

The Relationship Between Alcohol and Sleep

Alcohol has a dual relationship with sleep: it can make us feel sleepy initially while intoxicated and it can disturb our sleep as it wears off. The former characteristic led to alcohol’s frequent use as a nightcap, meant to assist in the transition to sleep. However, alcohol is a muscle relaxant. This can contribute to relaxation of the airway and worsen snoring and obstructive sleep apnea. In addition, alcohol has a short half-life, meaning that it wears off quickly. As the blood alcohol levels drop, decreasing through metabolism by the liver, this can contribute to sleep fragmentation and awakenings.

How Long to Wait Between Your Last Drink and Bedtime?

It is recommended that alcohol not be consumed in the last 2 to 3 hours before bedtime.

This timing actually varies somewhat based on your own rate of alcohol metabolism, which depends on the function of your liver, your body weight, ethnicity, and sex. It also matters how many servings of alcohol have been consumed.

As a general rule of thumb, it takes 1 hour for one serving of alcohol to be metabolized. Therefore, if you have a couple of drinks, you will want the last to be at least several hours before bedtime to avoid impacting your sleep.

If despite changing when you consume alcohol you continue to have difficult falling or staying asleep, speak with a sleep specialist about ways to help you to sleep better.

How Long Should You Wait Between Drinking Caffeine and Going to Bed?

By Brandon Peters, MD

Caffeine can be one of the great joys of life. If you have difficulty falling asleep, as occurs with insomnia, caffeine in coffee, tea, or soda pop may be the bane of your existence. You may wonder: How long should I wait between my last caffeine and going to bed? Learn how much time should elapse and what symptoms you might experience if you don’t wait long enough before going to sleep.

The Relationship Between Caffeine and Sleep

Good sleep occurs when it is properly timed to take advantage of both the body’s circadian rhythm and sleep drive. For most people, this means spending a prolonged period awake during the day (typically lasting about 16 hours) and attempting to sleep at night. In particular, the sleep drive may be affected by caffeine use.

The sleep drive is understood as the desire for sleep. It builds gradually with wakefulness due to the accumulation in the brain of a chemical called adenosine. Adenosine is a byproduct of metabolism and the longer we stay awake, the more it accumulates and the sleepier we gradually become. Caffeine directly blocks adenosine. This in effect reduces sleepiness and may contribute to difficulty falling or staying asleep after it is consumed. If you are extra sleepy, due to higher adenosine levels from poor quality or inadequate sleep, it may have little to no effect.

How Long to Wait Between Your Last Caffeine and Bedtime?

The million-dollar question is: How long should you wait between your last coffee or soda pop and going to bed? This is likely highly variable and is dependent on your individual levels of adenosine and tendency towards insomnia. For most people, caffeine should be avoided for 4 to 6 hours before bedtime. If you are highly sensitive, you might consider cutting it out after noon (or perhaps entirely).

Since there is some variability in its impacts, you could start by reducing it late and gradually move the deadline earlier as needed. Remember that it can be found in coffee, soda pop, tea, energy drinks, and even chocolate.

Caffeine may affect your sleep, but this may not be the only contributing factor. If you continue to struggle with insomnia, speak with a sleep specialist about other ways to improve your sleep, including participating in a cognitive behavioral therapy for insomnia (CBTI) program.

How Long Should You Wait Between Eating and Going to Bed?

By Brandon Peters, MD

If you eat late and have trouble falling or staying asleep, symptoms that characterize insomnia, you might wonder: How long should I wait between eating and going to bed? Whether it’s a midnight snack or simply your late dinner, learn how much time should elapse before bedtime and what symptoms you might experience if you don’t wait long enough before going to sleep.

The Relationship Between Food and Sleep

There are some foods that contain substances that may enhance sleep. For example, turkey and pork chops contain high levels of tryptophan, a substance that is metabolized by our bodies into serotonin and melatonin, sleep-inducing agents. In addition, some foods like cherries contain small amounts of melatonin. Other foods can be comforting, like a warm glass of milk, and this may help us to relax and mentally prepare for sleep. Alcohol in a nightcap can make us feel sleepy initially, but it wears off quickly and can actually fragment and disrupt sleep.

There is also some evidence that the timing of food can affect our sleep. It may prompt the release of insulin, which may have a role in shifting our circadian rhythm.

When Eating Undermines Sleep

Eating too close to bedtime can actually harm your sleep. This may be especially true if you eat too much or eat certain foods that induce heartburn. Lying down may cause reflux symptoms that cause burning chest discomfort and a bitter taste in your mouth. Spicy and acidic foods like citrus and tomatoes may be especially bothersome.

In addition, caffeine in coffee, tea, soda pop, energy drinks, and chocolate should be avoided. It blocks adenosine, a chemical that naturally makes us feel sleepy, and when consumed too close to bedtime may contribute to insomnia. It can also increase the need to urinate, which can lead to disruptive nocturia.

How Long to Wait Between Meals and Bedtime?

In general, it is recommended that you wait for 2 to 3 hours between your last meal and bedtime. This allows digestion to occur and the contents of your stomach to move into your small intestine. This will reduce the likelihood of heartburn symptoms. It may also reduce the chance of having sleep disturbances contributing to insomnia.

If after adjusting your meal times you continue to have difficult falling or staying asleep, speak with a sleep specialist about ways to help you to sleep better.

What Is Restless Legs Syndrome (RLS)?

By Brandon Peters, MD

Restless legs syndrome (RLS) is one of those conditions that sounds a little too strange to be true, but if you have ever laid down to fall asleep and felt an uncomfortable sensation of bugs crawling under your skin, you may be all too familiar with what RLS is. This condition may leave you kicking your legs as you fall asleep, but a better understanding of the disorder and its causes may lead to the treatment and rest that you need.

What is RLS?

RLS is a movement disorder that is characterized by unpleasant feelings in the legs associated with a need to move. The sensations (called paresthesias) may include aches, pulling, itching, or even the feeling of bugs crawling under the skin. The symptoms typically come on during periods of rest, especially at night, and are relieved by movement. They may make it hard to fall or stay asleep, resulting in insomnia.

There are four features that are used to diagnose RLS and these include:

1. An urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs.

2. The urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity such as lying or sitting.

3. The sensations are relieved by movement, such as walking or stretching, as long as the activity continues.

4. The sensations are worse during the evening or night.

Symptoms typically come on within 15 to 30 minutes of resting. In very severe cases, the problems may occur with any seated activity during the day, such as sitting in meetings or in a movie theater. This may lead to fidgeting, constant movement, or the need to kick or massage the legs to relieve the symptoms. Some people are so bothered by the symptoms at night that they will get out of bed.

Individuals with RLS may experience periodic limb movements of sleep (PLMS), which consist of sudden jerking leg movements involuntarily during sleep.

How Common is RLS?

Mild symptoms associated with RLS occur in 5 to 15 percent of the population. It seems to increase as we get older and occurs more commonly in women.

There are two types of RLS. The first, called primary (or idiopathic) RLS, has no clear cause and tends to run in families. The other type, called secondary RLS, occurs as the result of separate conditions, including iron deficiency, diabetes, pregnancy, and more.

Diagnosis and Treatment of RLS

RLS is diagnosed using the four criteria described above. A sleep study called a polysomnogram is not necessary but it may be helpful if the condition is resistant to treatment. It is important to identify any contributing causes so that these can be addressed appropriately. The treatment of RLS may include iron replacement, a combination of medications (including those that enhance GABA or dopamine), exercises, and other therapies.

Sources:

Allen, RP et al. "Restless legs syndrome prevalence and impact: REST general population study." Arch Intern Med. 2003; 163:2323.

American Academy of Sleep Medicine. "International classification of sleep disorders: Diagnostic and coding manual." 3rd ed Text Revision. 2014.

Hogl, B et al. "Restless legs syndrome: a community-based study of prevalence, severity, and risk factors." Neurology. 2005; 64:1920.

How to Choose a Sleep Doctor

By Brandon Peters, MD

If you are having difficulties sleeping, you may need a referral to a sleep specialist, but how should you choose a sleep doctor? There are certain characteristics that you should consider when selecting a specialist so that you get the appropriate testing and help that you need.

Who is My Sleep Specialist?

There are many individuals who will be involved in your care if you seek treatment for a sleep disorder. You will likely start your evaluation with your primary health care provider. This may result in a referral to a sleep specialist, most often a physician but sometimes a midlevel provider such as a nurse practitioner or a physician’s assistant working under the supervision of a physician. There may be ancillary staff involved as well, including polysomnographic technologists who do the sleep studies.

Sleep Doctor Training

Physicians who are certified as sleep specialists have many years of education. To become a doctor they graduate from college with a four-year degree and attend four years of medical school. They then complete a medical residency and a fellowship in sleep medicine. Many specialists can pursue a sleep fellowship, including: pulmonologists, neurologists, psychiatrists, otolaryngologists (ear, nose and throat specialists) and even general practitioners in family medicine, pediatrics, or internal medicine. Some physicians may dabble in sleep medicine, even if they do not have formal board certification.

Finding a Specialist with Credentials

No matter the specialty training, it is advisable to seek out a physician who is certified with appropriate sleep medicine credentials from the American Board of Medical Specialties. This implies that your doctor’s education has been verified and that they have been able to pass a board examination that tests their knowledge of sleep medicine. If you are to undergo additional sleep testing, you may want to find a sleep center that with accreditation from the American Academy of Sleep Medicine.

Selecting an Appropriate Center

Finding a sleep specialist can be a little intimidating, but once you have found a reputable provider, you may want to evaluate whether he or she can meet your needs. You may rely on friends or family for recommendations. It is also important to consider how your condition may be evaluated. You will want to select a center that can provide a thorough and appropriate evaluation, including any necessary testing such as:

• Home sleep apnea testing

• Polysomnography

• Multiple sleep latency testing (MSLT)

As part of this consideration, you may need to take into account cost as well as your insurance coverage. The resources available to you are always expanding and with a little research you should be able to find a reputable sleep specialist to meet your needs.

When College Classes Start Late, Students Sleep and Drink More — and Get Worse Grades

At first glance, it sounds like the perfect solution to the student sleep crisis: start college classes later in the morning so students can get more rest. In theory, better-rested students should have sharper focus, stronger memory, and improved academic performance. And in some studies of high schoolers, that’s exactly what happens.

But research on college students paints a more complicated picture. In some cases, later class start times are associated not with better grades, but with worse grades — despite students sleeping longer. The difference lies in what students do with that extra flexibility and how college culture shapes their habits.

The Promise of Later Starts

Sleep scientists have long known that young adults, like teenagers, have a natural tendency toward later bedtimes and wake times. In high school, early start times often force students to wake before their biological clock is ready, leading to chronic sleep deprivation.

College seems like the ideal place to fix this: if students can choose later classes, they can sleep closer to their natural rhythms. On paper, this should mean:

• More total hours of sleep

• Better mood and alertness in class

• Stronger academic performance

And indeed, surveys confirm that students with later classes often report getting more sleep — sometimes an hour or more extra compared to their peers in early sections of the same course.

The Paradox: More Sleep, Lower Grades

However, large-scale studies have found that college students who take later classes often have lower GPAs than those with earlier schedules. A notable example is a University of Washington and University of California, Santa Barbara analysis, which showed that students with later first classes went to bed later, slept later, and engaged in more late-night activities — including drinking — that negatively affected academic outcomes.

Here’s the paradox: while these students may sleep longer, the timing of their sleep and their overall lifestyle may be less compatible with optimal learning.

Why Later Starts Can Backfire in College

1. Shifted Sleep Schedule

When the first class isn’t until 11:00 a.m. or later, many students push bedtime into the early morning hours. They still get their 8 hours — but much of that sleep occurs in a delayed cycle that can interfere with morning alertness and alignment with the day’s demands.

2. More Time for Late-Night Socializing

A later start means less pressure to wind down early. Parties, bar nights, and dorm hangouts can stretch into the small hours, with students feeling less need to cut themselves off because they “don’t have to be up early.” This can increase alcohol consumption and reduce sleep quality, even if total sleep time is higher.

3. Increased Alcohol Use

Multiple studies link later first classes with higher drinking rates among college students. The reasoning is simple: fewer morning obligations lower the perceived cost of staying out late and drinking. Unfortunately, alcohol disrupts the second half of the sleep cycle, leading to lighter, more fragmented rest that’s less restorative.

4. Lower Structure and Discipline

Early classes can serve as an anchor for the day — a reason to get up, get moving, and start on assignments earlier. Without that anchor, some students procrastinate on both waking up and starting work. Evenings fill with social activity, while afternoons may be spent catching up on sleep or idly passing time, leaving less total time for focused study.

5. Delayed Learning Window

Cognitive performance has daily rhythms, and for many people, attention and memory are strongest in the late morning. Students who push their academic work later in the day may be working during a lower-performance window, particularly if they’re also staying up past midnight.

The Role of Personal Responsibility

The impact of late starts varies by student. Self-disciplined students who use the extra rest to fuel productivity may see benefits. But for those still adjusting to the independence and distractions of college life, later classes can feed into a cycle of:

• Staying up late → Sleeping late → Less time for daytime study → Increased evening socializing → Staying up late again

This cycle isn’t inevitable, but it’s common — especially among younger undergraduates.

Alcohol, Sleep Quality, and Academic Performance

Even moderate alcohol use before bed can reduce the proportion of deep slow-wave sleep and REM sleep. For students in the “late start” group who drink more frequently, the benefits of longer sleep may be offset — or erased — by poorer sleep quality.

Poor-quality sleep leads to:

• Slower information processing

• Reduced working memory capacity

• Weaker problem-solving skills

• More difficulty concentrating in lectures

When those effects stack up over a semester, grades can take a noticeable hit.

What the Research Suggests

Several key findings emerge from the research on this topic:

• Later first classes = later bedtimes. Students rarely use the extra morning time to get more early sleep.

• Alcohol use increases. The absence of morning obligations removes a deterrent to late-night drinking.

• Grades can drop. The combination of later bedtimes, lower-quality sleep, and lifestyle changes appears to outweigh the benefits of extra rest for many students.

One study even found that for each hour a student’s first class started later, their GPA was slightly lower — largely explained by differences in sleep timing and alcohol use.

Navigating the Trade-Off

This doesn’t mean late classes are inherently bad — but it does mean students and educators should be aware of the trade-offs.

For students:

• Treat a late start as an opportunity for better rest and earlier academic work, not just more social time.

• Maintain a regular bedtime, even on nights without early obligations.

• Watch for creeping increases in alcohol use and late-night activity.

For colleges:

• Offer education on sleep hygiene and the risks of excessive alcohol use.

• Encourage balanced scheduling that avoids both extremely early and very late first classes.

• Provide quiet study spaces in the mornings to encourage productive use of time.

The Bottom Line

Late-start college classes offer the promise of more sleep — and in theory, more alert, higher-performing students. But in practice, the freedom they offer can lead to later bedtimes, more drinking, and weaker daily structure.

For some students, that means worse grades, even with extra rest. The lesson isn’t that late starts are bad for everyone, but that their success depends on how students use the flexibility. Sleep isn’t just about quantity; it’s about timing, quality, and the lifestyle choices that surround it.

In the end, the best academic results come when students combine healthy rest with consistent habits — whether their first class is at 8:00 a.m. or noon.

This article was created using OpenAI’s ChatGPT on August 15, 2025 and it was personally reviewed and edited by Brandon Peters, M.D. to ensure its accuracy. This use of augmented intelligence in this way allows the creation of health information that can be trusted.

How Being in College Can Disrupt Sleep

For many students, starting college is like stepping into an entirely new world. There’s a new living environment, new social opportunities, academic challenges, and often a level of independence they’ve never experienced before. While these changes can be exciting, they can also wreak havoc on one of the most important — and underrated — foundations of well-being: sleep.

College life, for all its energy and activity, is a perfect storm of factors that make it easy to push bedtime later, cut rest short, and live in a cycle of fatigue. And while an occasional late night is part of the college experience, chronic sleep disruption can have serious consequences for health, mood, and academic success.

Why Sleep Is So Vulnerable in College

College students are technically adults, but their sleep needs remain similar to late teens: most still require 7–9 hours per night to function optimally. Unfortunately, surveys show that many college students average only about 6–6.5 hours on school nights, and they often catch up on weekends — creating an irregular schedule that throws off the body’s internal clock.

Several intertwined factors contribute to the disruption:

1. A Shift in Autonomy

In high school, many students had parents reminding them to go to bed, limiting screen time, and enforcing wake-up schedules. In college, that external structure disappears. Students set their own bedtime, often guided more by social plans or looming deadlines than by biological needs.

2. Irregular Class Schedules

Unlike high school’s consistent timetable, college schedules can vary wildly. One day might have an 8:00 a.m. lecture, while the next has the first class at 1:00 p.m. This inconsistency makes it tempting to stay up late on “light” days and sleep in, which can shift the sleep cycle later and make early mornings harder.

3. Academic Pressures and Workload

College courses often require more independent study, heavier reading loads, and larger projects. It’s easy for work to spill into late-night hours — especially when procrastination or underestimating assignments comes into play. For students balancing jobs or internships on top of classes, evenings may be the only time left to study, pushing bedtime further back.

4. Social Opportunities at All Hours

One of the joys of college life is the ability to hang out with friends whenever you want — whether that’s watching movies at midnight, attending campus events, or going out. Many social activities take place in the evening or late at night, creating a constant temptation to stay up past a healthy bedtime.

5. Living Environment

Dorms and shared apartments are rarely havens of quiet. Roommates may have different schedules, and communal living can mean noise in the hallways, shared bathrooms, and late-night conversations just outside your door. Even students who want to sleep may find it challenging in a bustling residence hall.

6. Technology and Screen Time

Laptops, smartphones, and gaming consoles are ever-present in college life. Not only can they consume hours that could be spent sleeping, but the blue light from screens delays the release of melatonin, making it harder to fall asleep. Students who scroll through TikTok or game until 2:00 a.m. may not feel sleepy even if they know they should.

7. Substance Use

Caffeine is a staple for many students — from morning coffee to late-night energy drinks — but too much, especially in the afternoon or evening, can make it hard to wind down. Alcohol, while sometimes making people feel drowsy, actually disrupts sleep quality and can lead to more nighttime awakenings.

8. Stress and Anxiety

The transition to college can be stressful: moving away from home, adjusting to new academic expectations, managing finances, and navigating social dynamics. Stress hormones like cortisol can make it harder to fall asleep, and worries often feel louder at night when everything is quiet.

The Consequences of Chronic Sleep Disruption

While the occasional late night won’t derail most students, consistently poor sleep can take a toll:

• Weaker academic performance: Sleep is critical for memory consolidation and focus. Sleep-deprived students struggle more with attention, problem-solving, and retaining new information.

• Mood issues: Chronic sleep loss increases the risk of depression, anxiety, and irritability.

• Physical health problems: Poor sleep can weaken the immune system, making students more prone to illness.

• Safety risks: Sleep deprivation slows reaction times, increasing the risk of accidents, especially for students who drive.

How Students Can Protect Their Sleep

While the college environment makes good sleep a challenge, it’s not impossible to maintain healthy habits. Small, consistent changes can make a big difference.

1. Set a consistent sleep and wake schedule. Even if classes start later some days, try to wake up within an hour of your usual time. Get 15-30 minutes of sunlight upon awakening.

2. Create a wind-down routine. Dim lights, read, or listen to calm music 30–60 minutes before bed.

3. Limit caffeine after early afternoon. Switch to water or herbal tea in the evenings.

4. Use screens wisely. Set a “screens off” time before bed or use blue light filters if you must use devices late.

5. Optimize your sleep environment. Earplugs, white noise apps, blackout curtains, and comfortable bedding can counteract noisy or bright dorm conditions.

6. Manage workload earlier in the day. Tackling assignments in the afternoon can free up evenings for relaxation.

7. Communicate with roommates. Agree on quiet hours and be respectful of each other’s rest needs.

The Role of Campus Support

Many colleges now recognize the importance of sleep for student well-being and academic success. Some offer workshops on sleep hygiene, quiet study spaces for daytime work, and counseling services for stress management. Residence hall staff may also help mediate noise issues or support students struggling with adjustment.

The Bottom Line

Being in college disrupts sleep for many reasons — from late-night socializing and irregular schedules to noisy dorms and heavy workloads. While the culture often treats staying up late as a normal part of student life, the reality is that chronic sleep disruption can sap energy, harm academic performance, and affect mental and physical health.

College students who learn to prioritize and protect their sleep gain a significant advantage: more focus, better grades, steadier moods, and greater resilience. In an environment where so much feels new and out of control, sleep is one area where smart habits can make all the difference.

This article was created using OpenAI’s ChatGPT on August 15, 2025 and it was personally reviewed and edited by Brandon Peters, M.D. to ensure its accuracy. This use of augmented intelligence in this way allows the creation of health information that can be trusted.

Poor Sleep Habits in College Undermine Grades

College students are often told that their academic success depends on studying hard, going to class, and getting involved on campus. But there’s another, often-overlooked factor that can make or break GPA: sleep.

In the college environment — with late-night socializing, heavy workloads, and the lure of endless streaming or gaming — healthy sleep habits are frequently the first casualty. Unfortunately, the cost isn’t just feeling tired. Poor sleep habits can directly undermine learning, memory, and overall academic performance.

Sleep Is Not Optional for Learning

Sleep is when the brain consolidates what it has learned during the day. Information from lectures, readings, and problem-solving sessions moves from short-term memory into long-term storage, a process that depends on uninterrupted sleep cycles.

When students cut sleep short, they lose deep slow-wave sleep and REM sleep — the two stages most strongly tied to learning and memory. The result:

• Weaker recall of key concepts on exams

• Poorer problem-solving ability in math, science, and technical courses

• Lower retention of foreign language vocabulary and grammar rules

• Reduced creativity in writing and design assignments

Studies (including my own research done when I was a college student as part of my senior honors thesis) have consistently found that students who regularly pulled all-nighters had lower GPAs on average than their peers who slept more consistently.

The All-Nighter Myth

Many students believe that staying up late before an exam to cram information is a smart strategy. In reality, the fatigue from lost sleep usually outweighs any benefit from extra study time. Sleep deprivation slows reaction time, clouds judgment, and makes it harder to focus — all of which can sabotage test performance.

Even worse, the information “learned” during an all-nighter is less likely to stick. Without the brain’s normal consolidation process during sleep, much of it fades quickly, leaving students with shaky knowledge for the next exam or assignment.

Inconsistent Sleep Schedules Hurt More Than Short Nights

It’s not just total sleep hours that matter — regularity matters, too. Many college students shift their bedtime by several hours between weekdays and weekends. This “social jet lag” throws off the body’s internal clock, making it harder to fall asleep and wake up on time when the week starts again.

Research has often found that irregular sleep patterns are strongly linked to lower GPA, even when total sleep time was adequate. Students with the most erratic sleep schedules perform worse academically than those with steady bedtimes, even if they occasionally got fewer hours of rest.

Other Ways Poor Sleep Habits Undermine Academic Success

1. Reduced Attention in Class
   Sleep-deprived students are more likely to zone out during lectures or miss important points. Even missing a few key details can affect understanding of complex topics.

2. Lower Motivation and Productivity
   Chronic fatigue makes it harder to start tasks, stay organized, and complete work on time — leading to last-minute scrambling and lower-quality assignments.

3. Weakened Immune System
   Poor sleep increases the risk of illness. Missing classes due to colds or flu means missed notes, lost participation credit, and less time to prepare for exams.

4. Emotional Strain
   Lack of sleep heightens stress, irritability, and anxiety, making it harder to collaborate on group projects or maintain the focus needed for sustained study.

Why Sleep Gets Shortchanged in College

Several factors make college life a perfect storm for poor sleep habits:

• Academic load: Students juggle multiple classes, each with its own deadlines.

• Part-time jobs: Evening or night shifts cut into rest.

• Social life: Dorm life, events, and late-night conversations keep bedtimes late.

• Technology: Smartphones and laptops are constant companions, and their blue light delays the body’s melatonin release.

• Perception of invincibility: Many students believe they can “catch up” on sleep later without consequences.

How Much Sleep Do College Students Really Need?

Most young adults need 7–9 hours of sleep per night to function at their best. Some may manage on 7, but regularly dipping below 6 hours can lead to measurable declines in attention, memory, and mood.

Strategies to Improve Sleep and Grades

While it’s unrealistic to expect perfect sleep in college, students can take steps to protect both their rest and their academic performance:

1. Aim for a consistent bedtime and wake-up time. Even a regular schedule with slightly less than ideal hours is better than wildly shifting times. Get 15-30 minutes of sunlight upon awakening with a regular wake time.

2. Limit caffeine in the afternoon and evening. Stimulants can delay sleep onset and reduce deep sleep quality.

3. Establish a wind-down routine. Dim lights, turn off devices 30–60 minutes before bed, and do a quiet activity like reading or stretching.

4. Use the bed for sleep, not study. This helps train the brain to associate bed with rest, not stress.

5. Be realistic about workload. Overcommitting to clubs, jobs, or activities can squeeze out rest.

6. Schedule study in daylight hours. This reduces the temptation to push work into late-night hours.

The Payoff of Better Sleep

Improving sleep isn’t just about feeling less tired — it has measurable academic benefits. Studies consistently show that students who get adequate, regular sleep:

• Score higher on tests and quizzes

• Submit higher-quality writing and projects

• Report lower stress and better mood

• Have higher overall GPAs

Better sleep also means fewer missed classes, more positive relationships, and greater resilience during stressful times like midterms and finals.

The Bottom Line

In the competitive academic environment of college, students look for every edge they can get. Ironically, one of the most effective “study hacks” isn’t another productivity app or late-night cram session — it’s simply getting enough sleep.

Poor sleep habits undermine grades by weakening memory, concentration, and problem-solving ability. The students who thrive aren’t the ones who sacrifice rest for work night after night; they’re the ones who respect the connection between healthy sleep and academic performance.

A solid night’s rest isn’t time lost — it’s an investment in sharper thinking, stronger learning, and higher grades.

This article was created using OpenAI’s ChatGPT on August 15, 2025 and it was personally reviewed and edited by Brandon Peters, M.D. to ensure its accuracy. This use of augmented intelligence in this way allows the creation of health information that can be trusted.