Q: What's the best way to fall back asleep once I've woken up in the middle of the night?

One of the most common frustrations I hear from patients who deal with insomnia goes something like this: "I look over to see my husband (or wife) asleep , and I'm wide awake. It makes me absolutely crazy." The truth of the matter is that just as each of us have different color hair, sizes, and shapes, so to do each of us differ in the way we sleep. When my patients tell me that they're bothered by middle-of-the-night awakenings, my first goal is to help them search for an identifiable and fixable cause. Is someone waking up nightly to urinate because they're drinking too much in the evenings? Is snoring from their bed partner disruptive? If a cause is evident, fix it!

Often, people wake in the middle of the night for no identifiable reason, though.

Many times, patients will tell me that the second they're awake, they can't stop thinking about work stresses, relationship problems, or whatever other issues might be weighing on their minds. I'll often hear expressions that go something like, "I can't stop the gears in my mind from spinning."

Although every person has a "different flavor" in terms of why they wake up and what keeps them awake, everyone can benefit from some basic rules and guidelines to follow.

Avoid activities that promote wakefulness. A common problem behavior I hear from patients includes reaching for that iPhone or Blackberry and emailing in the middle of the night. I've had several patients who nightly use their PDA to log in to their Facebook account and instant message with their other night owl friends. In addition to the activity itself, which activates us and keeps us awake, the bright light from these devices, held in the dark just a few inches from our eyes, also is disruptive to our sleep-wake cycle. Sometimes, if my patients can't stop reaching for their iPhone at 4 in the morning, I'll suggest that they keep it away from the bed- maybe even in another room.

Virtually any activity you can think of, I've had patients report to me that they do in the middle of the night. Eating, playing video games, exercising, and TV and computer. What each of these and others have in common is that they get our internal motor going. Remember, no one would ever try to fall asleep at the beginning of the night with their heart rates up, adrenaline pumping, and a full stomach. Yet scores of people try to do just that during their middle-of-the night awakening.

When we wake up and have a difficult time going back to sleep, we should ask ourselves: Is what I'm about to do going to wake me up more? Is it going to make it harder for me to eventually fall asleep? If the answer to either of those questions is yes, then try not to do it. Instead we should focus on relaxing and soothing activities that will facilitate our minds and bodies to reenter sleep. Try to make a list of acceptable middle-of-the-night activities, and, similarly, make a list of off-limit behaviors. Most of these will seem common-sense once you put them on paper. Whatever activity you choose should be conducive for you to eventually return to sleep.

If you're lying in bed for a while awake and sleep seems to be eluding you, it's all right to get up and do something else for a little while until you feel sleepy again. The last thing you want is to force yourself to remain in the bedroom awake and frustrated hour after hour and night after night.

Finally, if disrupted sleep with persistent and recurrent night time awakenings is your usual pattern, discuss this with your doctor or a sleep medicine specialist. Recurrent awakenings may be a sign of an underlying medical condition that needs to be addressed. Even if the problem is truly "just" insomnia, there are very effective treatments that may include cognitive-behavioral therapy and/or medications.


Roy Artal, M.D. F.C.C.P., is a board-certified sleep medicine specialist and medical director of Tower Sleep Medicine in Los Angeles. Raised in L.A., Dr. Artal received his undergraduate degree with honors from the University of Southern California (USC) in 1991, where he was the recipient of the Phi Beta Kappa Undergraduate Achievement Award, and his medical degree from the University of California, Los Angeles, School of Medicine (UCLA) in 1995. Following medical school, Dr. Artal completed his Internal Medicine Residency training at Cedars-Sinai Medical Center, Los Angeles, and his Pulmonary and Critical Care Fellowship training at the Cedars-Sinai-UCLA Combined Fellowship Program, serving as the Chief Fellow during his senior year. He is double board certified in sleep medicine by the American Board of Sleep Medicine and the American Board of Internal Medicine, is a Clinical Instructor of Medicine at the UCLA David Geffen School of Medicine, and is the Medical Director of Tower Sleep Medicine, a sleep disorders center in Los Angeles. Dr. Artal has been in private practice in Southern California since 2001.