Sleeping Difficulty: Causes, Diagnosis and Treatments

Sleeping difficulty can cause us to feel unwell during the day. Possible causes and treatment options are given here.

What is sleeping difficulty?

Sleeping difficulties are a form of insomnia and usually represent sleep that is not considered restful. Those affected wake up more often at night and then have problems falling asleep again – or the following sleep is only superficial. It is often called a sleeping difficulty if the person has difficulty falling asleep again at night for more than 30 minutes over a longer period of time and the symptoms shorten the general length of sleep to less than six hours. Among the causes are, for example, various illnesses that have to be treated accordingly.

Problems with falling asleep and sleeping through are widespread. It is currently assumed that almost one in four (around 24 percent) suffer from such sleep disorders. The combination of difficulty in falling asleep and difficulty in sleeping through is also the most common. Women are more frequently affected, and sleep problems also increase with age. But: Not everyone automatically suffers from sleep disorders in old age, as Professor Dr. med. Ingo Fietze, head of the Interdisciplinary Sleep Medicine Center at the Charité, reveals: “This assumption alone has the effect of a self-fulfilling prophecy for some people. I consider this to be problematic, because 30 percent are gifted sleepers and remain so throughout their lives.”

In fact, many of those affected suffer from problems in falling asleep as well as sleeping through the night, less from only one of the two forms of sleep disorders. And usually the sleep disorder starts with one of these forms and then spreads into a combination over the months and years.

As we get older, we not only get wrinkles, our sleep also ages: we have a little less deep sleep, dream a little less, have more frequent short, nightly waking phases. But we don’t notice them – and continue to sleep. This is all quite natural and nothing to worry about. – Prof. Fietze

Symptoms: How do sleeping difficulties make themselves felt?

There are several ways in which sleeping difficulties can make themselves felt. Some patients fall asleep quite quickly, but then wake up prematurely and can’t find their way to sleep at all, so they lie awake until they have to get up or fall asleep again after one or two hours. Others wake up frequently, but can then fall asleep again. The sleep remains restless and light, with each turning around in bed or through other possible stimuli the affected persons wake up immediately again. This is what we call frequent nocturnal awakening and not the classic sleeping difficulty. If this happens every night, then the sleep disorders become a heavy burden.

The following symptoms speak for sleeping difficulty:

• Very early awakening
• Frequent short awakening
• Lying awake for a long time at night (more than 30 minutes), fixation on falling asleep again – which makes you even more awake
• Nervousness to the point of fear of not being able to sleep
• Tachycardia, skipped heartbeat
• Sleep is restless and light
• Increased sweating
• Urge to move, especially in the legs (restless legs syndrome, also associated with tingling or pain)
• Daytime tiredness and exhaustion
• Performance decreases, concentration disorders and lack of drive occur
• Increased irritability up to depressive mood
• Tensions
• Gastrointestinal complaints
• Night and/or early morning headaches

By the way, waking up at night itself is not the real problem with sleeping difficulties. In fact, most people wake up more often at night, in some cases up to 20 times. However, those affected do not usually notice this at all: they simply turn over to the other side and continue sleeping without being disturbed. On the other hand, people who have a real sleeping difficulty wake up completely and often cannot fall asleep again.

Sleep disorders often lead to a vicious circle

Particularly when you are in the middle of your professional life, sleep disorders can be downright torturous – because if you can’t find the rest you need at night, you will have difficulty in getting your full performance during the day. This increases both the pressure and the error rate, which can lead to professional problems. The resulting mental stress in turn increases the sleeping difficulties.

When should I go to the doctor for sleeping difficulties?

Healthy sleep is essential for a good, long life. But to suffer temporarily from sleep problems is not dramatic. However, if the sleeping difficulties last longer than four weeks and occur at least three times a week, the doctor should look for possible causes or offer tips and help.

Causes and risk factors for sleeping difficulties

The causes of sleep disorders, if not exogenous factors such as stress, noise, heat etc. or internal factors such as pain or migraine etc. are based on a dysbalance of sleep-wake hormones in the brain. However, there are a multitude of triggers:

• Lifestyle: frequent consumption of stimulants such as alcohol and/or cigarettes. Alcohol in particular often makes it easier to fall asleep, but at the same time prevents you from sleeping through the night.
• Nutrition: Especially opulent and fatty foods in the evening are heavy on the stomach and promote sleep problems. But even a completely empty stomach can disturb sleep.
• Lack of exercise: If you do not get enough exercise, you are not physically active. Regular endurance sports during the day can prevent this.

• Irregular sleeping hours: If you always go to bed and get up at the same time, you promote healthy sleep. Conversely, irregular sleeping times can keep us awake longer.
• Mental stress: Stress, tension, and brooding, for example from unexpressed conflicts, keep us awake. Not only do they cause sleeping difficulties, but in the long run they can also lead to mental illnesses such as depression or anxiety disorders.
• Diseases: Various diseases can cause sleep disturbances. These include obesity, sleep apnoea, various gastrointestinal complaints, cardiovascular diseases, an overactive bladder, psychological and neurological disorders such as dementia or the restless legs syndrome, or hormonal disorders such as an underactive thyroid.
• Poor sleeping environment: Poor indoor air, an unsuitable mattress, too high a temperature in the room or noise, such as the snoring of your partner, can also cause sleeping difficulties.
• Certain phases of life: During pregnancy and the menopause hormonal fluctuations take place which can promote sleep problems. Shift work and long distance travel can also affect sleep.
• Medication: Some medications such as high blood pressure medication or asthma medication can also cause sleeping difficulties.

It is precisely the variety of possible triggers that can make it take time to find the individual problem. But in order to really be able to eliminate the sleeping difficulties with a therapy, one should never give up early. Even a single night of poor sleep can considerably reduce attention and reaction speed, but in the long run the possible consequences of sleep disorders are, as already described, much more serious.

Treatment: Are sleeping pills for insomnia the solution?

Many desperate affected people are more likely to take sleeping pills because they are perceived as a quick and easy solution to the symptoms. In fact, the sleeping difficulties themselves can usually be controlled well with a sleeping pill, and for the severe sleeping difficulties they are also the only effective remedy. For mild or incipient sleep disorders, the focus should rather be on sleep hygiene and cognitive behavioural therapy.

Therapy: Which treatment helps against sleeping difficulties?

There are several ways to get rid of sleeping difficulties. If there is an underlying disease, the first goal of the therapy is to treat it and thus get the sleep problems under control. If no exact cause can be found, a combination of different components is often used:

• Behavioural or sleep therapy: Various techniques are used to help patients fall asleep and sleep through the night again. For example, relaxation techniques are used.
• Improving the sleeping environment: This includes a comfortable room temperature, fresh air and switching off noise or light sources. It is often advised not to have possible sources of blue light, such as televisions, in the room at all, as this can affect the production of the sleep hormone melatonin. Prof. Fietze takes a somewhat more relaxed view of this: “If watching television helps you fall asleep, that’s perfectly fine. And the effect of watching TV away from bed on melatonin is completely overestimated. Besides, melatonin is not one of the strong sleep hormones.”

• Drugs: In some cases, medication can be useful to accompany therapy, but long-term use should only be undertaken in close consultation with the doctor.
• Introducing sleep rituals: Particularly in the case of sleep disorders, it can help to choose a ritual to be performed every night before going to bed in order to create a calm basic mood. Whether one reads a few pages or prefers to practice Hatha Yoga is up to the individual: What works is allowed. Even patients with sleeping difficulties can benefit from evening rituals.
• Keeping to bedtime: The body is practically a creature of habit: it gets used to times of activity and inactivity. That is why it is always advisable to go to bed at the same time for sleep disorders of all kinds. By the way, it is not at all bad in itself if someone always goes to bed very early, says Prof. Fietze: “It is not dramatic if you get tired at 8 pm and wide awake at 4 am. Then you still have a healthy seven and a half hours of sleep, but an earlier sleep phase. But you can also adjust this phase again so that you can participate in social life. If necessary, help is available from specialists in sleep centers.”

• Stay calm: Whoever wakes up in the meantime should not immediately tense up and worry that they will certainly not be able to fall asleep again. Tension makes it almost impossible to fall asleep again. You should also keep your eyes off the clock, otherwise you will often be calculating in your head how long you could still sleep. And that puts additional pressure. However, it is also no longer a total taboo break when you use the watch.
• Light dinner: Those who do without dinner completely can suffer from sleep disorders just as much as those who eat a greasy pizza in the evening. A light last meal two to three hours before going to bed is ideal. Prof. Fietze, by the way, also allows the popular bedtime snack: “Instead of going to bed hungry, it is better to eat a snack. The food you eat should be warm, but also sweet, or rich in carbohydrates. Nibbling a piece of cheese is not so good, because proteins keep you awake.”
• Avoid stimulants: The quality of sleep can suffer considerably from alcohol, cigarettes and the like. If you suffer from sleeping difficulties, it is best to avoid them altogether or at least limit your consumption considerably.

What if nothing works anymore and I’m just lying wide awake in bed?

“Get up, read, knit. “Just do something relaxing. The sleep will come back on its own. Or watch a preferably unexciting nature documentary or boring talk shows,” advises sleep expert Prof. Fietze.

You can get even more help for a good night’s sleep and against sleep disorders in our article “sleep tips“.