![]() Is your room dark enough when you’re trying to get to sleep? In theory, darker rooms mean better sleep. Sleep hygiene means creating an environment conducive to sleep. My algorithm for treating initial or middle insomnia is: sleep hygiene, calming exercises, therapy, supplements, medication. Terminal insomnia that isn’t depressive or circadian can probably be treated as middle insomnia that occurs very late in the night/morning. Most of this page will assume you have initial or middle insomnia. If it’s not depression, it might be a circadian issue consider changing the time you go to sleep or taking melatonin. This pattern is absolutely typical of depression, and should be considered a depressive symptom until proven otherwise (if you’re not feeling depressed, then you’ve proven otherwise). If this is new and makes you feel tired, then it might be a problem. If you’ve always done this and feel well-rested, it’s not a problem – it just means that you don’t need much sleep. Terminal insomnia means you wake up very early in the morning and can’t get back to sleep. But if you’ve suddenly developed this pattern and find it’s incompatible with your routine, it’s probably fair to try to see if you can quash it again. If you’ve gradually developed this pattern, it might be worth seeing whether you can live with it. If you’ve always had this pattern and it doesn’t bother you, there’s no reason to try to “cure” it. There’s a lot of evidence that people in pre-industrial societies practiced “biphasic sleep” – they naturally slept for about four hours, woke up for an hour or so, then went back to sleep for another four hours. There’s some debate about whether or not this is natural. Middle insomnia means you wake up in the middle of the night and have trouble getting back to sleep. Initial insomnia means you can’t get to sleep. If none of these apply to you, but you still can’t get to sleep, then you might have insomnia. This is a hard problem with no good answers, but it isn’t insomnia. Other people do this because they feel like they have no free time and the only way to get an hour or two to themselves is to cut into their sleep. – Do you stay up until long past your bedtime doing exciting things like browsing the Internet and playing video games, then have little trouble getting to sleep once you finally turn out the lights? If so, you don’t have insomnia, but you might have a video game addiction. If you can’t stop alcohol for a month to test if your sleep problems improve, you may have alcoholism and not insomnia. Try stopping alcohol for a month and see if your sleep problems improve. – Do you drink lots of alcohol, especially around bedtime? If so, the alcohol might be interfering with your sleep. I don’t have a great pharmacological explanation for why this should be, but I recommend that you experiment with quitting coffee before trying anything else to resolve sleep issues. – Do you use stimulants – coffee, Adderall, Ritalin, etc? Are they interfering with your sleep? Are you sure they’re not interfering with your sleep? I’ve had so many patients who swear that their coffee doesn’t affect their sleep because they only drink it in the morning and it’s out of their system by the early afternoon – and then as soon as they stop drinking coffee their sleep problems miraculously resolve. If so, you might have a circadian rhythm disorder, not insomnia, and you should try a circadian protocol of melatonin. ![]() These people might sleep fine if they were allowed to set their own hours, but aren’t able to handle the schedule imposed by a 9 to 5 job. Other people might naturally feel sleepy at 7 PM, but they force themselves to stay up until midnight, at which point they aren’t tired anymore. – Do you have a time you could easily sleep, but your schedule makes it impossible for you to sleep then? For example, some people naturally feel wide awake until 5 AM, then naturally start feeling sleepy around that time. Once you treat the anxiety, you’ll be able to sleep just fine. ![]() – Do you stay up all night ruminating and being anxious? In fact, are you anxious and ruminating all through the daytime too? If so, you might have an anxiety disorder, not insomnia per se. Before I try anything fancy for insomnia, I ask patients to check if they have any of the following simple problems: You can always brute-force the treatment of insomnia with sleeping pills, but it’s usually safer and longer-lasting to figure out the underlying problem. Insomnia is a “wastebasket diagnosis” – it’s what we call sleep problems if we don’t have a good explanation for them. ![]()
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