'I'm Tired But I Can't Sleep'

Q. For nearly two months I've been waking up in the middle of the night at the same time. I'm usually able to get back to sleep, but sometimes it takes an hour or more. I've tried turning down the heat and using a fan but it’s not helping. What can be causing me to wake up in the middle of the night?

A. The insomnia you're experiencing may be caused by a variety of factors. Sometimes a life event like a job loss or stress at home can contribute to sleepless nights. Depression or anxiety may also play a role in early morning awakenings. Certain medical conditions, as well as starting a new medication, might be factors related to disruptions in your sleep. It's also possible you are doing something that may be interfering with your sleep, such as drinking caffeinated products too close to bedtime. Since your sleep issues have been ongoing, you should visit your family physician before you experience physical and emotional tolls on your quality of life.

Symptoms of insomnia

Many people experience occasional sleepless nights, but when the problem extends for three weeks or more (and in your situation, two months) it's generally referred to as chronic insomnia. No matter what the length of time, symptoms of insomnia include the following:

• Difficulty falling asleep
• Difficulty staying asleep
• Restless or poor quality of sleep
• Early morning awakening with difficulty getting back to sleep

It's also important to know that insomnia is more common as we age, and affects women more often than men.

Sleep disruptors

When you visit your doctor, he or she will try to determine the cause of your interrupted sleep. Consider the following questions:

• When did the problem first occur?
• Have you been ill lately?
• Are you taking any new prescriptions or over-the-counter medications?
• Are you taking any herbal or dietary supplements?
• How much sleep do you usually get?
• Do you snore?
• Does your sleep schedule change?
• Are you beginning to worry about your ability to sleep?

Additionally, your doctor may ask you to keep track of your sleeping patterns over a two-week period of time. This would include the time you went to sleep and woke up, whether it was a continuous sleep or interrupted (need to urinate, shortness of breath, restlessness), as well as how you felt upon awakening (tired, cranky, refreshed).

Next, your physician may examine you for physical health concerns, while also taking care to assess your level of stress or depression.

Common sleep disruptors

In general, the causes of sleep disruptors can be categorized as temporary situations, medical concerns, prmiary sleep disorders, or psychiatric concerns. 

Temporary situations:

• Shift work
• Pregnancy
• Exercising before bedtime
• Environmental factors: too hot, too cold, too much light, too much noise
• Lifestyle factors: too hungry, too full, too much caffeine, too much alcohol
• Short-term illness such as sinusitis, bronchitis or toothache
• Short-term medications such as cough suppressants, decongestants and steroids (prednisone, others). Even medications recently prescribed for long-term use may cause difficulty with sleep and should be discussed with your doctor and pharmacist.
• Travel with or without a change in time zones
• Withdrawal symptoms from alcohol and/or drugs
• Smoking a tobacco product before bedtime
• Abrupt cessation of medications used for sleep and pain
• Poor sleep hygiene (eating late at night, completing work assignments while in bed, watching television in the bedroom)

Medical concerns:

• Respiratory difficulties such as asthma or shortness of breath
• Cardiac conditions including chest pain, congestive heart failure and irregular heart beat
• Musculoskeletal or rheumatologic conditions such as fibromyalgia, arthritis, and generalized pain
• Gastrointestinal symptoms from conditions such as gastroesophageal reflux disease (GERD), peptic ulcer disease or colitis
• Frequent urination due to urinary tract infection, certain medications (diuretics), uncontrolled diabetes, prostate enlargement, kidney stone, others
• Neurologic conditions such as Parkinson's disease, Alzheimer's, or brain injury

Primary sleep disorders:

• Obstructive sleep apnea
• Periodic limb movement disorder
• Restless leg syndrome
• Idiopathic insomnia (unknown cause that begins in childhood and continues into the adult years)
• Narcolepsy
• Circadian rhythm disorder

Psychiatric conditions:

• Anxiety
• Stress due to a temporary or permanent situation (economic worries, loss of a loved one, family or relationship concern, etc.)
• Bipolar disorder
• Depression

Depression is pretty conmmon, and while you did not say if your life situation has changed, the sudden alternation in your sleeping pattern may be an early clue to depression. As discussed by The National Institute of Mental Health, other signs of depression include the following:

• Unexplained irritability or restlessness
• Persistent aches and digestive problems that don’t seem to improve with treatment
• Feelings of hopelessness and guilt
• Lack of joy or interest in hobbies or activities that used to bring you pleasure
• Thoughts of suicide, withdrawing from friends and family
• Unexplained change in weight
• Loss of energy and a general type of “empty” feeling or sadness

If you identify with the feelings and changes listed above, please speak with your physician.

Looking for daytime clues

While brief or periodic insomnia may not cause you to fall asleep during the day, any type of regularly occurring sleep loss has the potential to impact your ability to stay awake. Because of this concern, your physician may ask you to complete a survey that may include the Epworth Sleepiness Scale. This is a general questionnaire to assess your likelihood of falling asleep during common and everyday situations such reading a book, attending a business meeting, or even while trying to maintain a conversation. If the result clues the physician in to a potential problem, it may indicate that a medical or primary sleep disorder like sleep apnea is contributing to your sleeping difficulty, and a referral to a sleep specialist may be advised.

Fortunately, many factors that affect your ability to get a good night of sleep can be addressed. The key is identifying what they are and taking measures to improve the situation.

For further information, visit your physician and check out the information available at Sleep Education, the National Sleep Foundation, and the Cleveland Clinic.

Find all articles by Dr. Rob.

Read More About Sleep Disorders on MSN Health & Fitness:

• Reality Check: Sleep Apnea
• Sleep and Seniors: Insomnia Isn't Inevitable
• Sleep: Your Body's Means of Rejuvenation
• Join the Discussion: Sleep Disorders Message Board

Do you have a health question you'd like to ask Dr. Rob? Send e-mail to experts@microsoft.com. Please include Ask Dr. Rob in the subject line.

Each of our experts responds to one question each week and the responses are posted on Mondays on MSN Health. We regret that we cannot provide a personalized response to every submission.

Robert Danoff, D.O., M.S., is a family physician and program director of The Family Practice Residency, as well as the combined Family Practice/Emergency Medicine Residency programs at Frankford Hospitals, Jefferson Health System, Philadelphia, Pa. He is the medical correspondent for CN8, The Comcast Network, a regular contributor to Discovery Health Online and a contributing writer to The New York Times Special Features. (Read his full bio.)