Hans Christian Andersen’s classic fairy tale “The Princess and the Pea” is about a young regal girl whose sleep is disrupted by a tiny legume tucked beneath a stack of twenty mattresses. Her heightened sensitivity was said to be characteristic of royalty. If so, it may be that we all become royal in our sleep.
The dark and quiet of night coupled with the vulnerability inherent in sleep leave us all with heightened sensitivity. We become more aware of sounds, scents, and signals from within such as heartburn, leg kicks, or achy joints. Of course, we are also more sensitive to bodily needs related to temperature, thirst, hunger and, most notably, the need to urinate.
Frequent nighttime urination or nocturia is a problem that affects millions. Defined as a chronic need to urinate at least two or more times during sleep, nocturia is common among men and women of all ages but increases to an estimated 50-60 percent of those older than 60. The associated sleep disruption can have a deleterious effect on one’s health, mood, and productivity.
People with insomnia frequently blame their bladders for their inability to sleep through the night. Although bodily signals are more difficult to sense when we are in deep or REM sleep, once we are awake, they can seem amplified against the stillness of night. Consequently, we may be more reactive to relatively small amounts of urine in our bladders than we are by day.
What really wakes us up?
Our princess didn’t know about that damned pea — she just couldn’t sleep.
Some of our nighttime awakenings are certainly due to an insistent bladder. But we often mistakenly blame the bladder when the real culprit is uncertain.
Beyond more obvious bumps in the night, a number of common medical and lifestyle issues can quietly but persistently disrupt our sleep.
Let’s call these things sleep snipers, as they awaken us then quickly slip back into hiding, leaving us unsure of their presence. They include GERD (gastroesophogeal reflux), periodic limb movements (PLMD), side effects of medications, and a number of breathing difficulties. And as we we know, the residual effects of excessive alcohol and caffeine consumption can also silently disrupt our sleep
REM sleep or dreaming can also act as a sleep sniper. Where nightmares might represent an all out attack, more subtle but challenging dream experiences can also disrupt our sleep, slip out of memory, and leave us baffled as to why we’re up. Most of what sleep specialists call wake after sleep onset or WASO occurs in the latter part of the night when we are in our most protracted periods of REM sleep. We may be especially sensitive to emotions that arise in our dreams.
What really keeps us up?
Hamlet’s soliloquy, "To sleep per chance to dream…," reminds us that resistance to dreaming might also contribute to keeping us awake. In reality, what wakes us up at night is not necessarily what keeps us up. Unless we are urinating numerous times or for impossibly long stretches, our bladders are not to blame. It’s perfectly normal to get up, empty our bladders, and then slip easily back to sleep.
If we can’t, it raises important questions about our psychological posture toward nighttime awakenings. What do we believe about these? Whatever the cause of our awakenings, they are commonly exacerbated by dysfunctional beliefs that overly pathologize them. Examples include the expectation that we consistently sleep through the night, the thought that occasional awakenings mean we have insomnia, and the idea that our sleep loss will quickly erode our health. It’s a slippery slope.
What can I do about these nighttime awakenings?
Begin by ruling out possible medical sleep snipers through a discussion with your PCP. Symptoms of actual nocturia can sometimes be managed with lifestyle changes such as curtailing the intake of fluids in the evening and reducing the consumption of caffeinated and alcoholic beverages. Recent research found that 2mg of melatonin prior to bedtime significantly reduced the disorder in older men and women. If lifestyle interventions are insufficient, your doctor may suggest medication.
It may also be helpful to actively work on befriending dreams.
Healthy dreaming supports learning, memory, and emotional health.
Attending to our dreams can be invaluable to our personal and spiritual development. Just as challenging experiences are a part of a every good life, challenging or bad dreams are a part of good dreaming. It’s important to listen.
Lastly, shift your attitude toward nighttime wakefulness as well as your strategies for getting back to sleep. Research over recent years suggests that being awake for a stretch in the middle of the night might actually be normal. Historically, when our sleep was not constrained by delayed bedtimes and enforced rising times, there was little pressure to sleep efficiently through the night.
Actively trying to get back to sleep inadvertently tethers us to our waking self, which by definition cannot sleep. From the perspective of the waking self, falling asleep is an accident. And learning to wholeheartedly surrender makes us accident-prone.
In the end, if you’re as lucky as our princess, maybe you’ll discover that the problem is, in fact, a pea or pebble in your mattress. An easy fix.