Why do you feel worse at 3am?

Transcript

Welcome to the sofidex Health Drive podcast series. Today we are talking about an hour most of us know better than we would like, somewhere around three in the morning, when you wake for no reason and cannot get back. You probably know how it goes. You surface in the dark, check the time, and within minutes something ordinary has grown enormous, so a bill becomes ruin and a headache becomes a diagnosis. And by the time the alarm goes, most of it has shrunk back to its normal size.

The advice on offer tends to be that it is just stress, or a list of things to stop doing before bed, and neither of those tells you why it happens at that hour in particular. And waking in the night is far more ordinary than it feels, because healthy adults wake around five times a night between sleep cycles and forget almost all of it by morning. So the question is not how to stop waking up. It is why the same thought weighs so much more at three than at nine, and whether that weight is telling you anything true.

We will follow one person through a bad month of nights, and look at what a sleep cycle is, what your body clock is doing in those hours, and why mood runs on a schedule. Then we get to what helps, starting with the clock by your bed, and to when it is worth seeing a doctor.

If you were awake last night, that is usually a feature of how sleep works rather than a fault in you, and we will be clear about the few times it deserves more attention. One thing before we start. This is health information, not medical advice, and nothing in it is a substitute for talking to your own doctor about your own treatment. What we can tell you is where all of it came from — 13 published sources, all listed with the episode. I want to do this one through a single person again, if that's alright. Not a real patient. Somebody we're making up, so we can follow him properly. Call him Rob. He's forty-four, he's a joiner, and he runs a small firm with two lads working for him. And most nights for the last month, he's woken up at seven minutes past three. He knows it's seven minutes past, because he checks his phone. And then it starts. A quote he gave last week that he's now sure was too low. The van's due its MOT. The VAT return. And a headache he had on Tuesday, which by twenty past three has become something he doesn't want to say out loud. Then the alarm goes at half six, and it's all just Tuesday again. A quote. A van. A headache.

And that's the thing I want to spend this episode on. Not the waking. The fact that the same three worries are unbearable at three and ordinary at half six. Nothing about the quote changed in those hours. Nothing about the van. So something changed in Rob. And you can say quite a lot about what, because a fair amount of it has been measured. Some of it's well established. One important piece is still a hypothesis, and I'll flag it when we get there. But by the end, I want Rob to have a plan for tonight. Not a list of things to feel guilty about.

Start with the waking though. Because Rob's convinced that's the problem. He used to sleep straight through, he says. Eight hours, like a log. Now he thinks something in him is broken.

He almost certainly didn't sleep straight through. Nobody does. Sleep isn't one long block. It's a series of cycles, and you come up near the surface at the end of each one. The textbook figure is four to six cycles a night, each one averaging about ninety minutes. And at the top of a lot of those cycles, you briefly wake. Properly wake. You might turn over. Pull the duvet back. And then you go down again and remember none of it. So the Rob who slept like a log was waking up too. He just wasn't keeping score.

How many times are we talking? Because briefly waking sounds like it could be once a night, maybe twice.

More than that. There's a small study from West Virginia that starts from the figure the field works with. Healthy adults wake between each sleep cycle approximately five times a night, and generally don't remember all of those wakings in the morning. And what that study actually measured was the other side of it. How long you need to be awake before your memory bothers to keep the waking. On average, it came out at about four minutes. Some people needed much less. And some needed much more. But it's the shape that matters for Rob. A waking of a few seconds is gone by breakfast. One that lasts several minutes usually isn't.

So waking at three isn't new for him. What's new is that he's remembering it.

That's my best guess for Rob, yes. And notice what that means. The trigger isn't the waking. It's that he stays awake long enough to lay down a memory — and the thing keeping him awake is the worry. So it's a loop. He wakes like he always has. Something catches. He's still awake at minute four, so he'll remember this one. And because he remembers it, he goes to bed the next night expecting it. There's one more ordinary reason, too. And this gets more common with age. A big meta-analysis of healthy sleepers found that time spent awake after first falling asleep goes up as adults get older. Rob at forty-four doesn't sleep like Rob at twenty-four. And that's not a fault in him.

Okay. But why three? Why not one, or five? Rob's very specific about it. It's always round about three, give or take a few minutes.

Partly arithmetic. If Rob's asleep by eleven, three o'clock is four hours in. With cycles of about ninety minutes, that's two or three cycles in. So three is simply one of the moments he's closest to the surface. And then there's the body clock. Your core temperature runs on a daily rhythm, rising and falling across the whole day and night. A review on insomnia and body temperature puts it like this: sleep is most conducive in the temperature minimum phase, and is disrupted in a zone following that phase. So there's a stretch of the night where sleep holds well. And a stretch just after it where sleep turns fragile. The exact clock time differs from one person to the next. But the shape doesn't. And the same review notes that people who wake early and can't get back tend to have that whole temperature rhythm running early.

So he's waking in the fragile bit. Fine. But that still doesn't explain why the van turns into a catastrophe. Plenty of people wake at three and just roll over.

No. And this is the part of the story I find genuinely strange. Because mood itself runs on a clock. Not just tiredness. Mood. There's a review called The Mind after Midnight that pulls together what's known about people who are awake during the biological night. It puts positive mood at its lowest between about one and four in the morning. And negative mood, it says, stays fairly steady through the day, then peaks sharply in the night. So Rob is waking at the very hour when his capacity to feel okay about things is at its daily low. And his capacity to feel bad about them is at its high. Same quote. Same van. Different instrument reading them.

Hang on, though. Is that just because he's tired? Anyone's grumpy when they've been woken up in the middle of the night.

Fair objection. And it's partly right. Being awake at night and being short of sleep get tangled together, and the research doesn't always pull them apart. But the mood rhythm isn't only tiredness. It's tied to the body's own clock time. And there's a second thing on top. The front of the brain, the part that does planning and judgement and keeps things in proportion, is at its weakest then. The review's phrase is that during the biological night, cognitive capacity and mood regulation are diminished. And it describes what that tends to produce. Ruminative, self-referential thinking. Fear. Anxiety. Hopelessness. Which is a fairly exact description of Rob at twenty past three.

So the worry feels more true at three. But it isn't actually any more true than it was at teatime.

That's it. And I think that's the most useful single sentence for Rob. At three in the morning, the thing measuring how bad things are is miscalibrated. It reads high. Every time. It's like a set of bathroom scales that adds a stone overnight and quietly takes it off again by morning. And you wouldn't start a diet because of the reading in the dark. And there's another reason it reads high, which is just practical. At three, Rob can't do anything. He can't ring the customer. He can't book the van in. He can't ask anyone about the headache. A worry you can act on turns into a task. A worry you can't act on just goes round.

And he's on his own with it. Jen's asleep next to him. He's not going to wake her up over a van.

Right. And that's not a small thing. There's a striking line in that same review. In American data, population wakefulness reaches its lowest point at around three in the morning. Fewer people are up then than at any other hour. So Rob isn't imagining the loneliness. He's awake at the emptiest hour of the whole day. Nobody to text. Nobody to say that quote's fine, mate, stop it. And the brain does with that silence what it does with any silence. It fills it. Usually with whatever's least finished.

Is there anything he can do with that, in the moment? Just knowing the instrument's off. Does that actually help, or is it the sort of thing that sounds clever in daylight?

It helps more than you'd think, as long as it's short. I wouldn't want Rob arguing with the worry at three. Because he'll lose. Arguing is exactly the kind of thinking that front part of the brain does badly at that hour. But he can label it. One line, in his head. This is the three o'clock version. Not, the quote's fine. Not, the headache's nothing. Just, this is the three o'clock version, and I'll look at it properly later. That's a much smaller job than solving it. And it's a job a tired brain can actually do.

Okay. So let's get to the phone. Because you flagged it right at the start. He checks the time. Every time. Three oh seven. Then twenty to four. Then quarter past four.

The phone's doing more damage than he realises. There's an experiment on almost exactly this. People with insomnia were told to watch either a clock or a display that wasn't a clock while they tried to get to sleep. The clock-watchers worried more. They took longer to fall asleep. And they overestimated how long it had taken them by more than the others did. Now, that was at bedtime, not in the middle of the night, so I'm carrying it across. But the mechanism's the same. Every time Rob sees the time, he does a sum. Four hours till the alarm. Three and a half. Three. And every sum is a little jolt of threat, right when he needs the opposite.

So what does he do instead? Just not look? Because I know what I'd do. I'd lie there wondering what time it was.

Turn it round. Literally. Phone face down, across the room, alarm set, done. If there's a clock, turn it to the wall. The point isn't willpower in the moment. It's making the information unavailable, so the sum can't happen. And here's the part people don't like. Knowing the time at three isn't useful. Because it changes nothing he can do. If it's three, he's in bed. If it's four, he's in bed. The only thing the number adds is the arithmetic. And the arithmetic is what turns being awake into being anxious about being awake. Which is a much worse place to try and sleep from.

And it's not only the clock on there, is it. Rob admits that once he's got the phone in his hand, he ends up reading his emails.

Which is the whole problem with the phone, in one sentence. It carries the clock, the inbox and the search engine. Three of the worst things a person can meet at three in the morning. So the clock does the sum. The inbox hands him a customer he can't reply to. And the search engine is where a Tuesday headache goes to become a tumour. None of those were in the room until he picked it up. So I'd want it out of reach. Not as a virtue. Just so that reaching for it takes long enough for him to notice he's doing it.

There's another thing Rob's started doing, and I suspect he won't want to hear about it. A whisky at ten. To knock himself out, he says. And it works. He's asleep in minutes.

It does work. For the first part of the night. And that's exactly the trap. The NHS advice on this is blunt. Alcohol can make you feel sleepy at first, but it can lead to poor sleep later in the night. Later in the night. Which, for Rob, means the very hours we've been talking about. So it's quite possible his nightcap is buying him an easy eleven o'clock and paying for it at three. I'm not going to tell him he can't have a whisky. That's not this show. But if he wants to run one experiment this month, it's a fortnight without it. And then see whether the three o'clock waking moves.

Then there's the other end of it. After a bad night he's been having a lie-in at the weekend, and he nods off in the van at dinnertime. That's just catching up, isn't it?

It feels like catching up. But it works against him. The NHS advice is to wake up and get out of bed at the same time every day, and not to sleep in after a bad night's sleep. Stick to the regular hours instead. Same with napping. No napping in the day. Because sleep he takes in the afternoon is sleep he won't be hungry for at three. So the lie-in feels kind, and it's quietly feeding the three o'clock waking. And there's one bit of that same advice I'd underline for Rob in particular, because he drives for a living. Don't drive when you feel sleepy. If he's nodding off in the van, the van should be parked.

Okay. So he's turned the phone over. He's skipped the whisky. He's up at the same time. And he still wakes at three, because, as you said, everybody does. What does he do in the bed? Right then?

The first thing is not to try. Sleep is one of the very few things that gets harder the more effort you put in. Trying to sleep is like trying to relax on command. So the instruction isn't get back to sleep. It's stop guarding the door. Let it be a waking. Lie there. Breathe out slowly. Let the van be a van for a minute. Most wakings end on their own, and he'll never know about them. But if he's still awake after what feels like a long while — not timed, because we've taken the clock away — and he's getting wound up, the advice is the opposite of what feels natural. Get up. Go to another room. Low light. Something dull. A book he's read before. And go back to bed only when he feels sleepy again. That has a name. It's called stimulus control. And the American Academy of Sleep Medicine's guideline suggests it as a treatment for chronic insomnia on its own.

Why get up though? That feels backwards. He's knackered. Surely lying there resting is better than nothing at all.

It feels that way. And resting isn't nothing. But think about what Rob's bed has turned into over the last month. It's the place where he lies awake doing sums about VAT. Every night he does that, the bed and the worry get a little more connected. Because brains learn by association, and they're very good at it. So the whole idea of getting up is to break that link. The bed goes back to being for sleep. Not for lying there losing a fight. And the getting up doesn't need to be dramatic. Ten minutes in the kitchen with the small light on. That's enough to tell his brain that the bed isn't where the fight happens.

And once he's up, what does he actually do in the kitchen? Because the obvious thing is the telly. Or the phone again, now he's allowed it.

So that's where I'd steer him away. The NHS advice says don't use devices like smartphones right before bed, because the blue light makes you more awake. Now, that advice is written about bedtime, not about three in the morning. But the logic carries. And the phone brings the inbox and the search engine back with it, which is the whole thing we've just taken out of the bedroom. So the kitchen job is something boring with his hands or his eyes. A paper he's already read. A cup of something without caffeine in it. Sorting the screws in the toolbox, if he's that kind of joiner. The aim isn't to enjoy himself. It's to be awake somewhere dull until his body asks to go back.

And what about the actual worries? Because the van genuinely does need an MOT. The quote might really be too low. He can't just not think about them.

No. And he shouldn't try to banish them, because that never works. What he can do is refuse to make decisions at three. Not because the worries aren't real. They're real. But we've just spent a good while on why three in the morning is the worst possible time to weigh them. So one useful move is a notepad. In the kitchen, if he's getting up. He writes the worry down. One line. Ring about the quote. Book the van. And then the deal is that it gets looked at at nine, by the version of Rob who has a working front brain and a phone line. But writing it down doesn't solve it. It just tells the worry it's been filed. And a filed worry goes round less.

And the headache. You skipped the headache. Because that's the one I'd be lying awake about, of all of them.

I didn't skip it. I was saving it, because it's the one the three o'clock brain is best at. A headache on Tuesday, nothing else going on, gone by Wednesday. At nine in the morning, Rob would call that a headache. At three, with his mood at its daily low and nobody to ask, it becomes the worst possible version. And that's the pattern. Because the three o'clock brain doesn't invent worries. It takes something real and small and hands it the worst ending available. So the rule for Rob is the same as for the van. Write it down. Look at it in daylight. And if in daylight he's still worried, that's exactly what a GP appointment is for. Not a search engine at half three.

So we've got the waking explained. The mood explained. The phone, the whisky, getting up. Is that enough? Or is there a point where Rob needs more than a handful of tips?

There's a point, yes. And I'd want him to know where. A few bad weeks during a stressful patch is just sleep doing what sleep does. Most people have them. But the NHS calls it long-term insomnia once it's gone on for three months or more. And if it's lasted that long, or it's making his days hard to cope with, that's the point to see a GP. Not because something's necessarily wrong with him. Because there's a treatment that genuinely works, and he won't get it from reading tips at three in the morning.

What's the treatment, then? Because I'm guessing that when he hears the word treatment, he's imagining sleeping pills.

He probably is, and it isn't. The first treatment is a talking one. Cognitive behavioural therapy for insomnia. CBT for insomnia, for short. And I want to be clear that it's not the same as sleep hygiene, the list of no screens, no coffee, a dark bedroom. It's a structured course that works on exactly the things we've been talking about. The bed and the worry. The clock. The beliefs about sleep that keep you watching it. And it's not a fringe option. The American College of Physicians guideline recommends it for all adults with chronic insomnia, as the first treatment. Before pills.

Wait, so the sleep hygiene stuff doesn't work? Because that's all anyone ever seems to tell you. Cut the coffee, buy blackout blinds.

It's not useless. It's just not a treatment on its own. The same sleep medicine guideline we mentioned suggests that clinicians don't use sleep hygiene by itself to treat chronic insomnia. And that makes sense once you've followed Rob. His problem isn't that his room's too bright. His problem is a learned loop between the bed, the clock and the worry. So swapping his pillow won't touch that. A dark, cool room is fine. Do it. But if he's done all of that and he's still awake at three, it's not because he's failed at sleep hygiene. It's because sleep hygiene was never going to be enough.

And does CBT for insomnia actually work? Like, in numbers. What would Rob notice?

It does, and the numbers are real, if modest. A meta-analysis in the Annals of Internal Medicine pooled 20 trials. After treatment, people fell asleep about 19 minutes faster, and spent about 26 minutes less awake in the night. Now, that might not sound like a transformation. 26 minutes. But think about which minutes those are. For Rob, they're the minutes between three oh seven and whenever he finally goes back down. The worst minutes of his day. And the review also found the changes seemed to hold at later time points, with no harms reported. Which is more than you can say for the alternative.

And the alternative is pills. Rob's mate swears by them. Takes one most nights, says he's never slept better.

And for a few nights, in a crisis, they have a place. But the NHS is clear about how short that place is. It says sleeping pills are only prescribed for a few days, or weeks at the most, and only when the insomnia is very bad or other treatments haven't worked. GPs rarely prescribe them for insomnia now. They can have serious side effects, and you can become dependent on them. So Rob's mate may well be sleeping. But it's not the first thing a GP will reach for. And it's not the thing that undoes the loop.

Here's my worry though. Rob goes to his GP, gets told CBT, and then there's a waiting list as long as his arm. Is this even available?

That's a fair worry, and NICE says it out loud. In its guidance on this, it notes that face-to-face CBT for insomnia is best practice, although its availability in the UK is limited. So what NICE has done is recommend a digital version. A self-help programme that includes CBT for insomnia, for people in primary care who'd otherwise be offered sleep hygiene advice or sleeping pills. That doesn't mean an app is as good as a person. NICE says itself there's no direct evidence comparing the two. But it does mean a waiting list isn't the end of the conversation. So it's worth Rob asking his GP what's available locally, by name.

I want to go back to something. You said the three o'clock brain gives things the worst ending. Is there ever a time when Rob should take the three o'clock feeling seriously?

Yes. And this matters. If waking very early comes with low mood that stays with him through the daytime, that's a different picture. The NHS lists waking up very early in the morning among the physical symptoms of depression. Alongside things like losing interest in things he used to enjoy, feeling hopeless, and finding it difficult to make decisions. So the question for Rob isn't, do I feel awful at three. Almost everybody does. It's, do I still feel low in the daytime. And the NHS puts a line under that: see a GP if you have symptoms of depression for most of the day, every day, for more than two weeks. So if that's Rob, it's worth an appointment in its own right. And it's not a sleep tip problem.

And if what comes at three is darker than that? Not the van. Thoughts about not being here at all.

Then it's not something to wait on. And it's not something to manage with a notepad. Thoughts of harming yourself are on that same NHS list of symptoms. And they're a reason to talk to someone now — today, a GP, NHS 111, someone you trust — rather than book something for next week. I'd say that plainly to anyone listening. And it ties back to what we said about three in the morning. It's the hour when the instrument reads worst and there's nobody else up. So if that's what the night is bringing, the answer is to make sure someone else knows. Not to get through it alone and hope the morning sorts it out.

Okay. But for the plain version, the three o'clock waking on its own, with Rob basically fine in the daytime. Is that something to worry about at all?

On its own, mostly not. It's a brain doing what brains do at that hour, in a body whose clock is at its low point, in a house where nobody else is awake. That's an uncomfortable combination. But it's an ordinary one. And I think knowing that's half the treatment for someone like Rob. Because a lot of what keeps him awake is the second worry. Not the van. The worry about being the kind of person who lies awake worrying about vans. So take that one away, and the first one tends to get smaller on its own.

And does it go away? Or is Rob stuck with three o'clock for good now, because he's learned it?

He's not stuck. That's the hopeful part of it being learned. A loop that was learned can be unlearned, and that's more or less what everything we've talked about is doing. Taking the clock away. Getting up instead of fighting. Keeping the same hours. And the NHS line on this is plain. Insomnia usually gets better by changing your sleeping habits. So the expectation for Rob isn't that he'll be lying awake at three for the rest of his life. It's that if he changes the habits, the three o'clock waking mostly goes back to being what it was before. A waking he never remembers.

Before we finish, what don't we know here? Because some of that sounded very confident, and I want you to draw the line.

Three things. The biggest is that the mood part, the Mind after Midnight idea, is a hypothesis. A well-argued one. But the authors are upfront that when such data weren't available, they used data from people after a night of sleep loss rather than people genuinely awake in the night. And those aren't the same thing. Second, the memory study was small. Just 39 healthy adults, wearing wrist monitors at home. And the people in it varied a lot. So about four minutes is an average, not a rule. And third, the clock experiment was about falling asleep at bedtime. I've carried it across to three in the morning because the mechanism fits. That's my extrapolation, not their finding, and I'd want it said in that order.

So it's tonight. Rob's listened to all this. What does he actually do, from the moment he gets into bed?

Phone goes across the room, face down, alarm set. No whisky this fortnight. Same getting-up time tomorrow, however the night goes. When he wakes at three, and he probably will, he lets it be a waking. If something catches, he tells himself it's the three o'clock version. If he's still lying there wound up after what feels like a while, he gets up. Kitchen. Small light. Dull book. Notepad. One line per worry. Then back to bed when he's sleepy. And in the morning, he does the one thing the three o'clock brain can't. He looks at the list in daylight, rings about the quote, and books the van. And if this is still going on at three months, or his days are going grey, he goes to his GP and asks about CBT for insomnia by name.

And the thing he was frightened of? The headache?

Was a headache. On a Tuesday. It got enormous because of when he was looking at it, not because of what it was. And if it's still bothering him in daylight, that's a perfectly good reason to see someone. But the size it reached at twenty past three wasn't information about the headache. It was information about twenty past three. And that's worth remembering, the next time something gets enormous in the dark.

And three things to take to his doctor, if it gets that far.

First. Could this be insomnia, and can I be referred for CBT for insomnia? Ask for it by name, because it's the first treatment, and it's not always the first thing offered. Second. If there's a wait, is there a digital CBT for insomnia programme I can use in the meantime? That's a real option, and it's in the guidance. And third. Could anything I'm taking, or drinking, be part of why I'm waking? Because alcohol and plenty of medicines can disturb sleep, and if that turns out to be the cause, it's the cheapest fix going.

If Rob takes one thing from all of this, what is it?

That three in the morning is the worst possible judge of anything. Not because his worries aren't real. Because the instrument he's reading them with is at its lowest point of the day, and there's nobody up to check it against. He's not broken. He's awake at a bad hour, doing sums he can't act on. So turn the clock round. Get up if it's a fight. Write it down. And let the version of him with the daylight and the phone line make the decisions. That's the one who gets things done anyway.