Awake at 3 a.m. ——What to Do About Early-Morning Waking HW04

Do you wake up at two, three or four in the morning and find yourself unable to fall asleep again? Early morning awakening can have many causes, including sleep timing, stress and anxiety, alcohol or caffeine, sleep apnoea, nocturia, menopause, pain, reflux and changes in mood. This book explores what modern sleep medicine and Traditional Chinese Medicine see differently, with a practical focus on what you can do—from CBT-I and daily sleep habits to UK pharmacy options, TCM approaches, food therapy, and knowing when to see a doctor.

What to do with Early-Morning Waking?

What to Do About

Fang Tianliang

Health & Wellbeing

 

1. Three in the Morning, and Wei Is Awake Again

Wei is forty-eight and works in sales management. For the past two months he has woken at around three in the morning. He is not woken by noise; he simply wakes. Once awake, his mind becomes crystal clear, and the things left undone in the day, next month’s targets and the children’s school fees queue up to be considered, one after another. He glances at his phone, glances again, dares not look a third time, and then lies there until daylight.

Waking much earlier than usual and being unable to get back to sleep is called early-morning waking, or terminal insomnia, in medicine.

Let us put the conclusion first:

Early waking is not in itself a disease, and it is not a diagnosis. It can be a matter of age, alcohol, breathing or routine, and it can also be a signal of stress, anxiety or mood. What matters is not “what time you woke”, but what else comes with it, and what you should do now.

This book will help you answer three questions: Which kind of early waking is mine, broadly? What should I do now? And when must I see a doctor? As always, we shall let two medicines speak in turn: how sleep medicine sees it, and how the classical formulas (jingfang) of Chinese medicine see it.

 

2. Why Is It the Second Half of the Night That Wakes Us?

Sleep is not a flat line

A night’s sleep is made of several cycles in succession, each lasting about ninety minutes and including light sleep, deep sleep and rapid-eye-movement (REM) sleep, in which dreaming is more common. In the first half of the night deep sleep takes up more of the time; in the second half deep sleep decreases, sleep becomes lighter and REM sleep increases. So the second half of the night is by nature the time when we wake most easily.

Two “alarm clocks” in the body

•         One is the circadian rhythm, regulated by the body clock in the brain, with body temperature and hormones rising and falling along with it. Around early morning the body’s stress hormone, cortisol, begins to rise to prepare for the day;

•         The other is sleep pressure: the longer you are awake, the stronger the urge to sleep, which is gradually discharged once you are asleep.

If sleep pressure is insufficient (a daytime nap, going to bed too early), or the body clock is shifted earlier (age, light), you may be “slept out” in the second half of the night and, once awake, lack the drowsiness to pull you back.

What commonly causes early waking?

Early waking is not only about mood; all of the following are common:

•         Ageing: deep sleep decreases, sleep becomes lighter and the body clock moves earlier;

•         Alcohol: drinking in the evening may help you fall asleep faster, but the second half of the night becomes fragmented and early waking is easy;

•         Caffeine: taken in the afternoon or evening, it affects the structure of the whole night;

•         Sleep apnoea: snoring, waking breathless at night and marked daytime sleepiness need to be checked;

•         Increased night-time urination: you get up to pass urine and then cannot get back to sleep;

•         Physical discomfort such as menopausal hot flushes, pain, itching or reflux;

•         Routine and environment: going to bed too early, a bedroom that is too bright or noisy, curtains that let light in;

•         Stress and anxiety: the mind will not stop, typically “thinking things over” after waking in the early hours;

•         Depression: early waking can be one of the sleep patterns seen in a depressive episode;

•         Medicines and other illnesses: some medicines, and conditions such as an overactive thyroid, can also affect sleep.

An important reminder: early waking by itself is not very specific. You cannot conclude from “waking early in the morning” alone that someone has depression, nor that it is “just not resting enough”.

 

3. When Is Early Waking No Longer Just a Sleep Problem?

Many people wake early for a long time without any other obvious trouble. That is closer to simple insomnia, and management is mainly cognitive behavioural therapy for insomnia (CBT-I). But if early waking comes with the following and lasts two weeks or more, it is worth seeing your GP or a mental health professional for assessment, rather than carrying on treating it as “not sleeping well”:

Red-flag signs

•         persistently low mood, and losing interest in things you used to enjoy;

•         very low self-esteem, or excessive self-blame;

•         difficulty concentrating, or a clear change in appetite or weight;

•         thoughts of harming yourself, or that “life isn’t worth living”.

If you have that last one, please do not carry it alone: in the UK you can call the Samaritans free helpline on 116 123 at any time, contact your GP, or call NHS 111 and choose the mental health option; if you are in immediate danger, call 999.

It must be stressed: early waking is not the same as depression. For most people who wake early, the cause is one of the commoner factors to be checked in the next chapter. Clinically, sleep is often also the thing that recovers more slowly once mood improves, so assessment and treatment usually go on together, rather than focusing on sleep as the only symptom.

 

4. What Should I Do Now? (The Most Practical Chapter)

Step one: look for red flags

Check against the red-flag signs in the last chapter. If any applies, do not manage it yourself: contact your GP or NHS 111. Other situations in which to see a doctor soon:

•         early waking has lasted several weeks and clearly affects your work, driving or safety during the day;

•         very heavy snoring, waking breathless at night, or excessive daytime sleepiness;

•         other physical symptoms as well, such as clear weight change, palpitations, or feeling hot and sweaty.

Step two: do a “cause check” first

Before rushing to find a method, look at the table below and see whether there is an obvious, easily adjusted cause:

What to check	What you can do
Drinking alcohol in the evening	Stop for one to two weeks and see whether early waking improves
Caffeine (coffee, strong tea, energy drinks, cola)	None after two in the afternoon
Daytime naps too long or too late	Keep a nap to twenty or thirty minutes, finished before three
Going to bed too early, or too long in bed	Do not go to bed earlier because you feel you “haven’t slept enough”
Bedroom light, noise, temperature	Blackout curtains, keep it cool and quiet, keep phones away
Frequent night-time urination	Drink less before bed; see your GP if it has clearly increased
Snoring, waking breathless	See your GP for assessment of sleep apnoea
Pain, reflux, menopausal hot flushes and so on	Treat the cause; see your GP if needed
Stress, worry	See the next step, and consider psychological support

Step three: the method sleep medicine has the most evidence for: CBT-I

For long-term insomnia, including early waking, modern guidelines usually put CBT-I first. It is not “just a chat”; it is a structured set of methods, whose core includes:

•         A fixed getting-up time, including weekends, which matters more than a fixed bedtime;

•         The bed is only for sleep: no scrolling, news or work thoughts in bed;

•         If you feel you have been wide awake for a while and are getting more and more restless, leave the bed, go somewhere dim and quiet and do something easy, then come back when sleepy. Do not look at the clock to judge whether it has been “twenty minutes yet”;

•         Do not stare at the clock; put the alarm clock and phone out of reach;

•         Keep up plenty of natural light and regular activity during the day. The timing of light affects the body clock; if you always feel sleepy very early and wake very early, a circadian rhythm that has moved earlier may be involved, and you should not try to adjust it yourself with bright light: ask a professional to work out the right timing of light;

•         Restricting time in bed, which is best done with professional guidance rather than squeezing it too far yourself;

•         for those whose mind will not stop after waking, set aside time before bed to write your worries on paper and deal with them in the daytime.

In the UK you can ask your GP about psychological support such as NHS Talking Therapies, and in some areas digital CBT-I programmes such as Sleepio are also offered; ask your GP what is available.

Step four: what can you buy at a UK pharmacy?

Walk into Boots, Superdrug or the supermarket medicines aisle in the UK and you will see several types of sleep aid, but they need to be treated with great caution. The brands below are examples, not recommendations, and you must read the ingredients and the instructions:

Type	Usual situation	Notes
Antihistamine sleep aids (ingredient such as diphenhydramine; for example Nytol-type products, and pharmacies’ own brands)	Sold in pharmacies; the NHS also states diphenhydramine can be used for short-term insomnia	Suitable only for short-term, occasional use; you may feel drowsy or groggy next day and should not drive; older people, and those with prostate problems or glaucoma, should ask the pharmacist first
Traditional herbal sleep products (such as valerian and hops)	Sold in pharmacies and health food shops	Based on traditional use; effect varies from person to person; ask before using with other medicines or alcohol
Melatonin	In the UK generally a prescription medicine	Do not buy it informally and take it yourself
Prescription sleeping medicines	Need a doctor’s assessment	Generally advised only for short-term use, with risks of dependence and side effects

Also watch for “night-time cold remedies” (Night Nurse-type products, for example): they often contain ingredients that make you drowsy, together with a painkiller or cough medicine. You cannot use them long term against insomnia just because they say “Night”, and you must not take them together with other medicines containing the same ingredients.

A special reminder: sleep medicines rarely solve “why am I waking early”, and long-term dependence can complicate the problem. If you can only sleep with medicine, or want to stop, ask your GP, and do not stop suddenly yourself.

Step five: when to see your GP

If insomnia has lasted more than three to four weeks and clearly affects your daytime life, contact your GP. You can bring a sleep diary kept for one to two weeks:

•         what time you went to bed, roughly when you fell asleep, how many times you woke in the night, when you finally woke and when you got up;

•         whether you had alcohol or coffee before bed;

•         how your energy and mood were in the day;

•         what was in your mind on waking.

This diary is useful to a sleep doctor and equally useful to a TCM practitioner.

A more practical approach: have a set routine ready for “waking in the night”

For many people the worst part of early waking is not the waking itself but not knowing what to do after waking, so they lie there anxious. You can prepare a set routine in advance:

1.        Do not look at the time. Once you look, the brain starts calculating “how many hours can I still sleep”, and the more it calculates the more awake you become;

2.        Try relaxing for a while first, with slow abdominal breathing: in for four seconds, out for six to eight, so that the body settles first;

3.        If you feel you have been wide awake for quite a while and are increasingly restless, get up. Go somewhere dimly lit and do something calm that does not need thinking, such as reading a paper book or listening to soft music;

4.        Do not turn on the big light, look at the phone or start dealing with work. Bright light and information make the brain more awake;

5.        When you feel sleepy, go back to bed. If you wake again, repeat the same steps.

The purpose of this routine is to let your brain learn again that the bed is for sleeping, not for worrying. The first few days may not be easy, but this is one of the most repeatedly validated parts of CBT-I.

How is anxious early waking different from early waking with low mood?

The two often overlap, but their common features differ, and can serve as clues when you talk with a doctor. They are not a diagnosis:

What to look at	More anxious	More low mood
In your mind on waking	Worries, plans, repeated “what if…”	Emptiness, self-blame, pessimism about the future
Daytime mood	Tense, restless	Low, unable to get going
Interest	Largely still there, but taken up with worries	Loss of interest in things once enjoyed
Sleep pattern	Difficulty falling asleep, waking in the night	Early waking more prominent, hard to get back to sleep

In real life many people have both. So do not label yourself; write down what you observe and let a professional judge.

The hour before bed: how can you spend it?

People who wake early often had the groundwork laid by the hour before bed the night before. A simple “slow-down” routine can be arranged like this:

•         dim the lights an hour before bed, and put the phone, computer and television on “do not disturb” or switch them off;

•         do one fixed, calm thing, such as a warm bath, a few minutes of stretching or a few pages of a paper book, roughly the same each day, so that the brain takes it as the signal that “sleep is coming”;

•         write down tomorrow’s to-do list and put it aside, telling yourself it is arranged;

•         do not deal with work email, read the news or argue in this period;

•         keep the bedroom cool, dark and quiet, and do not leave your phone by the pillow.

These things look small, but for someone used to “starting to think things over once I lie down” they train the brain: the day’s matters are dealt with in the day; at night the bed is for sleeping only.

 

5. What the Classical Formulas See: Why the Same Early Waking May Call for Three Different Formulas in Three People

Earlier episodes (L1 and L2) introduced Suanzaoren Decoction, Huanglian Ejiao Decoction and Chaihu plus Longgu Muli Decoction. This book asks a more interesting question: why, for the same early waking, might a TCM practitioner give three people completely different formulas?

How the classical formulas ask

The classical-formula (jingfang) approach, as represented by Ni Haixia’s teaching, does not begin by asking “do you have insomnia?”, but through a series of concrete questions judges what state the whole person is in:

•         How is your appetite? Are your stools normal?

•         Do you have energy? Do you still have the interest to do things?

•         Do you often feel like crying, or become irritable for no reason?

•         Is your mouth dry? Do you fear cold or fear heat?

•         When you wake, is it with a restless heart, a pounding heart or a tight chest?

These questions overlap quite a lot, in focus, with the questions of a modern sleep clinic, although the language system is completely different.

Three people, three kinds of “unsettled sleep”

Suppose three people all wake at three in the morning and cannot get back to sleep:

The first is in his early fifties, tired, sleeping lightly, exhausted on waking and yet unable to get back to sleep. The classical description of “vexation from deficiency and exhaustion with inability to sleep”, from the Jin Gui Yao Lue, corresponds to the line of thinking of Suanzaoren Decoction: leaning to “deficiency”, with the emphasis on nourishing.

The second has marked restlessness, a mind that will not stop as soon as he wakes, a dry mouth and tongue, and hot palms and soles. The Shang Han Lun, in the Shaoyin section, has the description “vexation in the heart, unable to lie down”, corresponding to the line of thinking of Huanglian Ejiao Decoction: leaning to “heat” and injured yin, with the emphasis on clearing heat and nourishing yin.

The third is tense and easily startled, with fullness in the chest and flanks and irritability, as though something presses on the heart. The Shang Han Lun has descriptions such as “fullness in the chest, vexation and fright”, corresponding to the line of thinking of Chaihu plus Longgu Muli Decoction: leaning to “stagnation” and fright, with the emphasis on easing and calming.

The three people’s “early waking” is exactly the same, but the classical formulas see three different whole-body states, so the approach is entirely different. This is correspondence of formula and pattern (fang zheng dui ying): what is looked at is not the symptom “early waking”, but the kind of person in whom this symptom grows. The Shang Han Lun also describes a more severe state of agitation, such as “unable to rest whether lying or rising”, showing that the classical formulas also noticed a link between “unsettled sleep” and “emotional state”, and distinguished them by severity.

Safety box: the above only introduces the thinking of traditional pattern differentiation. It is not a prescription, and you cannot match yourself to a pattern. These formulas need a qualified TCM practitioner to judge, one to one, whether they suit you, taking into account the medicines you take. Classical-formula differentiation describes a “whole-body state”, not a diagnosis in the modern medical sense; if you already show the red-flag signs above, you should have a medical assessment first, and TCM care can only be a supplement.

An interesting “hour”: chou and yin

A saying often heard among the public is that one to three in the morning is the “chou hour”, linked to the liver and gallbladder, and three to five is the “yin hour”, linked to the lung, so “waking at three” is explained as “something wrong with the liver”.

This belongs to the ziwu liuzhu time model of traditional Chinese medicine, a way in which the ancients observed bodily rhythms, with its own cultural and theoretical value. But it must be made clear that:

•         it is not the core of pattern differentiation in the Shang Han Lun classical formulas themselves;

•         it is a different language from the circadian rhythm and sleep cycles of modern sleep medicine, and cannot be matched directly;

•         you cannot conclude which organ is diseased from the hour of waking alone. The causes of waking at the same hour may be completely different.

 

6. Food Care in the Kitchen: Start with the Food-Medicine Substances

Under Chinese regulations there is a group of “substances that are traditionally both food and Chinese medicinal materials” (food-medicine substances for short), which may be used as food. Traditionally, for everyday care of “unsettled sleep”, the following ingredients are often used. This is a traditional way of thinking about dietary care; it is not a diagnosis, and does not replace sleep assessment and necessary treatment.

How do I know which one I am? Look first at the row you most resemble:

•         dry mouth, restlessness, hot palms and soles → look at “heat-leaning”;

•         tiredness, palpitations, light sleep and waking easily → look at “deficiency-leaning”;

•         tight chest, frequent sighing, unable to put things down → look at “stagnation-leaning”;

•         bloating, a heavy body, loose stools → look at “damp-leaning”.

If several fit, or you are not sure, you can book a TCM practitioner for pattern differentiation; do not mix things yourself.

Tendency	Daily direction	Ingredients traditionally used	Home preparations
Heat-leaning: restless, dry mouth, hot palms and soles, mind will not stop on lying down	Light, moistening	Lily bulb (baihe), ophiopogon root (maidong), lotus seed, mulberry	Lily bulb and lotus seed congee; ophiopogon and lily bulb tea
Deficiency-leaning: tired, palpitations, light sleep, wakes easily	Gentle nourishing	Jujube seed (suanzaoren), longan flesh, red dates, lotus seed	Longan and red date tea; lotus seed and red date congee
Stagnation-leaning: tense, tight chest, sighing, mood swings	Easing	Chrysanthemum, mint, tangerine peel	Chrysanthemum tea; tangerine peel tea
Damp-leaning: unrefreshing sleep, bloating, heaviness, loose stools	Strengthen the spleen, resolve dampness	Poria (fuling), coix seed, Chinese yam	Yam and coix seed congee; poria congee

A few reminders:

•         jujube seed is traditionally often associated with “sleep”, but if you are pregnant, or taking sedatives or other sleep medicines, ask a professional first;

•         longan flesh and red dates are sweet, so people who need to control blood sugar should watch total sugar;

•         do not eat too much or too late in the evening, or drink large amounts of water;

•         the effect of caffeine and alcohol is far greater than any bowl of congee. Manage those two first, then talk about dietary care;

•         traditional dietary care is supplementary and cannot replace CBT-I or a necessary medical assessment;

•         people with allergic tendencies should try new ingredients in small amounts first.

Everyday dietary-care foods mentioned in this book: lily bulb, ophiopogon root, lotus seed, mulberry, jujube seed, longan flesh, red dates, chrysanthemum, mint, tangerine peel, poria, coix seed, Chinese yam.

[HONGDAHEALTH dietary-care food link: to be added]

In the UK, foods may not claim to treat or prevent disease. Be wary of any food or supplement claiming “a sound night’s sleep in one evening” or to “cure insomnia”.

 

7. Two Systems: Which Stretch of the Road Is Each Responsible For?

Dimension	Sleep medicine / psychiatry	Classical-formula view (as represented by Ni Haixia’s teaching)
The core questions it can take charge of	Whether diagnostic criteria for depression and other conditions are met; risk assessment; CBT-I	Describing the state of imbalance of qi, blood, yin and yang as a whole, and individualised care
Tools used	Clinical interview, questionnaires (such as PHQ-9), medicines or psychological treatment where necessary	Six-channel differentiation, formula-pattern correspondence, the pulse

The two systems are not rivals; each is responsible for a different stretch of the road.

On evidence, let us be honest

By the “steps of evidence” used in this series:

•         traditional use and literature records of the classical formulas: yes, and abundant;

•         laboratory research on some single herbs (jujube seed, for example): some;

•         human clinical studies and randomised controlled trials of the compound formulas: limited in number and variable in quality;

•         independent replication: not much.

So we do not say “proven effective”, nor “without basis”. The more honest statement is: traditional experience deserves to be taken seriously, but it cannot replace CBT-I, which has been validated and is first-line treatment for insomnia, nor a professional assessment of mood problems. Use the methods with evidence first, then take traditional care as a supplement, under a qualified TCM practitioner.

 

8. Wei’s Story: The Extra Question the Doctor Asked

After Wei had done his sleep records and started trying the basic methods of CBT-I, the number of times he woke early did indeed fall a little. But at the follow-up the sleep clinic doctor asked him a few questions that seemed unrelated to “sleep”:

“Recently, do you still have the drive you used to have at work? When you look at things you used to like, do you still feel happy?”

Wei was taken aback and said: “Honestly, I have felt recently that nothing means much, but I thought it was just tiredness.”

The doctor said: “Insomnia and mood are sometimes two separate lines, and sometimes they get tangled together. I’m asking these questions not to put a label on you, but to be clear which line we are dealing with now.”

The follow-up showed that Wei’s state did not at present meet the diagnostic criteria for depression; it was simple insomnia with some degree of tiredness and mood fluctuation. The doctor advised him to continue CBT-I and arranged a review in a month. At the same time he was also receiving staged pattern differentiation from a classical-formula practitioner. The doctor reminded him particularly: if within the month he developed persistent low mood, loss of interest or thoughts of harming himself, he should not wait for the appointment but seek help at once.

In that month Wei did these things:

•         Week one: he stopped the evening drink and drank no coffee after two o’clock; he got up at seven every morning, weekends too;

•         Week two: if he could not get back to sleep after waking, he got up and went to the living room with a paper book, no longer lying there with his phone;

•         Week three: he began a sleep diary, and wrote the worries that kept coming round on a sheet of paper before bed;

•         Week four: he drank a cup of warm lily bulb and lotus seed tea in the evening, and went out more at weekends to get sunshine and walk.

A month later, the number of times he woke early had fallen from five or six a week to one or two, and when he woke, he found it easier to fall asleep again.

 

9. Questions Readers Often Ask

Q: If I wake at exactly three every day, is some organ diseased? A: Tradition has the “chou hour and yin hour” saying, but that belongs to another time model, and you cannot name a diseased organ from the hour of waking alone. What is more worth doing is to check alcohol, caffeine, breathing, routine and mood.

Q: When I can’t sleep, can I simply lie still and count it as rest? A: For a few people it helps in the short term, but if lying there makes you more and more anxious, get up. Being awake in bed for a long time lets the brain link the bed with wakefulness.

Q: Can I buy melatonin? A: In the UK melatonin is generally a prescription medicine; please do not buy it informally. Whether it suits you, ask your GP.

Q: Can I “make up” for early waking by sleeping in the day? A: An occasional nap is fine, but long daytime sleeps weaken the sleep pressure at night and make early waking worse.

Q: Is early waking normal as you get older? A: Sleep becoming lighter and shorter with age is common, but when it affects daily life, or comes with mood or breathing problems, it still needs assessment.

Q: Is a drink before bed to help me sleep all right? A: Alcohol may make you fall asleep faster, but it fragments the second half of the night and is often one of the causes of early waking.

Q: Can Chinese medicines and sleep medicines be taken together? A: Do not decide this yourself. Some herbs may interact with sedative medicines; please tell your doctor, pharmacist and TCM practitioner about all the medicines and supplements you take.

 

10. An Early-Waking Action Map: “If This Is Me, Where Do I Start?”

My situation	First thing	Daily care	Dietary direction	Next step
Occasional early waking, energy fine by day	Check alcohol, caffeine, naps, routine	Fixed getting-up time; daylight in the day	Plain, regular meals	See your GP if it lasts beyond three or four weeks
Snoring, waking breathless, very sleepy by day	Think of sleep apnoea first	Avoid alcohol and sedatives	Not applicable	See your GP first
Mind will not stop after waking, full of worries	CBT-I, and write the worries down	Get out of bed; do not stare at the clock	Heat- or stagnation-leaning may use the table	Consider psychological support; GP
Low mood and loss of interest as well, beyond two weeks	Do not treat as only insomnia	Get assessed soon	No dietary care yet	GP or mental health services first
Thoughts of self-harm or not wanting to live	Seek help at once	Samaritans 116 123; NHS 111; 999 if severe	Not applicable	Do not wait
Physical causes such as menopausal flushes, pain or night-time urination	Deal with the cause first	Treat the cause; see your GP	Choose by constitution	GP
Want to understand your constitution and overall state	Rule out red flags first	Keep a sleep diary	See the dietary table	Book a TCM practitioner for pattern differentiation

Need a TCM practitioner to differentiate your pattern from your overall state? If your early waking has been checked for obvious red flags and you want to understand your constitution and the direction of care, you can book a HONGDAHEALTH Chinese medicine consultation, where a practitioner will judge according to your overall condition.

[HONGDAHEALTH Chinese medicine consultation entry: to be added]

 

11. The Door That Was Never Opened

Many people treat the moment of waking in the early hours as an enemy to be dealt with. They stare at the clock and calculate how many hours they can still sleep, and the more they calculate the more awake they become.

But that moment is more like a door, and behind it is something you have not had time in the day to look at properly: pressure, worry, tiredness, and perhaps a mood that has quietly grown heavy.

Whether the door is opened depends on whether you have enough support, and on whether the person opening it is the right person. The sleep doctor can help you see whether this is a sleep problem or something else; the classical-formula practitioner can help describe what state the whole person is in; and what you have to do is not pretend the door does not exist.

If, reading this, you happen to have the thought that “life isn’t worth living”, treat it as an important signal, not as “didn’t rest well”: contact someone you trust, contact your GP, or call 116 123.

The dietary-care content in this book is traditional dietary knowledge and does not replace diagnosis or necessary medical treatment. For persistent insomnia, low mood, thoughts of self-harm and similar situations, seek professional medical help promptly.

For more information, please visit our website at theFTL.org — For Truth & Life. Thank you and see you next time.