Can't Sleep? What Insomnia Is, and the Treatment That Works

The thing worth knowing

Cognitive behavioural therapy, CBT, is the treatment a GP may offer for insomnia, according to the NHS, which also states that GPs now rarely prescribe sleeping pills to treat it.

The route is a GP appointment, and it costs nothing. The NHS advice is to make one if changing your sleeping habits has not helped.

See a GP about any of these

The NHS says to see a GP if changing your sleeping habits has not helped, if you have had trouble sleeping for months, or if insomnia is affecting your daily life in a way that makes it hard for you to cope.

It separately lists breathing that stops and starts, gasping, snorting or choking noises, and always feeling very tired during the day as reasons to see a GP about sleep apnoea, which it warns can be serious if it is not diagnosed and treated.

If you are having thoughts of harming yourself, the NHS says to call 111, which is open at any hour, or 999 if you feel you may be about to act on them. Samaritans are on 116 123.

Everything clinical below is taken from those NHS pages. Ten years in the bed trade makes me useful on duvets, pillows and mattresses and does not make me a clinician, so read this as general information rather than medical advice, and as no reason to put off the appointment.

What counts as insomnia

Insomnia is not one bad night, and it is not defined by hours slept.

It is difficulty falling asleep, staying asleep, or waking too early, despite adequate opportunity to sleep, with daytime consequences: fatigue, poor concentration, low mood, irritability.

The daytime part matters. Someone who sleeps five hours and functions well does not have insomnia; someone who sleeps seven and is exhausted may have something else going on. The NHS figure of 7 to 9 hours for adults is an average, not a nightly target to hit.

Short-term insomnia, in NHS terms, is insomnia lasting less than three months. It usually has an obvious trigger: stress, grief, illness, a new baby, shift work, and it often resolves on its own.

Long-term insomnia is insomnia that lasts three months or longer. That is the point at which the NHS advice stops being self-help and becomes an appointment.

Why it persists after the cause has gone

This is the most useful thing on the page, because it explains why people are still not sleeping long after the stressful period ended.

Why insomnia outlasts whatever started it. Each response in the loop is a sensible one taken on its own, and each adds hours of lying awake in the bed you want to associate with sleep. That is what cognitive behavioural therapy for insomnia works on rather than the original trigger, which is why dealing with the trigger often changes nothing. The 20 minutes is the NHS Every Mind Matters wording, which is to get up rather than force it and go back when you feel sleepy; it is a threshold for acting, not a measurement, and the NHS publishes no figure for how long falling asleep should take.

Something disrupts your sleep. You respond sensibly: go to bed earlier, lie in longer, try harder to sleep, nap when you can.

Those responses maintain the problem. More time in bed awake teaches your brain that bed is a place where you lie awake, and trying hard to sleep produces alertness, because sleep is one of the few things that gets worse with effort.

So the original cause goes and the pattern stays. CBT-I is aimed at the maintaining behaviours rather than the original trigger, which is why dealing with the trigger on its own often changes nothing.

What CBT-I actually involves

It is not relaxation content, and it asks more of you than a list of habits does.

Stimulus control. Bed is for sleep. If you have been awake around twenty minutes, get up, go to another room, do something dull in dim light, and return when sleepy. This rebuilds the association between bed and falling asleep.

Sleep restriction. Temporarily limiting time in bed so that it matches the sleep you are actually getting. This one is set and monitored by the clinician running the course, it leaves you short of sleep while it is working, and it is not something to improvise from a web page. There are deliberately no instructions for it here.

A fixed wake time, seven days a week, regardless of how the night went.

Cognitive work on the thoughts that keep people awake, particularly the arithmetic about how much sleep is left and what tomorrow will be like.

Sleep hygiene, which is included, and which is the part most people have already tried. The NHS tells you to see a GP when changing your sleeping habits has not helped, and that is the situation this course is for.

It runs as a course rather than a single appointment, which is why doing it with support rather than alone matters. Ask the GP what is available locally.

What to do tonight

While you arrange the above, these are the highest-value things and none costs anything.

The gaps are the ones the NHS publishes in its insomnia advice, counted back from the moment you go to bed: no smoking, alcohol, tea or coffee for at least 6 hours, no exercise within 4 hours, relax for at least 1 hour, and go to bed only when you are sleepy. The morning is marked because the NHS pairs getting out of bed at the same time every day with that last item, which makes the wake time the anchor and the bedtime the thing that moves. Two items on the same list, the late meal and the daytime nap, carry no published timing, so they are named without one rather than given a position here.

Get up if you have been awake around twenty minutes. This is the NHS Every Mind Matters advice in full: try not to force it, get up and sit somewhere comfortable, do something relaxing, and go back to bed when you feel sleepy.

Turn the clock away. Keeping clocks out of view and the phone face down is on the same NHS list. Knowing the time turns a brief waking into a calculation about sleep left, and the calculation is the part that keeps you awake.

Keep the wake time fixed even after a bad night. Two separate items on the NHS list say exactly that: get out of bed at the same time every day, and do not sleep in after a bad night's sleep.

Do not nap during the day, also on that list, because a nap spends the sleep pressure you need at bedtime.

Get out of the house during the day. Exercising regularly during the day is on the NHS list; going outside to do it covers both.

Sleeping tablets, and what to expect

The NHS position is that GPs now rarely prescribe sleeping pills to treat insomnia. Where they do, it is because the insomnia is very bad and other treatments have not worked, and then for a few days, or weeks at the most, because sleeping pills can have serious side effects and you can become dependent on them.

The pharmacy shelf is dealt with more bluntly still. The NHS says over-the-counter sleep aids cannot cure insomnia, that they may help you sleep better for 1 to 2 weeks, and that they should not be taken for any longer. It also says to check with your doctor before taking anything for your sleep problems.

None of that is a reason to refuse medication a GP judges appropriate, or to stop a prescribed medicine abruptly. It is a reason to ask about cognitive behavioural therapy at the same appointment rather than instead of it.

When it is not insomnia

Several conditions present as poor sleep and need different treatment.

Sleep apnoea, which the NHS describes as breathing that stops and starts during sleep, with gasping, snorting or choking noises and loud snoring. It presents as unrefreshing sleep and daytime tiredness rather than lying awake.

Restless legs, an urge to move the legs that worsens at rest and in the evening.

Depression and anxiety, which have a bidirectional relationship with sleep: each worsens the other.

Pain, menopause, thyroid problems, and medication effects, all of which are common and treatable.

If sleep has been poor for weeks, the appointment is worth making regardless of which of these it turns out to be.

Sleep basics

Other causes

The bedroom

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Questions people ask

What counts as insomnia?

Regularly having problems sleeping: trouble falling asleep, trouble staying asleep or waking too early, with daytime consequences. The NHS calls it short-term insomnia under three months and long-term insomnia at three months or longer.

What is the most effective treatment for insomnia?

The NHS says a GP may offer cognitive behavioural therapy, and that GPs now rarely prescribe sleeping pills for insomnia. The appointment is the route to it and it costs nothing.

Why does insomnia continue after the cause has gone?

Because the sensible responses to poor sleep maintain it. More time in bed awake teaches your brain that bed is where you lie awake, and trying hard to sleep produces alertness. CBT-I treats those maintaining behaviours.

What should I do if I cannot get back to sleep?

Get up after around twenty minutes, go to another room, do something dull in dim light and return when sleepy. Turn the clock away, because knowing the time turns a brief waking into a calculation that keeps you alert.

Are sleeping tablets a good idea?

The NHS says GPs now rarely prescribe them, and that pharmacy sleep aids cannot cure insomnia and should not be taken for longer than 1 to 2 weeks. Ask about cognitive behavioural therapy at the same appointment.