Insomnia: when you cannot sleep

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.

Short-term insomnia lasts days or weeks and usually has an obvious trigger: stress, grief, illness, a new baby, shift work. It often resolves on its own.

Long-term insomnia is three or more nights a week for three months or more. That is the point at which self-management stops being the answer and CBT-I is indicated.

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.

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 treats the maintaining behaviours rather than the original trigger, which is why it works when addressing the trigger does not.

What CBT-I actually involves

It is not relaxation content, and it is more demanding than sleep hygiene, which is why it works.

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 to match actual sleep, which consolidates it. The most effective component and the most uncomfortable, and it should be done with guidance rather than improvised.

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 is the least effective part on its own.

It typically runs four to eight sessions, and it usually gets worse before it gets better, which is why doing it with support matters.

What to do tonight

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

Get up if you have been awake twenty minutes. The single most useful behavioural change.

Turn the clock away. Knowing the time turns a brief waking into a calculation about sleep left, and that alertness is what keeps you awake rather than the waking itself.

Keep the wake time fixed even after a bad night. Lying in repays the debt tonight and moves the problem to tomorrow.

Do not nap while you are trying to re-establish a pattern, because it discharges the sleep pressure you need at bedtime.

Get daylight in the morning. Twenty minutes outdoors anchors the body clock.

Sleeping tablets, and what to expect

UK guidance is that hypnotics are for short-term use, typically a few days to two weeks, for severe or disabling insomnia.

They work in the short term. Tolerance develops, and stopping can produce rebound insomnia worse than the original, which is how short courses become long ones.

Over-the-counter antihistamine sleep aids cause next-day grogginess for many people and are not intended for ongoing use.

None of this is a reason to refuse medication if a GP judges it appropriate. It is a reason to ask about CBT-I at the same appointment rather than instead of it, and never to stop a prescribed medicine abruptly without discussing it.

When it is not insomnia

Several conditions present as poor sleep and need different treatment.

Sleep apnoea fragments sleep without waking you enough to remember it, so it presents as unrefreshing sleep and daytime sleepiness 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.

Related reading

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