Insomnia: why you cannot sleep and what works

What insomnia is

Insomnia is difficulty falling asleep, staying asleep or not waking before you meant to, despite having the time and conditions to sleep. It is called chronic insomnia when it happens at least three nights a week for three months or more and has consequences during the day: tiredness, irritability, poor concentration, low mood.

A bad week is not insomnia. Almost everyone sleeps badly during a stressful spell, with an exam, a baby or a worry on their mind, and sleep comes back on its own once the situation passes. Insomnia starts when sleep does not come back even though the situation has passed.

What usually keeps it going is the worry about sleep itself. After several bad nights, the bed stops being a place to rest and becomes the place where you fail to sleep. You go to bed earlier to catch up, stay longer trying, check the time, work out how much is left, and every calculation wakes you a little more. The body learns that bed is where it stays awake and alert. That learning, not whatever started it, is what has to be undone.

How to recognise it

• It takes you more than half an hour to fall asleep most nights, even when you get there exhausted.
• You wake in the small hours and your mind starts up on its own: to-do lists, worries, how long until the alarm.
• You wake before you meant to and cannot get back to sleep.
• You start thinking about how you will sleep tonight from mid-afternoon, and bedtime makes you nervous.
• You sleep better on the sofa, in a hotel or at someone else's place than in your own bed.
• During the day you are tired, irritable or scattered, and you have started cancelling plans or avoiding things because of sleep.

What works

Cognitive behavioural therapy for insomnia. It is what clinical guidelines recommend as the first treatment for chronic insomnia, ahead of medication. It is a structured programme that changes what keeps the problem going.

Reconnecting bed and sleep. The bed is used only for sleeping. If twenty minutes pass and you are not asleep, you get up, do something quiet in low light and come back when you feel sleepy. It is hard at first; within a few weeks the bed gets its meaning back.

The sleep window. It sounds contradictory, but you start by shortening the time in bed to match the time you actually sleep, then widen it as sleep becomes more solid. It is the part that costs the most and works the most.

The 3am thoughts. "Tomorrow will be a disaster", "I need eight hours or I cannot function", "I will never sleep well again". In therapy they are reviewed one by one, because they are what turn a bad night into a night on alert.

What does not help. Staying in bed longer to catch up, long naps, screens in bed, alcohol to fall asleep (it puts you to sleep, then breaks the second half of the night) and checking the time.

What therapy does and does not do. A psychologist does not prescribe or withdraw medication: that is your doctor's call, coordinated with therapy if you take it. It does not promise a number of nights either. What it does is give you a concrete plan, review it with you each week and adjust it to your case.

We Are Psycho is preparing a structured programme for insomnia. When it opens, this guide will point to it.

When to ask for help

A few bad nights in a difficult period do not need treatment: they usually pass when the cause does.

It is time to talk to a professional if the problem has lasted more than a month, if it happens three or more nights a week, if it is starting to affect your work, studies or mood, or if you have been relying on pills or alcohol to sleep for a while. Also if the insomnia comes with low mood, anxiety or pain, because they often need treating together.

If thoughts of hurting yourself or of not wanting to go on appear, do not wait: call 800 911 2000 (Línea de la Vida). In immediate danger, call 911. We Are Psycho does not provide emergency care.

Frequently asked questions

Is it dangerous to sleep five hours?

It depends on the person and on how you are during the day. Some people function well on fewer hours than they think they need. What matters is not so much the number as whether you wake rested and can function. A short spell of little sleep has no serious consequences; chronically short sleep is linked to worse health, which is why it deserves attention.

Do sleeping pills fix it?

They can help for a few days in a crisis, and that decision belongs to your doctor. But they do not treat what keeps insomnia going, and over time they lose effect or create dependence. That is why clinical guidelines place them behind cognitive behavioural therapy, not ahead of it.

How long does therapy for insomnia take?

Programmes usually run between four and eight sessions, but everyone responds at their own pace and nobody can promise you a timeframe. Typically the first changes show in the first few weeks and are consolidated afterwards.