Do I have insomnia?

Perhaps it's the hour when everyone else in the house is asleep, and you're the one still lying there, listening to it tick and creak. Or perhaps it's the morning after, and you're counting how many nights it has been now, and trying to remember the last time you slept straight through. Often whatever started it, a loss, a move, an illness, a hard stretch at work, has eased by now, and still the nights haven't come back with it.

Clinicians look for three things together before they call it insomniainsomnia Trouble falling asleep, staying asleep or waking too early, that keeps happening and affects how you feel or get on during the day.. There's the night itself: trouble falling asleep, staying asleep or waking too early²2 Edinger et al., 2021b, the long stretches awake, perhaps finding you can't nap even though you're worn out³3 NHS, 2024. There's the day, too, since the definition counts tiredness, a low or short-tempered mood, a mind that can't concentrate². Often it's the days that finally send people looking for help. And there's the chance to sleep: all of this happens despite enough time in bed and a reasonable place to sleep².

Clinicians describe chronic insomnia as happening at least three nights a week for at least three months². Anything shorter they call short-term, or acute, insomnia³⁴4 Ellis et al., 2015, and it's worth taking seriously even though it often passes. Those numbers describe a pattern, agreed on so that clinicians can talk about the same thing. They aren't a test you pass or fail by counting your nights. There's no scan or overnight test that finds insomnia in the body. A doctor recognizes it from what you tell them about your nights and days²⁵5 Riemann et al., 2023.

For many people it does. One US study watched it happen: 1,248 people aged 35 and over who slept well kept a sleep diary every day for a year⁶6 Perlis et al., 2020. Along the way a little over a quarter of them went through a spell of bad nights, and most of them found their way back to good sleep⁶. Out of the whole group, fewer than two people in a hundred ended the year with chronic insomnia⁶. The researchers who followed those diaries suggest that a short run of sleeplessness may simply be part of how a body answers stress or threat⁶. If your own bad nights are only a few weeks old, that may be what's happening: a body still answering a hard stretch, which often eases as the stretch does.

If your bad nights have gone on for months now, insomnia that has lasted that long tends to stay until something changes. In a Canadian study that checked on people with insomnia a year later, about three in four still had it⁷7 Morin et al., 2009b. The long kind also responds well to treatment⁸⁹8 Qaseem et al., 20169 Morin et al., 2009, even when it has lasted for years.

And even when it's been around a long time, it usually isn't every night. Poor nights tend to come in runs of a few, with better ones between¹⁰10 Perlis et al., 2014, which may be why a good night can arrive out of nowhere and then refuse to repeat.

Most people can point to the week it began. In one small UK trial, most of the people with new insomnia traced it to something ordinary, such as trouble at home, money worries or a change at work⁴4 Ellis et al., 2015. Once that has eased, it can feel faintly foolish to be awake at 2am when so much else has come right again. But what started the trouble and what keeps it going can be two different things²¹¹2 Edinger et al., 2021b11 Kalmbach et al., 2018. Insomnia often becomes a problem in its own right²¹¹, whatever set it off.

Clinicians often explain this with a three-part model from the 1980s: what makes someone prone, what sets it off and what keeps it going⁴¹²12 Spielman et al., 1987. It's a widely used framework rather than a proven account of every case², but it fits what many people describe.

The stressful weeks set it off. Then you start protecting your sleep: you go to bed earlier to give sleep more chance, you sleep in on the mornings you can, you stay in bed trying. You check the clock and work out that if you fall asleep now, you'll still get four hours. These are the very things, worry about sleep, irregular hours and too much time in bed², that the guideline review finds keep chronic insomnia going. The extra hours in bed spread the same sleep pressuresleep pressure The body’s need for sleep, which builds the longer we stay awake and eases while we sleep. more thinly across them. And night after night of lying awake in the same bed can teach your body to be alert there².

Clinicians think that learning is why you can be drooping on the sofa at 10pm and wide awake the moment your head meets the pillow, as the bedroom and the routine of going to bed come to set off alertness by themselves⁴. Trying harder may add to it, since sleep can't be made to happen, and striving for it may keep insomnia going¹³13 Broomfield & Espie, 2005. One model suggests that watching the clock feeds a loop in which worry raises arousal, you look for signs the night is going badly and you come to feel you slept even less than you did¹⁴14 Harvey, 2002.

Every one of those habits began as a way of looking after yourself. They aren't the whole story, either, since some of it, such as genes, other illness or a body that runs more alert around the clock², is nothing anyone chooses. But the habits are the part within your reach, so the early nights, the lie-ins and the hours awake in bed are where your own nights can begin to change.

If you've worked through the lists, cutting coffee, darkening the room, trying lavender, and you're still awake, that isn't because you did them wrong. US sleep specialists advise against using sleep hygiene on its own to treat chronic insomnia¹⁵15 Edinger et al., 2021. The likeliest reason the tips fall short is that they don't reach the part that keeps insomnia going.

What does reach it is CBT for insomniaCBT for insomnia Cognitive behavioral therapy for insomnia: a short course of practical, talking-based techniques that help retrain sleep. It’s the first treatment doctors recommend for long-term insomnia., the treatment US and European guidelines recommend first for adults with chronic insomnia, in person or online, including for people with other health conditions⁵⁸¹⁵5 Riemann et al., 20238 Qaseem et al., 2016. Over a few weeks it works on the habits and the worry themselves. In trials, people got to sleep faster and spent less of the night awake, while their total sleep barely moved¹⁶16 Trauer et al., 2015, so what it gives back is mostly the hours of lying there.

In one Canadian trial, the 160 adults who took part had lived with insomnia for sixteen years on average⁹9 Morin et al., 2009. They met in groups once a week for six weeks, and some went on to extra treatment after that. By the end, about half were in remission, and six months later the gains were still there⁹. A long history doesn't put it out of reach, and a fully online program has helped too¹⁷17 Ritterband et al., 2017.

If your bad nights are only a few weeks old, there's much less to go on. In one small UK trial, a single hour-long session of CBT-I helped far more people into remission within a month than waiting did⁴4 Ellis et al., 2015. There's more on what the treatment involves in what CBT for insomnia would ask of you.

Perhaps you're wondering whether a pill would be simpler. Pills and CBT-I seem to help about as much at first, but only CBT-I has shown benefits that last once treatment stops⁹¹⁸18 Perlis et al., 2022. That's the reason sleeping medicines come after CBT-I in the guidelines, usually short-term, when CBT-I alone hasn't been enough⁵⁸. As for the pharmacy sleep aids, fast-release melatonin and herbal remedies, the European guideline advises against them for insomnia⁵, and whether sleeping pills are safe to take looks at each one. So CBT-I comes first, and it's the one worth asking for.

If you've been taking a benzodiazepinebenzodiazepine A family of sedative medicines, such as diazepam and temazepam, prescribed for anxiety and sometimes for sleep. Taken for a long time, they can lead to dependence., a kind of sedativesedative Something that slows activity in the brain and makes you feel drowsy. sleeping pill, most nights, please don't stop it suddenly: the FDA advises cutting down gradually, with a plan made with your prescriber, to avoid withdrawal¹⁹19 US Food and Drug Administration, 2020. If a drink has become part of how you get to sleep, there's more on what it does to the night in how alcohol affects sleep.

If you've been wondering whether your sleep is enough of a reason to book an appointment, the NHS suggests going if changing your habits hasn't helped, if it has gone on for months, or if it's making the days hard to cope with³3 NHS, 2024. What you'd say fits in a few lines: how long it's been, how many nights a week are bad, what it does to your days, what you think set it off and what you've tried.

If you'd like, you could keep a rough note each morning for a week or two. It's only notes for the doctor, with nothing to grade, and it can say much of this for you: doctors find a sleep diary useful⁵5 Riemann et al., 2023. From there, they'll look for anything behind it, may offer CBT face to face or online, and may refer you to a sleep clinic if another sleep problem seems likely³. And if getting an appointment is hard, a fully online CBT-I program is another way in, and in one US trial, more than half of the adults followed up after signing up for one themselves were in remission a year later¹⁷17 Ritterband et al., 2017.

Some people dread the word, as though it were a sentence handed down, and others half want it, so that the struggle at last has a name. Either way, it describes a pattern of nights and days, recognized from what you tell someone²⁵2 Edinger et al., 2021b5 Riemann et al., 2023, and it says nothing fixed about who you are. People in the first weeks tend to speak of having a sleep problem, and a sense of being an insomniac can build over time⁴4 Ellis et al., 2015. So the more useful question may be what's keeping this going now: the early nights, the lie-ins, the clock, the long hours of trying. That's the part that can be unlearned. About half the people in that Canadian trial reached remission, after sixteen years⁹9 Morin et al., 2009 of bad nights on average.