By Dr Daniel S. Cohen · Updated: 10 May 2026
Summary
Sleeping badly is one of the most common clinical complaints in consultation. Almost everyone goes through, at some point in life, a stretch of insomnia after a setback, an important change or a period of intense stress. Those stretches usually pass on their own. The picture changes when insomnia takes hold: when it lasts for weeks, starts to weigh on mood, on work and on relationships, and the lack of sleep itself becomes part of the problem.
This article covers what insomnia in adults is, when it should be considered chronic, how it is assessed, what treatment actually works and when it is worth seeking professional help.
What insomnia is
Insomnia can present in three forms:
- Difficulty falling asleep: it takes more than 30 minutes for someone to fall asleep after going to bed.
- Prolonged night-time awakenings: a person wakes up several times during the night and struggles to fall back asleep.
- Early morning awakening: a person wakes up much earlier than wished and cannot fall back asleep.
These forms often combine; in addition, in many cases there is also a sense of non-restorative sleep: sleeping enough hours yet waking up just as tired.
What defines the clinical problem is not the specific number of hours, but the impact on daily life: tiredness, difficulty concentrating, irritability, drop in performance, low mood and increased risk of accidents.
When insomnia becomes chronic
When insomnia occurs at least three nights a week for three months or more, we speak of insomnia disorder (DSM-5-TR, ICD-11). Crossing into that category is not an academic detail: it marks the point at which letting time pass stops being a reasonable option, because the picture tends to be self-sustaining.
Why it persists
Almost always, chronic insomnia begins with something specific: a stressful period, a grief, a job change, a health concern. The trigger may pass, but the insomnia stays. Why?
Because the body and the mind learn not to sleep. Patterns appear that maintain the problem even when the original cause is no longer there:
- Anticipatory anxiety as bedtime approaches.
- Spending many hours in bed trying to sleep.
- Falling asleep on the sofa but not in bed.
- Looking at the clock at every awakening.
- Resorting to sleeping pills every night for months or years.
All these patterns look like a logical response to insomnia. Maintained over time, they are what perpetuates it.
How it is assessed
Assessment of insomnia in consultation is essentially clinical:
- Detailed clinical interview covering history of the problem, sleep habits, daily life, substances (caffeine, alcohol, screens, exercise), previous treatments and comorbidities.
- Sleep diary for two weeks: the patient notes bedtime, time taken to fall asleep, awakenings and wake-up time. It is the most useful practical tool, and reveals patterns the patient does not see.
From there, other conditions that can be confused with insomnia are ruled out.
What is not insomnia
Before starting treatment it is important to confirm the diagnosis, because some conditions can be confused with insomnia and actually require a different approach:
- Obstructive sleep apnoea: heavy snoring, breathing pauses, marked daytime sleepiness. Requires evaluation by a sleep unit.
- Restless legs syndrome: irresistible urge to move the legs at bedtime, relief on movement.
- Circadian rhythm disorders: the person sleeps well, but at shifted hours (falls asleep at 3 a.m. and wakes at 11, or the opposite).
- Early awakening with low mood: early awakening is a characteristic symptom of depressive episodes, and the full picture changes the management.
If any of these four situations matches what you are experiencing, the plan is not to attack the insomnia directly.
The treatment that works: cognitive behavioural therapy for insomnia (CBT-I)
Cognitive behavioural therapy for insomnia (CBT-I) is the first-line treatment according to the main clinical guidelines (AASM 2021, NICE 2022). Its efficacy is comparable to or greater than that of medication in the long term, without producing dependence.
It combines four components worked in parallel:
- Stimulus control. When insomnia has lasted for months, the bed stops being a neutral place and becomes associated with the frustration of trying to sleep without succeeding. The aim of this technique is to break that association: go to bed only when real sleepiness arrives (not by clock time), get up and leave the bedroom if sleep does not come within fifteen or twenty minutes, keep a fixed wake-up time and reserve the bed only for sleep. Over time, the brain comes to associate bed with sleep again, rather than bed with struggle.
- Sleep restriction. This is the most counter-intuitive component and, often, the most effective. If a person spends nine hours in bed but only sleeps five, the remaining four hours are time awake: sleep becomes fragmented and non-restorative. The technique consists of shortening the time spent in bed so it matches the time actually slept (calculated from the sleep diary). If the person sleeps five hours, they go to bed only five hours before the time they need to get up. It sounds harsh, but within a few days the body builds up sleep pressure, rest becomes more continuous and deeper, and from there the time in bed is gradually extended until it reaches the sleep the person actually needs.
- Cognitive restructuring. Much of chronic insomnia rests on catastrophic thoughts: “if I don’t sleep, tomorrow will be a disaster”, “I’ll get ill”, “I won’t get through the day”. These thoughts activate the alarm system, which is precisely the opposite of the physiological state needed to fall asleep. The work consists of identifying these thoughts, contrasting them with real experience (the person has functioned many times after a bad night) and reframing them in more balanced terms.
- Regulation techniques. Chronic insomnia goes hand in hand with physiological hyperarousal: tachycardia, muscle tension, shallow breathing and racing mind. Learning concrete tools (slow diaphragmatic breathing, progressive muscle relaxation and mindfulness) lowers that arousal and makes the transition to sleep easier. It is not about “relaxing in order to sleep” in the abstract, but about having a practical repertoire the patient knows how to apply when night-time arousal appears.
Most patients notice change within four to eight sessions. CBT-I requires coordination between psychiatrist and psychotherapist with specific training, especially when there is psychiatric comorbidity or prolonged use of sleeping pills.
When medication comes in
Medication has a role, but a bounded one. It is useful:
- In acute phases (intense stress, grief) to prevent the picture from becoming chronic.
- As a temporary adjunct while CBT-I begins to take effect.
- When there is psychiatric comorbidity (depression, anxiety) that justifies using a sedating antidepressant (trazodone, mirtazapine) instead of a hypnotic.
Let us be clear: what does not work is taking benzodiazepine hypnotics or Z-drugs (zolpidem, zopiclone) for months or years. They lose efficacy, generate dependence and, in many cases, become part of the problem. If you come to consultation with that pattern, withdrawal is done in a structured and gradual way, never abruptly, alongside the start of CBT-I.
Melatonin is mainly useful in circadian rhythm disorders (jet lag, delayed sleep phase in adolescents and young adults), not as a sleeping aid for common insomnia.
What does help day to day
Without replacing clinical treatment, several measures have good evidence:
- Regular schedule for going to bed and getting up, including at weekends.
- Bed only for sleep. Working, eating or watching series in bed weakens the bed-sleep association.
- No screens in the 60 minutes before sleep. Phone out of the bedroom.
- Caffeine avoided after 2-3 p.m. Its half-life is long in sensitive people.
- Alcohol: helps falling asleep but destroys the second half of the night. Not a good ally.
- Cool, dark, quiet bedroom.
- Regular exercise, ideally in the morning or early afternoon, not in the two hours before bed.
- Racing mind at bedtime: writing pending tasks and worries in a notebook earlier in the evening, outside the bedroom, releases the rumination load.
When to seek consultation
A professional assessment is worth considering when:
- Insomnia lasts more than three months.
- There is a clear functional impact: performance, mood, accidents or family conflict.
- You have been using sleeping pills for months or years and cannot stop them.
- There is early awakening accompanied by sadness, anhedonia or hopelessness.
- Atypical symptoms appear: heavy snoring with pauses, sleep paralysis, unusual behaviours during sleep.
- You have tried sleep hygiene measures and the picture does not improve.
More information on frequently overlapping or co-existing conditions in the articles on burnout in expats and ADHD in adults.
Conclusion
Insomnia is not a lack of willpower or a personal failing. It is a clinical condition with effective treatment when taken seriously. The good news: CBT-I works, without producing dependence, and its effects are sustained over time. Medication has its place, but as a punctual support, not as a fundamental solution. The earlier an insomnia that already meets criteria for chronicity is treated, the less likely it is to settle in for years.
Clinical references
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). APA, 2022.
- Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med, 2021; 17(2): 255-262.
- National Institute for Health and Care Excellence (NICE). Insomnia: management. Clinical Knowledge Summary, updated 2022. Access
- Riemann D, Espie CA, Altena E, et al. The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. J Sleep Res, 2023; 32(6): e14035.
- Wilson S, Anderson K, Baldwin D, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update. J Psychopharmacol, 2019; 33(8): 923-947. Access
About the author: Dr Daniel S. Cohen. Psychiatrist in Madrid, specialist in adult psychiatry and in child and adolescent psychiatry. Medical Director of Clínica Colev. Medical licence number 28/4003040 (Madrid Medical Council, ICOMEM). Available in Spanish, French, English and Hebrew. See professional profile.