Why is Insomnia So Hard to Fix? The Vicious Cycles of Chronic Insomnia

Updated: Oct 1, 2020

It is normal to have an occasional poor night’s sleep.

A sleepless night can be triggered by a number of different things. We can understand these various triggers through the framework for understanding sleeplessness described in this article.

Initial causes

Sleeplessness (not being able to fall asleep, not being able to maintain sleep, or not being sleepy in time for adequate sleep) can be due to one or both of the following:

  1. Your body not having enough sleep potential and/or

  2. Your body and mind not being deactivated enough

Anything that reduces sleep potential or increases activation has the potential to trigger a poor night’s sleep.

The initial cause(s) of sleeplessness may due to

  • not enough sleep potential due to lower sleep drive: be sleeping-in, napping

  • not enough sleep potential due to mismatch between your sleep schedule and your body clock: travelling from a different time zone, returning to school after sleeping on a later schedule during summer vacation

  • anything that reduces your body and mind's ability to deactivate for sleep: a night in which you were drawn into one too many YouTube videos, exercising too late, a noisy neighbour, a new sleep environment, a heatwave, stress over an upcoming deadline, an argument, a mistake made at work, exciting news, a medical illness, pain, etc.

Perpetuating causes of chronic insomnia

For some, once the initial cause of sleeplessness resolves, sleep gets back on track.

For others, the initial cause may resolve but the inability to sleep remains and insomnia takes on a life of its own.

Chronic insomnia develops for two main reasons:

  1. Higher activation due to sleep anxiety and behavioural changes in response to sleeplessness and exhaustion

  2. Less sleep potential due behavioural change in response to sleeplessness and exhaustion

Causes of increased activation in chronic insomnia

After a poor night’s sleep or a string of bad nights, a common and very understandable reaction is to become more preoccupied with sleep and the impact of poor sleep. This increased sleep preoccupation contributes to heightened anxiety and activation when trying to sleep.

Another very common and powerful factor that increases activation is that the bed becomes paired with high activation. Over time, the bed becomes a cue for the body and mind to enter a state of high activation when in bed.

It's not uncommon to respond to insomnia by spending more time awake in bed (both due to fatigue and also often with the hope for more sleep). Unfortunately, more and more time awake in bed strengthens this negative association.

Causes of lower sleep potential in chronic insomnia

Another common way of managing sleeplessness and the associated exhaustion is to sleep whenever possible and to reduce daytime activities as a way of conserving energy.

While these behaviours help in the moment (for example, you will likely feel better by sleeping in when you can), these behaviours unfortunately worsen insomnia in the long run.

Sleeping in, napping, and reducing activities all result in lower sleep drive for nighttime sleep.

In addition, sleeping in and not getting sunlight until later in the day can delay the body clock and increase mismatch between the clock and the desired sleep schedule.

In the sleep world, these helpful-in-the moment, harmful-overall behaviours are called maladaptive compensatory behaviours.

Chronic insomnia as a vicious cycle

Chronic insomnia is essentially a vicious cycle starting with sleeplessness, resulting in an increase in anxiety and exhaustion, followed by maladaptive compensatory behaviours that further perpetuate insomnia.

As this cycle continues day after day, insomnia takes a firm hold and becomes chronic.

Activation becomes higher and higher due to sleep anxiety and the conditioned response in bed while sleep potential generally becomes lower and lower due to compensatory behaviours like napping, sleeping in, and being less active.

Though acute insomnia is driven primarily by the initial triggers, with time, the main factors that drive chronic insomnia are these perpetuating factors. This explains why the initial trigger for insomnia can resolve but insomnia still persists and, often, worsens with time.

Addressing chronic insomnia

The overarching goals of addressing chronic insomnia are the same as when addressing less severe forms of sleeplessness:

  • building enough sleep potential

  • deactivate in time for a good night’s sleep

It is, however, much harder to follow through and stay on track with general sleep advice when you are struggling with chronic insomnia.

This is due to the amount of anxiety that surrounds sleep and the loss of confidence regarding sleep.

For example, it is difficult to avoid naps consistently when you have not been able to sleep well for days, weeks, or months. It feels completely counterintuitive in the face of overwhelming exhaustion and uncertainty about when sleep will next come.

When you’ve had the repeated experience that sleep doesn’t come easily, the attitude of ‘taking what sleep you can get’ is completely understandable. It’s, unfortunately, just not very helpful and keeps you stuck in the vicious cycle.

For someone who is not struggling with chronic insomnia and, therefore, the sleep anxiety and exhaustion is not as high, it is easier to follow-through with healthy sleep practices (for example, no napping, waking-up at a regular time, reducing coffee, etc.). There is also typically more flexibility to occasionally sleep-in, nap, or have an afternoon coffee because activation is not as high.

In chronic insomnia, often very high sleep potential is needed to override the very high activation. To treat chronic insomnia effectively, an intensive, time-limited, and coordinated effort is often needed to break out of the vicious cycle.

Cognitive-behavioural therapy for insomnia (CBT-I) typically can accomplish this in a few weeks with the use of a few key sleep interventions (sleep restriction therapy, stimulus control, sleep hygiene) to quickly boost sleep potential and reduce high activation. Other CBT-I strategies (relaxation and cognitive strategies) also target the high activation.

Once out of the vicious cycle, it then becomes much easier to maintain healthy sleep practices. Less effort, attention and care is required to keep sleep on track.

If you are interested in learning more about CBT-I and options for accessing CBT-I, please read this article.

Please remember, not everyone requires CBT-I and it is worthwhile to start with these recommendations for preventing sleeplessness and responding to sleepless-in-the-moment regardless of whether or not you do a course of CBT-I.

A future course of CBT-I is always a good option to keep on the back-burner and call upon when you are ready for an ‘all-in’ approach and you are able to devote the time, attention, and effort required to break out of the vicious cycle of chronic insomnia.

76 views0 comments