Insomnia: Why Sleep Won't Come — and What Actually Helps

It's half past two in the morning. Your thoughts are racing, your eyes drift to the clock, and with every passing minute the pressure to finally fall asleep grows — which makes falling asleep even less likely. If this sounds familiar, you are far from alone: roughly one in ten adults has clinically relevant insomnia, meaning persistent difficulty falling or staying asleep with daytime consequences.

Sleep disorders are not a side topic in our practice. Alongside sleep apnea and weight, they are among the most common reasons people come to us — and in most cases they are very treatable, once the cause is understood.

When is poor sleep a disorder?

Occasional bad nights are normal. We speak of chronic insomnia when symptoms occur on at least three nights per week for at least three months and impair daytime performance, mood or health. What matters is the daytime burden — not the number of hours slept, but the suffering and the consequences: poor concentration, irritability, exhaustion.

The most common causes

Insomnia is a symptom, not a single disease. Key triggers include:

• Psychophysiological insomnia: an acute sleep crisis turns into a learned pattern of tension and "trying to force sleep."
• Stress and rumination: an overactive mind keeps the nervous system in wake mode.
• Shift work and social jet lag: a disrupted circadian rhythm.
• Substances: caffeine, alcohol, nicotine and certain medications.
• Physical causes: pain, an overactive thyroid, restless legs syndrome — and, often overlooked, obstructive sleep apnea.

When is there more behind it?

This is where an internal-medicine perspective pays off. Someone who sleeps poorly, snores loudly and still feels wrecked in the morning despite enough time in bed may not have pure insomnia but a sleep-related breathing disorder. We therefore rule out organic causes — with a sleep diary, targeted lab tests and, if apnea is suspected, an ambulatory polygraphy at home.

What actually helps: CBT-I, not a standing prescription

The key message first: the guideline-based first-line treatment for chronic insomnia is not a sleeping pill, but cognitive behavioural therapy for insomnia (CBT-I). European and international guidelines recommend it as the method of first choice — with proven, lasting effect.

CBT-I combines several elements: sleep restriction (time in bed is deliberately shortened at first to build sleep pressure), stimulus control (the bed is re-associated clearly with sleep), reducing rumination, and realistic education about sleep. It sounds unspectacular — but it is clearly superior to sleeping pills in the long run.

And sleep hygiene?

Sleep hygiene alone does not cure chronic insomnia, but it is the foundation. What works:

• regular wake-up and bedtimes — including weekends;
• using the bed only for sleep, not for working or worrying;
• dim, warm light in the evening instead of bright screens;
• avoiding caffeine after early afternoon and alcohol as a "sleep aid" (it fragments sleep);
• if you lie awake for about 20 minutes, get up rather than tossing and turning.

Why not just take a sleeping pill?

Sleeping pills have their place — short-term, in acute crises, clearly limited. The problem is long-term use: many lose effect after a few weeks, can cause dependence and may affect sleep architecture. Honest advice is part of our care — even when the answer is sometimes "not the prescription, but the method."

What we do in the practice

We take sleep disorders seriously and approach them in a structured way: a thorough history, a sleep diary, ruling out organic causes (sleep apnea, restless legs, thyroid) and a treatment plan tailored to your situation. Where CBT-I is appropriate, we outline the steps and follow your progress.

More on our approach on the Sleep Disorders page. If snoring or daytime fatigue is also involved, the sleep diagnostics page is worth a look — and if weight plays a role too, the two are often more closely linked than people think.