Insomnia That Started With Something Else

It’s a common and confusing situation. Insomnia began during a hard stretch, the hard stretch ended, and the insomnia stayed. Insomnia that starts during a hard stretch usually settles: in a U.S. study that followed good sleepers for a year, 72% of those who developed short-term insomnia went back to sleeping well. But for some people it persists after the stretch ends. Once insomnia is chronic, meaning trouble sleeping at least 3 nights a week for at least 3 months, it often lasts: in a 3-year study of adults with insomnia, about three in four still had it a year later. That isn’t a failure to move on. It reflects something specific about how chronic insomnia works: the things that start it and the things that keep it going are often different, so removing the original cause doesn’t always fix it.

The Three-Factor Model

Sleep researchers often describe insomnia in terms of three kinds of factors. It’s a framework first described in the 1980s, and a practical one.

• Predisposing factors are the baseline vulnerability: a tendency toward light sleep, a mind that runs “on” easily, or a tendency toward anxiety. These are there before any insomnia is.
• Precipitating factors are whatever started it: a loss, a job change, an illness, a new baby, a stretch of shift work, a medication.
• Perpetuating factors are what keep it going after the trigger has passed, and they’re what treatment targets. They’re largely habits and learned patterns, along with arousal: behaviors such as spending extra time in bed and lying awake in bed, alongside thought patterns such as worrying about sleep, feeling keyed up before bed and unhelpful beliefs about sleep.

When someone still has insomnia two years after a divorce, the perpetuating factors often play a large role. Working through the divorce still matters, but on its own it may not change them. Researchers are still learning who recovers and who doesn’t: in one study of people with recent insomnia, a previous episode of insomnia, higher depression scores and more worry about sleep predicted that it was still there a month later.

What the Perpetuating Factors Actually Are

• Spending longer in bed. This is one of the most common and least helpful. After a few bad nights, people go to bed earlier and stay in bed later to catch more sleep. The result is more time lying awake, more broken sleep, and a stronger link in the brain between the bed and being awake. That’s why CBT-I limits time in bed to about the time you actually sleep.
• Conditioned arousal. After enough frustrated nights awake, the bed itself can become a cue for alertness. Many people describe being exhausted on the sofa and wide awake minutes after lying down. That’s often this learned link at work, not a coincidence.
• Effort. Trying to sleep tends to backfire. Sleep effort, the conscious push to make sleep happen, is a recognized feature of insomnia, and sleep doesn’t respond to effort the way most things do.
• Monitoring. Checking the clock at night, counting the hours left or obsessing over sleep-tracker scores can raise your alertness at exactly the wrong time. In one study, watching the clock while trying to fall asleep led to more worry and taking longer to fall asleep, and sleep clinicians have described patients preoccupied with their sleep-tracker data. A simple sleep diary is different: it’s a normal part of CBT-I, used to plan treatment.
• Worrying ahead. Worrying during the day about whether you’ll sleep tonight builds tension before bedtime even starts.
• Making up for it. Long naps, sleeping in, more caffeine, and alcohol each ease today’s problem and can make tomorrow night harder. Long daytime naps, a changing sleep schedule and alcohol can all feed insomnia, and although alcohol can make it easier to fall asleep, it makes sleep lighter, so you’re more likely to wake up.
• Beliefs about sleep. That you need an exact number of hours, that one bad night will ruin tomorrow, that you’ve lost the ability to sleep. These beliefs create the anxiety that keeps insomnia going.

Why This Explains So Much

It explains why treating depression doesn’t always fix the insomnia that came with it. Insomnia is one of the most common symptoms left over after depression improves. It helps explain why insomnia that started with a newborn can last long after the baby sleeps through the night, and why taking away the stressor sometimes changes nothing.

It also explains why sleep medication on its own often doesn’t resolve it. Medication can help you sleep in the short term, but it doesn’t change conditioned arousal, extra time in bed or beliefs about sleep. In a trial in older adults, gains were better sustained with behavioral treatment than with medication alone. Stopping sleeping pills, mainly benzodiazepines and “Z-drugs” (zolpidem, eszopiclone, zaleplon), can bring rebound insomnia, a temporary worsening of sleep that in the drug labels’ studies was usually limited to the first night or two (zolpidem label). Stopping after long-term use, especially suddenly, can also cause withdrawal, which with benzodiazepines can be serious, so they’re lowered with a gradual taper. Please don’t stop a medication on your own; some can cause withdrawal symptoms or a return of symptoms if stopped suddenly.

What Actually Addresses It

Cognitive behavioral therapy for insomnia (CBT-I) goes straight at the perpetuating factors, which is why it works when general sleep advice often doesn’t. It’s recommended as the first treatment for chronic insomnia in adults. Our post CBT-I: What It Is and Why It Works goes into more detail. The main pieces:

• Sleep restriction cuts back the extra time in bed, so sleep becomes more solid and your natural sleep drive builds again.
• Stimulus control breaks the link between the bed and being awake: using the bed only for sleep, and getting up when sleep doesn’t come.
• Cognitive work takes on the beliefs about sleep and the worry ahead of bedtime.
• Dropping the make-up habits: the long naps, the sleeping in, the alcohol.

CBT-I is typically 4 to 8 sessions, and its benefits tend to last beyond the end of treatment because it changes what keeps the insomnia going, not just the symptom. Shorter versions, called brief therapies for insomnia (usually 1 to 4 sessions), are another option, and CBT-I is offered one-on-one, in groups, by telehealth and through online programs. The early weeks can bring extra daytime sleepiness, so be careful about drowsy driving, and take care getting out of bed at night if you’re at risk of falls, as some older adults are. Sleep restriction isn’t right for everyone, including people prone to mania, people with poorly controlled seizures and people in safety-sensitive jobs, so it’s best done with a trained clinician. We don’t offer standalone weekly therapy, but we’re happy to help you find a therapist and, with your permission, we’ll coordinate with them.

What Still Needs Checking

Perpetuating factors explain a lot, but not everything. CBT-I can start alongside treatment for anxiety or depression; it has been studied in people with depression, PTSD, anxiety and other conditions. It’s also worth making sure nothing is still actively driving the insomnia. Common drivers include:

• Anxiety or depression that’s still active
• Sleep apnea
• Restless legs syndrome
• Alcohol
• A medication, or stopping one
• Pain from another condition
• A body clock that’s out of step with your schedule
• An overactive thyroid
• Menopause

Any of these can keep producing insomnia no matter how well the habits are handled. Looking for a psychiatrist in New Jersey to help with sleep? Our providers are board-certified psychiatric nurse practitioners (PMHNPs), who provide psychiatric evaluation and medication management. They can look at whether anxiety, depression or a medication is still feeding the insomnia, and tell you when it makes sense to see your primary care provider or a sleep medicine provider to check for something like sleep apnea or restless legs syndrome. Our sleep disorders page covers how sleep and mental health affect each other.

Why This Way of Seeing It Is Reassuring

Many people with long-standing insomnia have reached a fairly grim conclusion about themselves: that they’re just someone who can’t sleep, that their brain is broken, or that they’ve lost something most people have.

The three-factor model points somewhere else. The perpetuating factors are habits and beliefs, and those can change. Someone who has had insomnia for ten years isn’t a person with a permanently damaged sleep system; they’re a person in whom the same set of patterns has been running for ten years.

That shift matters in practice as well as emotionally. CBT-I asks for real effort over several weeks, and parts of it can feel uncomfortable at first. Seeing insomnia as a pattern that’s being kept going, rather than a fixed flaw, can make that effort feel worth it.

Frequently Asked Questions

Why do I still have insomnia after the stressful period ended?

Because what starts insomnia and what keeps it going are often different. Insomnia that began with a specific stressor is often kept going afterward by habits and thought patterns: extra time in bed, a learned link between the bed and being awake, trying hard to sleep, watching the clock, and worried beliefs about sleep. Removing the original cause doesn’t change those.

Why am I exhausted until I get into bed?

This is often conditioned arousal. After enough nights lying awake frustrated, the bed can become a learned cue for alertness rather than sleep. It’s a learned response, not a personal failing, and stimulus control (using the bed only for sleep and getting up when sleep doesn’t come) is designed to undo it.

Will treating my anxiety fix my insomnia?

Sometimes, but often not completely. If anxiety is actively driving the insomnia, treating it can help a lot. If the insomnia has started running on its own habits and patterns, those need attention too, and CBT-I can start alongside treatment for anxiety. That’s one reason people sometimes find their mood improves with treatment while their sleep doesn’t.

Why doesn’t sleep medication fix chronic insomnia on its own?

Medication can help you sleep, but it doesn’t change the patterns keeping the problem going: the learned link between bed and alertness, extra time in bed, effort and beliefs about sleep. Stopping a sleep aid suddenly can also bring rebound insomnia. CBT-I works differently because it targets those patterns, which is why its benefits tend to last. Talk with your provider before changing any medication.

What starts insomnia and what keeps it going are often different things. That’s why the stressor ending doesn’t always help, and why treating what keeps it going does. If sleep has been hard for a while, a psychiatric evaluation can look at whether anxiety, depression or a medication is part of the picture. Medication management can treat anxiety or depression that’s feeding the insomnia. CBT-I remains the recommended first treatment for the insomnia itself, and sleep medication, when it’s used, is usually considered short term, added when CBT-I alone hasn’t been enough.