Quick Summary: When you can't sleep night after night, the frustration compounds. You've tried everything, but nothing works. The problem is that "I can't sleep" doesn't always mean the same thing—chronic sleep problems have many different causes, and what helps depends entirely on accurate diagnosis. Sleep apnea, restless legs syndrome, thyroid disorders, circadian rhythm problems, and medication effects can all disrupt sleep in ways that mimic insomnia but require different treatments. True insomnia—difficulty falling or staying asleep despite having the opportunity—is distinct from these conditions. It's often driven by anxiety, stress, and nervous system hyperarousal that keeps you wired when you should be winding down. The good news: if other medical causes are ruled out and it is insomnia, there's a highly effective, evidence-based treatment. Cognitive Behavioral Therapy for Insomnia (CBT-I) addresses the root causes rather than just masking symptoms. Understanding what's actually keeping you awake is the first step toward finally getting the rest you need.

Why Can't I Sleep? Understanding the Real Reasons Behind Chronic Sleep Problems (And What Actually Helps)

There's a particular kind of exhaustion that comes from lying awake night after night, watching the hours pass, knowing you need sleep but unable to access it. You've tried warm milk, meditation apps, blackout curtains, magnesium supplements. Some nights you fall asleep only to wake at three in the morning. Other nights you can't fall asleep at all, despite being bone-tired.

When sleep problems become chronic, the question shifts from "How do I sleep tonight?" to "What's actually wrong with me?" This is the right question, but it doesn't have a simple answer. Chronic sleep problems can stem from dozens of different causes, and what's keeping you awake might be entirely different from what's disrupting someone else's sleep.

Understanding the landscape of sleep disorders is essential. Some require medical treatment. Others need specialized interventions. And if what you're experiencing is true insomnia, there's highly effective, evidence-based therapy that addresses root causes rather than just symptoms.

The Landscape of Sleep Problems: It's Not All Insomnia

When you say "I can't sleep," you might mean you can't fall asleep, can't stay asleep, wake too early, or feel unrefreshed no matter how long you're in bed. Each pattern can point toward different issues.

The International Classification of Sleep Disorders recognizes over 80 distinct sleep disorders, including insomnia, sleep-related breathing disorders, circadian rhythm disorders, parasomnias, and sleep-related movement disorders. This complexity is actually helpful—it means if one approach hasn't worked, you might be addressing the wrong problem.

Different sleep disorders require different interventions. Sleep hygiene advice that might help one condition could be irrelevant or counterproductive for another. If you have sleep apnea, no amount of meditation will fix the breathing problem. If you have delayed sleep phase disorder, trying to force yourself to sleep earlier often makes things worse.

Common Medical Conditions That Disrupt Sleep

Sleep Apnea: This affects up to 20% of people. Your airway becomes blocked during sleep, causing repeated breathing interruptions—sometimes hundreds per night. You're usually not aware this is happening, but you wake exhausted with headaches. Other signs include loud snoring, gasping during sleep, and excessive daytime sleepiness. Untreated sleep apnea increases risk for serious health problems. Treatment typically involves CPAP therapy or other interventions.

Restless Legs Syndrome: RLS creates uncomfortable sensations in your legs—crawling, tingling, aching—that create an irresistible urge to move. Symptoms worsen at night, making sleep onset nearly impossible. RLS can relate to iron deficiency, kidney disease, or certain medications. Treatment depends on identifying underlying causes.

Thyroid Disorders: When thyroid function is disrupted, sleep often suffers. Hyperthyroidism causes difficulty falling asleep due to nervous system activation, rapid heartbeat, and night sweats. Hypothyroidism can disrupt sleep through joint pain, cold intolerance, and increased anxiety. It also increases risk for sleep apnea and restless legs syndrome.

Other Medical Issues: Chronic pain, GERD, asthma, and neurological conditions can all make sleep difficult. The relationship is often bidirectional—the condition disrupts sleep, and poor sleep exacerbates the condition.

Circadian Rhythm Disorders and Medication Effects

Your circadian rhythm is your internal biological clock. Circadian rhythm disorders occur when this clock is out of sync with external demands. Delayed sleep phase disorder means you can't fall asleep until very late but sleep soundly once you do. Advanced sleep phase disorder is the opposite. Shift work disorder affects those whose schedules require wakefulness during natural sleep times. These aren't insomnia—your sleep system works fine on a different schedule.

Many substances and medications disrupt sleep. Caffeine has a five-hour half-life, meaning afternoon coffee affects bedtime. Alcohol helps you fall asleep initially but fragments sleep later. Stimulants, certain antidepressants, corticosteroids, and decongestants can all cause sleep disruption. Even sleep medications themselves can perpetuate problems through tolerance and rebound insomnia.

When It Actually Is Insomnia

Insomnia is difficulty falling asleep, staying asleep, or waking too early—despite having adequate opportunity and appropriate environment for sleep. That last part matters. If you can't sleep because of external disruptions, that's not insomnia. Insomnia is when you have time, space, and circumstances for sleep, but sleep won't come.

Chronic insomnia lasts at least three months, occurring at least three nights weekly. It affects roughly 10% of adults at diagnosable levels. The primary problem isn't breathing, movement, or circadian timing. The sleep system itself is intact. Psychological and behavioral factors are preventing it from functioning.

Even when insomnia begins during stress or illness, it often persists after the original cause resolves. This happens because insomnia develops its own maintaining factors. You might spend extra time in bed trying to "catch up," which weakens sleep drive. You develop anxiety about sleep itself—monitoring whether you're falling asleep, calculating hours you'll get, worrying about tomorrow. Your bed becomes associated with wakefulness and frustration.

Many people with chronic insomnia describe feeling "tired but wired"—physically exhausted but mentally unable to settle. This reflects hyperarousal: elevated physiological and cognitive activation incompatible with sleep. Anxiety plays a central role, whether generalized anxiety manifesting at bedtime or anxiety specifically about sleep. Some people have high "sleep reactivity"—their sleep is particularly vulnerable to stress disruption.

How Do You Know What's Causing Your Sleep Problems?

Consider these patterns:

• Loud snoring, gasping, or witnessed breathing pauses → possible sleep apnea

• Uncomfortable leg sensations worse in evening → restless legs syndrome

• Easy sleep on your natural schedule but struggle with conventional times → circadian rhythm issues

• Difficulty sleeping despite exhaustion, adequate time, and good environment → insomnia

• Other physical symptoms (weight changes, temperature sensitivity, pain) → underlying medical conditions

When sleep problems persist, self-diagnosis is risky. Many disorders share overlapping symptoms. If you've been experiencing chronic sleep problems—lasting more than a few months, significantly affecting daytime functioning, or with symptoms suggesting specific disorders—consultation with a healthcare provider or sleep specialist is warranted.

If It Is Insomnia, There's a Solution

Once medical causes are evaluated and other sleep disorders ruled out, the good news: Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia. Unlike sleep medications that produce temporary sedation, CBT-I targets factors that maintain insomnia.

Research shows CBT-I produces improvements that match or exceed sleep medications, with benefits persisting after treatment ends. Studies show average reductions of 20 minutes in time to fall asleep and 25-30 minutes in nighttime wakefulness, plus improvements in sleep efficiency, daytime functioning, energy, and mood.

CBT-I differs from generic sleep hygiene advice. It's structured therapy delivered over 6-8 sessions addressing specific patterns maintaining insomnia:

Sleep restriction temporarily limits time in bed to match actual sleep time, consolidating fragmented sleep and rebuilding sleep drive. Stimulus control re-associates your bed with sleep rather than wakefulness. Cognitive restructuring helps modify anxious thoughts about sleep. Relaxation training teaches arousal reduction techniques.

When therapists integrate Acceptance and Commitment Therapy principles, you learn to change your relationship with difficult experiences—noticing anxious thoughts without getting caught up in them, accepting discomfort rather than fighting it. How CBT-I and ACT work together to treat insomnia creates comprehensive treatment.

Evidence-based CBT-I therapy begins with thorough assessment, typically using sleep diaries. Treatment is collaborative with specific homework between sessions. The work isn't always comfortable—you might feel more tired initially as sleep restriction takes effect. But temporary discomforts lead to lasting improvements.

Most people see improvements within weeks. Unlike medication that stops working when you stop taking it, CBT-I skills continue serving you. What to expect in your first CBT-I session typically involves discussing sleep history, current patterns, and understanding maintaining factors.

For people whose insomnia is intertwined with chronic stress or trauma, trauma-informed approaches adapt techniques for nervous system dysregulation. When insomnia occurs alongside depression, integrated treatment addresses both simultaneously.

What Should You Do If You Can't Sleep?

If you're struggling with chronic sleep problems, here's a reasonable approach:

First, consider medical factors. If you snore heavily, have witnessed breathing pauses, experience uncomfortable leg sensations, have unexplained physical symptoms, or take medications affecting sleep, discuss these with your healthcare provider. Sometimes sleep studies or evaluations are needed.

Assess substance use. Review caffeine intake (including timing), alcohol consumption, and medications. These might contribute more than you realize.

If medical causes are ruled out and the pattern fits insomnia, consider seeking specialized help rather than continuing alone. Working with a therapist trained in CBT-I means you don't have to figure this out through years of trial and error.

Avoid endlessly trying new sleep aids without guidance. The search for solutions can itself become part of the problem, keeping your mind focused on sleep as something fragile requiring constant management.

Remember accurate diagnosis matters. Trying to treat sleep apnea with meditation or circadian rhythm disorder with sleep restriction won't work because you're addressing the wrong problem.

Moving Forward

When you can't sleep night after night, it's easy to feel hopeless. But chronic sleep problems are usually more fixable than they feel. The complexity of sleep disorders is encouraging—if what you've tried hasn't worked, you might simply be addressing the wrong cause.

If other medical causes are ruled out and you're dealing with insomnia, you're looking at a problem with robust, well-researched solutions. CBT-I has decades of research supporting it. It works not by forcing sleep but by addressing factors preventing your natural sleep system from functioning.

You don't have to keep suffering alone or spend years cycling through supplements and sleep tips that don't address the real problem. Professional evaluation can clarify what you're actually dealing with, and appropriate treatment can help you finally get rest. Your body hasn't forgotten how to sleep. It just needs the right kind of help.