"People can get themselves into this vicious cycle of worrying about sleep.
And if this happens night after night, just going to bed can become the cue that triggers the fight-or-flight response." ~ Dr. Leon Lack

If you’ve ever laid in bed watching the clock while your mind races, you know this feeling.

For many people living with fibromyalgia, insomnia is one of the most frustrating symptoms — especially when it becomes chronic. Not just trouble falling asleep once in a while, but the kind of pattern where your body feels exhausted, your brain won’t shut off, and night after night you’re left wondering why sleep just isn’t happening.

To help us understand what’s happening — and what actually helps — I’m joined once again by Dr. Leon Lack.

Dr. Lack is a sleep researcher and Professor Emeritus at Flinders University in Australia. He has spent decades studying circadian rhythms and insomnia, and his research has helped shape many of the behavioral treatments used today.

You may remember him from Episode 173 of the Fibromyalgia Podcast^® and its companion article, Fibromyalgia, Sleep, and Your Body Clock.

Today, we go deeper into insomnia — what causes it, why it can persist, and how you can begin retraining your sleep using approaches like Cognitive Behavioral Therapy for Insomnia (CBT-I).

What Is Insomnia? Symptoms and Causes

Let’s start with the basics. What is insomnia?

Dr. Leon Lack:
Insomnia is a fairly general term. It usually refers to people having difficulty with their sleep — but that difficulty can take several different forms.

Some people have trouble falling asleep when they first go to bed. For example, they may want to be asleep by 11:00 p.m. because they know they need to wake up at 6:30 or 7:00 in the morning to get enough rest. So they head to bed and try to do all the “right” things.

You may have heard strict “sleep rules” before — but not all of them are strongly supported by research.

A common example is the idea that you shouldn’t exercise in the evening because it will stimulate you too much. In reality, the evidence doesn’t support that very strongly. If the only time someone can get to the gym is between seven and eight at night, it’s still better to exercise. That’s unlikely to have much negative impact on sleep — and it may even help.

How Insomnia Becomes Chronic

A typical insomnia pattern looks something like this: a person goes to bed, turns off the lights, gets comfortable… and then nothing happens.

Adrenaline starts flowing, your heart rate increases, and blood flow shifts toward the muscles, preparing the body for action.

That’s not a state that’s very conducive to falling asleep.

The more someone tries to force sleep to happen, the more alert the brain becomes — which is part of what keeps insomnia going. Over time, your brain can start to associate the bed with wakefulness instead of sleep, so simply getting into bed can trigger alertness instead of sleep.

Acute vs. Chronic Insomnia: How Sleep Problems Become Long-Term

Is there a difference between occasional insomnia and chronic insomnia?

Dr. Lack:
Yes. In the sleep field, we distinguish between acute insomnia and chronic insomnia.

Acute insomnia usually occurs in response to a stressful event — things like the loss of a loved one, losing a job, or other major life disruptions. In the past, acute insomnia was defined as insomnia lasting up to about one month.

More recently, that definition has been expanded somewhat, and acute insomnia may now be considered to last up to about three months.

Once insomnia continues beyond that point, it’s generally considered chronic insomnia. At that stage, it’s very likely that conditioned insomnia has developed. This learned pattern is what keeps sleep problems going, even after the original trigger is gone. Your brain has learned to stay awake in situations where it used to sleep.

This conditioning can develop more quickly than you realize.

Tami:
I see this with many of my coaching clients. After a while, they develop an almost PTSD-like response to sleep. Just thinking about sleep can make them unable to fall asleep.

Fatigue vs. Sleepiness: Why You Can Feel Exhausted but Not Sleepy

You talked about fatigue and you talked about sleepiness as two separate things. Could you clarify that a bit for us?

Dr. Lack:
Yes — they are different concepts, even though people often use them interchangeably.

We’ve actually studied this by looking at how people understand words like fatigue, tiredness, and sleepiness.

What we found is that people experience these as quite different states.

Sleepiness isn’t usually seen as something negative. It’s more of a natural state — a signal that the body is ready for sleep.

Fatigue, on the other hand, is experienced as much more unpleasant and more intense.

Tiredness tends to fall somewhere in between the two.

So even though people may use these words in similar ways, they’re describing very different experiences— which is why you can feel completely exhausted but still not be ready for sleep.

How Is Chronic Insomnia Treated?

So when someone is dealing with insomnia, how is it usually treated?

Dr. Lack:
In the sleep field, the official recommendation is very clear: Cognitive Behavioral Therapy for Insomnia — usually called CBT-I — is considered the first-line treatment for chronic insomnia.

CBT-I is a structured, evidence-based approach that helps change the thoughts and behaviors that keep insomnia going.

The research evidence supporting it is overwhelming. In fact, CBT-I is generally more effective than medication, especially in the long term.

Pharmaceutical companies have spent decades trying to develop the ideal sleep medication. They’ve tested one drug after another, and while many of them can produce a small benefit in the short term, none of them actually address the underlying cause of chronic insomnia.

Most sleep medications reduce symptoms temporarily. They can help someone sleep a little better while they’re taking them, but when the medication is stopped, the insomnia often returns. That’s because the underlying problem — conditioned insomnia — hasn’t been treated.

From a scientific standpoint, CBT-I is clearly the most effective long-term insomnia treatment.

The practical challenge, however, is access — there simply aren’t enough clinicians trained in CBT-I. Even in large countries like the United States or Australia, the number of practitioners who specialize in this therapy is very small compared to the millions of people dealing with chronic insomnia.

That creates a difficult situation. The recommended treatment exists — but for many people, it’s very hard to find someone who can provide it.

How CBT-I Works to Retrain Your Brain for Sleep

So let's talk about CBT-I. Many people will have heard of cognitive behavioral therapy (CBT), but they might not be aware of CBT-I. It's essentially CBT specifically for insomnia, right?

Dr. Lack:
That's right.

In CBT-I, the behavioral part of the treatment is usually the most important — and often the quickest place to start.

The cognitive part can still be helpful, especially in helping people rethink some of the worries and assumptions they have about sleep — but it’s more like icing on the cake. While thoughts can play a role, the behavioral pieces of CBT-I are what drive the biggest changes.

Over time, chronic insomnia often becomes conditioned. The brain starts to associate the bed and bedtime with being awake rather than asleep. Instead of the bed acting as a cue for sleep, it can become a cue for frustration, worry, and alertness.

CBT-I focuses on reversing that learned association. The goal isn’t just to help you sleep — it’s to retrain your brain’s connection between bed and sleep.

To do that, the therapy uses a set of very specific behavioral strategies that help change the patterns reinforcing insomnia. Over time, those changes help restore the natural connection between the bed and sleep.

Re-Training Your Brain for Sleep

What are some of the behavioral strategies used in CBT-I?

Dr. Lack:
One of the most important techniques is called stimulus control.

The idea is simple: the bed should become a strong cue for sleep again.

When someone has been dealing with insomnia for a long time, they often spend hours lying awake in bed — worrying, thinking, and trying to force sleep to happen.

Sleep isn’t something you can force — trying harder often makes it more difficult.

Over time, people can start to associate the bed with being awake rather than sleeping — and stimulus control is designed to reverse that pattern.

That means using the bed only for sleep — not for worrying, watching television, or staying awake for long periods.

If someone goes to bed and finds they can’t fall asleep after a while, the recommendation is actually to get out of bed and go to another room to do something quiet and relaxing for a short time.

What matters most here isn’t choosing the “perfect” activity — it’s breaking the pattern of being awake in bed. When they start to feel sleepy again, they return to bed and try again.

Over time, this helps retrain the brain so that the bed once again becomes a powerful cue for sleep.

Why Spending Less Time in Bed Can Improve Sleep

What’s another strategy used in CBT-I?

Dr. Lack:
Another key technique is called sleep restriction — although a better way to think about it is limiting time in bed.

When people develop insomnia, they often start spending more time in bed trying to get enough sleep. They may lie awake for long periods, hoping sleep will eventually come. The problem is that this can actually make sleep more fragmented. Instead of building strong sleep pressure, the brain begins to associate the bed with wakefulness instead of sleep.

Sleep restriction works by temporarily limiting time in bed to a narrower sleep window based on the person’s current sleep pattern. At first, that can feel a little counterintuitive, because it may mean spending fewer hours in bed than someone expects. But the goal is to build more sleep pressure so the person falls asleep more quickly and stays asleep more consistently.

Once sleep becomes more stable, the amount of time in bed can gradually be increased again, helping restore a more regular and efficient sleep pattern over time.

Resetting Your Body Clock for Better Sleep

We talked quite a bit in our last interview about circadian rhythms and the body clock. How does that connect with insomnia?

Dr. Lack:
Our sleep is strongly influenced by the body’s circadian rhythm — the internal clock that regulates when we feel alert and when we feel sleepy.

For many people with insomnia, that rhythm can drift later over time. Irregular sleep schedules or late nights can gradually push the body clock later, making it harder to fall asleep at the desired time. One of the most powerful signals for stabilizing the body clock is morning light. Exposure to bright light shortly after waking helps signal to the brain that the day has begun, which in turn helps regulate when the body becomes sleepy later that night.

Editor's Note: We explored the connection between fibromyalgia, circadian rhythm, and morning light in more detail in a previous conversation with Dr. Lack. If you’d like to go deeper into how your body clock influences sleep, you can explore that here: Fibromyalgia, Sleep, and Your Body Clock.

Want to better understand how your body clock affects sleep?
Read: Fibromyalgia, Sleep, and Your Body Clock

Finding CBT-I Treatment and Support

The last question I want to ask about is access to CBT-I. We talked earlier about how effective it can be, but there aren’t many practitioners trained in it. What about online programs or apps? Are those helpful, or is it something people should try to do on their own?

Dr. Lack:
If people are convinced enough of the rationale behind CBT-I and are willing to follow the instructions carefully, many of the strategies can work when applied on their own. That said, most people find it much easier when they have some support.

We’re social creatures, and having someone paying attention — offering feedback and encouragement — can make a big difference in whether people actually stick with the program. Some of the instructions can sound difficult at first, but when people understand why they’re doing them and have someone helping them stay accountable, the results can be very good.

If you’re interested in working with someone trained in CBT-I, check out the CBT-I International Directory, which allows you to search for providers by location.

The number of trained practitioners is still relatively small, but it is growing. In most larger cities there are at least a few people offering this treatment.

Tami:
Accountability can make a big difference. When I was working on improving my own sleep years ago, I actually had a friend acting as my “sleep coach.” She had me text her every night when I went to bed. If she didn’t hear from me, I’d get a message asking, “Are you going to bed?”

Not all of us are naturally internally accountable. Sometimes we need that external support.

Dr. Lack:
Exactly. It’s a bit like having a personal trainer at the gym. That one-on-one encouragement often helps people stick with the program long enough to see real results. 

What This Means for Your Sleep

All of this points to something many people don’t realize at first:

Chronic insomnia isn’t just about not sleeping well.

It’s about patterns your brain has learned over time — patterns that can keep sleep disrupted, even after the original cause is gone.

That can feel frustrating, especially if you’ve tried to “do everything right” and sleep still isn’t happening.

But it also tells us something important:

If insomnia is learned, it can also be unlearned.

That doesn’t mean the process is always easy — especially when sleep is connected to pain, fatigue, and your nervous system.

But it does mean there’s a path forward.

Action Steps

If insomnia is something your brain has learned, it also means those patterns can change.

A good first step is to talk with your primary care provider and ask for a referral to a sleep specialist. A specialist can help rule out other sleep disorders, like periodic limb movement disorder or sleep apnea — which affects about 45% of people with fibromyalgia [1] — and may be contributing to your sleep issues.

A sleep specialist may also be able to provide CBT-I or refer you to someone who can.

You can also search the CBT-I International Directory to find a trained provider in your area.

If you want additional support, working with a Certified Fibromyalgia Coach^® can help you:

• understand what’s happening in your body
• find the right providers
• apply strategies in a way that fits your body
• stay consistent when it gets hard

As Dr. Lack shared, “One-on-one encouragement often helps people stick with the program long enough to see real results.”

Frequently Asked Questions (FAQ)