Key takeaways
- Insomnia is often more than a sleep problem. In many adults, especially when sleep disturbance sits alongside fatigue, anxiety, pain, gut symptoms or hormonal change, sleep is one expression of a wider regulation problem.
- Sleep hygiene matters, but it is not always enough. When the body is stuck in sympathetic overactivation, sleep hygiene may help, but it often does not reach the deeper physiology sustaining the pattern.
- Western and Eastern frameworks may be describing overlapping parts of the same human pattern. The West places the brain at the centre. The East places the heart. Both are concerned with a body that cannot down-regulate.
- The research on acupuncture for insomnia is more developed than many people realise, but study quality varies. The more interesting question is the mechanism: autonomic regulation, heart rate variability, melatonin rhythm, inflammatory signalling and limbic regulation.
- Chronic insomnia is not always solved by a single intervention. When sleep is one of several unresolved symptoms, the better question is often which systems are keeping the pattern active.
Why can’t I sleep?
Insomnia is one of the most common symptoms people see a doctor about, and one of the most often inadequately resolved.
In my clinical experience working with patients, the pattern many people fit is not what they expect. They are exhausted. They want to sleep. Their body is too wired to allow it. They have tried magnesium, melatonin, sleep hygiene apps and sometimes sleeping pills. Some can help, but the improvement often does not hold.
Sometimes the problem is simple: caffeine too late, alcohol, irregular timing or screens. But when insomnia persists despite sensible changes, the question becomes deeper. Why is the body still producing alertness when it should be producing sleep?
This article explains what insomnia can be at a physiological level, what can often most likely drive it, what can help, what tends not to, and when an integrative clinical assessment is the right next step.
What insomnia actually is
In most European countries, doctors and clinical psychologists use the International Classification of Diseases (ICD-10) to make a formal diagnosis. The ICD-10 defines non-organic insomnia as a disturbance of sleep onset, sleep maintenance, or poor sleep quality, occurring at least three times per week over a period of a month, with excessive focus on the sleep disorder, worry about its negative consequences, and a high degree of suffering or impairment of daytime activity 1.
The third edition of the International Classification of Sleep Disorders (ICSD-3) and the DSM-5 use similar criteria. Difficulty initiating sleep, difficulty maintaining sleep, waking up earlier than desired, with related daytime impairment such as fatigue, attention and memory problems, mood disturbance, daytime sleepiness, and reduced motivation. The sleep difficulty needs to occur at least three times per week and have been present for at least three months 2.
These are descriptions, not explanations. They name what someone is experiencing without accounting for why.
For the patient sitting opposite me, the question is rarely whether they meet the diagnostic criteria for insomnia. The harder question is why their system is still running this pattern, and what would actually change it. I have written more about this clinical situation in normal tests, persistent symptoms.
What causes insomnia
Most modern accounts of insomnia describe it in terms of contributors and risk factors rather than a single cause. This is accurate, but can leave patients feeling that nothing specifically is wrong, when something specifically can be.
The most important contributors to chronic adult insomnia, drawn from the published literature and my own clinical experience, include the following.
Stress and the hypothalamic-pituitary-adrenal axis. Insomnia and depression share an overlapping physiological mechanism: overactivity of the HPA axis and hypersecretion of cortisol 3–4. Cortisol is meant to be high in the morning and low at night. In many adults with chronic insomnia, this rhythm is reversed or flattened. The body releases cortisol at the wrong time. Sleep becomes biochemically difficult.
Sympathetic nervous system overactivation. A body in survival mode physiology runs the sympathetic nervous system continuously. Heart rate variability, a measure of variation between heartbeats and one indirect marker of autonomic flexibility, may be reduced 5–7. The body cannot transition into the parasympathetic state that supports deep sleep. This pattern is now described in fibromyalgia, chronic fatigue, post-viral syndromes including long COVID, and chronic anxiety, and it explains why these conditions so often co-occur with insomnia 8.
Mood disorders. Approximately 40% of people with insomnia have a coexisting psychiatric condition, most commonly depression or anxiety 9. The risk of developing depression is significantly higher in people with chronic insomnia than in those without it 9–10. These three patterns share underlying mechanisms and they rarely resolve independently 3, 8.
Female hormonal patterns. Insomnia is more prevalent in women than in men 11–14. Important contributors include the hormonal changes of the late luteal phase of the menstrual cycle, perimenopause, and menopause 15–16. Hot flashes and night sweats fragment sleep mechanically 15. The decline in oestrogen and progesterone also affects sleep architecture directly 16.
Chronic pain. Persistent pain, particularly the diffuse musculoskeletal pain of fibromyalgia and the visceral pain of irritable bowel syndrome, fragments sleep and is fragmented by it 8, 17. The pain conditions that share this picture often share something more specific: a body in sympathetic overactivation, with elevated systemic inflammatory markers (CRP, IL-1, IL-6, TNF-alpha) that can both fragment sleep and amplify pain perception through the hypothalamic-pituitary-adrenal axis and the autonomic nervous system 8, 18. The relationship is bidirectional.
Modern occupational stress. The development of laptops, smartphones, and the always-on work culture has measurably increased the prevalence of insomnia in working adults 11–13, 15, 19–20. A nationally representative survey in Norway found a workaholism prevalence of 8.3%, with younger adults more affected than older ones 21. The pattern has been seen across socioeconomic groups, with insomnia most consistently associated with lower income, lower education level, and lower house ownership, where individuals are more often holding multiple jobs and living in environments less conducive to sleep 22–24. There is also a developmental dimension: research on later school start times has shown improved sleep and academic performance, especially among students at the lower end of test grades, suggesting that the lifestyle-physiology mismatch begins early 25.
Substances and lifestyle. Caffeine in the afternoon, alcohol in the evening, late heavy meals, screen-mediated light exposure after dark, and irregular sleep timing all matter. So does shift work 26.
Nutrient status. Low Vitamin D, low magnesium, and low B12 have all been associated with sleep disturbance to varying degrees in the literature 27.
Gut and microbiome. The gut-brain axis modulates sleep through inflammatory and serotonergic pathways. Dysbiosis, particularly in people with IBS, has been associated with reduced sleep quality 8, 17–18.
What I think is more useful clinically, is that the pattern can be sustained by several of them simultaneously.
The deeper layer: a body stuck in survival mode
When I look at the literature alongside the patients I have seen clinically, the most useful way to understand chronic insomnia is a sleep problem that lives downstream of a regulation problem.
The body has several states. The parasympathetic, ventral vagal state supports rest, digestion, social engagement, and deep sleep. The sympathetic state is mobilised for activity, vigilance, and threat. A regulated nervous system moves between these states fluidly across the day.
When the body has been held in sympathetic activation for long enough, this fluidity is lost. Cortisol rises at night 3–4. Heart rate variability may drop. Inflammatory markers, particularly TNF-alpha and IL-6, are elevated 18, 28. The body may struggle to transition into the physiological state required for sleep, even though every part of the person wants to.
This can be why patients with chronic insomnia often also describe fatigue, anxiety, gut symptoms, chronic pain and the sense that they are running on empty 8.
Insomnia can sometimes be one of the most visible expressions of it.
What Eastern medicine sees in the same person
For most of medical history, the East and West have looked at insomnia through different lenses. These are different systems, not interchangeable. They may be describing overlapping parts of the same human pattern.
In Traditional Chinese Medicine, the Shen, often translated as the mind or the spirit, is housed in the Heart 29. When the Heart is supported, the Shen is calm and rest comes easily. When the Heart-Shen relationship is disturbed, the mind cannot settle 30. The patterns TCM describes for insomnia, including Heart Blood deficiency, Heart Yin deficiency, Liver Qi stagnation with Liver Yang rising, and Spleen Qi deficiency, can overlap clinically with presentations a Western doctor may describe as stress-driven, hormonally driven, perimenopausal, inflammatory, digestive, or post-viral 31–33.
In Ayurveda, the doshas, particularly Vata, Pitta, and Kapha, describe constitutional patterns that predict how a person experiences and responds to sleep disturbance. A Vata-aggravated insomnia often presents with anxiety, light fragmented sleep, nervous depletion, sensitivity, and a busy mind. A Pitta-aggravated insomnia can present with waking in the early hours, heat, irritability, intensity, night sweats, inflammatory tendencies, or digestive sharpness. A Kapha or ama-related pattern may present less as difficulty sleeping and more as heavy, unrefreshing sleep, morning grogginess, congestion, low motivation, or a sense of stagnation. The Ayurvedic approach to each is different.
In Western language, some of this may look like autonomic dysregulation, hyperarousal, inflammation, poor digestion, hormonal change or reduced restoration. In Ayurvedic language, many of these patients show features of aggravated Vata, disturbed agni, accumulated ama, or depleted ojas. In TCM language, it may appear as disturbed Shen, with the Heart affected directly or indirectly through the Liver, Spleen, Kidney or Stomach.
Why the pattern matters more than the label
This is where Ayurveda and TCM become clinically useful. Two people can both say, “I cannot sleep,” but the pattern underneath can be completely different.
One person may be anxious, dry, restless, sensitive to noise, and unable to switch off. In Ayurveda, this can look like aggravated Vata. In TCM, it may overlap with disturbed Shen, Heart Blood deficiency, or Liver Qi constraint affecting the Heart.
Another person may wake in the early hours with heat, irritability, night sweats, frustration, headaches, or digestive intensity. In Ayurveda, this often has a stronger Pitta quality. In TCM, it may resemble Liver fire, Yin deficiency, or Heart-Kidney disharmony.
Another person may sleep for long hours but wake heavy, foggy, swollen, congested, or unrefreshed. In Ayurveda, this may point toward Kapha stagnation, weak agni, or ama. In TCM, it may suggest Spleen deficiency, phlegm, dampness, or Stomach disharmony.
Insomnia is treated as a set of clinical pattern frameworks, each pointing to a different treatment. Used carefully alongside Western physiology, these traditions can sometimes produce a more complete map of the person than either framework gives alone.
How to sleep better
The honest answer is that what helps depends on what is sustaining the pattern. The same protocol that helps one person may do very little for another. The protocol is often sound. The driver is different.
That said, there is a consistent foundation. These are the things that can genuinely matter for many adults.
Light and circadian timing. Get bright daylight on the eyes in the morning, ideally within thirty minutes of waking. Dim artificial light in the evening 26.
A consistent sleep window. The body adapts to whatever timing you give it, but it adapts poorly to inconsistent timing. Going to bed and waking at roughly the same time, even on weekends, helps the circadian system stabilise.
Cool, dark, quiet. A bedroom around 17 to 19 degrees Celsius, with blackout curtains or a sleep mask can support sleep onset and depth.
Alcohol and caffeine. Caffeine after noon and alcohol in the evening both disrupt sleep architecture even when they do not seem to.
**Screens.**Switching from screens to a book can help as much for the cognitive content as for the light.
Body-based practices. Slow nasal breathing, gentle yoga, simple body scans, or any practice that genuinely calms the sympathetic nervous system supports the transition into sleep. 34–37.
CBT-I. Cognitive behavioural therapy for insomnia is the current first-line treatment for chronic insomnia in adults, and it deserves that place. In simple terms, it works on the relationship between thoughts and behaviour. Changing the thoughts that create sleep anxiety can change behaviour, and changing sleep-related behaviour can also change the thoughts that keep the cycle alive 38. It also provides important sleep hygiene and behavioural techniques, and the studies show that it helps. I incorporate aspects of this in my own practice to support patients with sleep. My question is not whether CBT-I works. It clearly can. My question is whether, in a person whose insomnia sits alongside nervous-system dysregulation, pain, fatigue, gut symptoms, hormonal disruption or chronic stress physiology, CBT-I is always the whole answer.
Targeted nutrient repletion. Vitamin D, magnesium, B12, and several other nutrients support nervous system regulation. The right combination depends on individual clinical context. I have written separately about Vitamin D deficiency and local primary-care testing habits.
Hormonal assessment. Perimenopause, late luteal phase patterns, and post-natal hormonal shifts can all influence sleep.
Gut work. Where gut symptoms are clearly contributing, addressing digestion, reflux, bloating, food reactions, inflammation or bowel rhythm can sometimes improve sleep.
Treatment of underlying mood and anxiety. Where anxiety or depression is driving the pattern, treating insomnia in isolation is realistically rarely ever the most optimal solution. The opposite is also true.
Acupuncture and body-based clinical work. Acupuncture has plausible mechanisms relevant to insomnia, including autonomic regulation, inflammatory signalling, melatonin rhythm and limbic regulation, but the quality of studies varies. You can read more about how acupuncture may help sleep, including how it works and why it may support nervous-system regulation.
Selective use of medication. Sleeping pills can help, especially in short-term, severe insomnia, and in some situations that relief is necessary. Benzodiazepines and Z-drugs can improve sleep in the short term, but the evidence does not support long-term use as the main answer for chronic insomnia 39–41. The deeper question is this: in chronic insomnia, how often are sleeping pills correcting the root cause, and how often are they temporarily suppressing one expression of a wider dysregulated pattern?
When to see a sleep specialist
The right person to see depends on what is actually driving the insomnia.
A sleep medicine physician can assess sleep apnoea, restless legs syndrome, circadian rhythm disorders, parasomnias, hypersomnia and complex insomnia. If there are witnessed apnoeas, loud snoring, daytime sleepiness disproportionate to sleep hours, or a high body mass index, polysomnography for example may be the right next step.
A GP, psychiatrist, or emergency service is the right first contact in an acute crisis. That includes active suicidal thoughts, mania, psychosis, or acute substance withdrawal. These situations need immediate, accessible care that a private integrative practice is not structured to provide. Where short-term psychiatric medication or CBT-I is the more appropriate route, both are addressed in their own sections of this article.
A broader integrative assessment, of the kind I offer in my practice, becomes more relevant when chronic insomnia has lasted more than three months, has not fully resolved with sensible foundations, and sits alongside other connected symptoms such as fatigue, anxiety, gut symptoms, persistent pain, recurrent inflammation or hormonal disruption.
What this means for chronic, unresolved cases
The clinical context in which insomnia can become a primary reason to seek deeper assessment can be being unwell for months or years or having multiple connected symptoms. In that context, what can work is addressing the underlying physiology sustaining the pattern across all of its expressions, with sleep being one of the first things to improve once the work is being done at the right level.
In practice, I manage this inside my mental health work. The wider medical context is in integrative medicine.
If you would like a short conversation to think this through, I do these on WhatsApp.
When this is useful in clinical care
This article is for educational purposes and should not be used as a personal recommendation to treat, test, or alter any treatment.
If you have ongoing sleep disturbance and believe a deeper integrative assessment is the right next step, feel free to read How I work →.
Medical disclaimer: This article is for educational purposes. It should not replace individual medical assessment, diagnosis, or treatment. Do not start, stop, or alter any medication or supplement based on this article alone. Persistent or severe sleep disturbance should be discussed with a qualified clinician who can evaluate your specific situation.
Frequently asked questions
What causes insomnia?
Chronic insomnia in adults rarely has a single cause. Common drivers include HPA axis dysregulation with cortisol hypersecretion, sympathetic nervous system overactivation, mood disorders particularly anxiety and depression, female hormonal changes around the menstrual cycle and perimenopause, chronic pain, modern occupational stress, lifestyle factors including caffeine and alcohol use, nutrient deficiencies, and gut dysbiosis. In many patients I see, several of these can be contributing simultaneously.
How can I sleep better naturally?
The foundations are bright daylight on the eyes in the morning, a consistent sleep window, a cool dark quiet bedroom, no caffeine after noon, no alcohol in the evening, and a calming pre-sleep routine. These help most people. For chronic insomnia driven by nervous system dysregulation, foundations can be necessary but not always sufficient. The deeper work involves regulating the autonomic nervous system through body-based practices, addressing nutritional and hormonal contributors, and treating any underlying conditions.
Is insomnia a sign of something else?
In adults with chronic insomnia, often yes. Approximately 40% of people with insomnia have a coexisting psychiatric condition, most commonly depression or anxiety. Insomnia is also associated with cardiovascular disease, metabolic dysfunction, and chronic inflammation. In integrative clinical practice, chronic insomnia is often one of several connected symptoms expressing an underlying regulation problem.
What is a sleep specialist?
The term can mean different things. A sleep medicine physician can assess sleep apnoea, restless legs syndrome, circadian rhythm disorders, parasomnias, hypersomnia, narcolepsy and complex insomnia, often using sleep studies when appropriate. A psychiatrist may be important where insomnia is linked with depression, anxiety, trauma, mania, psychosis, medication change or withdrawal. A GP may take the first medical history, review medication and arrange initial tests. If you are choosing between a psychiatrist and a psychologist, this guide explains who does what. An integrative physician may bring together conventional, Chinese medicine, and Ayurvedic frameworks where insomnia appears to be one part of a wider unresolved physiological pattern.
Can acupuncture help insomnia?
Some systematic reviews suggest acupuncture may help insomnia, but study quality has been variable and more rigorous research is needed. The most interesting part clinically is that proposed mechanisms include autonomic regulation, inflammatory signalling, melatonin rhythm and neurotrophic factors. I have written more about how acupuncture works in clinical practice.
What is the best supplement for sleep?
There is no single best supplement for sleep. The right approach can depend on the individual. Magnesium is the most commonly suggested, and it helps some people. The form of magnesium and the dose can both matter. Other supplements that may have a role in specific cases include glycine, L-theanine, and certain herbal extracts. Some can be safe to try independently. Others can interact with medications. A short clinical conversation usually clarifies which approach makes sense.
When should I see a sleep doctor?
Reasonable triggers can include chronic insomnia of more than three months that has not resolved with sensible foundations, sleep that is fragmenting your daytime functioning, the presence of other unresolved symptoms alongside the insomnia, and any features that suggest sleep apnoea such as witnessed apnoeas, loud snoring, or daytime sleepiness disproportionate to sleep hours. For sleep apnoea specifically, a sleep medicine physician with access to polysomnography can be the right referral. For chronic insomnia without apnoea, particularly where it is one of several connected symptoms, an integrative approach may be more appropriate because it looks at the wider pattern sustaining the insomnia.
Is chronic insomnia treatable without medication?
Often, yes. Sleeping medication can have a role for short-term, severe insomnia, but the literature does not support its long-term use, and most adults with chronic insomnia are not safely resolved by medication alone. The work can involve addressing the underlying drivers, which often include nervous system regulation, hormonal status, nutrient repletion, and treatment of any coexisting mood or anxiety patterns.
Should I take sleeping pills?
Sleeping pills can have a role in some situations. They can be reasonable for short-term severe insomnia in certain situations. Prolonged use can create its own problems.
Does insomnia get better on its own?
Acute insomnia, in response to a specific stressor, often does. In chronic insomnia, the same physiology that produced it can continue to produce it.
Dr Shehan Wijesingha, MD, M.TCM, DipAP, BMedSci, CPT, practises at Serenity Holistic Medical Clinic, Malta. He is Vice President of the Association of Ayurvedic Professionals UK. His 2019 Master’s dissertation explored the mechanisms by which acupuncture may resolve insomnia.