We are joined by Dr. Lauren Waterman, a consultant psychiatrist specializing in the intricate science of insomnia. In our conversation, we will explore the often-misunderstood differences between insomnia and sleep deprivation, the psychological traps that turn normal nighttime awakenings into sources of anxiety, and the neurochemical reasons behind feeling “tired but wired.” Dr. Waterman will also shed light on the effective use of supplements like melatonin, demystify core principles of Cognitive Behavioral Therapy for Insomnia (CBT-I), and explain why a consistent wake-up time can be more powerful than a fixed bedtime. Finally, we will discuss the warning signs that indicate a sleep problem is becoming chronic and how to seek the right professional help.
You differentiate between insomnia, where the brain struggles to sleep despite the opportunity, and sleep deprivation, caused by external factors. How does the brain’s adaptation to chronic insomnia explain why its long-term health effects might be less severe than those of sustained sleep deprivation?
It’s crucial to clearly separate these two concepts because they are often confused, even in scientific articles, which leads to a lot of misunderstanding. Sleep deprivation is what happens when your brain is ready and willing to sleep, but an external force prevents it. This could be a new parent with a crying baby, or in extreme cases, a form of torture designed to keep someone awake. It could even be something as common as having very loud neighbors in a noisy urban environment. Sustained sleep deprivation is genuinely harmful to human health and, at its most extreme, can lead to serious issues like heart attacks and premature death.
Insomnia, on the other hand, is an internal problem. You have the perfect opportunity to sleep—a quiet room, a comfortable bed—but something within your own brain is stopping you. This condition usually develops gradually, and over time, the brain does something remarkable: it adapts. Someone who consistently sleeps only four hours a night due to chronic insomnia won’t necessarily suffer the same severe long-term health consequences as someone who is sleep-deprived for the same duration. Their brain has learned to consolidate high-quality, deep sleep into a much shorter window. It becomes more efficient at getting the restorative sleep it needs in less time. This adaptation is a key reason why the physiological impact is different, even though the person with insomnia still feels the effects on their quality of life.
Many people worry when they wake up at night, yet you explain this is a normal part of sleep cycles. Could you walk us through the psychological shift—that “anxious driver” mindset—that turns a normal, brief waking moment into a prolonged period of stressful wakefulness for an insomniac?
It often shocks people, even other medical professionals, when I tell them that we all wake up about 10 to 15 times an hour. This is an evolutionary holdover from when we slept in caves and needed to be alert to potential dangers. Our brains are not yet adapted to locked doors, so they perform these quick environmental checks to ensure we’re safe before letting us fall back asleep. Most of the time, we don’t remember these awakenings because they are so brief.
The psychological shift is best explained with the analogy of a confident versus an anxious driver. If you ask a confident driver about their journey, they’ll give you the highlights: “I got in the car and drove here.” They don’t register every single detail because they are relaxed. An anxious driver, however, will remember every stop sign, every pedestrian, every green light, because their mind is hyper-focused and worried. A good sleeper is like the confident driver; they wake up, their brain registers that everything is fine, and they immediately fall back asleep without ever forming a memory of it.
For someone with chronic insomnia, their mind has become the anxious driver. When they experience that normal, brief awakening, their thoughts immediately latch onto it. They think, “Oh no, I’m awake. That’s it for tonight. How will I function at my meeting tomorrow? I’ll probably get fired, lose my job, my partner will leave me.” This cascade of catastrophic thinking triggers a stress response, flooding their system with adrenaline and making it impossible to relax and get back to sleep. The problem isn’t the waking up; it’s the panicked reaction to it that keeps them awake. Understanding that waking is normal can be the first step in disarming that anxiety.
People with chronic insomnia often describe being “tired but wired.” Can you elaborate on the neurochemical basis for this feeling of fatigue without sleepiness, and explain how this paradox makes it so difficult for them to fall asleep even when they feel physically exhausted?
This is a perfect description of the experience, and it’s essential to first distinguish between being “tired” and being “sleepy.” Tiredness is a feeling of fatigue, low energy, and a lack of motivation. Sleepiness, on the other hand, is the physical sensation of being about to drift off—your eyes feel heavy, and you might nod off. Someone with chronic insomnia feels deeply tired and fatigued during the day, but they rarely feel sleepy. They don’t just nod off in a movie theater or as a passenger in a car.
The “wired” part of that feeling comes from overactivity in the brain’s wakefulness pathways. We have sedative pathways that help us fall asleep, which are what traditional sleeping pills like zopiclone target. But we also have a separate wakefulness pathway regulated by a neurotransmitter called orexin. In people with chronic insomnia, this orexin system is often overactive, creating a state of hyperarousal. So even if their body is exhausted and the sedative pathways are trying to kick in, the wakefulness pathway is still firing on all cylinders, preventing them from crossing the threshold into sleep. Their brain simply won’t quiet down. This is why newer medications, like daridorexant, are designed to work differently by targeting and inhibiting this orexin system, directly addressing that “wired” feeling that keeps them awake.
Given that melatonin is often sold as an unregulated supplement and its active ingredient can be deactivated by light, what practical, step-by-step advice can you offer people for choosing and using it effectively? How does its mechanism differ from newer medications that target wakefulness pathways?
Melatonin is a natural hormone that our brain produces to regulate our internal sleep-wake clock. Its levels rise in the evening to prepare us for sleep and fall in the morning in response to daylight, which helps us wake up. The synthetic melatonin you buy is meant to supplement this natural process. However, the first practical step is to be an informed consumer. In the United States, melatonin is classified as a food supplement, not a medication, which means the FDA doesn’t regulate it for purity or dosage accuracy. Studies in the U.S. and Canada have analyzed popular brands and found that many products contained almost no active melatonin, while some had far more than the label claimed.
Secondly, and this is something very few people know, melatonin is highly sensitive to light. If you buy it as gummies in a clear plastic bottle, every time you open that bottle, light hits the product and deactivates the active ingredient. So, even if it had melatonin to start with, it might not by the time you take it. My advice is to seek out melatonin that is sold in individual, light-proof packaging, like foil blister packs, or in light-resistant capsules. This ensures the ingredient remains stable.
Finally, understand its mechanism. Melatonin works on your sleep-wake cycle, essentially telling your brain it’s nighttime. This is very different from newer medications like daridorexant, which work on the wakefulness pathway. Instead of signaling sleep, they actively block the orexin signals that promote wakefulness. So while melatonin is like gently dimming the lights, these newer drugs are like flipping the “off” switch on the brain’s arousal system.
You describe how a bedroom can become a stimulus for wakefulness. For someone trying to break this cycle using cognitive behavioral therapy for insomnia (CBT-I), can you detail how to correctly apply the “15-minute rule” and explain why sticking to it is so crucial for retraining the brain?
Absolutely. The brain is incredibly powerful at forming associations through a process called classical conditioning, just like Pavlov’s dogs learned to salivate at the sound of a bell. For a good sleeper, the bedroom—the sight of the bed, the feeling of the sheets—is a powerful stimulus for sleep. Their brain has learned that this place equals sleep. For someone with chronic insomnia, that association has been reversed. They may feel sleepy on the couch, but the moment they get into bed, their eyes pop open. The bed has become a stimulus for anxiety and wakefulness.
The “15-minute rule” is a core technique in CBT-I designed to break this negative association. It’s not about watching the clock, but about recognizing when you’re lying in bed feeling wide awake. If it feels like it’s been about 15 or 20 minutes and you’re not getting any closer to sleep, you must get up. Go to another room and do something calm and relaxing. You could read, listen to music, or even do some light housework—just avoid work, stressful topics, or anything too stimulating like the last episode of a thriller.
You only return to bed when you feel that genuine wave of sleepiness again, where your eyes are heavy and you feel you could nod off. If you get back in bed and are still awake after another 15 minutes, you repeat the process. Sticking to this is crucial for two reasons. First, it stops reinforcing the connection between your bed and the feeling of frustrated wakefulness. You are actively teaching your brain that the bed is only for sleeping. Second, it improves your quality of life. Instead of spending hours tossing and turning, consumed by worry, you get to spend that time doing something you might actually enjoy, which is a far better use of your night.
The advice to wake up at the same time every day is often more critical than having a fixed bedtime. Could you explain the concept of “sleep fuel” and how a consistent wake-up time, even after a poor night’s sleep, sets the stage for better sleep the following night?
The time you wake up is the anchor for your entire 24-hour body clock. From the moment you wake up, your brain starts accumulating a chemical that we can think of as “sleep fuel.” The longer you are awake, the more of this fuel you build up, increasing your “sleep drive” or pressure to sleep later that night. A consistent wake-up time ensures that this process starts at the same point every single day, creating a reliable rhythm.
Let’s say you normally wake up at 7 a.m. By 11 p.m., you’ve built up 16 hours’ worth of sleep fuel, which is usually enough to make you feel sleepy and allow you to fall asleep. But if you sleep in until 11 a.m. on a Sunday, by 11 p.m. that night, you’ve only accumulated 12 hours of sleep fuel. You simply won’t have enough sleep pressure to fall asleep at your desired time, which leads to difficulty sleeping on Sunday night and that classic groggy, sleepy Monday morning feeling.
This is why getting up at the same time every day, even after a bad night, is so critical for someone with insomnia. It might feel counterintuitive and difficult, but by forcing yourself to get up, you ensure that you start building that sleep fuel right on schedule. This consistency creates a strong, predictable sleep drive that will make it much easier to fall asleep the following night, helping to break the cycle of insomnia. Napping also sabotages this process, as it burns off some of that precious sleep fuel you’ve been accumulating all day.
When short-term sleep issues risk becoming chronic, what specific thoughts and compensatory behaviors—like napping or spending extra hours in bed—should serve as red flags? At what point should someone seek professional help, and how can they best advocate for themselves with a clinician?
Everyone experiences short-term insomnia from things like stress, illness, or even a heatwave. For most people, sleep returns to normal once the trigger is gone. The problem turns chronic when certain thoughts and behaviors take root. A major red flag is when you start worrying excessively about sleep itself. Your thoughts become centered on it: “How will I cope tomorrow if I don’t sleep?” or “I must get to bed early to catch up.”
This worry then leads to compensatory behaviors that actually worsen the problem. You might start going to bed much earlier or staying in bed later in the morning, trying to force sleep. You might start napping during the day to combat fatigue. These behaviors fragment your sleep and weaken your natural sleep drive. Spending 12 hours in bed but only sleeping for five of them teaches your brain that the bed is a place for being awake.
You should consider seeking professional help when you notice these patterns solidifying—when the worry about sleep becomes persistent and you’re relying on these unhelpful behaviors. If it’s been going on for a few weeks and isn’t improving, it’s time to act before it becomes deeply ingrained. When you speak to a clinician, be clear about the impact it’s having on your quality of life. Unfortunately, awareness of effective treatments like CBT-I is still quite low among many doctors, who may only suggest basic “sleep hygiene.” You may need to advocate for yourself by specifically asking for a referral for CBT-I, which is the gold-standard treatment recommended by clinical guidelines for chronic insomnia. Don’t be afraid to seek out an insomnia specialist if your initial concerns aren’t being fully addressed.
What is your forecast for the future of insomnia treatment and its integration into mainstream mental healthcare?
My forecast is one of hopeful but necessary change. For a long time, insomnia was viewed simply as a symptom of other conditions, like depression or anxiety, rather than a disorder in its own right. Because of this, it was often overlooked, and treatments were not well-resourced or taught in medical schools. I believe we are at a turning point where the medical community is beginning to recognize the bidirectional relationship between sleep and mental health—that insomnia can be both a cause and a consequence of mental health issues.
The future of treatment lies in raising awareness and accessibility. We need to educate more clinicians—from family doctors to mental health professionals—about evidence-based treatments like Cognitive Behavioral Therapy for Insomnia (CBT-I). This approach empowers patients by teaching them skills to manage their sleep, rather than just relying on medication. My hope is that CBT-I will become a first-line, easily accessible treatment offered through primary care and mental health services, both in the U.K. and internationally.
Ultimately, I envision a future where a “sleep check-up” is as integral to a mental health assessment as asking about mood or anxiety. By treating insomnia proactively and effectively, we can do so much more to improve not only people’s sleep but their overall health, well-being, and resilience. I am passionate about spreading this message because I know that with the right tools and understanding, we can make a profound difference in countless lives.
