Relapse happens in insomnia. It’s not a disaster, particularly if you have a plan.

insomnia relapseThe nature of insomnia is that symptoms can return. Sometimes this occurs during periods of stress when poorer sleep is to be expected, and other times somewhat unexpectedly. Research and experience shows that this is just part of what happens with insomnia, even if people are generally managing their symptoms well. The key to managing these episodes of return of symptoms or insomnia relapse is to recognise that it’s just a short-term return to poor sleep, that can be managed, and that things will swing back to better sleep. For many people I see, who have had a very difficult time with insomnia over many years, when they get a return of insomnia symptoms they can get a strong fear that they’re going back to the “bad old days”. But, that is rarely the case, particularly if people are confident that they have a strategy for managing sleep and put that in to place.

Don’t insomnia symptoms just go away once treated?

It’s important to understand the difference between acute and chronic insomnia. Acute insomnia, or sleep difficulties that have only been present for a few days or weeks and occur in the setting of a clear trigger such as stress, busyness or illness is very different from chronic insomnia, where symptoms have been present most of the time for 3 months or more. Whilst acute insomnia usually settles quickly once the triggers have passed, hence the advice to avoid stress, cut back etc, this doesn’t happen with chronic insomnia. Once people have had trouble with sleep for 3 months or more, it’s likely that symptoms will persist even once the triggers have passed, unless they get treatment. Even though treatment can be very effective at reducing the day-to-day symptoms and impact of insomnia, when triggers such as stress or illness return, people can get a relapse of insomnia symptoms.

There has been some really important Australian research published recently in the journal Sleep Medicine, showing that sleep problems in early adult life increase the risk of insomnia later in life. Of the 10% of women aged 22 to 27 who reported having sleep difficulties, over the subsequent 9 years, 45% had persistent sleep problems and 21% had intermittent problems, This research really highlights the importance of intervening early in insomnia and teaching people strategies for managing their sleep to prevent ongoing symptoms.

I discuss the differences between acute and chronic insomnia in more depth in this audio interview.

Treat relapse like acute insomnia and with a plan

plan to manage insomnia

Although the best long-term treatment for chronic insomnia is cognitive behavioural therapy (CBTi), once someone with chronic insomnia has had CBTi and symptoms are beginning to settle, short-term relapses are best treated in the same way as acute insomnia.

People have their ‘maintenance’ treatment, putting in to place strategies they have learnt through CBTi, and sometimes use of a medication. However, when symptoms of insomnia worsen in the short-term, additional strategies need to be put in place. This can be adjusting sleep timing, shortening the time in bed and re-introducing stimulus control measures, and, if needed, increasing or re-introducing medication in the short-term. It’s helpful to have a plan to manage relapse when it occurs, and important to implement it early to settle symptoms, as when insomnia symptoms recur it can result in a return of anxiety about sleep which is one of the factors that worsens insomnia symptoms.

Details on making a plan to deal with insomnia are in this post.

Managing insomnia in the long-term

I think about managing chronic insomnia in 3 phases:

  1. Initial phase (3 months) – This is when people are seeking help and starting treatment. In this phase I like to start cognitive behavioural therapy, and will sometimes use medications as a ‘holding’ strategy to give people some relief of their symptoms whilst they are working on non-drug strategies and developing confidence in these techniques
  2. Consolidation phase (3-6 months) – In this phase, people are usually feeling that their insomnia symptoms are much better controlled and they are less concerned about their sleep. They’ve finished a course of CBT and may have come off or be reducing medications. In this phase, it’s important not to go back to old sleep habits too quickly as the chance of relapse is higher. It’s also a time where people are starting to become confident in their own ability to manage their sleep problems, but not feeling as if they are totally in control. Return of symptoms, or relapse, is common in this phase, and important to get on top of quickly, as the fear of returning to how things were is still fairly real.
  3. Maintenance phase (after 6 months) – By this phase, people are pretty comfortable with their sleep and usually off medication, unless there is also a physical or mental health component to their insomnia. They know what they can get away with without it impacting on sleep, and have a fair idea of how to manage sleep most of the time. But, as with everyone, things happen unexpectedly that can throw sleep out. When this happens, it’s important to have a plan outlining what steps you will take to get sleep back on track (as discussed above and in this post) to get things back on track.

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