Insomnia Isn't Just Not Sleeping. It's a System That's Learned the Wrong Thing.

Insomnia in Hong Kong: What It Actually Is, Why Generic Sleep Advice Doesn't Fix It, and What Does

By John Corbett | Psychologist | Hong Kong

Most people who come to me with insomnia have already tried everything.

The sleep hygiene checklist. The no-screens-before-bed rule. The magnesium supplement and the chamomile tea and the white noise machine. The blackout curtains. The consistent bedtime that lasted three weeks before the schedule collapsed. The melatonin, which helped for a night and then didn't.

They have done the reasonable things. They continue to not sleep well. And they are beginning to suspect — correctly — that the problem is not one that reasonable surface adjustments are going to solve.

This article is about why.

Insomnia is not just difficulty sleeping. It is a condition in which the brain has learned — through a process that is entirely understandable and largely automatic — to associate the bed, and the act of trying to sleep, with wakefulness, vigilance, and threat. The surface symptoms are visible: difficulty falling asleep, waking through the night, early morning waking that can't be corrected, daytime fatigue that coffee helps but doesn't resolve. What is less visible is the mechanism underneath — the self-reinforcing cycle that keeps those symptoms in place long after the original cause has passed.

Understanding that mechanism is the beginning of actually addressing it.

What Insomnia Actually Is

Insomnia is one of the most common health conditions in Hong Kong — and one of the most underdiagnosed.

The estimated prevalence of insomnia symptoms in Hong Kong is 39.4% — approximately 2.2 million adults. A population-based study of Chinese adults in Hong Kong found a prevalence rate of 33%. Nearly 40% of Hong Kong adults report insomnia symptoms, a rate greater than many Western populations.

These are not numbers about people having the occasional bad night. Clinically, insomnia disorder is defined as persistent difficulty initiating or maintaining sleep, or non-restorative sleep, occurring at least three nights per week for a minimum of three months, accompanied by meaningful impairment to daytime functioning.

The word persistent matters. Insomnia is not sleep disruption that continues because the original stressor continues. It is sleep disruption that continues — and often worsens — after the original trigger has resolved. The person whose insomnia began during a difficult professional period and never stopped even after the period passed. The person who slept fine for forty years and now, for reasons they cannot identify, has not slept well in two. The person who is tired all day and alert the moment they get into bed.

This persistence is not weakness. It is the mechanism. And understanding the mechanism is what the generic sleep advice misses entirely.

How Insomnia Becomes Self-Sustaining

The most useful model for understanding chronic insomnia is the three-P model developed by sleep researcher Arthur Spielman.

The model identifies three categories of factors: predisposing factors that create vulnerability to insomnia — things like a naturally more reactive nervous system, a tendency toward anxious processing, or a lighter baseline sleep architecture. Precipitating factors that trigger an episode — a stressful life event, a period of illness, a significant professional or personal disruption. And perpetuating factors — the behaviours and thoughts that maintain the insomnia once it has established itself, regardless of what originally caused it.

The treatment-relevant insight is that CBT-I — the most evidence-based treatment for chronic insomnia — focuses almost entirely on perpetuating factors. Not on what started the insomnia. Not on the stress that triggered it or the circumstances that initially disrupted sleep. On the habits, beliefs, and patterns that are keeping it going now.

What are those perpetuating factors?

Conditioned arousal. This is the central mechanism of chronic insomnia. Through repeated association of the bed with wakefulness and frustration — through lying awake for hours, through the mental effort of trying to sleep, through the accumulated experience of the bed as a place where sleep does not come — the brain learns to associate the bedroom environment with alertness rather than rest.

The association is Pavlovian. The bed becomes a cue for arousal in exactly the way a dinner bell becomes a cue for salivation. It happens automatically, below the level of conscious intention, and it becomes more entrenched with each night it is reinforced. The person who reports that they can fall asleep on the sofa but becomes wide awake the moment they get into bed is describing conditioned arousal precisely.

Sleep effort. The harder you try to sleep, the harder sleep becomes. Sleep is a passive process — it cannot be willed or forced. The act of monitoring for sleep, of assessing whether sleep is approaching, of evaluating the adequacy of the night's sleep — all of these maintain the cognitive arousal that prevents sleep from occurring naturally. The person who lies awake thinking about whether they are falling asleep is, by that very act, keeping themselves awake.

Extended time in bed. The intuitive response to sleeping poorly is to spend more time in bed — going to bed earlier, lying in later, napping during the day to compensate. This is understandable and counterproductive. It dilutes sleep pressure — the biological drive to sleep that builds across waking hours — and expands the window of time in bed relative to actual sleep, reinforcing the association between bed and wakefulness.

Catastrophising about sleep. The thoughts that form around insomnia — "I'll never sleep properly again," "tomorrow will be terrible if I don't sleep now," "this is destroying my health" — are not irrational. They are the responses of a distressed mind to a genuinely difficult situation. But they maintain the arousal that prevents sleep, and they are typically more catastrophic than the situation warrants. Sleep science consistently shows that people with insomnia underestimate how much they are sleeping and overestimate the functional consequences of a poor night — partly because the hyperarousal of insomnia distorts perception of time spent awake.

The Hyperarousal Problem

Underlying all of these perpetuating factors is a physiological state that is worth naming directly: hyperarousal.

People with chronic insomnia show elevated physiological arousal around sleep — higher heart rates, elevated cortisol, increased metabolic rate, and a brain that, measured by EEG, shows more high-frequency activity during sleep than is typical. This is not the same as being anxious in the conventional sense. It is a state of chronic physiological activation that the nervous system has settled into — a baseline that is set too high for the passive, low-arousal conditions that sleep requires.

The hyperarousal is both a cause and a consequence of insomnia. Poor sleep elevates the physiological stress response. Elevated stress response makes sleep harder. The cycle reinforces itself.

This is why people with insomnia often report feeling exhausted but wired — tired in the body and alert in the mind simultaneously. The fatigue is real. The arousal preventing sleep is also real. They coexist. Addressing only one without the other does not resolve the condition.

Why Sleep Hygiene Isn't Enough

Sleep hygiene — the set of behavioural recommendations most commonly offered for sleep difficulty — is not wrong. Consistent timing, dark and cool environment, reduced caffeine in the afternoon, limited alcohol, reduced screen stimulation before bed — these things matter. They create the conditions that support sleep.

But for someone with established chronic insomnia, sleep hygiene addresses the context without addressing the mechanism. The conditioned arousal, the sleep effort, the hyperarousal, the catastrophising — none of these are resolved by a blackout curtain or an earlier bedtime. The mechanism continues to operate within the improved context.

This is why the person who does everything right — consistent timing, good sleep environment, no screens, wind-down routine — continues to lie awake. Not because they are doing it wrong. Because the system is not primarily a context problem. It is a learning problem. And the solution to a learning problem is a different kind of learning.

What Actually Works: CBT-I

Cognitive Behavioural Therapy for Insomnia — CBT-I — is the first-line treatment for chronic insomnia recommended by sleep medicine guidelines globally, above sleep medication, above supplements, above any behavioural advice given in isolation.

The evidence base is substantial. CBT-I produces a 70 to 80% response rate, with approximately 40 to 50% of patients achieving remission — a clinically meaningful reduction in insomnia severity. And critically, the gains are durable. Unlike sleep medication, which manages symptoms while they are being taken, CBT-I changes the mechanism. The improvements persist after the treatment ends.

CBT-I is not a sleep hygiene list. It is a structured intervention with specific components, each targeting a specific perpetuating factor.

Stimulus control addresses conditioned arousal directly. The core principle: the bed should be used only for sleep. If you cannot sleep, you get up. The association between bed and wakefulness is weakened by withdrawing from the bed during wakefulness, and the association between bed and sleep is rebuilt through consistent pairing. This feels wrong, initially — getting out of bed at 3am when you are exhausted seems counterintuitive. It is also the most effective single behavioural intervention for insomnia that exists.

Sleep restriction therapy addresses extended time in bed and diluted sleep pressure. By temporarily limiting time in bed to match actual sleep time — even if that means initially limiting time in bed to five or six hours — sleep pressure builds rapidly. The subsequent nights consolidate into more efficient, deeper sleep. This is one of the most counterintuitive components of CBT-I and one of the most effective.

Cognitive restructuring addresses the unhelpful beliefs and catastrophising that maintain arousal around sleep. Not positive thinking — accurate thinking. The belief that a poor night will make the following day unbearable is, in most cases, more catastrophic than the reality. The belief that chronic insomnia is permanent and untreatable is factually incorrect. Identifying and testing these beliefs changes the cognitive component of the arousal cycle.

Relaxation techniques — progressive muscle relaxation, slow breathing — address the physiological hyperarousal component. These are not primarily about producing calm before bed. They are about reducing the baseline arousal level that is set too high for sleep to occur.

Sleep education — understanding the mechanism described in this article — is itself an intervention. Understanding why the symptoms are occurring reduces the catastrophising that maintains them. Knowing that conditioned arousal is reversible, that sleep restriction works, that the mechanism is not permanent — this is not reassurance for its own sake. It is information that changes the relationship to the condition.

A Word on Sleep Medication

Sleep medication — prescription hypnotics, antihistamine-based over-the-counter remedies, and the various supplements that are marketed for sleep — deserves an honest treatment here.

Medication can provide short-term relief. For acute sleep disruption — the insomnia that follows a bereavement, a significant stressor, a change of environment — short-term pharmacological support can prevent the acute disruption from becoming entrenched. That is a legitimate use.

For chronic insomnia, the evidence is more complicated. Sleep medication does not address the perpetuating factors — the conditioned arousal, the hyperarousal, the beliefs and behaviours that maintain the condition. It manages symptoms while it is being taken. When it is stopped, the insomnia typically returns, sometimes with a rebound effect that is worse than the original condition.

There is also the question of dependence and tolerance — the need for escalating doses to achieve the same effect, and the difficulty stopping once a pattern has been established.

CBT-I has been shown to be as effective as medication in the short term and significantly more effective in the long term. It has no side effects. Its effects do not diminish with time. And it addresses the mechanism rather than the symptom.

This is not an argument against medication in all circumstances. It is an argument for understanding what medication does and does not do — and for seeking access to the treatment that has the strongest evidence, which in the case of chronic insomnia is not medication.

What Insomnia Does During the Day

For completeness, it is worth naming what chronic insomnia actually costs in the hours outside the bedroom — because it is not just a night-time problem.

The cognitive consequences are well-documented: impaired attention, reduced working memory, degraded processing speed, and poorer decision-making. The person with chronic insomnia is not just tired during the day. They are cognitively operating below their baseline — often without being able to accurately assess how far below, because insomnia impairs self-assessment in the same way that other forms of sleep deprivation do.

The emotional consequences are equally significant. Chronic insomnia is associated with significantly elevated rates of anxiety and depression — not merely as co-occurring conditions, but through a bidirectional mechanism in which poor sleep makes both worse, and both make sleep harder. The emotional regulation that adequate sleep provides — the overnight recalibration of the amygdala, the REM processing of emotional experience — is disrupted night after night.

And there is a quality-of-life dimension that is harder to quantify but no less real. The person managing chronic insomnia is doing something most people don't see: carrying the weight of anticipatory anxiety about the night ahead through every waking hour, while simultaneously managing the impairment of the previous night's poor sleep. The social, professional, and relational consequences of this — the irritability, the reduced availability, the diminished patience — accumulate quietly and rarely get named for what they are.

The Specific Picture in Hong Kong

The prevalence figures for insomnia in Hong Kong — approaching 40% of the adult population — are not difficult to explain given the structural features of professional life in the city.

Long working hours that push the active portion of the day into the hours that should be sleep transition time. A culture that treats late availability as commitment and early starts as discipline — compressing the sleep window from both ends. The ambient stress of a high-pressure professional environment that keeps the nervous system in a state of activation through the evening. Client entertainment culture that introduces alcohol — which disrupts sleep architecture — on multiple nights per week.

These are structural conditions. They do not cause insomnia directly in most people. But they create the conditions in which insomnia can take hold — and they make the already-difficult task of addressing it harder, because the environmental factors that would support recovery are, in many cases, difficult to access.

For the professional in Hong Kong who has been managing chronic insomnia alongside a demanding career — attempting to function adequately on poor sleep while maintaining the performance that is expected — the picture is one I recognise. And the thing I most consistently want them to know is that the mechanism, while self-sustaining, is also reversible.

Chronic insomnia, addressed properly, responds to treatment. Not always quickly, not always linearly, but the research on CBT-I is consistent: the majority of people who engage with the treatment properly see meaningful and lasting improvement. The system that learned the wrong thing can learn again.

Frequently Asked Questions: Insomnia Hong Kong

How common is insomnia in Hong Kong? 

The estimated prevalence of insomnia symptoms in Hong Kong is approximately 39.4% — around 2.2 million adults. A population-based study of Chinese adults in Hong Kong found a prevalence rate of 33%. These rates are higher than many Western populations, reflecting the structural features of Hong Kong's professional and urban environment.

What is the difference between insomnia and poor sleep?

Poor sleep refers broadly to sleep that is insufficient in duration, disrupted, or non-restorative — for any number of reasons including stress, environmental factors, or lifestyle. Insomnia disorder is a specific clinical condition defined by persistent difficulty initiating or maintaining sleep occurring at least three nights per week for three months or more, accompanied by meaningful daytime impairment. The key feature of insomnia is its persistence — it continues even when the original trigger has resolved, maintained by the self-sustaining mechanisms described in this article.

Why doesn't sleep hygiene fix insomnia?

Sleep hygiene improves the conditions for sleep but does not address the mechanism maintaining chronic insomnia — specifically conditioned arousal, sleep effort, hyperarousal, and catastrophising beliefs about sleep. For someone with established chronic insomnia, addressing the context without addressing the mechanism produces limited and often temporary improvement.

What is CBT-I and does it work for insomnia in Hong Kong?

Cognitive Behavioural Therapy for Insomnia is the first-line treatment for chronic insomnia recommended by sleep medicine guidelines globally. It produces a 70 to 80% response rate, with approximately 40 to 50% of patients achieving clinical remission. Unlike sleep medication, the improvements produced by CBT-I persist after the treatment ends, because the treatment addresses the mechanism rather than managing symptoms. CBT-I is available in Hong Kong through trained psychologists and clinical psychologists.

Should I take sleep medication for insomnia?

Sleep medication can provide short-term relief and is appropriate in some circumstances, particularly for acute insomnia. For chronic insomnia, however, medication manages symptoms rather than addressing the underlying mechanism — and improvements typically do not persist after the medication is stopped. CBT-I has been shown to be as effective as medication in the short term and significantly more effective in the long term, with no side effects and durable gains.

Can a psychologist in Hong Kong help with insomnia?

Yes. CBT-I is a psychological treatment delivered by trained psychologists and clinical psychologists. When insomnia is accompanied by anxiety, depression, burnout, or the specific pressures of demanding professional life — as it frequently is in Hong Kong — a psychologist can address both the sleep difficulty and the psychological factors that are contributing to and maintaining it. John Corbett is a psychologist based in Hong Kong working with executives and professionals on sleep, performance, and psychological wellbeing. To arrange a consultation, visit johncorbett.com.