The Harder You Try, the Further It Gets

When sleep becomes something to achieve, effort and monitoring can keep the problem going. This is one well-described loop, not the cause of every case of insomnia.

This is Part 2 of a five-part series on sleep and mental health. The other parts cover Less Time in Bed, More Consolidated Sleep, You’re Not Weak. It May Be Rebound, He Can’t Fall Asleep. It May Not Be Defiance, and Sleep Was the First Thing to Change.

You go to bed tired. Then sleep becomes a test. You check the time. You scan your body. You count tomorrow’s losses. You may open a tracker score before your feet reach the floor. A partner asks for the morning report. Soon, the whole night can feel under a spotlight.

For some people, this struggle becomes part of what keeps insomnia going. Small experiments and broader clinical research support that possibility. They do not show that effort, clocks, trackers, or families cause every case. Pain and breathing problems can matter. So can body-clock timing, medicines, substances, mood symptoms, noise, or caregiving. This article helps you spot a performance loop. It shows how to set kinder limits around monitoring. It also explains when formal sleep care is safer.

Key takeaways

• Sleep effort means trying to make sleep happen. It is not the same as caring about sleep. It is not your fault.
• Clock or tracker feedback can raise worry for some people. It can be neutral or useful for others. Context matters.
• A consumer sleep score cannot diagnose insomnia, sleep apnea, or another sleep disorder.
• Family support works best when it is invited, practical, and free of nightly grading.
• Reducing struggle is not a substitute for evaluation or cognitive behavioral therapy for insomnia, called CBT-I.

Zoom

When sleep becomes a performance test

Sleep is partly automatic. You can prepare for it. You cannot command the exact minute it begins. That creates a hard problem when sleep has been unreliable. Sleep can feel very important. You may watch closely for proof that it is coming.

Researchers call one part of this sleep effort. It means deliberate attempts to make, control, or force sleep. The Glasgow Sleep Effort Scale was made to measure that experience. It is a research and clinical measure. It is not a diagnosis. A 2024 scoping review linked sleep effort with insomnia symptoms. Much of the evidence was cross-sectional. That means effort and insomnia were measured at the same time. It cannot tell us which came first.1

Sleep effort is also different from sensible preparation. Taking prescribed medicine as directed may be necessary. So may using an alarm, making the room safer, arranging infant care, or protecting sleep time. The concern is a loop. In that loop, every action becomes a test of whether sleep will obey.

The Spotlight That Will Not Dim is a useful image. Attention may keep turning toward the clock, body, bed, and tomorrow. Each cue can then feel larger. Yet this image has a limit. Caring less will not solve insomnia. Nor will relaxing on command or switching off one lamp. Attention is one possible maintainer. It is not the only cause.

The performance loop is a model, not a verdict

Several insomnia models describe a loop like this:

1. A poor night, or fear of one, raises the stakes.
2. You monitor the time, your body, the room, or tomorrow’s performance.
3. Worry and effort rise. You may change plans to protect yourself.
4. Wakefulness feels longer or more threatening.
5. Sleep seems fragile, so monitoring increases the next night.

The strongest direct evidence comes from small experiments. It does not prove the whole chain. Two experiments were published in 2007. People told to monitor a clock reported more worry. They also took longer to fall asleep than those without that instruction. In people with primary insomnia, a clock display caused more reported worry than neutral digits. The clock group also reported longer sleep onset and greater overestimation.2

Those studies matter because monitoring was manipulated. They also have strict limits. The samples were small. The exposure was brief. Key outcomes were self-reported. The studies do not show that looking at a clock causes chronic insomnia. They do not show that covering a clock cures it.

A much larger sleep-center study linked frustrated time monitoring with insomnia severity and sleep-aid use. The study was cross-sectional. Insomnia could have increased checking. Checking could have increased distress. Another factor could have shaped both.3

This distinction matters. A model can help you test a pattern without blame. If you notice the loop, you did not create insomnia on purpose. You may not notice this loop. Your symptoms are still real.

What this is and is not

Sleep-related worry is concern about sleep or a bad night’s effects. It may focus on health, work, parenting, mood, or safety. Some worry is realistic. A person who nearly fell asleep while driving has a safety problem. That is not a thinking error.

Conditioned arousal is the idea that bed or bedtime can become linked with alertness, frustration, or dread after many difficult nights. It is a treatment model. Improvement with stimulus control does not prove that conditioning caused every case.

Hyperarousal can mean mental, emotional, brain-based, or body-based activation. Studies use many measures. They include surveys, brain activity, cortisol, and heart rate. No single biomarker diagnoses it. You should not be told that insomnia exists because you are too anxious or thinking wrong.

Sleep-state discrepancy means experienced sleep differs from diary, actigraphy, or sleep-lab estimates. That does not mean a person is lying. It also does not mean the device owns the truth. Insomnia is partly defined by lived difficulty and daytime effect. A sleep-lab study answers one question. A clinical actigraph or consumer wearable answers another. Diaries and patient history add lived context.

Who this evidence fits

Most direct evidence comes from adults with insomnia disorder or raised insomnia symptoms. Some comes from healthy adults in short experiments. Many studies used unmasked reports. People knew whether they got treatment or saw feedback. That can shape expectations. Experienced sleep still remains a valid outcome.

Device studies compare tracker estimates with polysomnography, the overnight sleep-lab test. Those studies offer an objective comparison. They are often one night long. They also test a set device and algorithm. Results may not transfer after a firmware update. They may differ in older adults, people with insomnia, or those with another sleep disorder.

Evidence is thinner for pregnancy, shift work, severe mental illness, and seizure disorders. It is also thin for safety-sensitive work and major medical or brain conditions. Some symptoms need more than an effort-loop explanation. These include loud snoring, breathing pauses, or gasping.19 Other signals include sleep attacks or unusual nighttime behavior. They also include severe restless legs, schedule drift, marked mood activation, or substance withdrawal.

Clocks: a tool can become a judge

A clock has useful jobs. It wakes you. It supports medication timing. It also helps with work or caregiving. The goal is not to remove time from your life. Notice when a useful tool becomes a running score.

One low-risk experiment is to keep the alarm. Turn an unneeded display away for a few nights. Do not keep counting how many hours remain. In the morning, note whether worry changed. This is a reasonable adaptation based on small clock experiments. It is not a proven treatment by itself.

Keep the clock visible if time checks are needed. This may be for health, medicine, dependent care, work, or safety. If removing it raises fear, stop the experiment. Discuss the pattern with a clinician. The point is to learn, not pass.

Trackers: information, error, and expectation

Consumer sleep trackers estimate sleep from signals such as movement and heart rate. They do not measure sleep in the same way as polysomnography. A 2025 validation of six devices in 62 adults found that the devices detected sleep much better than wake. Wake specificity ranged from about 29% to 52%, and sleep-stage agreement was fair to moderate.4

Those numbers are not permanent ratings for every device. Models and algorithms change. Performance also differs by sleep measure and population. A 2026 review of five observational studies found poor to moderate agreement between wearable data and validated reports of sleep quality. Agreement was weaker in insomnia samples.5

The American Academy of Sleep Medicine says consumer sleep technology should not be used to diagnose or treat a sleep disorder unless it has been appropriately validated and cleared for that purpose. It can be discussed within a full clinical evaluation.6 The National Sleep Foundation takes a compatible but more optimistic view: science-backed tools may support sleep health, while users should avoid overreliance and remember that technology does not replace expert evaluation.7

Can the score change how you feel?

Yes, at least in a short experiment. Sixty-three adults with insomnia were randomly shown positive or negative sham sleep feedback. People who received negative feedback later reported more fatigue and sleepiness and less alert thinking. Objective vigilance did not clearly differ.8 This suggests that feedback can shape symptom appraisal. It does not show that trackers cause insomnia.

Can tracker use help?

It can. In a small, short study of healthy young adults, feedback produced a small improvement in reported sleep disturbance, while total daily sleep did not change. The study was funded by the device maker.9

In another trial, 113 adults with elevated insomnia symptoms received either sleep education or a five-week package with wearable feedback, brief guidance, and clinician contact. The guided group had a modest improvement in insomnia severity. It did not clearly improve anxiety, depression, daytime impairment, or the gap between experienced and recorded sleep. Device discomfort was common.10

That is a balanced result. Guided interpretation may help some people. The study did not show that a wearable alone treats insomnia or that every person should track.

Orthosomnia is not a formal diagnosis

In 2017, clinicians described three people whose pursuit of ideal tracker data appeared linked with sleep distress. They called this orthosomnia.11 The term can name a recognizable experience, but it is not a DSM or ICSD diagnosis.

Later surveys and a new scale have explored rigid or interfering tracker use. Estimates depend greatly on how researchers define the term. That tells us the field is still developing. A better question for daily life is simple: does the data help a useful decision, or does it make sleep feel more fragile and graded?

CBT-I can address the loop without blaming you

Cognitive behavioral therapy for insomnia, or CBT-I, is a multicomponent treatment. It is not a sleep-hygiene handout or an app that gives bedtime tips. Article 1 in this series owns the full treatment guide and safety screen. [Internal link to Article 1 pending]

In this article, three links matter:

• Cognitive work tests catastrophic predictions and rigid rules about sleep and tomorrow.
• Stimulus control changes what happens when bed has become linked with long, frustrated wakefulness.
• Time-in-bed work can reduce long periods awake in bed, but it must be individualized and monitored. This article does not provide a formula.

Two 2024 component network meta-analyses agreed that behavioral components such as stimulus control and sleep restriction were important. They did not agree fully on the unique added effect of cognitive or acceptance-based methods. Both rely on assumptions about how components combine.1213

Relaxation may help. It is not harmful by definition. Yet a helpful skill can become another test if the rule becomes, “I must relax correctly or I will fail.” A clinician can help turn relaxation back into an option rather than a demand.

Paradoxical intention is sometimes discussed for insomnia, but its evidence base is small and often older. This article does not give instructions for doing it on your own.14

The household can lower pressure without walking on eggshells

Insomnia affects more than one person. Partners may lose sleep, take over morning duties, cancel plans, become quiet, offer reassurance, or ask for a detailed report. Some of that is caring. Some may reduce distress tonight while making sleep feel like a household emergency tomorrow.

Direct evidence is limited. A small study of 21 people found that positive partner comments were linked with larger improvement during CBT-I, but it could not prove the partner caused the change.15 In 2026 qualitative interviews with 30 couples, people described emotional support, help, time together, and better understanding during partner-assisted treatment.16

No direct trial was found showing that “Did you sleep?” causes insomnia. The same is true for tiptoeing, morning score discussion, or repeated reassurance. The guidance below is a reasonable, consent-based adaptation, not a list of proven causes.

Your job

Notice when checking or control has become a performance test. Keep appropriate evaluation and treatment. Report dangerous sleepiness, mood change, breathing symptoms, or another safety concern.

Your family’s job

Ask what support is wanted. Help with one agreed plan. Replace nightly grading with a calm question about support, function, or safety.

What neither of you has to do

You do not have to prove how many minutes you slept, debate a wearable score, keep the whole house silent, or turn a partner into a therapist or monitor.

When the plan needs professional help

Get help when insomnia persists, function is falling, the loop is hard to change, or symptoms suggest another sleep, medical, medication, substance, or mental-health problem.

A one-week boundary experiment

This plan is for observation and coordination. It is not a sleep-window plan, medication change, or full CBT-I treatment.

Choose one target. Examples include the number of times you seek the time, morning distress after viewing a score, or whether sleep discussion creates conflict.

Choose one action for three to seven days:

• Keep the alarm but turn an unneeded clock display away.
• Delay viewing a consumer score until later, or pause the score view, if the data is not needed for care.
• Replace the morning sleep grade with one agreed support question.

Time needed: about one minute in the morning. Materials: a short note. People: you, plus a support person only if invited.

On a low-capacity day, write three words: checking, distress, function. Use low, medium, or high. If you miss a day, restart without catching up.

Review the result at the end. Note whether pressure fell, function changed, or the plan created a new ritual. Continue only if it is useful and light. Simplify or stop if it became another test. Seek formal care if insomnia or impairment continues.

Words you can use

Patient: “I want less sleep scoring in the morning. Please ask what support I need instead.”

Partner or family member: “Would you like practical help, quiet company, or no sleep questions today?”

Clinician: “My clock or tracker seems to change my worry. Can we review whether the data is useful and what else needs evaluation?”

Patient: “I am trying to reduce the struggle, not ignore the problem. I still want evidence-based care.”

Measure real-life progress

Do not use one night or one consumer score as the grade. Look across days or weeks at:

• how much time and attention sleep consumes.
• bedtime dread and morning distress.
• sleep continuity as experienced in a diary.
• daytime alertness, fatigue, and driving or work safety.
• mood, concentration, and ability to do planned activities.
• family conflict and the amount of accommodation.
• treatment burden.
• whether you are getting appropriate care.

A lower tracker score with less distress and better function may still be progress. A higher score with dangerous sleepiness is not reassurance.

Access at three levels

Start today: Use the one-week observation plan with one target and one action. It costs nothing and does not require a private bedroom or wearable.

Lower-cost support: Ask a primary-care clinic, behavioral health clinic, health system, insurer, community mental-health center, or employee assistance program whether it offers group, telehealth, or guided digital CBT-I. Ask about fees, language access, disability access, privacy, age limits, and wait time before enrolling. Availability varies, so no specific product is promised here.

Formal care: Look for a clinician trained in behavioral sleep medicine or CBT-I. Ask how they screen for sleep apnea, restless legs, circadian problems, bipolar symptoms, excessive sleepiness, medicines, substance effects, and safety-sensitive work. A sleep-medicine evaluation may be needed when another disorder is suspected.

If you share a room, work shifts, care for someone overnight, live with noise, lack internet, or have a disability that changes how you use bed, say so. A workable plan should fit your real setting.

Coordination plan

Goal: Reduce one unhelpful monitoring loop while protecting safety and needed care.
Baseline: Three to seven days of checking, distress, and function.
Strategy: One clock, tracker, or morning-question boundary.
Owner: Patient. A family role requires clear, revocable consent.
Frequency: One brief morning note.
Review date: Within one week.
Information shared: Only what the patient agrees is needed for the plan.
Escalation: Persistent impairment, dangerous sleepiness, breathing symptoms, severe mood change, substance or medication concern, or inability to stay safe.

When to get more help

Emergency help now

Call 911 for immediate physical danger, severe breathing trouble, inability to awaken, seizure, suspected overdose, dangerous confusion, psychosis, mania, or withdrawal, or when waiting is unsafe. If there is suicidal intent, an immediate plan, or inability to stay safe, call or text 988 for the U.S. Suicide & Crisis Lifeline, and call 911 when there is immediate physical danger.17

Prompt clinical evaluation

Seek prompt help for falling asleep while driving, near misses, repeated unintended sleep, falls, hallucinations, marked mood or energy change, worsening depression, substance concerns, loud snoring with gasping or breathing pauses, or severe loss of function. Do not drive when sleepy.18

Routine troubleshooting

Arrange routine care when the goal is unclear, the plan adds burden, access is blocked, symptoms persist after a fair trial of appropriate care, or the approach needs adaptation.

Frequently asked questions

Am I causing my insomnia by trying too hard?

No. Sleep effort may become one part of a loop for some people, but insomnia has many possible causes and maintainers. Noticing effort is a chance to change the plan, not a reason for blame.

Should I throw away my clock or sleep tracker?

Usually not. Keep alarms, medical functions, and useful data. If unnecessary checking raises distress, try a brief, reversible boundary and review whether it helps. A clinician should guide any data needed for care.

Can a wearable tell whether I have insomnia?

No. Consumer trackers can estimate patterns, but they do not diagnose insomnia or replace a clinical history. Their accuracy varies by device, algorithm, measure, and population.

Is orthosomnia a real diagnosis?

Orthosomnia is an informal descriptive term, not a DSM or ICSD diagnosis. It can describe distress or rigid behavior around sleep data, but current case, survey, and scale research does not establish formal diagnostic criteria.

What should my family ask in the morning?

With your consent, a family member can ask, “What support would help today?” or “Is there a safety concern?” No trial proves that one morning question changes insomnia, so the goal is lower pressure and useful support, not a new rule.

If you or someone else may be in immediate danger, call 911. For suicidal crisis support in the United States, call or text 988.

This article is for education and is not a diagnosis or an individual treatment plan. Sleep problems can have more than one cause. A qualified clinician can help you choose care that fits your health, medicines, schedule, and safety needs. Do not start, stop, taper, or change a prescription medicine based on this article.

Tools you can use

The toolkit expands the worksheets and scripts. It does not replace assessment or CBT-I. Complete only the parts that feel useful. A support person participates only with the patient’s consent.

Toolkit asset 1: Performance-loop diagram with evidence grades

Poor sleep or fear of poor sleep
Low-certainty link to increased monitoring

↓

More worry, checking, and control effort
Low-certainty experimental and associative support

↓

More arousal or compensatory behavior
Low-certainty support; no universal mechanism

↓

More wakefulness or more perceived wake time
Low-certainty direct evidence

↓

Sleep feels fragile and must be controlled
Very-low-certainty reciprocal link back to effort

Toolkit asset 2: Reasonable preparation or forcing sleep?

Toolkit asset 3: Clock and tracker boundary experiment

Purpose: Learn whether less unnecessary data exposure changes pressure. It is not treatment by itself.

Choose one boundary:

• Turn one unneeded clock display away while keeping the alarm.
• Pause morning viewing of a consumer score.
• Ask a family member not to discuss tracker data unless invited.

Choose one outcome: worry, checking, morning distress, function, or conflict.

Duration: Three to seven days. Stop sooner if distress rises or necessary care is disrupted.

Daily note:

• Boundary used: yes, no, or not possible
• Checking: low, medium, or high
• Distress: low, medium, or high
• Daytime function: low, medium, or high
• Safety concern: none, describe, or urgent

Review: Continue if the boundary is useful and light. Simplify if it adds work. Stop if it increases distress. Get clinical help if persistent insomnia, impairment, or another disorder remains possible.

Toolkit asset 4: Morning check-in reset

Consent question: “Would you like me to ask about sleep in the morning, ask only about safety, or wait for you to bring it up?”

Support-first choices:

• “What would help today?”
• “Is there a safety issue, such as driving or a fall risk?”
• “Would practical help, company, or space feel best?”

Avoid unless invited: asking for exact hours, opening the tracker app, debating whether the person really slept, predicting the day from one night, or offering medication advice.

Reset line: “I think my questions are adding pressure. I will step back. Tell me what kind of support you want.”

Toolkit asset 5: Family behavior and evidence matrix

Toolkit asset 6: Daytime worry and problem-solving parking sheet

Use this in daylight, not as a rule you must complete before sleep.

The thought that keeps returning:
…

Is there a real task inside it? yes, no, unsure

If yes, the smallest next action:
…

Who owns that action: me, support person with consent, clinician, workplace, school, other

When I will review it:
…

What can wait:
…

Safety check: Does this involve driving sleepiness, suicidal thoughts, possible mania, severe withdrawal, breathing trouble, seizure, psychosis, overdose, or inability to stay safe? If yes, use the urgent-help plan rather than parking it.

Toolkit asset 7: Real disturbance or sleep-emergency ritual?

Full troubleshooting table

Toolkit asset 8: Routing guide

Formal CBT-I or behavioral sleep care: Persistent difficulty falling or staying asleep despite adequate opportunity, with distress or daytime impact, especially when bedtime has become linked with effort and monitoring.

Sleep-medicine evaluation: Loud snoring, witnessed breathing pauses, gasping, irresistible sleep attacks, cataplexy, complex nighttime behavior, severe restless legs, progressive sleep-time drift, or unclear diagnosis.

Mental-health evaluation: Panic, trauma symptoms, OCD-like checking, worsening depression, marked agitation, reduced need for sleep with rising energy, hallucinations, psychosis, or suicidal thoughts.

Medical or medication review: Pain, reflux, nocturia, menopause symptoms, pregnancy, thyroid symptoms, new medication, stimulant or steroid exposure, alcohol or cannabis effects, or withdrawal.

Environmental and social support: Unsafe housing, crowding, noise, caregiving, shift work, transport, school or job demands, disability access, or cost barriers. These are not personal failures.

One-page coordination worksheet

My useful goal:
…

What I am observing: checking, worry, function, conflict, other

Baseline dates: … to …

One strategy:
…

Patient owns:
…

Family may help with, by consent:
…

Information I agree to share:
…

Review date:
…

Continue if:
…

Simplify or stop if:
…

Call a clinician if:
…

Urgent plan: 911 for immediate danger; 988 for U.S. suicide or mental-health crisis support; do not drive when sleepy.

Related reading

• Less Time in Bed, More Consolidated Sleep
• You’re Not Weak. It May Be Rebound
• He Can’t Fall Asleep. It May Not Be Defiance
• Sleep Was the First Thing to Change
• Sleep Anxiety and the Science of Sleeping Without Pills
• Adenosine, Caffeine and Sleep Pressure

References

1. Marques DR, Gomes AA, Meia-Via AMS, et al. Sleep effort and its measurement: a scoping review. Journal of Sleep Research. 2024;33(6):e14206. doi:10.1111/jsr.14206. PMCID: PMC11597019. Full text 2. Tang NKY, Schmidt DA, Harvey AG. Sleeping with the enemy: clock monitoring in the maintenance of insomnia. Journal of Behavior Therapy and Experimental Psychiatry. 2007;38(1):40-55. doi:10.1016/j.jbtep.2005.07.004. PMID: 16793001. Full text 3. Dawson SC, et al. Use of Sleep Aids in Insomnia: The Role of Time Monitoring Behavior. Primary Care Companion for CNS Disorders. 2023;25(3):22m03344. doi:10.4088/PCC.22m03344. Full text 4. Schyvens AM, Peters B, Van Oost NC, et al. A performance validation of six commercial wrist-worn wearable sleep-tracking devices for sleep stage scoring compared to polysomnography. Sleep Advances. 2025;6(2):zpaf021. doi:10.1093/sleepadvances/zpaf021. PMID: 40303381. PMCID: PMC12038347. Full text 5. Srivali N, Cheungpasitporn W. Concordance of wearable device sleep metrics with patient-reported sleep quality: a systematic review. Sleep Medicine. 2026;144:108941. doi:10.1016/j.sleep.2026.108941. PMID: 41946254. Full text 6. Khosla S, Deak MC, Gault D, et al. Consumer Sleep Technology: An American Academy of Sleep Medicine Position Statement. Journal of Clinical Sleep Medicine. 2018;14(5):877-880. doi:10.5664/jcsm.7128. PMID: 29734997. PMCID: PMC5940440. Full text 7. Dzierzewski JM, et al. Sleep Health and Consumer Technologies: A Position Statement from the National Sleep Foundation. Sleep Health. 2026. doi:10.1016/j.sleh.2026.02.003. PMID: 41792005. Official PDF: Full text 8. Gavriloff D, Sheaves B, Juss A, et al. Sham sleep feedback delivered via actigraphy biases daytime symptom reports in people with insomnia: implications for insomnia disorder and wearable devices. Journal of Sleep Research. 2018;27(6):e12726. doi:10.1111/jsr.12726. PMID: 29989248. Full text 9. Berryhill S, Morton CJ, Dean A, et al. Effect of wearables on sleep in healthy individuals: a randomized crossover trial and validation study. Journal of Clinical Sleep Medicine. 2020;16(5):775-783. doi:10.5664/jcsm.8356. PMID: 32043961. PMCID: PMC7849816. Full text 10. Spina MA, Andrillon T, Quin N, Wiley JF, Rajaratnam SMW, Bei B. Does providing feedback and guidance on sleep perceptions using sleep wearables improve insomnia? Findings from “Novel Insomnia Treatment Experiment”: a randomized controlled trial. Sleep. 2023;46(9):zsad167. doi:10.1093/sleep/zsad167. PMID: 37294865. PMCID: PMC10485571. Full text 11. Baron KG, Abbott S, Jao N, Manalo N, Mullen R. Orthosomnia: Are Some Patients Taking the Quantified Self Too Far? Journal of Clinical Sleep Medicine. 2017;13(2):351-354. doi:10.5664/jcsm.6472. PMCID: PMC5263088. Full text 12. Furukawa Y, Sakata M, Yamamoto R, et al. Components and Delivery Formats of Cognitive Behavioral Therapy for Chronic Insomnia in Adults: A Systematic Review and Component Network Meta-Analysis. JAMA Psychiatry. 2024;81(4):357-365. doi:10.1001/jamapsychiatry.2023.5060. PMID: 38231522. PMCID: PMC10794978. Full text 13. Steinmetz L, Simon L, Feige B, Riemann D, Johann AF, Ell J, Ebert DD, Baumeister H, Benz F, Spiegelhalder K. Network meta-analysis examining efficacy of components of cognitive behavioural therapy for insomnia. Clinical Psychology Review. 2024;114:102507. doi:10.1016/j.cpr.2024.102507. PMID: 39504928. Full text 14. Jansson-Fröjmark M, et al. Paradoxical intention for insomnia: a systematic review and meta-analysis. Journal of Sleep Research. 2022;31(2):e13464. doi:10.1111/jsr.13464. PMID: 34405469. Full text 15. Ellis JG, Deary V, Troxel WM. The role of perceived partner alliance on the efficacy of CBT-I: preliminary findings. Behavioral Sleep Medicine. 2015;13(1):64-72. doi:10.1080/15402002.2013.838768. PMID: 24527869. PMCID: PMC4425373. Full text 16. Lalor AF, Durukan M, Hamill K, Mellor A, Drummond SPA. Effects of a partner-assisted insomnia intervention on couples’ relationships: a qualitative study. Sleep Medicine. 2026;139:108746. doi:10.1016/j.sleep.2025.108746. PMID: 41494331. Full text 17. 988 Suicide & Crisis Lifeline. Get Help. Accessed August 31, 2026. Full text 18. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Driver Fatigue on the Job. Accessed August 31, 2026. Full text 19. National Heart, Lung, and Blood Institute. Sleep Apnea Symptoms. Accessed August 31, 2026. Full text

If you or someone you know is in crisis

• Call 911 or go to your nearest emergency room for any life-threatening emergency.
• 988 Suicide & Crisis Lifeline — call or text 988, available 24/7. En español: marque 988 y oprima 2. Veterans: 988 and press 1, or text 838255.
• Crisis Text Line — text HOME to 741741.
• The Trevor Project (crisis support for LGBTQ+ young people) — call 1-866-488-7386, or text START to 678-678.
• National Sexual Assault Hotline (RAINN) — call 1-800-656-HOPE (4673) or text HOPE to 64673; free, confidential, 24/7. Online chat at RAINN.org/hotline.
• National Domestic Violence Hotline — call 1-800-799-SAFE (7233) or text START to 88788; 24/7, help in 200+ languages. Online chat at TheHotline.org. If your phone or computer may be monitored, calling from a safer device is an option.
• Riverside County — Inland SoCal Crisis Helpline 951-686-HELP (4357), 24/7 (Inland SoCal United Way / 211+, in partnership with RUHS-BH); Community Access, Referral, Evaluation and Support (CARES) Line 800-499-3008, 24/7.
• San Bernardino County — Access Unit (Behavioral Health Helpline) 888-743-1478, 24/7; Mobile Crisis/CCRT 800-398-0018 (24/7, all ages) or text 909-420-0560. Arrowhead Regional Medical Center (ARMC) has a dedicated walk-in adolescent psychiatric ER (ages 13–17).
• Children under 13 — call 911 for immediate danger, contact your county's mobile crisis team (they respond to all ages), or go to the nearest pediatric emergency room.
• California Peer-Run Warm Line (non-crisis — someone to talk to) — call or text 1-855-600-WARM (9276); daytime and evening hours, not a 24/7 line.
• NP Fady (non-emergency) — for routine scheduling or questions, call (909) 707-6261. This line is not monitored for emergencies.