The 3 Ps of Insomnia: How 1 Bad Night Turns Into 100
If you suffer with chronic insomnia, you may be able to pinpoint when it started.
Maybe it began around the time you suddenly found yourself unemployed. Maybe it started while you were recovering from an injury and had trouble sleeping due to pain. Or maybe it was triggered by a bout of depression or some other psychiatric or medical condition.
Either way, months or years may have passed since that original trigger. You’re back to work or totally recovered from your injury, but here you are still struggling to sleep. Why does insomnia persist even after you’ve resolved the original trigger?
Spielman's model of insomnia
Back in the 1980s, Arthur Spielman introduced a model of understanding insomnia that helps us answer this question. Spielman’s behavioral model of insomnia -- often called “The 3 Ps Model” -- posits that 3 sets of factors contribute to insomnia: predisposing, precipitating, and perpetuating factors.1
Predisposing factors are those qualities that make us vulnerable to having trouble sleeping in the first place. Much like we each might have baseline risk factors for heart disease or diabetes, we may also have risk factors for developing insomnia. These predisposing factors are often characteristics that are outside of our control, such as our genetics and whether we’re prone to be worriers. While there’s not much we can do about most predisposing factors, they are also not usually enough to cause insomnia on their own.
Precipitating factors are the things that trigger the first few sleepless nights. They are typically short-term stressors such as worrying about a presentation at work or battling the flu. They can also be more serious stressors such as experiencing a trauma or having a serious medical condition. If the model ended here, then your sleep should go back to normal once the precipitating factor is resolved. But we know that doesn’t happen in the case of chronic insomnia.
That’s where perpetuating factors come into play. After suffering through a few days or weeks of bad sleep, we often start to develop habits to help us cope with fatigue and sleeplessness. These behaviors usually help us get through those first few exhausting days that follow poor sleep.
A closer look at perpetuating factors
For example, taking an afternoon nap may help you feel less fatigued, and sleeping in on your day off may help you temporarily make up for the “sleep debt” you incurred during your work days. But after a while, these strategies stop helping and, like the name suggests, actually perpetuate sleeplessness.
Napping during the day makes it more difficult to fall asleep at night and sleeping in on the weekends can throw off our circadian rhythms. Over time we also tend to develop negative thoughts and expectations about sleep. You might find yourself worrying about how you’re going to function the next day or predicting that tonight is going to be another sleepless night. These thoughts may pop into your head automatically and you may even have reasons for thinking this way, but one thing is for sure: no one has ever gotten a good night’s sleep after telling themselves, “I’m going to get fired if I don’t fall asleep right now!”
These perpetuating factors help us understand why insomnia can persist even after the initial stressor has resolved. While one set of factors triggered your first few sleepless nights, a very different set of behaviors and thoughts continue to drive insomnia long after.
There are treatment options
The good news is that once we become aware of our unique perpetuating factors, we can change them. In my experience, the most effective treatments for insomnia (such as cognitive behavioral therapy for insomnia, or CBTI) will teach you to identify and change those bad habits and negative thoughts. The even better news is that treatment might only take a couple of months, while improvement can last indefinitely.
In my clinical work, I routinely witnessed Vietnam-era Veterans resolve 40+ years of insomnia after just 5 to 6 weeks of treatment. It is important to note that treatments like CBTI go well beyond the typical sleep hygiene tips that you’ve probably tried already. So if you’ve hung blackout curtains and replaced your mattress but still can’t sleep, it may be time to try something different.
Do you have any other health conditions besides insomnia?