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- [00:00]
A
It's 3am you're wide awake, not panicked, but you're just on. Your brain is running tomorrow's to do list, last week's awkward conversation, and the math on exactly how few hours you have left before the alarm goes off. And the more you do that math, the more awake you get. If that's you three, four nights a week, you're not alone. About one in 10 adults meets the clinical definition of chronic insomnia. Most never get diagnosed, never get treated, and instead end up on a midnight scroll being sold magnesium pills, pills, mouth tape, 300 trackers, and melatonin gummies. For us neurologists, sleep isn't just stressed. It's when your brain does some of its most important work. As you sleep, your brain runs a cleaning cycle, flushing out the metabolic waste that builds up all the day, including the very protein linked to Alzheimer's disease. So night after night, year after year, bad sleep isn't just an energy problem, it becomes a brain problem. And it runs both ways. Poor sleep can speed up brain aging, and a changing brain can wreck your sleep. There's so much noise out there regarding sleep, so much sleep content engineered to make you anxious and then sell you the fix. So we brought in two of the sharpest people in this field to cut the signal from the noise. What actually fixes sleep? What's a waste of your money? And when is a bad night just a bad night versus something worth paying attention to? Our guests are two experts who come at this from completely different angles. Dr. Sujay Khan Sagra is a sleep neurologist at Duke University. He's the director of Duke's Pediatric neurology Sleep medicine program and an assistant professor in Duke's School of medicine. Sujay gives us the why, the biology of sleep, what's happening in your brain chemistry, and a brilliant, honest rated rundown of every sleep aid you've ever heard about. Then we have Dr. Shelby Harris, who is a clinical psychologist and a behavioral sleep medicine specialist. She gives you the how, the psychology of why you can't shut your brain off, the trap of chasing perfect sleep, and the treatment that actually works. Much of her practice is women in perimenopause and menopause, which she calls a perfect storm for sleep. And here's what struck us most. These two never spoke to each other, and they landed on almost the exact same conclusions. When that happens, pay attention. This is your brain on insomnia. So let's talk about sleep. And why is sleep important?
- [02:28]
B
Well, to think about it this way, A dolphin is air breathing. So in order to sleep at night, it actually sleeps with one side of the brain off and the other side on and alternates. In fact, one of the eyes are open and it's functioning and the other side is completely asleep. Imagine that.
- [02:44]
A
Mind boggling.
- [02:45]
B
That's remarkable sacrifice.
- [02:48]
A
I wish humans could do that. Just shut off half of your brain,
- [02:51]
C
the other one on.
- [02:52]
B
So much done. But that's what the dolphins do, because they have to be able to breathe and come to the surface. Most animals, whether it's flies, worms, even jellyfish, who don't even have a central nervous system, have to sleep.
- [03:05]
A
You never think of worms sleeping, but they do sleep.
- [03:08]
B
They do. And everything that has some sort of nervous system has adapted this function of sleeping. Why is evolution, which is so efficient, introduced a process that puts these animals at such distress and sometimes at peril? Imagine one third of your life, all these animals who work so hard to protect themselves, that are so diligent while awake, then at night, they shut everything off. They are blind to the world, they're deaf to the world. Their musculature is completely turned off. Their reflexes are not working. They're paralyzed one third of their life. And the reason is because sleep is literally that important. Maintenance is an incredible machinery that maintains this incredibly sophisticated machine that's constantly working. The fact that a brain at any one minute has a hundred million functions happening at any one time, it's just remarkable. And it's also the most vascular organ. So the blood flow, the neuronal connections, the axon transfer of neurotransmitters through millions and billions of connections. That's a lot of work.
- [04:12]
A
Just thinking about it makes me tired.
- [04:14]
B
Exactly. So that maintenance system is necessary for all organisms that have any form of central nervous system.
- [04:21]
A
Fascinating. So when you look at it from a mechanistic perspective, two main things happen when people go to sleep. The first thing is a cleansing system gets activated, and we can talk about the details of what that means. The second thing is your memories get organized and they get consolidated during sleep. But the cleansing system is just wonderful. It's such a fascinating feature of sleep. And it used to be theoretical and they studied it in animals. But recently they were able to image the glymphatic system and the cleansing system in the human brain.
- [04:54]
B
Absolutely. What it is is imagine a city. It's a massive city. And at night all the cars are off. The cities actually widen. So it's a better system than a normal city. And this incredible cleaning crew comes in and the washing starts. And the washing is not these little trucks that just, you know, push away the leaves and water. It's a massive river of water cleaning up entire cities and entire road systems. That's the lymphatic fluid that runs through the brain. And then at the same time, these workers come in these microglia that are incredible at what they do, which is cleaning all the debris. In this case, it could be amyloid, it could be tau, these proteins that usually accumulate in pre Alzheimer's and other disease states. And besides those two, many other byproducts that need to be eliminated. And they clean everything out and then they flush it into the lymphatic system and out of the body. That's remarkable. And every time you don't get good sleep, the garbage and these proteins actually accumulate. That's the remarkable glymphatic system of the brain. The second part is memory consolidation. And that's where all these memories that have accumulated during the day and even previous nights, they're organized into, right, folders, files and cabinets and are connected to past memories. And it's not just files and folders or cabinets. It's better than that. It's connected to memories that are sustained, that are powerful, which means that they're anchored well. And there's a third component. Oh, eliminating bad memories or eliminating unnecessary memories, that's another thing that happens during night.
- [06:23]
A
I'm glad we're talking about it because in the western world especially, sleep is considered as an afterthought. You know, the phrase I'll sleep when I die is such a great example of how we think about it. But the third of our life that we spend unconscious was actually never time stolen. It actually is the shift that keeps the other two thirds from falling apart. And it's so, so critical for us to think about it that way. The brain that won't slee sleep is a brain that is quietly losing itself. So we wanted someone who could explain what's actually happening in our brains and be honest about which of the hundred things that you've been told actually works. Suja Khan Sagra is that person. Let's get into it.
- [07:05]
C
Sujay, it is so wonderful to speak with you again. I was just, we were just chatting before we pressed the record button of how much we love your content, the language that you use, the way you empower people. We're so excited to have you here on our podcast again.
- [07:22]
A
So thank you.
- [07:22]
D
The feeling is absolutely mutual. Love what you all do. Sharing information for the masses in a palatable way. It's. It's a wonderful thing. So thank you.
- [07:31]
E
It's a critical. It's a critical tool. I mean, you're an academician Duke University. You do research, you do clinical work. But we are at a time where science communication is as important, if not more so, than the science itself, because the science has been bastardized. That's a technical term. But it's very few who do the science, apply the science and then communicate the science. Don't let this get to your head too much, but you are literally one of the few that does all of that and then does it in a funny way, so it sticks.
- [08:08]
C
Oh, I love it.
- [08:09]
E
Gods of Hulu, Gods of Netflix. He needs his own show.
- [08:13]
D
It would be a show sober. I would just lull you to sleep every single night. Right. You just tune into Netflix. Oh, that probably goes against Netflix goal, which is to keep you kind of streaming for hours and hours. But I would just bore you to sleep with science.
- [08:25]
E
You know, some people, a lot of people are looking for that because. Because it's a major problem. Sleep is, or lack thereof, is a major problem in. In America, in the west, and throughout the world. Now, this is a something that should come naturally. It's a very unusual thing. I mean, we're writing our third book. One whole section is sleep. And I had to do so much research into the anthropology, evolution of sleep. Here you have a situation where a species became multicellular to survive, to make sure that it can eat, reproduce, and stave off danger. And then in the middle of all that eight hours where you're paralyzed and knocked out. What is that all about?
- [09:12]
D
What is this famous. And you may have put this in your book. There's this famous quote by an evolutionary biologist. If sleep did not play an absolutely vital role, it's the biggest mistake that evolution has ever made for the very reason you just mentioned. Right. You're a sitting duck. What are you doing to help propagate the chances that you are going to pass along your genes to the next generation? You're just sitting there doing nothing. And so it's got to play a vital role. And I think the answer is becoming more and more clear the more we learn about sleep and sleep science.
- [09:41]
E
Yeah. For most of human history, sleep has been. Has been a central theme from the time that humanity started communicating. But it's never been as much of a problem as it is now. Tell us, why is sleep, or lack of sleep such a problem now?
- [09:58]
D
Well, a lot of it depends on personal expectations around sleep and how we spend our waking hours. A lot of it is pressure from cultural, you know, pulls and pushes regarding what we should be doing with our time. A lot of it just comes down to also brain physiology and what actually keeps us engaged and excited about certain things that might pull us away from sleep. Misinformation regarding what we are capable of, what we should be doing regarding our sleep, how much sleep we actually need and what that means for us. Long term capitalism in societies like ours in the United States, where there's more of an emphasis on how hard you're working during the day, not necessarily how well you're resting at night. And that's also a big problem, I think. And I always say, you know, if you look at all of the driving forces regarding what, what people tell you to do, is anybody out there motivated to help you sleep? Like apart from maybe like mattress companies or pillow companies? But, but let's look at, let's look at social media, right? We are in, in the past people used to say we used to colonize land right in space and now we're in the business. The biggest companies in the world are in the business of colonizing our time, like our, our, our time. And the more time that they have, the better their company does. And so Netflix is not motivated to help, help, you know, you sleep. Instagram is not motivated to help you sleep. Food companies, right, they, they do better if you're awake more hours. Like anything that you think of that's driven by monetization usually does better by depriving you of sleep and sending you the message that you don't necessarily need to sleep. And the only person that really kind of benefits when you sleep, the big scheme of things is you, right? You're the one that benefits. But none of these other forces in the world are benefiting. So it really is this mismatch between what we know is a biological imperative and what everybody else is telling you to prioritize. And again, as you mentioned, a huge problem.
- [11:52]
E
Is there data that reflects this change? I mean, I think one of the major inflection points was the phone, the smartphone that made information and connectivity ubiquitous. It became ever present and you couldn't escape it. I remember, yeah, I'm that old. I had before flip phones in my pocket. I remember my brother in law was the first one that got one of those phones that you could carry with you. She was ob GYN and he was the coolest thing the planet because he had this huge phone with this container and all that, but there was no connectivity.
- [12:27]
C
What year Was that.
- [12:30]
E
We don't worry about it. Yes, we don't.
- [12:32]
D
It's so funny you mentioned this because I was talking to my children about this very conversation. I remember the first time we had a phone we could put in the car. It was this American cellular phone, this big bag, and you velcroed in the phone and then you talk and it was this amazing thing. You are now connected in a way to the planet outside of your computer system, in your home. Right. So now it's. It's that connectivity is following you around. And then fast forward to now where we can't escape it. Yes. There is data that says that we are sleeping less over time. The. The types of questions we even ask in research have shifted from. For, like teenagers, the question used to be, how many hours do you spend on your phone? And now the questions are more like, do you spend all of your time on the phone or less than all of your time on the phone? You know, like. Because literally the number of hours on average that our teenagers are spending behind a screen is starting to get really a little bit ridiculous and scary, to be honest. So, yes, over time, we are becoming more sleep deprived.
- [13:30]
E
You know what the funny thing is, I thought I was pretty disciplined. I have so many things, so many irons in the fire from the company to not for profit, to academic and to publication and all of that stuff. And I said, I'm not that often on the, on the Internet. And then my kids had, of course, this is a reverse. And what usually happens is parents check on their kids. Well, my kids checked on me. They had this tool where on the phone showed how many hours I was on Instagram and TikTok and all that. And it was embarrassing.
- [14:03]
D
Yeah, they pulled the UNO reverse card on. Yeah, yeah, yeah, they did, they did.
- [14:08]
C
They pulled it up. Yeah.
- [14:09]
B
But the point of that being is
- [14:11]
E
these systems are so addictive, so surreptitiously in a very, in a very quiet and psychologically astute way.
- [14:23]
B
Take what you said.
- [14:24]
E
Colonize your time hours at a time without you even knowing. When I saw that, I was actually shocked.
- [14:30]
C
Yeah. And we actually even, you know, we were looking at our patterns of making it sound okay to be on our phone and not sleep and the language that we create. And, you know, we're pretty health literate. We're in it. We're aware. And it was such a, you know, an unexpected moment where like, yeah, oh, yeah, we're, we're stuck. We're doing the same thing that we
- [14:52]
D
tell everybody else not to the Amazing thing. And even for me, you know, the sleep doc, when I look at my phone, it even shocks me. I'm like, I'm spending this much time checking my email on social media, even on like just messages, sending text to, to one another, there is like this frightening data where people have done the math right? They're like, okay, if you're going to sleep eight hours per night for your, for your life, that's a third of your, of your life. You're going to spend this much time showering, this much time eating, this much time, you know, in the, in the bathroom, this much, you know, time grooming, this much time at work. And then when you look at how much time is left in your life, you know, to do whatever it is, go out and touch some grass, go on a, go on a vacation, be on your phone. When you look at the amount of time that's left, screens occupy almost all of that remaining time. Almost all that remaining time. And we have like a sliver of time left to experience consciousness outside of having a screen in front of our face. And that's really what kind of shook me a little bit to my core, to be like, wow, I'm spending all of my consciousness behind a screen all the time. And there are ways in which that ends up impacting sleep. One is just the sheer time factor, right? There's only so many hours in a day. If you spend 14 hours on the phone, sleep is naturally going to suffer. But the neurochemistry that's going on in your brain when you are tied to a device, dopamine, and being involved in these social networks where people are responding to your content and you're responding to others, whether it be norepinephrine, because you're so riled up by some of the things that you're seeing that are really emotionally taxing, Right. I mean, we see horrible things happening in the world right now. And when you see that at nighttime, before you go to sleep, it's not creating the neurochemistry milieu that's ideal to help you have a good night of sleep. So there are many ways in which these devices are sapping energy. Now, I say that as someone that's very active on social media and will say that, yes, all of these tools play a role and can be helpful in ways as long as they're consumed in moderation and with a critical eye. But if you look at the net effects overall, it's hard to justify that. It's a net positive for humanity. Absolutely. So really, we look Back to our diagnostic manual we call the International Classification of sleep disorders. Edition 3 is what we're on right now to see how we'd formally characterize insomnia. And there's a definition for chronic insomnia and it's essentially a constellation of potential complaints. And if you meet those criteria, which can be, you know, one difficulty with falling asleep or maintaining, maintaining sleep or waking up too early, the problem should cause some sort of negative daytime manifestation, whether that be fatigue, you know, mood instability, difficulty making it to work, some sort of a daytime impact. And then the complaint should be going on for at least three days out of each week and for at least three months in duration overall that characterizes chronic insomnia. And of course the sleep issue shouldn't be explained by other factors, other medical conditions, inadequate opportunity to sleep, all those types of things. So that's kind of the formal definition of chronic insomnia. But if we just take a big picture, it's, it's some sort of a sleep disturbance when it comes to quantity or quality that then has a daytime manifestation. That's like my broad definition of a sleep disorder in general. And insomnia is a subset of that that applies specifically to getting adequate quantity in most cases of sleep.
- [18:01]
C
Yeah, insomnia can be quite isolating because I don't think there's like a, I don't know if there's a support group.
- [18:07]
D
I think it's probably called TikTok. You know, like there's, I think a lot of avenues where people get together and have. Yeah, I mean it's incredibly common. You know, when it comes to difficulty like a sleep complaint, the vast majority of adults at some point in their life will have a sleep related issue. Chronic insomnia, thankfully, as an entity is much less common and the numbers vary, but I'd say any, if I'm going to quote it last check, probably somewhere between 20 and 30% of individuals likely have experienced chronic insomnia at some point. And it's likely very under diagnosed because many people don't seek help, they seek hacks online and other quick fixes. Yeah, I think the nature of insomnia is one of, that the issue can perpetuate itself over time based on how we are approaching it. And I do think we are caught in a system in which the people feel like the sleep issue, there's like a one answer and they have to find that one answer as opposed to fixing like a multifactorial kind of global approach to sleep. And so I think a lot of these Poor sleep issues just kind of continue and kind of perpetuate because we're not addressing some of the core issues, right? That's right. I kind of say that, you know, when you're not sleeping, usually it's multiple wheels in a car that are not working and you have to fix all of those wheels in the car for the car to go forward. One third of adults will complain occasionally of sleep related issues. So around, you know, around 30%, about 10% of adults long term will meet criteria for chronic insomnia that's diagnosed chronic insomnia. And most adults unfortunately go their whole lives probably without a formal diagnosis. So the true numbers are likely much higher.
- [19:44]
E
As far as the psychological ones, stress, anxiety and depression, and all of these are very common causes of insomnia, aren't they?
- [19:55]
D
That's right. And we think the arrow points in both directions. If you have sleep challenges, they can predispose you to things like anxiety and mood disorders and vice versa. We know those disorders can also impact your sleep.
- [20:05]
E
What about chemically? I would like to start with melatonin as the chemical that drives this whole process and then let's see if we can deconstruct from there.
- [20:12]
D
Yeah, we can certainly start with melatonin. I'll tell you that the neurochemistry behind sleep is fascinating. And it has diffuse neural networks and involves a whole host of systems, including our ascending reticular activating system and histamine and norepinephrine and serotonin. And it really gets deep. But melatonin is a great place to start because it's something that's commonly we talk about. Melatonin is what we'd consider the clock setter when it comes to our circadian rhythm. And even though circadian rhythm is often tied to sleep, the circadian rhythm is this internal body clock that does many, many, many things for our bodies, including at an organ systems level and even a cellular level. It keeps things running in a 24 hour pattern, which is why our GI system acts differently depending on the time of the day. Our lungs act differently depending on the time of the day. And all that is kept in sync with melatonin signals. And most of the melatonin comes from the pineal gland, which is kind of the center part of our brain. And the pineal gland secretion of melatonin is kept in sync by the suprachiasmatic nucleus in the hypothalamus. And so there's lots of parts that are involved, but in a chemical basis, melatonin is really Telling our brains it's dark outside. Do what you do when it's dark outside. Evolutionarily, whatever your body tends to do when it's dark, that's what you should do when melatonin is seen. And so that's like, that's the core of melatonin. It starts the process of telling our body it's getting dark, you should start sleeping. Interestingly, and I don't want to go into too many rabbit holes here, but nocturnal animals also secrete melatonin at night. And for them, melatonin tells their brains to do the opposite. It signals them to actually be awake. So that's why melatonin in and of itself does not have big sleep inducing properties. It's more of a, hey, it's night time, do what your brain does when it's nighttime.
- [22:01]
E
Oh, wow, that is so cool.
- [22:04]
D
Absolutely.
- [22:05]
C
So in owls and in nocturnal animals is completely the opposite. It's like, hey, time to eat.
- [22:11]
D
That's right. Yeah, it's time to party. Yeah. So when it comes to sleep, you know, we think there are a couple of key neurotransmitters. We know acetylcholine, for example, plays a role in dreaming and REM sleep. We know that dopamine, norepinephrine and histamine are all chemicals that tend to keep you awake. Gabaergic, you know, when you have more GABA in your system tends to be more inhibitory and helps with sleep. And all of these end up kind of working together in a fascinating way to make sleep a flip flop switch. Either you're asleep or you're not. And your brain is whether you know either in sleep or not at any given time. And so it's fascinating. Serotonin has some kind of mixed Data. We're not 100% sure which direction serotonin likely goes, but other ones we feel a bit more strongly about.
- [22:55]
E
Melatonin is affected by light.
- [22:57]
D
Yes.
- [22:58]
B
So how acutely is it affected?
- [23:00]
E
So a lot of times we tell people don't have blue light, it can acutely affect you. So I would love for you to tell us how quickly it responds to light and what type of light.
- [23:12]
C
Or on the opposite side, when they actually ask you to not directly look at the sun. I think that's silly and I would love to hear the sleep doc talking about that a little bit. But, you know, at least getting some daylight earlier in the morning might actually help. Right. Regulate your melatonin.
- [23:25]
A
What are your thoughts?
- [23:25]
D
Yeah, yeah, no, these are all fantastic questions. We could probably talk an hour about each of these questions. When it comes to light, we've probably, you know, the pendulum swings in different directions. I think sometimes we probably overblow how much the effect of a little bit of light at nighttime will have on somebody's sleep, you know. And so I will tell you that the duration of light seems to play a role, the intensity of light plays a role and the wavelength of light plays a role. Plays a role. And the overall timing in regarding what time of our day we're seeing that light. The closer I get light to the deeper parts of my night, the more disruptive and the more shifting it can be. So if you're somebody that's in bed, Maybe you watch TV for 20 minutes and you keep the lights fairly dim. When the TV turns off, you fall asleep within 15 minutes, you wake up fine the next day, you don't have a problem that needs fixing. However, there are some people that are having lights that are very bright that are really close to the face for long periods of time. And we think that will probably end up suppressing melatonin. But again, it's not like an immediate like, oh, I've seen for the second now my melatonin is decreased. It's likely due to overextended periods of time. And the problem is we also can't do real time kind of like microdialysis analysis to be like, oh, how much melatonin do you have with quick light exposure? So I don't think we have a great sense of just how quickly when it comes, like one minute versus five minutes versus 10 minutes. What we do see is these global shifts in your circadian timing based on exposure to light. I think the bottom line here is don't get overly fixated on being like, I have to avoid all light and if I saw a screen for one minute, it's going to end up killing my sleep. We don't think it really works that acutely or is that impactful.
- [25:04]
E
Amazing.
- [25:05]
A
What's the data?
- [25:06]
C
How strong is the data behind the concept of exposing yourself to daylight first thing in the morning?
- [25:12]
D
We love that as a general recommendation and these kind of scientific rationale is that our circadian rhythms by nature are a little bit longer than 24 hours. We sleep in roughly 24 point to 24.2 hour cycles. That's our natural kind of circadian rhythm length. Every morning when you get bright light, your body is like, oh, actually it's, it's the day is shorter, slightly shorter than I thought and helps keep you locked into that 24 hour pattern. And so getting that light exposure in the morning is probably one of the best things I think you can do to keep your body in a regular schedule. Particularly for night owls who have a tendency to naturally delay their body clock day after day if they didn't have those light cues at the right time in the morning.
- [25:55]
C
Amazing.
- [25:56]
A
So if someone comes into your clinic
- [25:58]
C
and says, you know, Dr. Consagra, I can't sleep, I have insomnia, and of course you have a long questionnaire to ask them, like, what does that even mean? What does the pattern look like? And then evaluate their environment. But what are some of the common things? If you could quickly just identify what are some of the common things that you ask to find out what the, what problem they have.
- [26:20]
D
Absolutely. So in the pediatric space, I will tell you that, that depending on which age you are. So for infants, you know, young infants that aren't, you know, when they're old enough to be able to quote, unquote, sleep through the night, it's usually what we call a behavioral insomnia of childhood, needing sleep crutches or assistance for helping them maintain sleep. For toddlers, it's usually ends up being limit setting or perhaps some nighttime anxiety. But for older folks, let's talk about adolescents and adults. Apart from going through, you know, basic sleep hygiene, looking at their medical history, looking at what medications they're taking, when it comes to sleep disorders in general, the two most common things that I will see are chronic insomnia, right? Or a delayed circadian rhythm, what we call delayed sleep wake phase syndrome, where they're like, I gotta go to bed at 9pm but their body, their body clock is not ready to go to bed until midnight and that creates difficulty of falling asleep. And then when they have to wake up super early, it makes it, it's really hard for those individuals to wake up at an early hour. So those are the two most common things. And one thing I will ask, which is not a perfect question, but one question that can help is how the individual feels when they're laying in bed and actually trying to fall asleep. Do they feel wide awake? Like, oh, I could stay awake for hours and then have difficulty with waking up in the morning and prefer to sleep in on the weekends. That points more towards a circadian rhythm issue perhaps, as opposed to someone with insomnia who oftentimes does feel tired, they feel sleepy and they just have a hard time turning their brain off. They tend to ruminate, they tend to think and Rolodex through thoughts at nighttime. If they wake up during a normal awakening at night, they may have a harder time going back to sleep. This is kind of more of a. Points me more towards insomnia. And again, not a perfect distinction, but a helpful question I will ask to point in one direction or the other.
- [28:01]
C
Amazing. And the treatment depends on the reason why they have it. And so it could be varied.
- [28:08]
D
Absolutely. And this is like the favorite question I get from my colleagues, like, hey, this patient cares sleep. What should we do? And my, my answer is, I have no idea. I have no idea what to do until I assess them. Because there's so many things that can end up affecting your sleep that, you know, my new patient evaluations take me an hour. But when we look at those two core things we just talked about, if it's delayed sleep wake phase, oftentimes we use melatonin in low doses from reliable sources. Morning light, bright light, and less light in the evening hours leading up to bed, in hopes of shifting the circadian rhythm, which is their main issue, as opposed to insomnia, where the core treatment is cognitive behavioral therapy for insomnia to help reverse some of the negative associations. This conditioned arousal they feel when they're in their bed, this kind of battlefield they're in every time they lay down in bed, trying to fall asleep and battling with their own brain. That's what CBTI is geared to do, help you with that internal struggle and battle.
- [29:04]
C
We love cbti. I mean, it's just so beautiful, not just for sleep, but for shifting perspectives
- [29:09]
A
about life in general.
- [29:11]
C
I mean, I've had such great experience with that.
- [29:14]
E
In our populations, we actually teach cognitive behavioral therapy techniques. And it's important because much of this can be self. I mean, there should be always oversight. There should be, you know, clinical oversight. But the language is simple enough and understandable enough where people can actually start applying it in their life very, very easily and effectively.
- [29:36]
C
So true.
- [29:37]
A
How long does it take for the
- [29:38]
C
circadian rhythm to change? Because sometimes people get very frustrated and then they quit and say, like, yeah, it's not working.
- [29:44]
D
Yes, there is a practical, like, real life use answer, and then there's a scientific answer of like, the maximum ability to shift in real life situation, I'm expecting somebody to try to shift their body clock by five or ten minutes a day if I'm moving in the earlier direction. Moving your body clock earlier is almost always much harder than moving it later. That's why it's much easier to fly west, because we're asking our bodies to do everything later than Typical. And it's much harder when we fly east, when we're trying to have our bodies do things earlier. So practically speaking, I'm asking them to make a shift by five or ten minutes a day in the right direction. Now, the scientific answer is if you had everything right, light exposure, the perfect time, everything set up the right time, you could shift by as much as we think two hours, because likely the maximum shifting earlier and about three to four hours is the maximum you can shift later. But that's in like perfect laboratory setup kind of environment. Practically speaking, we're talking small shifts each day.
- [30:42]
C
Amazing, amazing. And you mentioned something about melatonin. You said low dose melatonin from the right sources. What did you mean by that?
- [30:49]
D
Yeah, so melatonin in our country here in the US Is not fda, it's not regulated, it's not by prescription. You know, many European countries, melatonin is a prescription hormone, essentially. And so here, anybody can just put it in a bottle or label it as melatonin. We have some good studies that show there's lots of variability in the amount of melatonin, these bottles, and sometimes they have these weird additives that, you know, we didn't even know were supposed to be in there. So I, if I'm using melatonin as a circadian shifting agent, I'm usually looking at more trusted sources, you know, like some of the generics from the big box pharmacies, you know, some of the brand names that are, that are more trustworthy and have been in the space for a long time. And so we just have to be careful just picking up any bottle from a shelf and saying, oh, yeah, it's got melatonin. It says it's melatonin. It should be fine. For me, it's just the nature of the supplement market. I'm always weary.
- [31:38]
C
Wow, okay. Good to know that. Good to know that. One of the things that we hear often, even at parties from family members and in our community is parents of newborn children having difficulty with sleep. And I honestly feel guilty sometimes when I make a post about, you know, the importance of sleep for adults and its relationship with cognitive decline later on. And then I have, you know, huge number of lovely moms and, you know, parents, they're saying, oh, I'm doomed. This is it for me. I'm done. I'm definitely getting Alzheimer's disease. What do you see in your practice? Because you work with children and adults as well. How can, is this something that gets better over time? What are some of the things that they can do to take care of their brain health.
- [32:23]
D
Yeah, so I, I do, I, I am very appreciative of how much now awareness is out there regarding sleep and the health impacts. And sometimes paradoxically, that can work against us in sleep medicine where people get so kind of caught up to be like, oh, am I going to have this and this problem because I can't sleep? And then they can't sleep because they're thinking about not getting enough sleep. My tagline here for everybody is sleep is important, but it's not important enough to lose sleepover. All right, so think about that for a second. Right? It's like, yes, it's important, but I try to, even as a sleep dog say we have to temper that a little bit just to keep you on the right path. Yes, we're learning much more about the overall risks when it comes to your brain. However, when it comes to sleep debt that you've accumulated, unless you're in like these really, really extreme sleep deprivation kind of situations, usually your brain can pay back the sleep debt and get back to a kind of a normal cognitive functioning, you know, standpoint. Now there's also some data that says that if you're extremely sleep deprived for long periods of time, could you perhaps be burning out some of the wake promoting centers of your brain? It's possible. For example, if you have untreated sleep apnea for a long time, even if you treat the sleep apnea, many people still feel residual sleepiness that might be, that might need medication, intervention to help make them feel more awake even when the sleep apnea is treated. So I do have people keep that in mind. But for the most part, sleep can find ways of taking care of itself. When you get so sleep deprived, your brain just starts pushing you into micro sleeps, if need be, to try to catch up on some of that sleep. And usually your brain can maintain its function if you make concerted effort to regain some of the sleep that you've lost.
- [34:01]
E
So the two concepts, the two treatment mechanisms that we talk about often, one is medication, we'll talk about that. And the other one is cbti. Let's start with medication. If somebody has insomnia, there is a place for medication, right? I know that's a very difficult concept to bring up in a context like this few minutes because it's a complex concept. You have to take everything into consideration. But generally, how do you approach the pharmaceutical side of things?
- [34:25]
D
Yeah, medications certainly have their place in, in my mind, oftentimes sleep docs might be the least likely to Prescribe one of the classic things that you would associate as a sleep aid. Just because we're in the habit of trying to push towards taking away things that could be disrupting sleep and then introducing things like CBTI that long term seem to do better than medications alone. But medications do have their role. I will tell you that if somebody is doing cbt, I actively invested, still having some challenges. A short term course of a sleep aid can sometimes be useful if you're getting somebody acclimated to CPAP and they're having a hard time adjusting to sleep. Sometimes in that scenario, having a gentle sleep aid can be helpful. The problem is that people oftentimes are reaching for things that are over the counter that are essentially just kind of throwing a sleep book at your head to knock you out without actually addressing the underlying issue and really kind of sustaining your neurochemistry in a way that's advantageous to your daytime function. For example, many of the over the counter stuff are just fancy antihistamines. No matter how they label this bottle, it's just another antihistamine like Benadryl or Benadryl equivalent, which is not ideal for your brain long term and can actually worsen other underlying sleep disorders like restless leg. So we have to be careful with medications and always do it under the kind of supervision of ideally a sleep trained professional.
- [35:43]
E
Fantastic.
- [35:43]
C
What's the evidence around some of these quote unquote natural products for sleep? You know, they're everywhere and they're quite expensive. Some of them are so expensive. And they could be herbs and teas and things of that nature. What's the evidence behind that?
- [35:56]
D
Yeah, there's very little evidence for almost all of the things that are out there. Otherwise, you know, we would, we would use them on a regular basis. And I always say that all of the sleep disorders that we know of that are going to affect sleep, none of them, you know, physiologically have like a chamomile deficiency, you know, or like, you know what I mean? Like there's no lavender deficiency syndrome that we know of or, you know, a scented candle deficiency syndrome. So, so I always say let's get to the underlying root cause of what your problem is rather than trying to mask it with mumbo jumbo. And, and that usually comes down to some of the disorders we've already talked about, whether it be chronic insomnia, circadian rhythm issues, it can be quality disruptors like sleep apnea, restless leg, and then let's, let's use supplements in a way that we know they should Be used, for example, with restless leg, oftentimes it's iron deficiency. And that situation, yes, iron as a supplement can be very helpful to get you on the right track. So I'm not anti supplement. I'm anti, like using things that don't make physiologic sense. And so, you know, people talk about magnesium all the time. You know, everybody's suddenly magnesium deficient. And I will tell you that the data behind using magnesium is like a fraction of what the hype shows around magnesium. And there might be a signal there. And I'm not. You know, it's one of the more benign kind of supplements to use in most situations, unless you have kidney issues and you tend to build up your magnesium levels, but you're still spending money on something that you're expecting results from. And so, you know, I, I'm always, I'm always. I'm skeptical and weary by nature. And supplements just really take. Bring my yellow flag and red flag antenna up at all times. The whole goal regarding cbti, the way that I like to think about it, is that when you get into bed, right, it should be a welcome, friendly, safe, comforting space. And all of our goals of CBTI is to help induce that natural passive thing known as sleep. Let it enter your brain because you have primed your brain to be in that nice, calm, safe sleep space. Okay. I wish sleep was an active switch we could turn off. It's not. So we have to have our brains and our bodies in that, in the right kind of right atmosphere to accept this passive thing. That's sleep. So how do we do it? Well, one common thing we use, again with the help of a sleep professional, is sleep restriction. Or some people use sleep constriction, which is slightly different. But sleep restriction is essentially, somebody says, I can't sleep, So I spend 10 hours in my bed, and I hope I get six hours out of that 10. And they're like expanding their time in bed. And we say, you actually, you want to do the opposite. I don't want you to spend too much time awake in bed because that perpetuates insomnia in many situations because you're spending a lot of time awake and frustrated. So we narrow down that sleep window. And then once they're sleeping well and they're filling up, you know, 85% or more of their time with sleep, then we start to gradually expand that sleep window. So that's sleep restriction therapy. Probably one of the most effective ways of dealing with insomnia. And why most medical residents even if they have insomnia at baseline, the residency hits and suddenly the insomnia is much better because they are so sleep restricted. Second thing that we often use is called stimulus control therapy. The way I like to think about this is when you walk into your favorite restaurant, you naturally start feeling hungry because your brain knows what happens in that restaurant. If you walk into the gym, you start feeling revved up and energized because you know what happens in the gym. Well, when you walk into your bed, your bedroom is laid out in your bed. I want your brain to feel a sense of calm relaxation, not a sense of worry and dread. So if you are laying in bed and it's taken you more than 20 or so minutes to fall asleep and you don't feel sleep coming, we actually recommend getting out of your bed and doing something boring until you feel sleepy again, with the main goal of pairing laying in bed in your bedroom environment with comfort, not this internal rolodexing and worry. So we don't want to pair it with too much time awake. That's stimulus control. We will use techniques like Paradoxical Intent, where we actually train folks to say, when you're in bed, instead of thinking about sleep, I want you to think about quietly laying awake and being completely comfortable with the wake state. Hey, look, it's been five minutes. I'm still awake. That's okay. That's what I'm trying to do. I'm trying to lay here quietly awake. And that paradoxically often makes you relaxed enough that sleep is passively accepted and then you fall asleep. There are a few other things, like journaling during the day, decatastrophizing you. I mentioned this already, where we try to change people's mindset around how they frame sleep and lack of sleep. There were some other, like, popular techniques, social media that popularize things like cognitive shuffling, which don't have as much data to support them, but are likely benign, where you kind of shuffle through like a word and you think of lots of other words that start with the letters in that word. These are other techniques, all of which is to help try to relax your body. Meditation, mindfulness before bed, all that can also be a helpful part of cbta. And sometimes we get overly fixated on saying, okay, you have to have a sleep bed, a set bedtime, right? Even we were guilty of this in the sleep medicine world. Oh, you have to have a set bedtime. In my book, a set wake time is actually much more important than a set bedtime. You know, if you're keeping that Wake up time relatively similar, but if you're not sleepy at 10 o', clock, you don't necessarily have to jump into bed because that's your quote unquote bedtime. As long as over time you're getting the full amount of sleep that you need on average. So wake up time is more important, I think. And then set bedtime.
- [41:14]
E
Amazing.
- [41:15]
C
One insomnia myth that you would like for it to retire forever.
- [41:19]
D
A lot of people get in the habit of thinking, okay, I'm a bad sleeper and that's just who I am. Right. So they think of insomnia something that is part of their, their entity that they cannot, they won't be able to treat. And I like to say no, just because you are not sleeping well today does not mean that you cannot sleep well in two or three, four months. And the other thing is that there are rarely quick fixes for sleep. Just like exercise, just like diet. It takes time, you know, it takes time and dedicated effort, sustained effort over time to fix your sleep. So don't think of it as a quick sleep hack. Think of it as a journey.
- [41:54]
C
That's so empowering. And especially the fact that it takes a long time. Yeah. People usually don't see the benefits right away, but it does make a huge difference. What is the most overrated sleep advice?
- [42:04]
D
I would probably say magnesium. Taking magnesium just based on the, the data that we have to support it versus how much people are selling magnesium. It's. I would say that's pretty overhyped. I would say that in some situations trackers are also very overhyped. It's great for bringing awareness to your sleep. I love what it does. I love some of the newer technology that's actually screening for things like sleep apnea. The newest Apple watches can actually screen for sleep apnea. That's amazing. I love that. But people that are fixated on this number that they get in the morning and you know, want to optimize that number. I would just be weary of becoming overly fixated on sleep. Something that should just happen hopefully naturally if the right circumstances set up.
- [42:49]
C
Beautiful. That's wonderful to hear that. What is one of the most underrated sleep skill?
- [42:54]
D
Underrated sleep skill, I think is the ability to, to, to quiet the mind. And this is probably why meditation can be helpful. You know, the skill of sitting quietly without having to Rolodex through thoughts can be very challenging for some people. And this is where sleep is a little bit unfair. There are some that can easily quiet their minds and others that really just, just Can't. Based on likely neurophysiology and genetics, you know, and so I think it's really. Can't overemphasize the. The impact that being able to quiet your mind can end up having on your sleep.
- [43:27]
E
Amazing.
- [43:28]
C
That's very, very helpful. Sujay, you're incredible. What else are you looking forward to and that you're hopeful for as far as the future is concerned?
- [43:35]
D
Yeah. I hope we continue to spread awareness regarding sleep. I hope that we can make sleep easier for parents. We talked about lullaby, the smart crib mattress. I'm hoping we're in an era where we can help use technology in the right ways to help decrease the pain of sleep deprivation, because it is one of the pains of life, for sure. And so, yeah, I think we're at an exciting place right now when it comes to the merging of technology and science, and we hope to continue using technology in the right ways.
- [44:03]
C
I love that.
- [44:03]
E
I want to do one more exercise. On a scale of 1 to 10,
- [44:07]
B
how helpful is this sleep aid or
- [44:10]
E
strategy for most people? Great. First one, Consistent sleep wake schedule.
- [44:15]
D
Yeah, I would. I would give that probably a 5 out of 10 with. With emphasis more towards wake. Consistent wake schedule than consistent sleep schedule.
- [44:24]
A
Morning sunlight exposure.
- [44:26]
D
Yeah, I'd give that a 7 out of 10. I like morning light. Again, don't get out there and put, you know, look at, look at the sun. But getting that early morning light can be helpful for keeping your body clock lined up.
- [44:36]
E
Okay. CBTI. Cognitive Behavioral Therapy for Insomnia.
- [44:39]
D
10 out of 10. Yep. Love it. Great data to support it if you have insomnia. Chronic insomnia, CBTI is a great place to go.
- [44:46]
C
Sleep hygiene education alone, sleep.
- [44:49]
D
I would give that a. Yeah, this is a tough one. I'm going to give that a 4 out of 10. And this is why I like sleep hygiene. And sleep hygiene is really, really important. But I gave it a 4 out of 10 to emphasize the fact that sleep hygiene is a treatment for poor sleep hygiene. And it's not a treatment for insomnia. It's not a treatment for circadian rhythm issues. It's a treatment for poor sleep hygiene. So many people get frustrated by people saying, oh, just, you know, just have that routine and just avoid caffeine and, you know, try to drink some herbal tea at night and you try to get some exercise. You can do all the sleep hygiene things perfectly and still suffer from insomnia. So this is just a shout out to those that are doing all those right things and yet still have sleep issues. Because there are other ways of addressing the core sleep issue you have other than just sleep hygiene. But it is a good foundation to build from if you have not gotten good sleep hygiene as part of your overall sleep approach.
- [45:44]
E
Exercise timing, morning versus evening.
- [45:47]
D
Yeah, yeah. So I will, I will say morning exercise, great. You know, I give that 8 out of 10. Evening exercise will range anywhere from 1 out of 10 to 8 out of 10. And that all depends on you. So if, if you can exercise late at night, still fall asleep, fine, wake up the next day and you're doing great, then exercise whenever the heck you want, no problem. But if it's a problem for you, we do know exercise will increase your body temperature for a longer period of time. Body temperature likes to drop when we go into deep stages of sleep. And so for some it can cause challenges with sleep onset. And if that's you, I would move exercise earlier. Usually if like 4 to 6 hour range before bedtime, you're definitely in the safe spot. The later you get, the more careful you have to be.
- [46:32]
C
Low dose melatonin, if used for a
- [46:34]
D
circadian rhythm shifting, for example, shift work for jet lag. For those that have delayed sleep, wake phase syndrome, I give it a 9 out of 10. If you're using it as a quote unquote band aid for sleep, I give you a negative 3 out of 10 on melatonin.
- [46:51]
C
Oh, wow.
- [46:52]
B
Okay.
- [46:53]
C
Very good to know.
- [46:54]
E
Fantastic. Okay, next one. We talked about this, but I want
- [46:57]
D
to score magnesium 2 to 3 out of 10. Only because so many people swear by it. And we have to. You know, although I'm a. I like empirical data, you know, I also understand when there's a signal coming through, we have to pay attention to it. And there's some data, particularly in the elderly population, that magnesium could help. So I'll give it two or three out of ten. Again, there's, it's not necessarily a treatment for chronic insomnia. That's CBTI.
- [47:20]
C
Valerian root.
- [47:21]
D
Yeah. I mean, probably a zero out of 10. You know, I don't, I just don't think the data is there for valerian
- [47:27]
E
root, CBD products for sleep.
- [47:29]
D
0 out of 10 in my mind. But we know that it does have an effect on sleep. You know, we do know that it can shorten sleep latency. You know, it can help take the edge off of anxiety and help people fall asleep. The problem is it's also a REM suppressant and so you end up getting less REM sleep. We think REM sleep is Important. That's why when people stop using CBD or, you know, thc, they tend to have these really vivid dreams. I like REM sleep, and so that's why I also give that a really low score.
- [47:59]
C
Blue light blocking glasses.
- [48:02]
D
Yeah, this, this is, this is tough one. I would, I mean, I'd give it some points. I'd give it maybe a 4 out of 10. Again, if your problem is such that you have a delayed sleep phase tendency, you have this cavity tendency. You can't avoid getting light when it comes to I need to have my screen on for homework or wherever I live, there's sun out for 20 hours. Yes, that can help for that specific problem. But if that's your specific problem, that can be somewhat helpful. But again, not the holy grail for sleep.
- [48:32]
E
Unfortunately, white noise machines.
- [48:37]
D
This is a really hard one. Again, people sometimes swear by that. I am a purist, and so I would say use it only when you need. So I'd probably give it like a 3 out of 10. I'm all about having a consistent kind of background noise or quiet, whatever it be, in your environment. I like that better than music. I like it better than having tv. An appropriately distant white noise with the decibel level not too high, especially for our young children, is probably not the worst thing. But ideally for a short enough period of time that helps with sleep. And then you try to wean off of it. That's my goal. I'm a purist. Try to get rid of everything that you're using, quote unquote, to be a crutch to help you sleep.
- [49:12]
C
What about sleep tracking wearables? You know, whether it's the ring or the wristband.
- [49:17]
D
Yeah, I would give those, you know, similar, probably. Some are like a 4 out of 10. Great for raising awareness. Great for helping you if you're in the mode of experimenting, like, oh, maybe have a little extra drink at night and you want to see how your sleep does if you don't drink. Or maybe you're eating too late at night and you want to see the sleep quality when you don't do that. If you're using it to help make tweaks modify. Great, as long as you're not getting over fixated on it. They've coined this term called orthosomnia, where sleep worsens because you get too fixated on the numbers from your trackers. I don't want you to have orthosomnia. I want you to use it as a tool to push you in the right direction. I will Tell you that the technology is getting better. But from a sleep physiology standpoint, when people say deep sleep and light sleep, and there seems to be some magical, you know, goal to maximize your deep sleep, I actually say you shouldn't have 50% deep sleep. You know, that's actually a sign of a problem. You know, you should be spending about 20 to 25% of your time in deep sleep. And the rest of it should be in, quote, unquote, light sleep. REM sleep physiologically is a lighter form of sleep. And so is that calculated as light sleep or deep sleep? I don't know how they're calculating that, but REM sleep is also really important. But physiologically is a lighter stage of sleep. Again, the technology is getting better now. They tend to break it up in, you know, like rem, core sleep, deep sleep. I think that's probably the right way of describing it.
- [50:37]
E
Physiologically cool mattress or temperature regulated beds.
- [50:42]
D
If it works for you, seven out of ten, you know. But do you need it? You know, it really depends on whether you tend to be really hot sleeper. Yes, our body temperature. It's nice that it falls at when we get into deeper stages of sleep. And so if it helps you, fantastic. I'm not opposed to that. But do you absolutely need it? No. You can sleep fine on a regular mattress.
- [51:02]
C
And I do mouth taping for better sleep.
- [51:05]
D
Only in the setting of treated sleep apnea. If you're using nasal CPAP and you have oral venting so the air is coming out of your mouth, that would be the only situation in which I would recommend mouth taping. I would never recommend mouth taping for anyone that has not gone to sleep doctor and done a sleep study to see if they actually have sleep apnea. Because if you have sleep apnea, you can't breathe through your nose and you're breathing through your mouth. Guess what? If you tape off your mouth too, you're occluding the only patent airway that you have and you need to breathe at night. Breathing is super important. Right. And it's one of those vital things. Yeah, absolutely.
- [51:41]
C
Great.
- [51:41]
E
And then last one is a layup. Alcohol as a sleep aid.
- [51:45]
D
Yes, please. Negative 10. Negative 10. Please don't use alcohol as a sleep aid. We know that it helps you, quote, unquote, fall asleep, but it's a sedated sleep. You end up waking up earlier than you want. You have more fragmented sleep. You probably wake up to use the bathroom. We think alcohol is a net negative on your sleep. So please don't use that to help you with sleep.
- [52:05]
E
Fantastic. Fantastic.
- [52:07]
B
That's it.
- [52:07]
C
Sujay, you're amazing. We love you.
- [52:09]
D
Thank you for all you both do to help spread the word of science and and the evidence based approach in science. Super appreciated. And I wish we had more people like you on social media, but we certainly need more people like you. So thank you for what you do.
- [52:21]
C
Thank you so much, Sujay.
- [52:24]
A
So Sujay gave us the biology and the bottom line is that the thing that works isn't a pill, It's a behavioral therapy. But that raises the harder question, if we know what works, why is it 3am and you still can't shut your brain off? That gap between what you know and what your body does at night is psychology and it's where most people have trouble, especially women in midlife. So we called someone who lives in that gap Every single day, Dr. Shelby Harris.
- [52:53]
C
Dr. Shelby Harris, it's so wonderful to connect with you. Thank you so much for your time. As I was telling you before I hit the record button, I'm such a big fan of your work. I love how you communicate with with people on social media and I've seen you speak on multiple different platforms and I'm just so happy to be connected with you here. Thank you.
- [53:14]
F
Thank you so much for having me. I'm really looking forward to talking with you.
- [53:17]
C
Likewise. Likewise. So insomnia is something that I personally have experienced and I don't think there's anybody on earth who hasn't experienced a little bout of insomnia. I feel like it's a very feared condition, but at the same time it's like one of those things where people have it and they just think like, oh, well, this is just normal and they live on with it and they don't really seek a lot of help. In your practice, what are the kind of patients that you see?
- [53:46]
F
You know, I see. I would say up until about seven or eight years ago, I mostly saw people who had had insomnia for decades, like 10, 20, 30 plus years, and had never really done anything about it or were trying different medications and then the medications would stop working. And so they were coming to me at the behest of their clinicians usually, or their. Their primary care or sleep medicine doctor saying we need to do something about this past eight years or so. I would say I'm seeing younger and younger people come in because there's more of a conversation out there about for better or for worse, honestly, about the importance of sleep in brain health and development. And that we have options available for treatment, so people are trying to get treated earlier. And I would say a lot of my patients, I see men and women in all different ages, but many of them are women in the perimenopause menopause stage. That's kind of my main area specialty. So I do tend to get a lot of women in that area.
- [54:50]
C
That's fantastic. And it's a great representation of the different facets that is needed for people to understand how to help patients with sleep disorders. That's wonderful. In your experience of working with so many patients with insomnia, I think a great place to start is the general definition. What is insomnia? Because a lot of people have variations of these symptoms. But what is insomnia? And what are some of the different types of insomnia that people experience in their life?
- [55:20]
F
Yeah, so insomnia in general, we used to have lots of different types of insomnia and all these different kind of classifications of it. But we really more recently have lumped it all into just generally an insomnia. We don't have like primary and secondary, all these other terms, because we treat it all pretty much the same way and we think about it that way. So insomnia in general is trouble falling asleep, staying asleep, and. Or awakening earlier than you would like to. And it has to happen at least three times a week for at least one month to be considered short term and at least three months to be considered chronic. So that definition, I teach that definition to every single patient that comes into my office because it normalizes an episode of poor sleep a night here and there as being okay if you have. We all. Sleep doesn't occur in a vacuum. We all have a week of significant stress here and there, or one night here and there of some bad sleep. But if you're generally meeting the criteria of being content with your sleep at least five nights a week, most weeks of the year, then you don't actually meet the criteria for insomnia. Because I think the way that we think about in our society too much, especially with the advent of social media, is it puts too much pressure on. Sleep is important. Don't get me wrong, that's what I do for a living. But it makes people think that we have to have perfection every single day. And we're always optimizing what's the hack. And what it does is it makes people actually get more anxious about their sleep. Sometimes they freak out after one night, and then that can actually start an insomnia period actually happening.
- [56:55]
C
I think I learned it from you. The concept of sleep anxiety or this overzealous approach to sleep where just thinking about falling asleep in itself is keeping you awake. Yes.
- [57:05]
F
You're getting in your own way. And this is, this is something I see all the time. And it's getting worse, I think over the years too, because we have so much more access to information and people who aren't really experts in sleep or talking about it so much that it's making some people a little bit more or a lot more anxious about it. They're getting in their own head and then they end up not being able to sleep.
- [57:25]
C
I'd like to continue this chain of thought, but a little bit of digression. Do you think technology and these wearables have to do anything with it? With the concept of too much information? When you're aware of every single single thing that is happening to you or with you and your sleep cycle, like these little charts that you see, do you think they actually cause anxiety as well?
- [57:44]
F
They can, yeah. So we have some research. My colleague Kelly Glaser Barron termed. She came up with the term orthosomnia a number of years ago. And it's. We. I see it a lot in the New York City area. People who have insomnia, they use these trackers to try and gain insight. But usually the insights it gives you are things that most people with insomnia are already aware of. And they've already limited the basic sleep hygiene issues that could be an issue or a problem for them. And so all it does is heighten their awareness of their sleep and make them more focused and anxious by it. The wearables are good for people who don't make sleep as much of a priority in their lives or who might need someone to point out, okay, maybe you're burning the candle a little bit too much at both ends and you're like working too late, you're out too late, you're not getting enough sleep, or maybe the alcohol is impacting your sleep. But the vast majority of people who have insomnia end up with these trackers. It ends up actually making them more anxious. So there's a few reasons. So if someone is having an issue with falling asleep at the beginning of the night, it can be due to many different reasons. The the most common is if it's true insomnia, so that trouble falling asleep despite adequate opportunity for sleep at night, it's that we see a lot of times people either get in their own head with anxiety, so they have a very Busy brain, there's this kind of hyper focus and just the brain is just super awake and it's just thinking, thinking, thinking. And they have trouble, like they often say, like, I just can't turn the volume dial down. And so sometimes they're trying to go to sleep out of fatigue when they're tired, but their body's circadian pattern is not sleepy enough that they're going to bed too early. And that's partially why they might be exhausted, but they're laying there with a very alert, active brain. So we sometimes will actually change the timing of when they go to bed for a short while to go to bed later. So it almost overrides the busy brain a little bit. So we might change the timing of it. The middle of the night can happen because, I mean, there are many reasons why this can happen, but the most common reason for that same awakening every night can be hormonal changes. It can be if you. Well, first of all, the biggest thing is that people wake up every time you go to sleep and you have a sleep cycle. So you go awake, then you go into really, it's like stage one, which is this kind of in between. Then you have stage two, which is like the middle level of sleep, and then stage three, which is deep sleep. So you go right into deep sleep typically, and then you cycle up a little bit of REM and then you have an awakening and then you repeat that cycle again. So after every cycle you have an awakening. So some people in the cycles are usually around 90ish minutes. It varies based on the person. But people oftentimes they wake up, they automatically think it's a problem, they look at the clock, they get frustrated. They've trained themselves now to have the awakenings routinely and to like be upset by it. And that's why you might see that you have a similar wake time all the time, is because you're actually training yourself to look at the clock and get more frustrated. So that's another big common thing that we'll see a lot of times. And also throughout the night you might have more awakenings because you've literally been asleep or you've been asleep for a few hours. You've paid back some of that. We call it sleep debt, that appetite for sleep, that it gets harder to sleep as deeply as the night goes on. In menopause and perimenopause, the rates of sleep apnea in that age range almost get equal to men. And you don't have to be, you don't have to be overweight older, you can be thin, fit, and still have sleep apnea. So sleep apnea is pauses, cessations in breathing, snoring for some people. Choking in the middle of the night can be very subtle for some women. And they get missed all the time. They come into my office saying, I have insomnia and I take sleep meds and I wait, feel worse during the day. And I asked them just a simple question. Do you have any pauses in your breathing? Do you snore? How do you feel during the day? And I find out that there's some of that going on. And then they actually end up having sleep apnea when some of these other sleep meds probably were making the problem worse.
- [61:35]
C
Yeah, yeah. And you may have noticed this too. Sometimes it's just general fatigue. They don't necessarily even tell you that, you know, they can't sleep very well. I've had patients who come in and say, I'm just tired, I'm tired, I can't think properly. And now I've trained myself to make sure that we ask about sleep and to, you know, just have the. The referral button, you know, on speed dial to send them for a sleep study because it's so prominent, it's so prevalent. And like you said, you know, you don't necessarily. There's always this picture of someone who, you know is overweight or, you know, the typical pictures or the checklist that people think of when sleep apnea comes to mind. It could happen to anyone. It could happen to a very lean, metabolically healthy person. So it's really important to rule that out. So thank you for mentioning that. Of course, you work with individuals, both males and females, but specifically the patient population that you're interested in. You said menopause, perimenopause. Can you tell us what actually happens during that stage of our life and how does that impact our sleep?
- [62:46]
F
Yeah, so this is an interesting stage in that I always call it like the perfect storm of three different areas that kind of converge. And remember, you can start having perimenopausal sleep disturbance in your 30s. Like, sometimes it get. That gets missed too. It can really be brewing earlier than most people think. What happens is you have the changes biologically. So we see the shifts in hormone, in hormones. So we see estrogen drops, we see progesterone change. Those drops are very much associated with hot flashes, night sweats, waking up with a racing brain that we see a lot of times in this age range. Then the other pieces that happen are we think about psychological issues we see women tend to have higher rates of anxiety and depression, and we see that happening here. And then the other big thing that does not get spoken about enough, in my opinion, is the societal. The social changes. So a lot of women are in their late 30s, 40s. I mean, I'm in my late 40s. I see it happening with myself. Like there's we. A lot of women are having kids later in life, so they have these kids who are sometimes 10, 11, 12, or even younger. Then they have aging parents that they're having to take. So there's that sandwich generation. And then on top of that, women are working more than ever and working outside the house and having more stressors that there's never a time to physically and mentally turn off. So you put that with the psychological stressors and then the hormonal changes. Perfect storm. All at once.
- [64:18]
C
Oh, my gosh. Thank you for saying that. I was speaking with Jen Gunter about hormone replacement therapy, and we both actually talked about this. You know, the sandwich generation issue, the fact that there's so much expectation and pressure on U.S. women during our 40s. And I think you and I are in the same age range. I'm also in my mid, mid-40s. And all of that. All of that. The psychological pressure, the pressure that you put on show, the expectations, your job dealing with so many relationships. Like you said, perfect storm. So women need to realize that it's just this exactly weird, strange time in our life where everything's happening at the same time. So it's not just one thing. It could be multiple different things.
- [65:03]
F
Right. And the good stressors too. Right? All these things, like you can be getting promotions or like all these great things can be happening, but it's just a lot all at once. Like, I have also on top of like the sandwich stuff, I have a kid who's going to be going to college in a few years. So, like, you have all these other things that you're having to think about while also having hot flashes and night sweats and all that other stuff too.
- [65:22]
C
It's really tough. It's really tough.
- [65:23]
F
I've been doing this long enough that I can tell with some patients when there is a lot of anxiety. Like we were talking about sleep anxiety. There's a lot of anxiety around sleep and a lot of pressure about sleep and what sleep means to them and what it. What it does for them in their lives. That I know whether I have to talk a lot more about the cognitive aspect versus just the behavioral stuff that we might be doing. So I Can kind of, you have to tailor it. There's a lot of people that will be like, oh, you can do this four week session program. And I think I get that for a lot of people. But, but you also have to think about the individual. And there's a lot of people that might fall in one bucket versus another and there's a lot of individual factors that can be throwing sleep off for people that I think you're doing a disservice if you don't personalize things for them.
- [66:11]
C
Amazing. Beyond you know, figuring out their psychological background and that baseline where they come from, are there any other tests or referrals that you recommend for your patients to do when they seek help for insomnia?
- [66:26]
F
Yeah, I mean I think initially we have just some initial scales that I'll do with patients. Like I do something called the Piskey, the insomnia severity Index. I always look, most of them are self report. Honestly at the beginning I'll look at a patient's level of sleepiness. Actually this doesn't get spoken about enough either is that people with insomnia, just straight insomnia typically will say when you ask them, do you nap? They'll say, oh, I try. Even when I try, I can't nap. But someone who has insomnia plus some other co occurring issue like depression, sleep apnea, a restless leg issue, let's say they often will have more sleepiness than a typical just straight insomnia person. So I always give that sleepiness scale as well because that will help me to think about other things that might be going on as well and then to think, okay, do we need to do a sleep study with this person? And then if I do that then I'll look at anxiety levels, depression levels, I'll give some of those scales and then we don't usually do a sleep study right off the bat for someone with an insomnia that's not in the guidelines right now because a lot of times it just tells us they were laying there awake. But if there's some extra sleepiness, some possible other issues going on, I'll refer for an at home. It usually starts off as an at home sleep study and then if, if that's negative, but we have a high suspicion something's going on, then we'll do an in lab study.
- [67:51]
C
Yeah, that's fantastic. Just from personal experience with my patients, I feel like a lot of people don't do it the correct way at home. And either the machine falls apart or. But I think it's A good screener like you said.
- [68:05]
F
That's exactly what I always say. It's just a screener. So if we know that you have, if we see sleep apnea on it, we're pretty confident that you have sleep apnea. But if it's negative, it's not a definite, you don't have it. So if you think some. The other piece of advice I give to anybody who's listening is if you're, you're confident something else is going on and you had a negative sleep study at home, try to push for a follow up in lab to get more data because it also really is just measuring breathing. It's not looking at your limbs, it's not looking at leg movements and we're not actually looking at sleep so much. It's approximating sleep based on your breathing and metrics at night.
- [68:41]
C
That's fantastic.
- [68:42]
F
And I encourage people too. If you're afraid of getting a study or having, getting evaluated, at least know what you're dealing with. Like, if you're like, I don't want to get diagnosed with it because I'm not going to follow through with the treatment, at least then know that you have that issue because if you're going in for surgery, God forbid you have any issues. Like they'll know in your chart that they have to make adjustments for sleep apnea when you're going under. So like those kind of things with medications, it can be helpful to have that there to begin with. With it's hit or miss. So just despite the narrative that's online nowadays, it can really be a game changer for a lot of people. Those are not the people that come to me though. Remember that? So it can be a game changer for a lot of people, but it really is not the game changer that everyone thinks it will be. So it can give someone some modest improvement, sometimes no improvement. And we do. But it doesn't mean it's all or nothing. You have to do hormone therapy or like if that doesn't work, then you have another options. We have other options like cbt, which I'm sure we'll talk about. CBT for insomnia is actually more effective than in recent data than hormone therapy
- [69:50]
C
for some people really actually compare CBT with hormone therapy.
- [69:54]
F
They did. There was a study done that was presented at, I think it was the NAMS conference a year and a half ago and was showing that CBT was more effective. So. But it's a pride. Yeah.
- [70:06]
C
Yeah, I'm surprised.
- [70:07]
F
Yeah. So hormone therapy is fantastic, but the way that it gets kind of touted as this cure all is kind of makes people when it doesn't, when they don't respond to it or they can't take it, make them think that there's no other options. Yeah, so I think the fact that it's called cognitive behavior therapy with the T on the end, it, it's, it's a bit of a misnomer. And I think that honestly there's a bit of a marketing issue with it is that I think a lot of people don't want to go to get the treatment because they think they're going to be in just a typical psychotherapy where we're going to like analyze yours. It couldn't be more different. So cbt, Cognitive Behavior therapy was a treatment or is a treatment modality that has been around since about the 60s, early 70s by a man named Aaron Beck. And they've kind of, he did cognitive therapy and they combined it with some behavioral. And it was originally done for anxiety and depression issues and we've kind of now adapted it since the 90s or so to be for insomnia. But it's a little, it's pretty different from when people think about, oh, I've done CBT already. It's very different from anxiety and depression treatment. So what it is is it's a limited number of sessions. Typically I usually say I see people anywhere from four to 12 sessions. Four to eight is usually the average. Sometimes I've seen people in just as quick as two sessions. Sometimes the longer numbers are more for people who have a lot of co occurring issues or they're trying to taper off of sleep medication. So it takes longer to get kind of adjust every time we taper down. So what we do is when we think about the C and the B, we usually start with the B part, the behavioral part. So the behavioral modules are really, they're sleep hygiene. But sleep hygiene is really just like the basics. It's nothing that really moves the needle. So it's actually the control group in most insomnia studies. But if you're drinking a huge jug of caffeinated soda at night, we got to make sure that that's not an issue. You're not doing that to make everything else work better. But we don't usually expect the sleep hygiene stuff to do its job or to fix it. And then we add in two other big modules. So the one would be sleep restriction. I don't like the name. My old mentor Michael Thorpey and his colleagues came up with that name. It's very scary when we talk about it that way to some people. So I call it time in bed restriction. So what we do is if someone's in bed eight hours, but they're only sleeping, let's say five and a half or six, there's a mismatch. So we want to limit that time in bed to have them go to bed later and wake up earlier. And we figure out what that window is so that their body. We work on the quality first, so we help them fall asleep faster and so stay asleep more. And then once their quality is more improved, then we work on getting them more quantity. Everyone thinks about quantity. Eight hours you have to get. And we think about quality first. So we limit the time in bed and then slowly trick your body into giving you more sleep. And then the other module of behavioral is stimulus control. So it's the laying in bed, tossing and turning, worrying, trying to force yourself to go to sleep. Like the effort that we put into sleep, the busy brain, the anxiety about being in bed. So we come up with other things to do outside of the bed to help quiet the body and the brain around sleep. So that's usually what I start with. And tracking your sleep on a diary, that's what I start with. Usually in the first session, sometimes the second session with every single patient. And then we add in the cognitive stuff if we need to with some patients. So that would be the pressure people put on themselves to sleep. The worries about sleep we might add in mindfulness therapy. So practicing mindfulness during the day, not at night, so that you're learning to kind of let go of busy thoughts. And then sometimes we'll build in. This is more behavioral relaxation, those sorts of things to help just kind of quiet the body and the mind before bed. And we'll add those modules in if we need to over time. But usually four to eight sessions for most people. And I don't even see people weekly. I see them every other week. But it's the gold standard treatment for insomnia. It works better than the medications in the long run and has fewer side effects. The biggest side effect is you might be a little bit sleepier at the beginning as we're restricting your time in bed. But usually that lasts just for a few weeks and then it starts to turn around. And aside from time and money and the limiting the time in bed, it's a better treatment for most people long term?
- [74:30]
C
Oh, most definitely. I mean, I've just. Being a neurologist, I've seen the most amazing Things happen. To my patients who've been through cardiobehavioral therapy, it takes time, and, you know, they're given homework. They have to do certain things because it's a completely. You know, it's a shift of. Of a frame of mind. You think about sleep, and you treat sleep differently when you go through cbti. So it does take a lot of time. And I feel that, you know, most people do really well. There are some people who are just impatient and they don't stick with it, and those are the ones who don't see the benefit from it. But overall, it's just. Just incredible. Have you seen some impatient people who
- [75:12]
F
just, like, drop it all the time? Yes. It's like, you know, it's. It's the sort of thing where impatience, but also consistency is really. You know, some people will say, well, I did it for three or four nights. I was like, well, you've had insomnia for 10 months. You have to be. You have to give this a few weeks of being consistent, because if you're doing only for a few days, and then you lose the consistency. You're not actually getting the. The kind of compression that we need to see happen. But, yeah, it's. You have to kind of put it on the back burner. The, like, immediate results. And the thing, too, is that we're in such a culture of just take a pill to fix the problem. Like, it doesn't work that way.
- [75:45]
C
Yeah, absolutely. I love that. And have you ever referred people for multi. Multimodal treatments as well? So say, for example, they're here with you to get, you know, more knowledge and kind of get trained in cbti, but you also put them on medication and you work with their physician. Is that possible, or is it one or the other?
- [76:04]
F
It doesn't have to be one or the other at all. So the most common thing that I see is that someone will come to me on medications that might. The medication might have helped somewhat, but not enough. So we'll combine it with CBTI to help bolster the medication effects or then to be able to reduce the medication if we're able to. Sometimes people will only get so far with me that then I'll refer for medication. But we always like to combine it, when possible, with a little bit of the behavioral stuff, because that helps at least to get you on the lowest dose possible of medication, where you really learn the appropriate ways to use it. And then if someone, let's say, has issues with significant anxiety and depression, you could still do cbt. For insomnia, you don't have to send them elsewhere. But if I find that, let's say they have a lot of depression or anxiety that's getting in the way of them doing, following through with some of the recommendations that I'm having, then I will refer that even though I do that treatment myself, I usually, just because I'm so busy with the sleep patients, I'll refer out for depression or anxiety treatment separately.
- [77:05]
C
That's amazing. What are some of the biggest. I guess one of the most common myths around insomnia that you come across with? I mean, one of them is if you have insomnia, there's really nothing you can do about it. But what are some of the other misunderstandings about insomnia or sleep in general that you come across within the community when you talk to people or your patients?
- [77:25]
F
There's a few. So the biggest one that I see is that, and I had to debunk this a few times already this morning, is that sleep is a kind of offline process where you should just be out cold the entire night and then wake up in the morning and then start your day. What that. The disservice that does to people is that they may. It makes them think that sleep is this completely like just offline process where you don't have awakenings and it, it takes what's normal out of the picture. We all have cycles throughout the night and awaken. Like I was saying that it's totally normal to have an awakening, so I have to do a lot of education on that. But the time that you're awake for can be, or how broken your sleep is, that's when we'll start to intervene more. But one awakening for 10, 20 minutes, you use the bathroom, you go back to sleep is not necessarily problematic, especially if you feel fine during the day. The other thing I hear a lot is that as you get older, it's normal to get less sleep and there's nothing that you really can do about it. That's not true at all. Sleep, older adults get a little bit less, but that's mostly because they nap a little bit more during the day. And then they're also having more broken sleep sometimes because it's lighter sleep, so there might be more pain, having to use the bathroom, things like that might be going on. But it's also normal to have less deep sleep the older that you get. But to get drastically less sleep and just say, oh, that's totally normal. That's not, and we need to do something about it.
- [78:48]
C
I'm so glad you said that. But that's going to worry a lot of our elderly audience here because it's so common to have inside insomnia as you grow older. How much is too much sleep?
- [78:59]
F
There's not really a specific number, but over what we found is like less than 6 and more than 9. Should make you start thinking, okay, is this. They're in the outliers where it's okay, but more often than not, there's usually something else going on. So if you feel like no matter how much sleep you get, it's just not refreshing or you're sleeping so long that it's getting in the way of you being able to live your life, then you might want to bring that up to someone.
- [79:25]
C
If people are night owls and I'm putting my hand on my chest because I am a night owl, right? It just, you know, I am my most creative self after 11pm I don't know why I've always been that way, but I am like awake and I'm energized after 11pm and all my family is like, they're in bed. But, you know, so if people have that tendency of sleeping late and waking up late, and the society is not made for that, how do you help them?
- [79:54]
D
What do you do?
- [79:55]
F
So, yeah, so the first thing we always try to encourage is if it's fine, there's no other sleep disorders going on. You just have a natural circadian preference to be a night owl. So for some people, not in your case here, but for some people, we'll just encourage them, like, why do you have to go to bed earlier? Like, if you just kept, you got enough sleep, but it was on that delayed schedule, then this will solve a lot of issues and it's actually not a problem. When it becomes a problem, we call it delayed sleep phase sleep disorder. We put the D on the end is when it creates an issue and you'll be able to live your life. You have kids, you have to go to work, whatever it is. So there are different treatments that we have available. That's when we might use very low dose melatonin. I'm talking like a half a milligram. But we're not using it the way that most people incorrectly use it for insomnia. We're using it multiple hours before you would naturally get sleepy to kind of coax the system into pulling it a little bit earlier over time. So little doses timed appropriately with a professional can help. Sometimes we use light therapy, so I'll use bright light therapy in the morning. But you have to also time that appropriately because sometimes you might just wake up really early and put on a bright light that actually worsens it. So we have to be appropriate, thinking about the timing. And then sometimes this is a little harder for a lot of people to do, but we'll have them stay up later and then wake up later over the period of a week until their clock comes back around. So we have different treatments that are available that are effective, but it takes work. So if you can, if you work freelance and you're just waking up earlier and going, you're trying to go to bed earlier because society says you have to, if you don't actually have to lean into it, it might actually be more freeing.
- [81:30]
C
That sounds incredible. Thank you so much for, for addressing it. All right, I'm going to ask you a couple of the controversies and some of the stuff that is being spread out on social media about sleep and insomnia, and if you could kind of just, you know, quickly tell us what you think about it. Melatonin you address. So it can actually be helpful. But I think it's. I don't think a lot of people actually understand how to use it. What are your thoughts on melatonin?
- [81:59]
F
That's exactly right. So melatonin is, first of all not regulated in the U.S. so it, you know, it's buyer beware a little bit. Unless you buy something that's like USP or NSF verified, then, you know, a third company has kind of looked at it to verify what's in the bottle. But the problem is in our society, it's like more is better. That's what we think of. And so people keep taking 5 milligrams, 10 milligrams. I've had patients take upwards of 40 milligrams of melatonin just because they thought more was better and they're taking it at bedtime. What melatonin really is, is a shifter of your sleep wake pattern. So we use it for circadian issues. So jet lag, shift work. You're a night owl who can sleep eight hours, but we want to shift you earlier. We're using it in tiny doses to kind of change your circadian timing. But it really, the data on it for insomnia is kind of lacking. It's very mixed and it's not so great. So most people who come to my office have tried melatonin doesn't really do that much for them. And then the other issue is it's not without side effects. You can feel Nausea. You can feel more sleepy the next day. Vivid dreams are really common in nightmares, so you have to. It's a little bit buyer beware and kind of caution with how to use it. You can get, like, hot chocolate laced with melatonin nowadays. So it's like. I'm like, no.
- [83:14]
A
Oh, my goodness.
- [83:15]
C
No.
- [83:15]
F
It's not how we use it.
- [83:16]
C
Yeah, that's not good. What are your thoughts on magnesium?
- [83:19]
F
Magnesium different from melatonin. So magnesium melatonin is really like a circadian signal kind of for us, for a hormone. Magnesium is more. I always think of it like it's the sort of thing that just kind of relaxes you. So it's not really a sleep inducer. But if you find that you are tense, you're a little bit more keyed up when it comes time for bed. Magnesium for some people can help kind of set the stage for sleep. So some people, it helps a little bit. It's still a bit mixed on it, but I find that it helps you to set the stage a little bit for sleep if you struggle with that.
- [83:52]
C
Okay, thank you. What are your thoughts on CBD or THC compounds?
- [83:58]
F
So cbd, another kind. It can relax some people. Most people who come to my office find it didn't do that much, the thc. Some people swear by it and say it's great. But in sleep medicine, we don't really love it because it can make people feel more groggy the next day. We know that there's some links with cognitive issues for some people, so we really prefer not to use it if possible now.
- [84:22]
C
Thank you. Is it true that alcohol helps you fall asleep but hurts your sleep quality?
- [84:27]
F
Exactly. Yep.
- [84:29]
C
So no nightcaps. That's not a good idea at all.
- [84:32]
F
Within. Within three hours of bed. Try to limit it.
- [84:34]
C
Three hours. What are your thoughts on some of these herbal teas and the mixes? Gosh. I mean, there's like an entire aisle of sleep products now and in every grocery store. And then there are these teas, valerian root and everything else. What are your thoughts on that? Do they help?
- [84:51]
F
They don't really do all that much. And then the other thing, too is, like, if it helps to calm you, fine. But then you're adding in supplements that might have issues with. If you're already taking medications and you're trying valerian, like, you want to make sure that some of these things don't. Aren't contraindicated with your medications, too. But also, then you're drinking liquids before bed, which might make you have to Pee more. So it's just another thing to keep in mind. None of these things are really a cure for most people with chronic entrenched insomnia.
- [85:19]
C
That's a great thought. I mean, it just makes you pee more. So it's really not a good idea for you to be drinking tea before going to bed. And then as far as sleep medications are concerned, I mean, you know, view you said that, you know, they can actually be a part of the solution. Sometimes they can be part of the problem too, when people actually get addicted to the medication. And I believe CBT I helps with that as well. For people who want to be off of medication.
- [85:46]
F
Yeah, that's actually the vast majority of what I do with patients is that it's usually working with people who are on medication, didn't know about cbti, then learned about CBT I and then come to me, and then we learn to kind of. We treat them with their provider who's prescribing. We slowly step down the medication, help them learn other techniques and tools to be able to sleep better.
- [86:07]
C
That's amazing. What's in store in the future as far as sleep psychology and CBTI is concerned? Anything new happening? Are you excited about anything? Any new modalities coming out?
- [86:19]
F
Yeah, I think that there is another kind of area of sleep psychology called ACT therapy for insomnia. So acceptance and commitment therapy, which has some head. There's. There's a little bit of head to head comparisons of ACT therapy and cbti. And I think we're starting to learn which patients would be better with ACT therapy for insomnia versus cbti. CBTI is really about changing your thoughts about sleep, changing your behaviors. So it's. It's weirdly effort based to try and take away the effort. ACT therapy, which is also used for anxiety and depression, is about being mindful, letting go of thoughts, kind of seeing every night as a new night without putting lots of, like, restriction on and all the different modules. It's much more fluid. And so we're learning the patients that get more. Some patients do get more anxious by CBTI because we're limiting their time a bit and doing all these things that sometimes doing ACT therapy to learn to let go, let go of control can actually be more beneficial. So we're really trying to figure out which patients to triage into which type of treatment, which I find so exciting.
- [87:23]
C
That is wonderful. All right, Shelby, true or false? Everyone needs eight hours of sleep.
- [87:28]
B
False.
- [87:29]
F
Do you want me to explain?
- [87:30]
C
Yes, please.
- [87:31]
F
Okay. The range for most people fall between Seven to nine. Some people are a little bit more outliers lower, like lower six. Some a little bit more than nine. The eight is just because it's easier to report and it's in the middle. That's it.
- [87:45]
C
Good to know.
- [87:45]
A
True or false?
- [87:46]
C
Watching TV in bed always ruins your sleep.
- [87:48]
F
No, it's not true. It's not true or that's false? I should say. So we try to have the bed really be about sleep and sex and relaxation and not using the tv. But there's really. I would say it's kind of a mixed false. There's more and more data coming out that the screen is not necessarily. The blue light from. Is not necessarily as bad when you're in the evening, throughout the night. It's not great when you're supposed to be sleeping, but some people actually find it's calming for their brain. They sleep fine with it. No problem. It's more of. A lot of. It's the content of what you're looking at and if you have it right in your face like that, that sort of stuff.
- [88:22]
C
Oh, my gosh. Netflix lovers are rejoicing right now.
- [88:25]
F
Well, it's not a. It's not a carte blanche, but it's like for some people, if it's like not actually causing a problem and you feel fine during the day, don't go crazy. Just make sure you're turning it off and you have good limits with it.
- [88:37]
C
Because I've sorry to kind of like drag this on, but, you know, I hear people saying it calms me down. Like the, the hum or the noise and even the flicker of the TV actually calms me down. So coming from Dr. Shelby Harris, you're saying that it could be okay.
- [88:51]
F
It could be as long as you can set the limits and it's not getting in the way of you being able to sleep. Like, you're not like Netflix the auto. They keep playing into the next episode and the next episode. That's not good. You have to make sure it's right.
- [89:04]
C
It should stop. Ok, that's fantastic. True or false. You can catch up on sleep on weekends.
- [89:10]
F
Middle kind of true and false. So if you lose a little bit here and there during the week, like we're talking like an hour, hour and a half. Okay. You might be able to catch up a little bit on the weekends. The problem is most people are in such a sleep debt during the week that there's no way you can make up on the weekend. And then you just keep compiling this debt essentially weekend after weekend, week after week that you're just lost.
- [89:32]
C
Wow. I'm learning so much from you. All right, the last one, True or false? Naps are always bad for insomnia.
- [89:39]
F
False. So for some people we can build in like a 20 minute nap. I do this a lot with my older adults. For example, we'll build in a 20 minute nap earlier in the day. And that's the beauty of doing a sleep diary. We can kind of keep track without being too exacting. We can keep track of building in. That short nap earlier in the day impacts the sleep or not at night.
- [89:57]
C
My goodness. Shelby, I learned so much from you. Thank you so much for your time and I hope this is first of many conversations in the future.
- [90:06]
F
I would absolutely love that. Thank you. This is a wonderful conversation.
- [90:14]
A
So that was an amazing conversation by Dr. Shelby Harris. And I love how we are at a place where both Sujay and Shelby agree that cognitive behavioral therapy is the first line to go with. And I'm, I'm very happy to hear that. I also want to make sure that we talk about a group of individuals that don't really fit here. And these are individuals who don't have the luxury to go to sleep at night. We're talking about shift workers, about parents to newborns, about caregivers who have to wake up at 2 or 3 in the morning because their loved one has dementia and is wandering, or individuals who have night shift jobs and they just can't sleep at all. Whenever we put a post about sleep on our social media, those are the individuals that usually make a comment. So it would be unfair for us not to talk about that here.
- [91:02]
B
I want to start with the most important part. Fear. I want them to not be afraid. It's okay to have season a period of difficulty with sleep because it is recoverable.
- [91:13]
C
Agreed.
- [91:13]
B
And this is not just me giving false hope. There's data that actually corroborates this. So if you have several months because you're a new mother or you have a job that actually completely alters your sleep cycles for a period of time, that's not something that to be worried about. The worry is probably more destructive than the process itself.
- [91:33]
D
That's true.
- [91:33]
B
The damage happens when sleeplessness or sleep disorders happen over long periods of time. Decades long.
- [91:41]
A
Exactly. And also individuals tend to have other ways of taking care of their brain health and general health. So, for example, exercising or eating well or keeping your mind active.
- [91:52]
C
So do you think that it would
- [91:54]
A
be appropriate to say that people can actually start focusing on other things to take care of themselves if their sleep is not perfect.
- [91:59]
B
Actually, that's a very important point because what happens when people have sleep disorders, they let everything else fall apart as well. I want you to focus on that. In particular, if you recognize you're having a period of time where you're having sleep disorders, then you can focus on other things, make it strategic. If you exercise and bring that as part of your regular daily cycle. If you eat well, if you keep your mind active, if you stress, manage through cognitive behavioral therapy and other things, you will do so much good for your brain. That might actually give you a. A tremendous amount of recovery and leeway for that period when you're having difficulty with sleep. So it's not an all or none. You can compensate with all these other positive activities as well.
- [92:42]
A
The second thing for the listeners who are shift workers or who don't have that luxury is for them to protect one solid block of sleep. One solid block of sleep and start and stop chasing getting seven to eight hours. I think getting four to five hours of solid sleep and then maybe a nap during the day could actually benefit
- [93:06]
B
them significantly as compared to 8 hours of broken sleep throughout the night. And the reason we want to focus on that is that also takes away the stress. If you know that I'm going to focus on four to five hours and I'm going to get that and then I'm going to have a nap that takes away the stress, that actually opens up the possibility of having better sleep. What happens is people focus on perfection. And even that eight hours is completely broken up into multiple segments that are incomplete and the kind of sleep that doesn't allow you to get into any depth.
- [93:35]
A
Those power naps in such situations are gold. So shamelessly take a nap and don't worry about not getting perfect sleep, which is really important is light. And then the third tip, which is really important is light. Light is basically your clock. So making sure that when you go to sleep, whether it's during the daytime or if there is light outside, get light blocking curtains, get into a very, very dark room and try to stay away from light as much as possible. And then when you have to be awake, get some light exposure. Of course, if the sun is not there, you would have to rely on some artificial lights. But that truly makes a difference because it tells your brain that it's daytime and you actually start getting a surge of energy and you can function properly. That's what melatonin does as well in the brain.
- [94:21]
B
That's right. It's a trigger. It's not a drug that suppresses your central nervous system. It's a trigger. Now, that brings up the concept of your relationship with light. I want people to recognize that that's a relationship. That's one of your oldest relationships as a species, as a sentient being. It was the sun that woke you up and it was the sunset that put you to sleep. We have to recognize it's light. That's the relationship that you have to manage and perfect. So one of the things we talk about, always make your room a very light, controlled room, be it with your phone or absence of a phone or computer or TV or any blue light or any blue light, and also with very bright lights in your bedroom, because that's also something that will trigger awakefulness. So that relationship is important. So those are three good strategies for an individual that has difficulty with sleep or are part of that population that has to have a period a season with, you know, poor sleep hygiene.
- [95:22]
A
Absolutely. I just wanted to kind of highlight caregivers here, especially caregivers of parents or loved ones with dementia or some health issues. Again, it kind of comes back to the oxygen mask rule. You cannot function on an empty tank. You have to take care of yourself. This is not a luxury. It's actually maintenance. And so finding respite care, finding someone to cover for you, getting some help so that you can sleep maybe one or two nights a week so that you can recover and be energetic and be available for your loved one is so critical for brain health. I just have a soft spot for caregivers out there because we hear it quite often, and sleep is a huge issue in that community.
- [96:03]
B
And you had been a caregiver recently to your mom, and we saw what that took. And we really appreciate all those that are going through this process, and we're with you. But make sure that you take care of yourself, because if you don't take care of yourself, you're not going to be any good for anybody else anyway.
- [96:21]
A
Absolutely. So this is a time for you to rely on a friend, a relative, and even some organizations offer respite care as well, so that you could be the best version of who you are for your loved ones. Okay, for everyone, here's what's actually true. The stuff the algorithm will never sell you. One, the gold standard for chronic insomnia is cognitive behavioral therapy for insomnia, cbti. Not a pill and not a supplement. Both of the doctors said it independently. A handful of sessions, lasting results and no side effects. Two, Melatonin is a darkness signal, not a sleeping pill. It only tells your body it's night now. 3. The supplement aisle in your pharmacy is mostly hope in a bottle. No sleep disorder is caused by a chamomile deficiency. Magnesium is overhyped, alcohol is the net negative and expensive tracker can make things worse if you're already anxious. 4. And this is the big one, anxiety about sleep causes bad sleep. Eight hours is the middle of a normal range. Not a pass or a fail line. One bad night is just a one bad night. So this week pick two, not all five. Number one, anchor your wake up time same time every morning even after a rough night. Number two, get lighten your eyes in the first hour of waking I outside if you can. Number three, stop chasing the number. Drop the eight hour rule and the tracker obsession please. Number four, if you're truly stuck, ask for cognitive behavioral therapy, not a prescription. Number five, if you nap instantly and snore or you're exhausted during perimenopause, get checked for sleep apnea. It gets missed constantly in women. Sleep is very important. But and we love how Sujae puts this, it's not so important that it's worth losing sleep over. So take the pressure off. Pick two of the tips we just discussed and start tonight. We hope you enjoyed this conversation as much as we did. Thank you so much for listening. This has been your brain on insomnia and we have been your hosts, Doctors Aisha and Dean Sherzai. Thank you.