The Peter Attia Drive - #341 - Overcoming insomnia： improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia ｜ Ashley Mason, Ph.D.

00:00:00.000 Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:16.540 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

00:00:21.520 into something accessible for everyone. Our goal is to provide the best content in health and

00:00:26.720 wellness, and we've established a great team of analysts to make this happen. It is extremely

00:00:31.660 important to me to provide all of this content without relying on paid ads. To do this, our work

00:00:36.960 is made entirely possible by our members, and in return, we offer exclusive member-only content

00:00:42.700 and benefits above and beyond what is available for free. If you want to take your knowledge of

00:00:47.940 this space to the next level, it's our goal to ensure members get back much more than the price

00:00:53.200 of the subscription. If you want to learn more about the benefits of our premium membership,

00:00:58.000 head over to peteratiyahmd.com forward slash subscribe. My guest this week is Ashley Mason.

00:01:06.460 Ashley is an associate professor at UCSF, where she leads the Sleep, Eating, and Affect Laboratory.

00:01:12.860 Her research focuses on non-pharmacologic interventions for mental health, particularly

00:01:17.180 exploring how treatments like whole body hyperthermia, mindfulness-based approaches can

00:01:21.720 improve mood disorders, sleep, and eating behaviors. She's also the director of UCSF's Center for

00:01:27.400 Obesity Assessment, Study, and Treatment, known as COAST. Her work integrates clinical psychology

00:01:34.180 with integrative medicine, aiming to develop accessible treatments that address the biological

00:01:38.860 and behavioral aspects of health. In this episode, we focus almost entirely around one area of her

00:01:45.900 expertise, which is Cognitive Behavioral Therapy for Insomnia, or CBTI. Ashley gives us a masterclass

00:01:52.880 exploration of CBTI, including various methods, including time in bed restriction, stimulus control,

00:01:59.200 and cognitive restructuring to combat insomnia. We speak about how to manage racing thoughts and

00:02:04.100 anxiety, and Ashley shares techniques like scheduled worry time to address stress during the day and

00:02:10.900 prevent sleep disruption at night. We talk about the impact of temperature regulation and the role

00:02:15.980 of warming extremities and optimizing sleep environments for effective sleep onset. We

00:02:20.940 discuss behavioral and cognitive interventions and the impact of leveraging small, actionable changes

00:02:26.800 in thoughts, feelings, and behaviors to overcome patterns of insomnia and other mental health

00:02:31.640 challenges. Ashley shares some sleep hygiene fundamentals addressing blue light exposure, food, and alcohol

00:02:38.040 intake, and creating bedtime routines for better sleep. She provides practical tools for tracking

00:02:43.220 progress, like using sleep diaries and A-B testing to identify and refine effective interventions. And we

00:02:49.660 explore the potential for AI and digital tools to democratize access to CBTI and address the growing

00:02:55.240 demand for sleep therapy. So without further delay, please enjoy my conversation with Dr. Ashley Mason.

00:03:01.120 Hey, Ashley, thank you so much for coming to Austin to talk about a lot of interesting things. Let's start

00:03:12.100 with the one that I think everybody listening can probably relate to at least once, which is insomnia.

00:03:17.780 Where did your interest in insomnia arise?

00:03:20.460 Well, I've been interested in sleep for a long time. I was fortunate to go to the University of Arizona for

00:03:26.160 my doctoral work. When I was there, the late Dick Bootson was also there. And he's one of the co-inventors

00:03:32.420 of cognitive behavioral therapy for insomnia. And I think I found it particularly interesting because

00:03:38.420 it works so well. We have so many different psychological treatments, and they all have varying

00:03:44.700 degrees of efficacy and effectiveness. And the thing about cognitive behavioral therapy for insomnia is that

00:03:50.200 it's kind of like a recipe. If you do it, it works. And this was always just so interesting to me because

00:03:59.020 it was so different than so many other psychotherapies out there that had just so much more unpredictable

00:04:03.820 outcomes. I would say that I became much more interested in it after my postdoctoral work when

00:04:12.680 I'd gotten to UCSF. I was a postdoc at UCSF, but I started my assistant professorship at UCSF.

00:04:18.620 And there was this gaping hole in treatment availabilities for people with insomnia. And I thought,

00:04:24.860 oh, this might be a good way for me to get back into some clinical work. I was doing just research at the

00:04:28.940 time. I fell back in love with it because there's almost nothing as rewarding as being able to see a

00:04:35.100 patient seven times. And that seventh time, have them say something to you along the lines of, have my life

00:04:41.640 back. I'm going to go get my driver's license back. I'm not afraid to drive with my kids in the car

00:04:46.620 anymore. I'm going to go back to work. I have my life back. Not much better than that. And so I grew

00:04:53.720 the clinic that I do CBTI in. And now I just love it so much that I do it on top of my job. Like I do

00:05:00.900 it at night with patients after hours because it's the most rewarding thing and you can have such a big

00:05:06.060 impact and people need it.

00:05:07.960 Before we dive into what CBTI is and how it works and how profound it can be, let's maybe help folks

00:05:15.780 understand a little bit about insomnia and maybe go through some of the definitions around the

00:05:21.140 different types of insomnia and maybe some of the different causes for it and maybe even what some of

00:05:26.820 the other treatments are, pharmacologic and otherwise.

00:05:28.860 Broadly speaking, most people at some point in their lives are going to have an issue with

00:05:34.080 insomnia. I think some 90% of adults at some point are going to struggle with insomnia and point

00:05:39.940 estimates I think at any given moment might be between 5 and 10%. The interesting thing about

00:05:45.220 insomnia is that it's a very clinical diagnosis. There's no blood test for insomnia. We can't put

00:05:51.560 you in a sleep lab overnight and do a test to see if you have insomnia. And we don't diagnose

00:05:57.880 insomnia based on one night of bad sleep. If someone says, oh, I didn't sleep at all last night or I

00:06:03.020 haven't slept even for just the last week, that's not going to get you a diagnosis of insomnia.

00:06:07.320 And there's a whole suite of different insomnias that we could talk about. But I think the point

00:06:14.300 that is the most salient is just that when you have a problem sleeping and when it's been going on for a

00:06:19.340 long time, at least like three-ish months, when you really feel it's a problem, that's when it's time

00:06:25.340 to get help. Because there's plenty of people who don't sleep a whole lot, but it's not distressing to

00:06:31.820 them. It's not causing any problems in their life. They're not going to meet a definition of

00:06:36.480 insomnia per se. It's the folks who will tell you that I can't sleep. I haven't been sleeping for

00:06:43.020 months. It's interfering with my life. It's really upsetting. And they've probably already started

00:06:48.940 trying a whole bunch of things to try and help themselves to fix it. And this is where things get

00:06:53.040 interesting. And just to be clear, Ashley, when you say that a point estimate of 5 to 10% of the

00:06:59.200 population would have insomnia at any point in time, you mean according to that definition where

00:07:05.100 it's been going on for months, it's causing distress, and it's impacting life?

00:07:08.860 Yeah, broadly speaking.

00:07:09.880 So it's low-end 1 in 20, high-end 1 in 10 people, adults?

00:07:13.960 Adults, yes. By the way, I do not do pediatrics, so please assume everything we're talking about

00:07:18.580 today is adults.

00:07:20.120 So that's a higher estimate than I would have guessed, given your definition. If the definition

00:07:24.740 was three nights of bad sleep, I would say, yeah, that makes sense.

00:07:27.920 Yeah. That's at any given point in time. Insomnia is, for most people, probably quite episodic.

00:07:34.980 It's not necessarily a permanent state. People go in and out of it. And the question is,

00:07:39.680 how quickly do people go out of it when they go in it? And that's what CBTI is so beautiful for.

00:07:44.860 It's helping people get out of it quickly. There's going to be things in your life that are going to

00:07:48.860 just happen, and they're going to put you over the threshold for insomnia. So maybe we can talk for a

00:07:53.740 minute about how insomnia begins and then how it's perpetuated, because these things are actually

00:07:57.600 quite different. So you and I and everybody have a certain level of predisposing factors that are

00:08:03.520 going to put us at risk for having sleeping problems, in particular insomnia. Then we may

00:08:09.520 experience what's called a precipitating factor. That could be a major life event like losing your

00:08:16.080 job, getting a divorce, getting in a car accident, some major unexpected unhappy life event that might

00:08:22.740 throw you into a bout of insomnia. That event will end, though. That event ends. The car accident

00:08:28.200 ends. It resolves. The job loss ends. You get a new job or you don't. The divorce ends. You move on.

00:08:34.660 But in the meantime, when you're dealing with that event, you develop behaviors to cope with it.

00:08:40.340 And so you might, for example, pop a Benadryl to help you sleep or an Ambien, something stronger.

00:08:45.440 You might start taking naps the next day after a bad night of sleep to try and cope with it.

00:08:49.820 You might start reading in bed a lot or flipping through your smartphone in bed. Doing all these

00:08:55.920 different types of behaviors to try and help yourself calm down and actually get to sleep,

00:08:59.140 which in the short term make a lot of sense. You're trying to help yourself in the acute moment.

00:09:04.300 But in the long term, these kinds of behaviors aren't actually doing you any favors. And over time,

00:09:11.060 that precipitating factor is going to go away. But all of these behaviors that you've started doing

00:09:16.620 to respond to the precipitating event, they're what stick around. And those are what are going

00:09:21.520 to perpetuate insomnia symptoms and problems. Can you say more about the predisposing factors?

00:09:26.940 Are those genetic? So there's, of course, genetic predisposing factors. I've had patients come and

00:09:33.920 say, I'm a really light sleeper. Can you fix that? That's going to be pretty tough to fix. I'm going to

00:09:39.280 recommend something like earplugs, an eye mask, a white noise machine, what have you. But yes,

00:09:44.560 there are going to be predisposing factors. So if you are higher on the general psychological

00:09:50.980 reactivity, you're going to probably get pushed over the threshold more easily than someone else.

00:09:57.080 Some people might get in a car accident, a fender bender, and they're over it by the next day. The

00:10:00.900 car's in the shop, whatever. Other people might feel antsy about driving for a while after that.

00:10:06.640 They might feel more anxious as a result of that event. And that's going to differ from person to

00:10:11.080 person. You can argue that that's genetic. You can argue that that's based on early childhood or

00:10:16.800 other experiences. But nature and nurture probably both contribute to that predisposition. And there's

00:10:23.060 not a whole lot that we can do about that. But this is the beauty of cognitive behavioral therapy

00:10:27.680 for insomnia. When people come in for treatment, they're often pretty focused on what caused their

00:10:35.420 insomnia. And I actually don't ask people what caused their insomnia until the end of my first

00:10:40.580 session with them. I'm asking them all these other kinds of questions about their behaviors now.

00:10:44.600 And at the end, I ask, okay, so when did this start? What do you think might have caused this?

00:10:51.280 And get their attribution for what's going on. Because at the end of the day, the intervention's

00:10:55.480 the same. And that's what's beautiful about this and might differ a lot from the practice of

00:11:00.660 medicine. I'm not an MD. I'm a PhD. I think in a lot of disease states, we often look at what caused

00:11:06.000 what's going on. I'm not really concerned. I'm more concerned about what you're doing now that's

00:11:11.060 perpetuating the problem. And that's where I intervene. And that's why this particular treatment

00:11:15.840 is so effective for so many different presentations of insomnia and causes of insomnia. Whether people

00:11:23.240 have difficulty falling asleep in the beginning of the night, waking up in the middle of the night,

00:11:27.400 waking up too early in the morning, you might think on their face, these people all need

00:11:31.700 wildly different treatment. But that's not actually the case.

00:11:35.400 Yeah, that makes a lot of sense. So the focus is much more on the coping strategy and the behavior

00:11:40.980 that came out of the predisposing factor or the precipitating event actually is really...

00:11:45.560 Used to respond to the precipitating effect. Exactly.

00:11:48.160 Okay. Can we talk a little bit about, is there a difference, for example, between the individual

00:11:53.060 who can't fall asleep, this initiation of sleep insomnia versus the person that I hear much more

00:11:59.580 about, frankly, I experience more, which is, it's not that hard for me to fall asleep, but boy,

00:12:06.160 I will jolt up at one in the morning with some thought or anxiety that I can't get out of my mind

00:12:14.300 and my mind starts running and I can't go back to sleep. Or I get up because I got to pee,

00:12:18.800 but when I come back, I erroneously just do something with my mind where I get thinking

00:12:25.960 about the day's problem or whatever, whatever. Do you think of those as difference or the

00:12:29.800 different side, same coin, I guess?

00:12:31.700 Those people need the same stuff. And the people who can't fall asleep at the beginning of the night,

00:12:37.320 their mind's just racing earlier than yours. Yours is just waking you up. And there's a whole

00:12:42.620 suite of interventions that are part of cognitive behavioral therapy for insomnia.

00:12:47.140 There are a lot of ways that I could approach an answer to this question. So I think starting by

00:12:53.360 addressing the racing mind issue. I always tell patients, if you don't deal with what's causing

00:12:59.360 you stress or anxiety during the day, it's going to demand to be dealt with in the middle of the

00:13:03.700 night. It's going to say, oh, Peter, I noticed you're laying there peacefully, not doing any work

00:13:08.700 or tasks and you don't have anything you need to do right now. So you're going to pay attention to me

00:13:12.320 and it's going to demand your attention at that time. Other people, that happens right when their

00:13:16.680 head hits the pill at the beginning of the night. Oh, you're relaxing now. Okay, here's your 10

00:13:20.040 things to worry about. So one of my favorite interventions that's actually born of anxiety

00:13:25.340 treatment, but that I've co-opted and I've moved into cognitive behavioral therapy for insomnia because

00:13:31.040 it fits with the theoretical framework is something called scheduled worry time. This sounds a little

00:13:37.300 bit pedantic and silly, but hear me out. If a patient came to me and said, Ashley, I worry all

00:13:43.760 day. I'm worried about all of these things. My life is just a constant ball of worry. And I said,

00:13:48.580 okay, I've got a solution for you. And it's two words. Ready? Stop it. That wouldn't work.

00:13:56.100 It doesn't work. I take the opposite approach. Okay. This is really important to you. This is

00:14:00.620 something you're doing all the time, all day. Guess what? What do we do with things that are really

00:14:04.060 important to us? Make time for them. We schedule them. Exactly. Back in the day of paper calendars,

00:14:09.520 this felt like a different exercise. Now people get out their phones, but I have them get out their

00:14:14.300 phone or whatever and say, all right, we're going to schedule worry time. And it's going to be an

00:14:18.040 hour a day for the next seven days. It is non-negotiable. I may or may not schedule an email

00:14:24.520 to go out to you at the end of that time. And you have to go and reply to it and tell me what you did.

00:14:29.460 And what we find is that when people work with this during the day, it does two things.

00:14:35.000 The first is, let's say it's 9am and you are trying to do something in your life and instead

00:14:41.640 a worry pops up. You can actually think, oh, okay, I don't have to deal with this now. I'm

00:14:45.780 going to write this down because at four o'clock I've got scheduled time to deal with this.

00:14:49.720 So that way you're uncluttering the rest of your day by moving all of the worry into that scheduled

00:14:55.500 time. So this could be a valuable technique, even absent insomnia.

00:15:00.000 Totally. I'd say that probably between a third and half of my patients who come in with insomnia,

00:15:04.760 they've got some bad sleep stuff for sure. But for some of those people, it's a primary anxiety

00:15:09.760 disorder and sleep is suffering also. Whereas other folks, it's primary insomnia and that's

00:15:16.060 driving them anxious. But to rewind back to your earlier question about the middle of the night

00:15:20.680 versus the beginning of the night. So the other thing that scheduling worry time does besides

00:15:24.680 uncluttering your whole day is it helps you get it done during the day so that when your

00:15:29.040 head hits the pillow, it's not there. Oh, I already worked on this. And also the knowledge,

00:15:34.680 oh, I have time set aside tomorrow to work on this or to think about this. So I don't have to do that

00:15:40.560 now. Cognitively, this all makes sense and you would maybe think you can think your way out of

00:15:45.340 this, but you can't. You actually have to try it. And I've done this with a lot of people.

00:15:51.560 I've done this with doctors, police people, people from all walks of life can really find this

00:15:59.420 valuable. The other thing when it comes to falling asleep at the beginning of the night versus the

00:16:04.420 middle of the night is that there's sometimes low hanging fruit that we can think about.

00:16:09.460 You mentioned getting up to go to the bathroom. I've found that for a lot of men who are 45 and

00:16:15.320 up who still have a prostate, just not drinking very much fluid with dinner and after dinner is

00:16:21.500 huge. And also throwing an electrolyte tab in there can really help. Granted, it's got to be

00:16:27.740 the right osmolarity and everything else, but there are ways to find this. Don't slam Gatorade at night.

00:16:32.060 That's not what I'm suggesting, but just throw a noon tab or whatever element, whatever electrolyte

00:16:38.000 replacement. I've had some male patients go from waking up three times in the night to pee to one time.

00:16:44.540 And the fewer times you wake up in the night, the fewer times you risk not falling back asleep.

00:16:50.280 So little things like that can actually make a difference for waking up in the middle of the

00:16:54.820 night. The other one I have about the middle of the night is a little more out there, but hear me

00:16:59.740 out. If I had five cents for every time I took away a down comforter from someone and their sleep got

00:17:07.760 better, I'd have like $8. I mean, this is huge. And this is because everybody's heard of circadian rhythm,

00:17:13.520 but it's missing a word. Circadian temperature rhythm. Your body is supposed to be its coolest

00:17:19.380 at night and its warmest during the day. And my favorite people to talk with about this are

00:17:23.660 actually anesthesiologists. They know more about body temperature than anyone. It's remarkable.

00:17:29.620 But what I've had the great good fortune of learning is that your body temperature,

00:17:34.600 it's supposed to be the warmest during the day and the coolest during the night.

00:17:36.720 When we do things like trap heat with down comforters, quilted nonsense, even cotton replacement,

00:17:45.700 if the word duvet is in it, comforter is in it, it's a no for me. And I give people a handout. I'm

00:17:51.360 like, here's the definition of a cotton blanket. Here are links to examples of what cotton blankets

00:17:55.140 are. If you are cold, buy two, buy three, use these. And I'm telling you, it's made a huge difference

00:18:03.780 for a lot of women in particular with night sweats. And people wake up less sometimes because they're

00:18:09.980 not giving their body this message that it's time to wake up because they're not as warm.

00:18:14.240 People complain about their feet and their hands. And I say, that's fine. You can put your down

00:18:17.520 comforter over the foot of your bed. You can wear some socks. But I take body temperature regulation

00:18:24.460 very seriously. And sometimes it's a quick fix and we don't need a whole lot of muss and fuss.

00:18:29.380 This is a very long word to answer your question, but I'll finish after this. The people at the

00:18:33.400 start of the night, it's worth asking people at the start of the night if they're cold,

00:18:37.200 if their hands and their feet are cold. Have you ever tried to fall asleep when your hands and

00:18:40.180 your feet are cold? Yeah. I try to be uncomfortably cold when I get into bed.

00:18:44.120 Right. But your hands and your feet? No, generally not. I mean, it's just my body. But again,

00:18:48.760 I'm using a device to cool me as well. Slightly different. But spoiler alert, it's pretty hard to fall

00:18:54.300 asleep when you have cold hands and feet. And what we have data on from some interesting

00:18:58.360 research in a totally different realm is that people with extremity circulation disorders who

00:19:03.940 have really cold hands or something like that. Yeah. They will have what we call early insomnia,

00:19:08.380 which is difficulty falling asleep at the beginning of the night. And when they get successful treatment

00:19:12.460 or when you warm their hands and their feet, much easier to fall asleep. The whole warm foot bath

00:19:17.420 before bed thing, that's an actual thing. Your extremities help you dump heat. So when you actually

00:19:23.360 warm your hands and your feet, you can actually help dump heat from your core because you're

00:19:27.340 vasodilating. And when you fall asleep, you want to be dumping heat from your core. Hard to do that

00:19:32.560 when you're vasoconstricted in your hands and your feet. So for folks who have trouble falling asleep

00:19:36.700 at the start of the night, we want to make sure their hands or feet are warm enough and that they've

00:19:40.900 dealt with the thoughts and the worries during the day and that they're not trying to go to sleep at

00:19:45.980 nine o'clock when their body doesn't want to go to sleep until 11. A lot of people just think,

00:19:50.220 I need to have this much time in bed each night. And they get into bed and they struggle for two

00:19:54.800 hours before their body actually wants to go to sleep. So a major part of CBTI is aligning when

00:20:00.560 your body can produce sleep with when you're in your bed. I want to kind of go into many more of

00:20:05.700 these because I know this is the exciting stuff that people are interested to hear about. I do want

00:20:09.200 to take one step back and just make sure we understand what constitutes cognitive behavioral therapy

00:20:14.500 before we even get into cognitive behavioral therapy for insomnia. So we've had a podcast where we

00:20:18.720 talked about dialectical behavioral therapy, DBT, but we haven't covered CBT. Can you give us a little

00:20:24.760 bit of the tapestry of what defines it and why it of course then has this additional subset of

00:20:32.220 treatment for insomnia? I should have done that first. Cognitive behavioral therapy, my favorite way to

00:20:37.660 think about this is in a triangle. We have thoughts, we have feelings, and we have behaviors. You can think

00:20:43.400 about this triangle as having these three pieces that are all connected. And cognitive and behavioral

00:20:49.600 therapies or cognitive behavioral therapies generally will focus on one intervening on this

00:20:55.500 process between thoughts, feelings, and behavior, thoughts, feelings, and behavior on one of these

00:20:59.780 sides of the triangle. So let me just spell out a quick example process. So let's say we have a patient

00:21:05.980 with type 2 diabetes who has the thought, I'm never going to be able to get my blood sugar under

00:21:11.920 control. I'm never going to be able to manage this. I'm not going to be able to do this. When a person

00:21:16.180 has those thoughts, how do they feel? Crummy, feel bad about themselves. When people feel bad about

00:21:20.480 themselves, what do they do? Eat some chocolate cake. Eat some chocolate cake. What does that do? That

00:21:24.780 reinforces the thought, I'm never going to be able to do this. So we've got this pattern of thoughts,

00:21:28.760 feelings, behavior on repeat. Cognitive behavioral therapies will choose where to intervene on a process in that

00:21:35.480 triangle. Cognitive behavioral therapy for insomnia, for example, is really focused on the area between

00:21:41.500 thoughts and feelings in many ways, because people will have a lot of thoughts. I can't sleep. I'm never

00:21:47.240 going to be a good sleeper. If I don't sleep eight hours tonight, I'm going to lose my job, whatever.

00:21:52.680 And then the big emotions that follow from that. We work on questioning a lot of those thoughts to then

00:21:57.840 recalibrate the feelings that follow. Like, oh, if I don't sleep eight hours tonight, I won't feel great

00:22:02.480 tomorrow, but I'll probably be okay at work. The feeling is much smaller than, if I don't sleep

00:22:07.140 eight hours tonight, I'm going to lose my job tomorrow. They're noticeably different. In terms

00:22:11.840 of depression, an example that I like might be someone saying, oh, I'm really depressed now, but

00:22:17.800 when I feel better, I'm going to take my grandkids to the movies. That's what I'm going to do. I'm going

00:22:22.540 to take my grandkids to the movies. I'm going to take them to the zoo. I'm going to do all these

00:22:26.500 things. So as a therapist, what I might do is I'd have the patient write all of this huge long list of

00:22:31.900 stuff they're going to do when they feel better. And then you know what I'm going to do. I'm going

00:22:35.400 to get out their calendar with them and I'm going to say, all right, I don't care how you feel.

00:22:39.580 We're scheduling all of these things. So we're intervening on that behavior to thoughts line.

00:22:45.080 So we're going to make them take the kids to the zoo. We're going to make them take the kids to the

00:22:49.220 movies. And then the kids are going to have a great time. And the patient's going to come back

00:22:52.660 and say, oh, you know what? Pretty kick-ass grandma. Kids had a great time. This was pretty great.

00:22:57.260 So we're intervening on the behavior to change the thoughts about the self. Like, oh, I'm going

00:23:02.540 to do these things when I'm better. A major feature of cognitive behavioral therapies is

00:23:07.120 intervening on behavior to change thoughts, but also intervening on thoughts to change feelings.

00:23:13.920 And there's just many, many applications for this. Cognitive behavioral therapy has been adapted

00:23:19.120 for a whole host of disorders, for eating disorders, for insomnia, specifically for anxiety.

00:23:25.420 That's going to be more in the thoughts and feelings realm too.

00:23:28.740 Is that kind of running the triangle in the other direction? So you change behavior to change

00:23:33.800 thought, you change thought to change feeling?

00:23:36.040 Yeah. So you can change thought to change feeling. You can work on behavior to change thought. You can

00:23:40.920 operate on any way of those with different techniques that have been just repackaged into different

00:23:47.120 therapies.

00:23:48.200 And tell me a little bit about the history of CBTI specifically. When did the idea come to

00:23:54.020 existence in a way that's been packaged more or less the way it is today?

00:23:58.360 Cognitive behavioral therapy for insomnia is actually old news. I mean, we can go back to

00:24:03.420 the 1970s. I remember when I was learning cognitive behavioral therapy for insomnia,

00:24:08.440 one of the most fun studies to read about was this study of, I believe it was college-aged men who were

00:24:16.020 not doing well academically. And the intervention that they did with them was one of the two pillars

00:24:22.800 of cognitive behavioral therapy for insomnia, which is called stimulus control. And what they did with

00:24:28.400 these young men is they told them, all right, you're going to be assigned a carol in the library.

00:24:33.020 And in this carol is the only place you can study. You can't study in your dorm. You can't study outside.

00:24:38.920 Can't study anywhere else. Just this carol. And only this amount of time can you study each day.

00:24:46.460 If you're on a roll, we don't care. You have to stop. If you're miserable, we don't care. You just

00:24:51.240 have to keep on doing whatever portion of the study over and over again that you're stuck on.

00:24:56.220 So they trained these young men to just study in that one place. And it succeeded in helping

00:25:03.700 these men. And these men were struggling with anxiety or actual insomnia? Academically. This is

00:25:08.800 just stimulus control, where we learn to associate a place with a behavior. And fast forward a little

00:25:17.080 bit. It was called the Bootsen method at one point for Dick Bootsen. But one of the hallmarks of

00:25:22.460 cognitive behavioral therapy for insomnia is your bed is only for sleep. There are two things you're

00:25:27.980 allowed to do in bed. I always tell my patients, your two things that you can do in bed are sex and sleep. 0.63

00:25:32.460 If you're not sure if something counts, message me and I'll clarify it for you real quick, whether it

00:25:37.320 counts in one of those two buckets. But we really want to just associate the bed with sleep.

00:25:44.140 And to be clear, just going back to this study, was there a belief or were some of these guys

00:25:48.740 studying in bed? They were studying in their dorms, in their beds and everywhere else. I mean,

00:25:53.480 everywhere. So this wasn't specifically a study focused on sleep per se. It was just focused on this

00:25:59.240 associative pattern that became the bedrock of this treatment. And we can go back even further

00:26:06.200 and we can look at Pavlovian conditioning, the dog and the bell and the food. And we don't need to go

00:26:11.200 over what that whole thing was again right now. But the point just is that the dog came to associate

00:26:15.920 the bell with getting food. And a lot of times when people are struggling with sleep, you know what

00:26:20.800 they're doing in their bed? They're reading, they're scrolling, they're watching TV, they're listening to

00:26:25.900 podcasts. They're doing like everything. A lot of people, by the time they get to me, they're camping

00:26:30.480 out in their bed just in case they're able to sleep. Oh, I'm going to go have a snack in bed because

00:26:34.280 if I'm sleepy enough, I'll roll over and take a nap and I'll get some extra Zs. So people have moved so

00:26:39.180 much of their lives into their beds that it's completely dissociated from sleep. That's one of

00:26:44.740 the bedrocks. And then another bedrock is what we now call time in bed restriction. This used to be

00:26:52.460 called sleep restriction. But I don't know where along the way in the last number of years it went

00:26:58.260 from being called sleep restriction to time in bed restriction. But whoever made the change, I'm still

00:27:02.600 not sure who made that change. I am thankful to them for it. Because the other key component of CBTI is

00:27:08.140 that we restrict the amount of time that a patient is in bed to match how much time their body can actually

00:27:15.020 produce of sleeping. A lot of times people with insomnia will say, okay, I need to be in bed for at least

00:27:19.960 12 hours if I want to get seven hours of sleep. I know it's hard to believe, but it's true. And we

00:27:26.620 just obliterate that notion. And this is another core and very old part of CBT that dates back, what,

00:27:33.860 1970s, 80s? But when you take those two parts, then you start to add in some of the cognitive

00:27:41.200 components that have been around also for decades. The cognitive therapies part, the Aaron Beck stuff with

00:27:46.980 cognitive restructuring, which is where we take a thought. Have you ever heard that phrase,

00:27:50.800 don't believe everything you think? So you take a thought, and on the classic thought record tool,

00:27:56.480 you'll have patients write down the thought, write down how they feel, rate their feelings from,

00:28:00.960 say, zero to 90%. And then we have them write down, what's the evidence for this thought?

00:28:05.560 If you had to go to court right now, and there was a judge and a jury and what have you,

00:28:10.640 and you had to present evidence for your thought, what would you be able to present?

00:28:14.660 Evidence for a thought is not another thought. It's not a belief. It's evidence. Last time I

00:28:20.440 slept six hours, I got a worst grade on a test or something. That would be evidence. You got a

00:28:26.920 worst grade on a test. But then we look at all the evidence for a thought, we look at all the

00:28:29.960 evidence against a thought. Like, oh, last time you didn't sleep so well, you didn't get fired,

00:28:35.900 still did fine in school, whatever the thing. And then we create a balanced thought, which is,

00:28:41.260 even though I'm not going to be as well rested, I'll still get through this day.

00:28:45.480 Then we have people re-rate their emotions, re-rate how much they believe this new thought,

00:28:49.400 this whole song and dance. This is the cognitive component. And that's kind of the bedrock of so

00:28:54.720 much of cognitive therapy. Of course, people have so many negative thoughts about sleep and

00:28:59.640 dysfunctional thoughts about sleep that aren't true or that are catastrophizing and whatnot.

00:29:04.160 That is also blended in to the treatment. And then we have relaxation techniques, which are

00:29:10.940 things like progressive muscle relaxation that came along as well. And those are part of the

00:29:15.520 treatment. Progressive muscle relaxation will be like where you squeeze your hands and let it go

00:29:19.500 and squeeze your hands and let it go and then squeeze your arms and let them go and move through

00:29:23.520 your whole body to get out of your head and into your body. And I don't know what order those

00:29:27.760 actually were packaged into CBTI. But I can tell you the first two, the stimulus control

00:29:34.160 and the time in bed restriction, those are among the earliest parts of CBTI. And what we know from

00:29:39.860 dismantling studies is when you take either of those out of the treatment, no dice.

00:29:45.520 Yeah. I want to talk about both those a little bit more. I want to bracket sleep hygiene and come

00:29:50.520 back to it because I think, again, the temperature and all that light stuff, we shouldn't gloss over

00:29:54.300 that even though it's easy to take for granted. And I know that many people listening to this podcast

00:29:58.620 will have heard other content where we talk about it, but I'd love to have it all in one place.

00:30:02.460 I think the time in bed restriction is pretty interesting. And in talking with sleep physicians

00:30:08.540 who also implement this, it seems quite draconian at the outset. It can be remarkably difficult.

00:30:16.860 They're giving people five hours in bed max and they're really trying to force sleep pressure.

00:30:22.700 How do you navigate that and how do you decide how hard to squeeze the tube of toothpaste?

00:30:26.740 Let me draw a line in the sand between what CBTI says broadly as a treatment and then how I've

00:30:32.740 actually implemented it in my clinic. So what CBTI will have you do is they will have you,

00:30:38.520 and I say you as the royal you, your patient, they will have you fill out something called a sleep

00:30:41.740 diary. And this is a paper diary that covers seven days. Because if I asked you how well you slept

00:30:48.420 four nights ago, you'd be like... It's like a food frequency questionnaire in epidemiology.

00:30:52.900 Totally. Total waste of time.

00:30:54.020 Total. So you have to do it every morning. Okay. And of course, I'm not obsessed with it being exact

00:30:59.720 because I'm much more interested in the picture pattern of it. If you asked someone to fill it

00:31:04.020 out for just one day and then worked with that, you'd have a totally distorted picture. You wouldn't

00:31:07.500 know what you're working with. But what classic CBTI does is they'll take that seven day sleep diary

00:31:12.200 and then they will actually use it. The time you got in bed, time you fell asleep, how many times you

00:31:17.460 woke up, how long you were awake, what time you woke up. It has all of these different questions

00:31:22.920 in it. And you can use that to calculate how much time a person was sleeping on average over the

00:31:29.180 course of the week. And what CBTI does is it says, you patient, why don't you pick what time you want

00:31:35.380 to get up every day? And then you would ostensibly pick a time. The CBTI clinician, let's say your sleep

00:31:41.500 blog said you were naturally sleeping six hours a night. The clinician would add 30 minutes to that

00:31:46.540 and make it six and a half hours and then work backwards from your chosen wake time.

00:31:51.200 So let's say you chose a wake time of 7 a.m. I would work back six and a half hours to get to a

00:31:58.100 bedtime for you of 1230 a.m. And of course, that's the bedtime of your childhood dreams. Imagine going

00:32:03.140 to a sleepover and your friend's mom saying, all right, kids, you can't go to bed until after 1230

00:32:08.660 a.m. Kids love it. Adults think this is torture because it is. That's what classic CBTI would do.

00:32:15.820 Six hours being the number?

00:32:17.300 Six and a half. You get that half hour of grace. As far as I know in CBTI, almost nobody's restricting

00:32:24.760 less than five and a half hours. Five and a half seems to be the floor. I've not seen people

00:32:29.800 restricting to five. There are a subset of people, and I don't know the data on this because I don't

00:32:35.260 even know if the data exists on this, who are what we call genetically short sleepers. And these

00:32:41.740 people know who they are. They have always been like this. And it's not upsetting and distressing

00:32:46.420 and causing them grief. We're not talking about those people. Okay, so that's what CBTI will do.

00:32:51.680 And just to be clear, let's say five and a half is the floor. Six is typically what you would do.

00:32:56.820 So six and a half in bed. Well, no. If your body is producing six hours of sleep, I add 30 and I get

00:33:02.820 six and a half. If your body is producing only five and a half, I add 30 and you get six. So I do this

00:33:08.900 computationally for each person. I see. So when I bring my sleep log to you, you've seen that for

00:33:14.700 the past week, I've been spending 12 hours in bed. But by my recollection, because I'm looking at the

00:33:20.580 clock when I'm not sleeping, I'm only getting six and a half hours of sleep in the 10 or 12 hours I'm

00:33:27.360 laying there, you're going to say, oh, okay, that's your sleep time. Take that, add 30. That's your time

00:33:32.280 in bed. I got it. Yes. Yes. And here's where what I do is slightly different, but also the whole

00:33:39.380 theoretical underpinning is not disturbed at all by the way that I do this. So how many times have you

00:33:44.480 had a patient come to you and say, oh, I really want to be that person who wakes up at 5 a.m.,

00:33:49.580 get to go on my day. I want to get my exercise in. I want to get my meal prep in, do all this stuff.

00:33:55.640 And you're like, oh, okay, cool, cool. So you want to be a five in prison. What time do you get up now?

00:33:59.280 Oh, like 11. And I'm like, oh, okay. All right. So this whole part in CBTI where people choose their

00:34:04.840 wake time, that's not a thing for me. In my clinic, we play a game called democracy within a dictatorship.

00:34:11.600 What that just means is that instead of just letting patients carte blanche choose their wake time,

00:34:16.360 I actually look at their sleep diary and I let them think they're choosing their wake time. And if I

00:34:20.280 agree with it, they will have chosen. If I don't, the dictator comes in and I look at their diary and

00:34:26.460 if they are getting up at 7 a.m., 6 a.m., 7 a.m., 7 a.m., 6 a.m., 6 a.m., 6 a.m. And they say to me,

00:34:35.460 oh, I want to wake up at 8.30. I will say, well, we have no evidence that you can sleep until 8.30.

00:34:40.900 That's not realistic. But we have evidence that you can sleep until 6 because four of the last

00:34:47.100 seven days, you made it until 6. So 6 o'clock is your wake time. And this is not anywhere in CBTI.

00:34:53.800 I've spoken with a lot of my colleagues who do CBTI and asked them, how do you choose a wake time? And

00:34:57.960 there is no standardized method. But by using this method, I'm definitely making sure that I'm at

00:35:04.080 least gating the patient's sleep at a reasonable time. Because if I let that patient just choose 8.30 a.m.

00:35:08.860 as their wake time, and they were only producing six and a half hours of sleep.

00:35:13.200 They're going to bed at one in the morning.

00:35:14.680 They're going to bed at two in the morning, and they're getting up at 8.30 because they chose their

00:35:19.440 wake time as 8.30. But really, they're going to wake up at like six or seven, and they're not even

00:35:23.100 going to cash in on the full six and a half hours that they should be getting a bed. So I've added in

00:35:28.540 this component of my own of setting their wake time to be a much more reasonable time. And then what I do

00:35:35.500 before giving them a bedtime, I give them a week at that wake time. And I see how much sleep is your

00:35:40.680 body producing with this new wake time. Now, let's say you're doing the sleep log, and they're

00:35:47.040 spending, you know, eight hours in bed, getting four hours of sleep. Let's say they're getting

00:35:53.420 five hours of sleep, eight hours in bed, and then they're taking an hour nap a day. So they're

00:35:59.940 removing all their sleep pressure during the day by taking that nap, but they kind of need to take the

00:36:03.960 nap because they're not getting enough sleep. So they're in this vicious cycle. So do you add the

00:36:08.040 hour of nap time back to sleep and say, actually, you're getting six hours of sleep. Let's do the

00:36:13.440 exercise based on five plus one plus a half, 6.5? No, no, no, no, no, no, no. We want to extinguish

00:36:18.660 that sleeping during the day thing. So there's a difference between a person without insomnia

00:36:23.160 healthily using naps, and then there's a person with insomnia who's napping to compensate for what's

00:36:28.520 not happening at night. So I think that to best explain this, I should just finish this example

00:36:33.480 of the wake time thing because this directly ties in. If I'm setting their wake time and then I'm

00:36:38.480 seeing how much time they're actually producing sleep, that first week when I give them the wake

00:36:42.020 time, I don't give them a bedtime. I don't even do time in bed restriction that first week because

00:36:46.580 for some people, setting a wake time solves the issue, which is kind of nuts. But one or two of every

00:36:54.000 eight patients who I see, because I see patients in groups of eight, will have a huge improvement

00:36:58.460 from just having a consistent wake time because their body actually recalibrates and they start

00:37:03.600 getting sleepy at a more consistent time each night because they're not doing that. And I do say in that

00:37:08.740 first week, I take away the naps. I say, I don't care how you slept last night. You need to just stay

00:37:12.900 awake until you're ready to go to sleep. No naps for now. Now, when I have patients, probably older

00:37:20.220 patients, like 80 and up, I'll be okay with a nap, but I'll often, at this stage, I'll say, look,

00:37:27.040 you have an opportunity of 25 minutes. And a 25-minute nap opportunity means you set the alarm

00:37:33.000 for 25 minutes, you get in bed, and it's going to go off 25 minutes later, and that's when you get up.

00:37:37.000 I don't care how long you actually slept during that time because I don't want you going into

00:37:41.240 phase three or phase four slow wave deep sleep during the day because that's what's going to really

00:37:47.240 mess you up at night. A stage two sleep nap is not really an issue during the day as much. It's

00:37:54.260 not going to be so bad. But at this stage of the person with insomnia that we're talking about,

00:37:58.520 I don't want them taking a one-hour nap in the day. And they come back that second week having

00:38:03.020 done the wake time that I said, and I then recompute how much time in bed they're spending.

00:38:07.360 And then I still use that wake time, and I then calculate their bedtime. And then the true time

00:38:13.240 to bed restriction begins week two. Okay. But just to be clear, if you have someone who is using a nap

00:38:19.580 to compensate for their insomnia, step one is just kill the nap. Kill the nap. And then let the cards 0.91

00:38:25.820 settle where they may for a week, recalculate actual sleep time, and then go through the exercises

00:38:31.560 described. I've made this point on a podcast before, I think, but just want to get your blessing.

00:38:37.860 When we're on bow hunting trips, you are going to bed insanely late and waking up insanely early.

00:38:45.380 It's just the nature of when you get back to camp and eating, and then you got to be up super early.

00:38:50.140 So I've never been on one of these trips where I could actually be in bed for more than five and a

00:38:55.380 half, six hours in a night. So the strategy is to get that sleep, but then I always try to get a 90

00:39:02.000 minute nap at around one in the afternoon. And the reason I pick 90 is to get a full sleep cycle.

00:39:09.560 And I tend to function incredibly well under those circumstances, because remember, you're also very

00:39:13.640 physically active. Like this is demanding time. So would I be better off not doing that nap midday?

00:39:19.760 Oh, that's a bow hunting trip and you don't have insomnia. That's not a problem.

00:39:22.920 Okay. All right. Got it.

00:39:23.880 Yeah. Totally different monster. And I tell people too, a lot of the last few years,

00:39:28.380 people have had serious illnesses. They've had COVID, they've had whatever. When you're sick,

00:39:32.320 all bets are off. What I tell people is, if you need a nap when you're sick, you need a nap when

00:39:35.900 you're sick, but we maintain stimulus control. You don't nap on the couch. We're only napping in bed.

00:39:41.220 And if you're awake and feeling sick, then you can be on the couch, not in bed.

00:39:45.480 While we're on that topic, what do you say to the legions of people watching who

00:39:50.060 fall asleep watching TV on the couch?

00:39:52.300 Oh, the worst. A lot of people fall asleep on the couch because they're just so overtired

00:39:59.920 that the ship has sailed. Their body's ready to go to bed and they're just letting it and they're

00:40:05.340 not getting up and doing the thing. I tell people, look, if you want to prioritize your sleep,

00:40:10.680 pay attention to your body. When you're watching TV, do you notice that you're starting to nod off?

00:40:15.060 Do you notice your eyelids feeling heavier? Your hands feeling warm? Are you starting to sag a little

00:40:18.720 bit? Okay. These are indicators that it's probably time to get off the couch and go to bed. For people

00:40:24.800 who can't figure that out, I say, okay, you want to watch TV at night? Sit in a stool. You're going

00:40:28.440 to figure it out real fast.

00:40:30.400 What about just the social dynamic of it, which is when you have a couple, not that I'm saying this

00:40:35.100 from experience at all, and one part of that couple, they want to be together and watch TV,

00:40:41.140 but one member of that team falls asleep immediately while the other does not.

00:40:47.000 And the one that does not tries to tell the one that is to go to bed, but that one wants to be

00:40:53.400 with the other. I don't know if you can ever imagine a scenario like that.

00:40:56.440 Yeah.

00:40:56.940 I'm just making it up.

00:40:58.580 Okay, good. I'm glad you're making that one up. I have a lot of these couple level issues that come

00:41:02.320 up in sleep clinic. This is not uncommon because what's more intimate than being completely

00:41:07.600 unconscious next to another person. If you think about it evolutionarily, that's probably the

00:41:12.320 riskiest thing you can do. So there is this desire for closeness in lots of couples, and it

00:41:17.840 becomes a challenge when one of the members of the couple has a sleep problem. And the first step is

00:41:22.460 remembering this is not necessarily permanent. We need to go about fixing this now, and then we can

00:41:27.240 find a new winning solution. So in the interim, I'm assuming you've already tried maybe watching

00:41:34.100 something different on TV that might be more exciting to the second partner, et cetera. It's not

00:41:39.140 about the boringness of the show per se. Doesn't appear to be.

00:41:42.380 Okay, good. So if that's the issue, then I would say, hey, if this is a priority, what are we going

00:41:47.900 to do? We're going to schedule it. We're going to schedule time to be on the couch together at a time

00:41:52.620 when I can definitely be awake and be spending meaningful time with you.

00:41:56.100 The problem is sometimes other members of the family who tend to be smaller also tend to be

00:42:03.900 occupying all of the bandwidth during those earlier hours when the member of the family in

00:42:11.700 question is able to be awake. This is a hard problem to scale. But what I would just say is

00:42:17.740 if you're actually ready to go to bed and your body is saying that you need to sleep, you should

00:42:23.600 probably do that. It's more likely that then you'll be awake the next day and be a more pleasant,

00:42:30.260 exciting partner to be around and be able to have more meaningful experiences with your partner

00:42:36.800 that way. Otherwise, I tell people, look, this is an issue. If it's really an issue, we're going to

00:42:41.240 get a babysitter. Figure it out. There are ways to get around these things. People just often want it

00:42:47.820 to work like they see in the movies. Like, oh, this should be easy.

00:42:51.500 Obviously, I'm talking about my wife here, so I'll stop double speaking. But if my wife falls asleep 1.00

00:42:56.420 every single time on the couch, but then when said Netflix is over and we go up to bed,

00:43:02.000 she falls right back asleep and it doesn't seem to keep her awake, is it pathologic?

00:43:07.900 This isn't necessarily a problem. But what I would say is we sleep more deeply at the beginning of

00:43:12.380 the night. We experience more slow wave sleep in the first half of the night and more REM sleep in

00:43:16.880 the second half of the night. I think other podcast guests you've had can definitely go into the

00:43:21.220 neurobiology of this much more deeply. But a way that I like explaining this has to do with

00:43:25.660 evolution. If you think about it, when we're deeply, deeply asleep, we're kind of tuned out.

00:43:30.380 And on the prairie, when we figured, okay, it's safe to go to sleep right now,

00:43:33.700 our bodies prioritized getting that really deep sleep when we knew it was safe. And then as the

00:43:37.380 night goes on, we sleep more and more lightly, which makes sense because, hey, there could be

00:43:40.880 lions and tigers around or whatever that are going to come and eat us. So evolutionarily speaking,

00:43:45.280 it was adaptive to sleep more deeply in the first half of the night. Now, if your wife is falling

00:43:50.940 asleep on the couch and getting some of that sleep at that stage of the night and maybe getting

00:43:55.320 more interrupted aspects of that, because there's noise from the TV or whatnot, it could be

00:43:59.860 disturbing the quality of... That's the drawback.

00:44:01.040 That's the drawback.

00:44:01.860 Yeah, it makes sense.

00:44:02.960 To that effect, on the prairie, it also makes sense that evolutionarily, there's diversity in

00:44:08.180 people who are night owls and early morning larks. We needed that diversity in order to keep the

00:44:13.060 tribe safe from the threats on the prairie. Some people were staying up late. Okay, no lines. Some

00:44:17.480 people were up early. Okay, no lines. And there's nothing pathologic about being a person who's going

00:44:23.400 to be more likely to fall asleep earlier. Be a person who's more of a night owl. And it's very

00:44:27.700 hard to change that. A lot of patients want to change it.

00:44:30.940 Broadly, two to three different archetypes of that. I know there's a circadian rhythm test you

00:44:35.980 can take online that gives you a sense of it. I almost think it's so self-evident if you pay

00:44:41.440 attention to your patterns.

00:44:43.440 It is. I'm really a clinician, so I deal with what's in front of me all the time. I'm not so

00:44:49.380 concerned about these tests. I'm more concerned about what's the problem that's messing up your

00:44:53.040 life right now and how can we work around that.

00:44:55.720 Let's go back to sleep hygiene for a second. We talked about temperature. Nowadays, we have these

00:44:59.640 incredible devices that can cool our mattresses and things of that nature. Obviously, we have air

00:45:04.780 conditioning that can cool the room. Do you have a preference for one or the other? I mean,

00:45:11.380 clearly, not everybody needs to buy a mattress cooling device if they can't afford it. That

00:45:15.160 shouldn't be an impediment to sleep. Do you have a room temp set? We typically talk about the mid-60s

00:45:20.140 as an ideal room temp. Do you adhere to that?

00:45:22.140 Yes. Mid-60s is terrific. If people say, oh, this is just too cold, I say, well, what's too cold?

00:45:26.800 And often they will say, my feet. And we have wonderful solutions for that. They're called socks.

00:45:31.380 We can get really thick socks. I'm also not opposed to, you know, those tiny little heating pads you can

00:45:36.020 get, they're like this big foot and a half by a foot or something. Putting one of those in the foot of

00:45:40.320 your bed, it's gotten auto shut off. It shuts off after like an hour or something to fall asleep

00:45:45.280 with. I don't have a problem with that. There's no issue there. But yes, a cool room is definitely

00:45:50.740 key. And insert my refrain about down comforters, duvets, et cetera. Get cotton blankets, get cotton

00:45:56.860 sheets. Let's talk about light. Do we need to have it so pitch black you can't see your hand in front

00:46:02.320 of your face? Do we need to block the moonlight? How dark do we need it to be? This is a common

00:46:09.180 question. If you closed your eyes right now, you'd be able to tell that it's light in this room.

00:46:14.220 We can sense light through our closed eyelids. And many women would tell you that their eyelids seem 0.53

00:46:20.420 to get thinner as they age. So I think an eye mask is a great addition. And this is for a lot of people

00:46:26.200 with early morning awakenings. Eye mask can be a game change because they don't realize that what's

00:46:30.720 causing their early morning awakenings is a little bit of light getting into the wrong part of their eye,

00:46:35.700 indicating it's time to be awake right now. I don't know the details on what wavelength of

00:46:41.260 light that is or what necessarily the light is coming from, whether it's a light outside from

00:46:46.200 the sun or the moon or whatever it might be. But the point just is a lot of folks with early

00:46:50.300 morning awakening can really benefit from having something covering their eyes, whether it's a

00:46:55.460 sleep mask or there's like hats that go down here now. I'm a big fan of making your room dark.

00:47:01.200 I am one of those people who travels with a roll of black electrical tape because you go to a hotel

00:47:05.700 room and there's like 50,000 lights everywhere. You wouldn't just get relief from the eye mask?

00:47:10.980 I do, but I'm one of those people who rips my eye mask off in the middle of the night and I've tried

00:47:14.580 every single eye mask and it's coming off. So I like to wear it. I start with it. I try and keep it on as

00:47:21.720 much as I can. But I also, if there's egregious lights in a room, I cover them with a lot.

00:47:26.220 Meaning like you're going to cover the alarm clock and or whatever the.

00:47:28.920 Oh yeah. No, there's none of that in my room.

00:47:30.680 My trick is I unplug alarm clocks because I realize sometimes they're so complicated that

00:47:35.280 they just go off in the middle of the night and I didn't realize it. And yeah.

00:47:38.100 Oh, totally. And the microwaves are the worst. Those are the blinking time.

00:47:42.140 But you mentioned the cooling mattress stuff, which I'm intrigued by, but I also am concerned about.

00:47:48.580 It seems that a lot of these mattresses have settings where you can make it cooler,

00:47:52.480 but also you could make it warmer. And I worry about two things. One is I worry about messing

00:47:58.700 with our circadian temperature biology because you remember in the 1980s for a hot minute when

00:48:04.100 electric blankets were really popular and all of a sudden they're not. They were starting to see

00:48:08.960 associations between electric blanket use and some cancers. And at the time there was a lot of

00:48:14.580 speculation that this was related to EMF. But the great thing that time does is it gives us more

00:48:19.380 perspective. And there are some indications that actually that might've been messing with circadian

00:48:24.260 temperature. And that might've been part of the issue. We know that night shift work is

00:48:28.960 carcinogenic. Do we though? Yeah. Night shift work's been declared a carcinogenic. Well, I mean,

00:48:34.200 no disrespect to the WHO, I don't know what I believe that they say. I know that there's an

00:48:38.380 association between night shift work and cancer, but do we really know that it's causal?

00:48:43.560 I think if we go Bradford Hill on this and we look at temporality, I think that there are

00:48:49.920 age-matched case control studies where they can look at people going through different control for

00:48:57.180 history effects to see are people getting more and less cancers. It is tricky because if, for example,

00:49:01.980 you look at firefighters, they're way more likely to get cancer. They work way more.

00:49:05.360 They have way more chemical exposure. They have way more other things in the mix. But I think that

00:49:10.140 some of the more classic studies have also been done with hospital workers, also confounding effects.

00:49:15.860 How do we get around the confounding effects of the obvious dietary shifts that occur in people

00:49:20.200 when they're working under those conditions? I mean, if I think back to how I ate in residency

00:49:25.820 or how I eat after a night of poor sleep, I mean, to me, that would be more the cause. I'd put more

00:49:33.100 of that on kind of the metabolic ill health that might result. But carry on.

00:49:37.380 Yeah. I think that it's often hard for people to sleep during the day. Making that change from

00:49:42.680 going to sleeping at night to being a person who sleeps during the day, for some people,

00:49:47.120 it's not even possible. You talk to some night shift workers, they sleep very little because they

00:49:51.820 just can't sleep during the day. They're not able to flip their circadian biology. But there's a whole

00:49:58.020 history, and I know we'll probably talk about thermal stuff in a bit, but of looking at

00:50:03.000 disruptions in circadian temperature as one of the most common circadian disruptions in mental

00:50:09.900 health disorders. But going back to the cancer thing, what would be the believed mechanism of

00:50:14.360 action? I would talk to an oncologist about that, and I would probably talk to a circadian biology

00:50:20.980 person about that. But what I can just speak to is just my understanding that electric blankets are

00:50:27.100 no longer here with us and very common because there were these observed ill health effects,

00:50:32.880 whether they're due to EMF or whether they're due to messing with your body temperature at night.

00:50:37.460 But what concerns me about some of the exogenous interventions like mattresses that might heat up

00:50:43.600 is there's supposed to be a normal circadian temperature rhythm that we do during the day and

00:50:50.000 during the night. And when we start imposing things on that, some of these mattresses can

00:50:55.020 actually be set to cycle at different temperatures during the night and all of these things.

00:50:59.480 Yeah. So the one that I use, just by full disclosure, I'm an advisor to that company.

00:51:03.600 The one that I use, you change how cold it is throughout the night. So I think I run it as,

00:51:09.340 I think the settings go from zero to minus 10. Minus 10 is the absolute coldest. Zero is no

00:51:15.200 temperature change. Is that like a point scale or is that degrees?

00:51:17.420 No, it's a point scale. Yeah, yeah, yeah. Yeah. So I think I get in and I have it at

00:51:22.400 minus five and then I run it down to minus 10 and then I bring it up to minus five in the morning,

00:51:28.820 something to that effect. So I'm taking it from cold to really cold up to cold.

00:51:34.200 Right. Okay. So where my concern is just that-

00:51:37.320 You're saying people would heat themselves with these things. Yeah. But that gets to the point,

00:51:41.140 which we know we don't want to be warm. We don't want the duvet.

00:51:43.720 Right. But a lot of people get in bed and they don't like feeling cold because it is easier to

00:51:49.660 fall asleep when your hands and your feet and your skin is warmer. So people will maybe mistakenly do

00:51:54.540 this for more of the night than they should. And I'm just concerned that our circadian temperature

00:52:01.340 rhythm is an exquisitely controlled system. And a 10 point scale on a device, I think,

00:52:09.640 pales in comparison to the complexity of what our bodies need to do in terms of temperature

00:52:13.700 during the night. The good news is if you can keep your room at 65, none of this matters.

00:52:18.020 And the biggest challenge, honestly, is hotels for most people. It's where you have the hardest

00:52:21.720 time. Hotels are the worst. And there are some mattresses now, they're just hot. There's a short

00:52:26.940 list of mattresses. I just tell people like, look, that's going to be a hot mattress. Don't get that.

00:52:31.320 And you want to be really careful to make sure that you can be cool in your bed. And I think the

00:52:36.600 easiest way to do that, if you don't have the money to splurge on something that's going to be

00:52:41.060 a mattress that's going to definitely be cool, would be keeping your room cool.

00:52:45.040 What about blue light before bed? I've looked at these data quite a bit. And I would say that

00:52:52.520 six years ago, I was in the camp of every light had to be red. So I had to have my phone shifted

00:53:01.160 into a red light phase. My computer shifted into a red light phase. I had all of these apps that

00:53:05.940 managed all of this stuff. So as soon as the sun went down, blue light was being removed from my

00:53:11.960 electronics. And I have to say, I sleep subjectively and objectively better today. I say objectively,

00:53:20.480 if you can believe what a sleep tracker tells you, but we can bracket that and come back to it,

00:53:25.300 we should. Never taking blue light out of my devices, but instead paying attention to what I'm

00:53:31.780 consuming. In other words, my new hypothesis has become, it's not the blue light that is the

00:53:37.980 problem. It's the stimulus that often comes with the blue light. In other words, not looking at social

00:53:44.760 media, regardless of light color is a far greater positive impact on my sleep than looking at those

00:53:53.480 things, but just making sure that there's no blue light coming through. So let's talk about that.

00:53:58.080 What is the role of minimizing blue light when it comes to preparing for sleep?

00:54:04.160 First, I want to completely agree with you. We didn't evolve for the neural experience of Instagram.

00:54:08.960 We're not ready for that. I think regardless of what color light you're getting your Instagram on,

00:54:13.920 that's probably not helpful before you go to bed. So I think that you're entirely right. I think the

00:54:18.720 larger problem is not necessarily the blue light, but is the thing that we're interacting with,

00:54:23.800 whether it's an iPad or a phone or a computer, because typically those things are going to involve

00:54:28.680 social media, work, email, all of these other things that I think are much more potent disruptors

00:54:35.140 of sleep than the blue light itself. I must caveat this though. I have had a few patients who they were

00:54:41.560 not using Instagram before bed. They were not doing email before bed. None of this.

00:54:47.000 Not doing anything stressful or stimulating. No, but I just finished with a patient recently like

00:54:51.800 this who found that using orange colored glasses, and I'm talking orange colored glasses, not those

00:54:58.300 beautiful blue light blocking glasses that are clear lenses that I'm not sure what they're really doing

00:55:02.860 sometimes. I'm talking ugly motorcycle looking orange lenses. I found that a handful of patients

00:55:10.740 wearing these two hours before bed, it completely ameliorates their sleep onset insomnia such that

00:55:17.400 they were able to almost immediately quit Ambien. The beauty of these interventions is if you can

00:55:22.560 isolate them to one change at a time, you can be empirical about it. And something like wearing

00:55:27.640 glasses is benign. I mean, you're only out the money you spend on them. And if it works, great.

00:55:34.720 And if you really want to test it, take them off and see if your symptoms return. And if they don't,

00:55:40.200 maybe it fixed you, maybe it wasn't that. Who cares if they return and you can fix it? Yeah. Like

00:55:44.300 I try not to be terribly dogmatic about this stuff, but I also think that when people go to

00:55:50.480 great lengths to remove blue light without removing stimulus, they're missing the boat a little bit.

00:55:57.540 And for me, social media is not much of a stimulus actually, because I don't pay that much attention

00:56:01.140 to it, but work is. So for me, the single worst thing I can do right before bed is look at email.

00:56:08.560 Whereas watching TV, it's a total beautiful way for me to be distracted by watching something

00:56:14.860 mindless on Netflix for an hour. And as long as I don't go and check my email and see what got sent

00:56:21.200 to me in the last hour, it'll be great. It doesn't matter that I just finished watching a big bright

00:56:26.180 screen of Netflix. It doesn't seem to impact me. Well, one is much more interactive and stressful

00:56:31.080 and one is very passive when you're just watching a movie that has nothing to do with you,

00:56:34.180 no bearing on your life. What I would say back to your, what I'm going to call A-B testing,

00:56:39.080 whenever you want to test one of these individual, what I call low hanging fruit interventions,

00:56:43.600 you want to collect your own data on a paper sleep diary for two weeks, make the change.

00:56:48.440 You must do it for two weeks. And there's a few more low hanging fruit pieces of sleep hygiene.

00:56:53.920 By the way, do you have a nice template? We have one that we give our patients. Again,

00:56:57.100 it's super low tech. It's a piece of paper.

00:56:58.600 So low tech.

00:56:59.120 Do you have one on your UCSF website?

00:57:01.420 I can make it public. Yeah.

00:57:02.680 Yeah. Yeah. Okay. Maybe we'll link to it in the show notes.

00:57:04.660 Yeah. Easy to do.

00:57:06.020 We'd link ours as well, but yours is probably better. Ours is like boxes you color in.

00:57:10.440 Oh yeah.

00:57:10.900 And it's like you put C when you had caffeine, A when you had alcohol, E when you exercise. So

00:57:17.060 we're documenting when did you exercise? When did you have food, alcohol, caffeine, and when were

00:57:20.940 you in bed and when were you sleeping by the shading?

00:57:23.460 Yours might be even more high tech than mine, but what I will tell you is mine is just enough to get the

00:57:28.760 information that I will definitely act on and nothing else. But I will tell you, can I go over

00:57:33.460 a couple more pieces of low hanging fruit on sleep hygiene?

00:57:37.140 Yep.

00:57:37.880 Okay. So back to the glasses. If you are a person who has trouble with what we call early insomnia,

00:57:42.980 so difficulty falling asleep at the beginning of the night, and you're already not looking at your

00:57:47.520 email, not doing Instagram, you're just annoyed that you cannot fall asleep at the beginning of

00:57:52.200 the night. It's worth it to try these glasses for two hours a night for two weeks and see what

00:57:56.020 happens. It's so easy to do.

00:57:58.480 To be clear, is there a particular brand?

00:58:01.560 I have no affiliations with any of these things. I can tell you there's some really nice ugly ones

00:58:06.500 from lowbluelights.com, I think, if they're still in business. But they look like motorcycle goggles.

00:58:12.080 I do think that the wraparound feature is important because if we're going for it, let's go for it.

00:58:16.780 It's a worthy thing to do.

00:58:18.660 Another important thing to do is to talk to your physician.

00:58:22.700 I'm not a physician, but I work with a ton of them. And I learned this from an anesthesiologist.

00:58:28.640 All medications have circadian effects. All of them. Somehow, it's probably not known for all of

00:58:34.180 them how they do, but they do. Make sure you are taking your medications at the same time every day

00:58:38.940 and at the right time of day. For example, I once had a patient coming in saying they were taking

00:58:44.020 450 milligrams of bupropion for depression before bed. No. That's going to be a pretty stimulating dose

00:58:50.440 of something to take for bed. So make sure that you go over your medications with your doctor

00:58:55.000 and that you're taking them at the optimal times of day and be really consistent with your medications.

00:59:01.040 And another one that is a particularly low-hanging piece of fruit is something called

00:59:06.560 decaffeinated coffee. Turns out there are speculations that decaf coffee can have as much

00:59:12.560 as 15 to 30 percent of the caffeine that regular coffee has. I haven't found that reference.

00:59:18.180 I've dug. I've tried to find one that will show that. I haven't found exactly that.

00:59:22.860 But there are some data from 2006 that were published saying that 15-ish percent. But then

00:59:27.680 again, more recent data have shown that Starbucks, I think, says that their 12 ounce has 155 milligrams

00:59:33.600 of caffeine. But outside laboratory testing found 310, something like that. So when you're

00:59:39.920 decaffeinating coffee that's much more caffeinated than you started with, this can make an absolutely

00:59:44.600 huge difference. I tell people we're done with caffeine by 11. That's my 11 a.m. That's my

00:59:49.580 standard. Unless we've got an extreme phase delay or phase advance, I should define those terms.

00:59:54.960 A phase delay is when you go to bed really late and you wake up really late. A phase advance is

00:59:59.120 when you wake up really early and you go to bed really early. So someone who's waking up at like

01:00:03.800 3.30 in the morning and going to bed at like 8 p.m., that would be a phase advance. Phase delay would

01:00:11.560 be like, I'm going to bed at 3 a.m. and I'm waking up at 10 a.m. So in those cases, I might do something

01:00:17.160 differential with the caffeine. But for most people who are neither of those, I'll cut it off

01:00:22.020 at 11. That includes your caffeinated coffee and your decaffeinated coffee. And I never take people's

01:00:26.920 caffeine away. Caffeine withdrawal is not something I want to deal with in my clinic, and I don't think

01:00:32.000 it's necessary. You can cause a lot of damage taking away someone's coffee. People really don't like

01:00:36.980 that. It really puts them in a bad mood. And it's not necessary. So I tell people, do not change how

01:00:42.660 much coffee you're drinking. Put it all before 11. Just move it all.

01:00:47.320 What fraction of people are such rapid caffeine metabolizers that they seem immune to caffeine and

01:00:52.680 sleep?

01:00:54.000 I think that that person doesn't actually exist. I need to be convinced what the normal caffeine

01:00:59.700 half-life is four to six hours. So even if we take someone who's four hours, that means after four

01:01:06.280 hours, you still have half of a cup of coffee. And after eight hours, you still have a quarter of a

01:01:11.500 cup of coffee. And if you have that coffee at 2 p.m., and that coffee actually had 310 milligrams of

01:01:19.320 caffeine in it, and it was only a tall coffee from Starbucks, there's a lot of contingencies to build

01:01:24.360 in here. But I could tell you people, someone we both just know, actually stops using decaf coffee

01:01:32.320 after dinner. And it's a world of difference for their sleep quality. People will say, oh, no, I fall

01:01:37.340 asleep just fine. It doesn't affect me. Well, it is affecting you. It's affecting the electrical quality

01:01:42.120 of your sleep throughout the whole night. And I would refer you to talking to a sleep neurologist

01:01:47.040 to interpret some of those sleep studies and talk with you more about that. For my purposes,

01:01:53.020 all I need to know is the person who's trying to fix the insomnia is, oh, you're having two decaf

01:01:57.680 coffees after dinner every night. That could add up and that could be doing something, and that could

01:02:02.180 make your sleep less restful. Okay. Low-hanging fruit. Just stop it at 11. Stop it. Like, do the

01:02:07.640 experiment at a minimum. Okay. So those are three. But don't reduce it is the key thing. Any other

01:02:13.400 really obvious things to A-B test for two weeks? No, I think that that's the major part. I will tell

01:02:19.860 people also, people like to fall asleep with podcasts on, don't do that. Including this one, right?

01:02:26.220 Right. Yeah. This is an easy one to fall asleep to, but I don't know. I hope that people aren't

01:02:31.560 falling asleep listening to this. Although, if this helps some sleep. One other thing I want to

01:02:35.040 talk about is on the relaxation techniques, where does or does mindfulness-based practice come into

01:02:40.020 it? So anyone who's done mindfulness-based meditation probably appreciates how difficult

01:02:45.560 it is. It's not like transcendental meditation where you're focusing on a mantra. You're instead

01:02:51.800 focusing on a sensation, typically breathing. But body awareness is a thing that you want to focus

01:02:57.240 on. Is that counterproductive or is it productive as you're laying there awake?

01:03:02.180 So my unsatisfying answer to so many questions is always going to be, it depends,

01:03:05.880 because there's moderator variables. And when it comes to CBTI, what we know is that what's been

01:03:11.160 tested is progressive muscle relaxation, which you could argue is a form of a body scan, which is part of

01:03:17.140 many mindfulness practices, where you scan your whole body, you think about your hands, you notice

01:03:22.500 how they're feeling, are they warm, are they soft, whatnot, and you move through your whole body.

01:03:26.320 With progressive muscle relaxation, you squeeze your hands and you let them go. You squeeze them

01:03:30.540 and you let them go. It's more of an active process that you're paying attention to throughout

01:03:34.760 your body. Doing this in bed right before you fall asleep for a few minutes is fine. That's the one

01:03:40.320 exception to the sleep and sex rule. I tell people that it's also fine to practice this in other parts

01:03:45.320 of your house. You don't have to just be in bed. But the body scan and mindfulness in general has

01:03:50.300 been studied in combination with CBTI. And what the data have shown is somewhat fascinating. There's

01:03:57.140 no actual differential improvement on sleep duration or metrics of sleep. But people like

01:04:05.360 the mindfulness stuff. They report they're more happy with it. They like doing that. But in terms of

01:04:10.280 actual improvement on sleep outcomes, I don't think it really adds too, too much to CBTI. The effects

01:04:16.440 with CBTI are pretty whopping. When it's done well, 50 to 60% of people can get remission and 70% can get

01:04:24.280 clinically meaningful improvement to their sleep. So in the world of psychological treatments,

01:04:29.760 that's really good. But to circle back to your question, mindfulness is great. I think there's a lot

01:04:36.140 of practical uses for it for helping yourself when you're in psychological states you don't want to

01:04:41.620 be in. It's a great way to be in life. But when it comes to sleep, do I need you to start a

01:04:47.680 mindfulness practice to improve your sleep? No. So you mentioned 50 to 60% of people are going to

01:04:52.760 have a remission. Closer to 50, but yeah. 70% will have a meaningful clinical improvement. Of the 30%

01:05:00.560 that do not. Why? When does the treatment fail? The treatment fails when people don't do it.

01:05:07.100 So in other words, we're really saying 30% of people are not able to adhere to the treatment.

01:05:11.620 I wouldn't go that far. There are some people who are genetically short sleepers.

01:05:15.580 And at some point, this may become distressing for them. I had a story of a patient who was in her 70s,

01:05:22.020 came to me saying, I have a huge problem. My sleep is not good. And I asked her, okay, so tell me all

01:05:28.320 about this. She was like upper 70s, had a volunteer job, really active, full workout plan. I'm like,

01:05:36.060 you're crushing it, lady. What's the problem exactly? She says, well, I joined this study

01:05:40.520 and I had to wear this wearable device. And I woke up in the morning and it says that things are not

01:05:47.080 going well every morning, morning after morning. And it says I'm at risk for different things. I'm not

01:05:52.740 going to say which wearable company it was. And I said, oh, okay.

01:05:55.320 There's an amazing treatment for that. Can I see the wearable device?

01:05:57.920 Can I please just have that wearable device?

01:05:59.940 Here's my vice grips.

01:06:00.900 Boom. Exactly. This was a while ago, but I took it away from her and the wearable devices now are

01:06:07.200 not doing this. This was, gosh, seven, eight years ago.

01:06:10.860 I made a note to ask you this question. When do you tell people, because we do this with our patients,

01:06:16.840 which is take the tracker off. We're doing a six month tracker holiday, done with the tracker.

01:06:22.460 Done.

01:06:22.680 So is that mainstay part of your treatment is like, let's get all that anxiety out of there?

01:06:27.640 For people with insomnia, I tell them, yes. Coming to me in my clinic, the people who have

01:06:34.640 bothered to wait a year and a half to get into the clinic, those people, yes, I am telling them that.

01:06:40.460 And so to go back to your 30% of people, the genetically short sleepers who become distressed

01:06:45.120 about their sleep are not going to be helped by CBTI. They're not.

01:06:49.120 Maybe they shouldn't be helped. Maybe there's nothing to fix.

01:06:51.060 Correct. But they're presenting, so I'm putting them in the group. And then, yes, we know that

01:06:55.520 there's such a huge body of data on CBTI at this point. It's just wonderfully studied. And we know

01:07:01.540 that when people don't do the treatment, it doesn't work. Adherence is a major, major component.

01:07:06.300 Duration of treatment also matters. It seems that if you do four or more sessions with a therapist

01:07:12.300 doing the CBTI, your outcomes are going to be way better than if you try and cut it way short with one

01:07:16.420 or two. My treatment is five sessions. I do an intake, you get five treatment sessions,

01:07:20.820 and then I do a follow-up where we just tidy things up.

01:07:23.580 And the space between them is a week?

01:07:25.300 Always one week. I am militant about this. If you're going to miss a week, you can't be in it.

01:07:30.220 You have to wait for the next cycle.

01:07:32.160 Given that people are waiting a year and a half to see you,

01:07:35.400 tells me that there's a mismatch on the supply-demand curve.

01:07:39.360 Yeah.

01:07:39.420 Why is that the case?

01:07:41.420 First of all, there is a great directory. Can I give you for the show notes?

01:07:44.620 Yes.

01:07:45.140 So there's actually a way you can look up-

01:07:47.220 We use it ourselves.

01:07:48.580 The Society of Behavioral Sleep Medicine thing?

01:07:50.280 Yeah.

01:07:50.300 Yeah.

01:07:50.840 So that is how you would find a provider who definitely knows how to do CBTI.

01:07:55.460 One of the major problems comes down to psychologists and providers taking insurance. A lot of the

01:08:02.940 best folks there in private practice, they don't take insurance. And you could be paying hundreds of

01:08:08.160 dollars a session to see them. And they're pretty backed up as it is, and they don't take insurance.

01:08:13.600 I am fortunate. I get to work at UCSF at the Osher Center for Integrative Health, and

01:08:17.600 we take Medicare and all kinds of insurance so people can pay minimal or non-existent co-pays

01:08:24.260 to see me. And there are other CBTI providers at UCSF. Their wait lists are long, long, long too.

01:08:31.880 In fact, in order to see patients now with any volume, I don't see individual patients. I see

01:08:37.820 eight patients at a time in group medical visits. And I do it 90 minutes every week,

01:08:42.420 all eight patients in that 90 minutes to get it done.

01:08:46.720 So what will it take for AI to replicate what you're doing to scale this much more? Because

01:08:53.020 a lot of this, a lot of the work I do can be done by an AI. How much of the art and science of this

01:09:01.780 is teachable to LLMs, and at least as another offering? I'm not saying it should ever displace

01:09:07.580 what you're doing or what a therapist is doing. But if we have a backlog of people for years,

01:09:14.280 shouldn't we have an alternative which might say, look, there's an online course that you can do that

01:09:18.960 will give you 70% of the value of what you might get sitting in the group with Ashley?

01:09:24.340 Hey, if you can find a way to replace me, I'm here for it.

01:09:27.440 Or just come up with an alternative to scale.

01:09:30.040 Here's the issue. There are some CBT apps, smartphone apps, interventions out there.

01:09:35.740 And I've had patients who've tried these while they're waiting.

01:09:38.840 Yes, exactly.

01:09:39.580 And they'll come in and they'll say, oh, it might have helped a little bit.

01:09:43.440 And I think the major issue is that many, many people with sleep problems think that their sleep

01:09:47.740 problem is unique. It's special. This can't be treated by just a generic app.

01:09:53.100 My problem is different. And the joy of me having a group is that people can hear that

01:09:58.340 everybody's problems are different. And I'm going to treat you all the same way.

01:10:01.700 Y'all are going to do the same things. You might do it at different times,

01:10:03.760 but you're all going to do the same things. And I think that there is a world where AI can

01:10:09.800 help with the personalization aspect. I'm actually helping a company that's making an app. It's called

01:10:16.000 Rest. And they are integrating AI to use, for example, the way that I calculate someone's wake

01:10:23.100 time, which is not something that's in standard CBTI. They're incorporating that and they're able

01:10:28.940 to actually do more tailoring. And I'm excited to see where it goes. But I think that the biggest

01:10:33.220 fly in the ointment with this is going to be getting patients to look at the fact that they

01:10:37.240 have been assigned to wake up at the same time every day for the next seven days and think,

01:10:41.500 oh gosh, I only wake up at 5 a.m. two days a week. Normally now I have to do it every day.

01:10:46.940 Getting them to really do it is going to be hard. Before my patients enroll in my clinic,

01:10:51.400 they watch a 10-minute video. And it's a really scary video. In that video, I'm basically saying,

01:10:56.260 look, this is going to be hard. You're going to hate me. You're going to want to make a dartboard

01:10:59.680 with my face on it and play darts on it. You are going to suffer in the beginning of this treatment.

01:11:04.860 But guess what? You have been suffering for months or years. Now you're going to suffer for

01:11:11.260 five weeks. You're going to do it my way. And if you don't like it, you can go back to your way.

01:11:15.000 This is five weeks of your life. How bad can it be? How much worse can it get?

01:11:19.140 So I do one of these kind of pep talk videos. There's just something about knowing that someone

01:11:25.060 else is actually really paying attention to one of the biggest problem, if not the biggest problem

01:11:30.700 in your life at that moment. Sleep is a 24-hour-a-day problem. This is not just a problem at night.

01:11:35.680 It is affecting you all day. It is intensely personal. So it's a lot to trust an algorithm

01:11:42.420 or an app to know, oh, okay, I really should do these things. I think it's a big ask and it's hard.

01:11:49.600 By the way, when you're giving them that bootcamp speech, is the time in bed restriction typically

01:11:54.540 the thing that causes the most distress?

01:11:56.500 They don't know about that at that stage. People are in the dark at that stage. I just say,

01:12:00.040 look, we're going to do this thing. It's going to be really hard. You're going to get worse before

01:12:03.500 you get better because everybody sleeps less the first couple of weeks while we're getting

01:12:06.820 all these things lined up. And for some people, what ends up being the hardest is the wake time

01:12:13.380 because they're used to just sleeping in whenever they can or catching up on those hours when they

01:12:18.520 can. For other people, the super late bedtime that I give them, that's what crushes them.

01:12:24.840 They're like, oh my gosh, I have to stay up until then. But the great news is that we dial it back

01:12:29.420 over time. And I don't think we talked about this part with time in bed restriction,

01:12:32.180 which is just that there's a benchmark for efficiency, sleep efficiency. And we define

01:12:37.400 sleep efficiency as the amount of time that you're in bed sleeping divided by the entire

01:12:42.160 time that you're spending in bed. And the benchmark is 85%. So each week I'm actually calculating sleep

01:12:47.740 efficiency from people's paper sleep diaries. And once we do time in bed restriction, if they are

01:12:52.540 above 85%, I move their bedtime back 15 minutes. And then if that's the same for another week,

01:12:58.820 you move back another 15 minutes. And people say, 15 minutes, what? Who cares? I'm like, oh,

01:13:03.700 you'll care. After four weeks, that's an extra hour every night. That's huge.

01:13:09.180 And are people able to, with a high enough fidelity, report awake time in bed? For example,

01:13:16.100 like if I were doing this, let's assume I've got a clock next to my bed that I can look at,

01:13:20.200 because you have to do that for this purpose. You have to have some device to keep track of time.

01:13:24.460 So I get in bed because my time in bed tonight is 11 and my wake up time tomorrow is 530. Okay. So I

01:13:31.700 get in bed. It's 11. Check. Okay. How do I know what time I fell asleep? Let's just say I didn't

01:13:36.800 have an issue falling asleep. How do I know if it's 1115 versus 1130? I'm looking for the difference

01:13:42.580 between five minutes and 50 minutes for that time to fall asleep thing, right? And in the middle of

01:13:47.280 the night when you're waking up, guess what? If you're not getting laid, you're getting out of bed.

01:13:50.660 So you can look at the clock and be like, all right, I'm out of bed. And then you have to go do

01:13:54.100 what I call a very fun and potentially embarrassing activity. Embarrassing meaning if your boss caught

01:14:01.960 you doing this activity during the workday, you should feel embarrassed. So for example,

01:14:07.180 reading People magazine or reading some trashy magazine, you wouldn't want to be caught at your

01:14:11.220 desk doing that at work. That's exactly what you should be doing in the middle of the night.

01:14:14.840 So person wakes up at two in the morning and they can't go back to sleep. Get up,

01:14:19.360 go and do something that is not productive, not rewarding in the way that, hey, this is,

01:14:26.720 I'm building a pattern around getting up and doing something I like. So I wouldn't be able

01:14:30.620 to get up and play chess. I wouldn't be able to do the online chess thing that I love.

01:14:34.900 Maybe, maybe not. I mean, I tell people they can play solitaire. Adult coloring books are all the

01:14:39.200 rage. I couldn't check email. No. Work-related work is a definite no.

01:14:43.740 What about scrolling social media? No, no. We don't like that. Although that meets the criteria

01:14:49.120 of you wouldn't want your boss catching you doing it. We don't do social media or interactive.

01:14:53.900 Read for pleasure? That's fine. Okay.

01:14:56.340 But we don't read about global warming, current events, politics, pandemics. Those things are

01:15:02.120 off the menu. Stock trading?

01:15:03.920 Ooh, not if it's stressful. I wouldn't do that.

01:15:06.800 Okay. So there's a narrow subset of activities that you are going to get out of bed to do.

01:15:10.780 Yeah. Stuff that's kind of boring, but entertaining enough. Because we don't want you to get a habit

01:15:16.740 of looking forward to doing something in the middle of the night. This happens with parents.

01:15:19.940 Like a parent, for example, who might be busy all the darn day with their kids and their family's

01:15:25.040 needs and everything else. Then in the middle of the night, they wake up and it's like, oh,

01:15:28.580 this is me time. This is when I'm going to do all these really fun things that I don't get to do

01:15:33.380 during the day. We don't want to make a habit of you time being between 3 and 4 a.m. That's really

01:15:38.600 when you want you to be sleeping. Sometimes you have to schedule that stuff during the day,

01:15:42.580 but we want the stuff in the middle of the night to be mildly boring. And to that end,

01:15:44.920 back to your blue light thing. I don't mind if people watch, for example, an episode of MASH

01:15:49.560 or Gilligan's Island or Sex and the City or some other sitcom. I like 20-minute episodes because

01:15:54.860 then you can generally turn it off, check in with your body, think, am I ready to go back to sleep?

01:15:58.860 And then you can go back to sleep. Do you remember in the 90s, if you played video games ever,

01:16:03.440 how we had those cartridges and we'd put them in. And sometimes we have to take them out and

01:16:07.760 blow them out to put them back in and reset them because they would freeze. That's what you're doing.

01:16:12.960 When you get out of bed in the middle of the night, you do a different activity,

01:16:15.880 you're resetting and then you're going back to sleep instead of just having stewed in bed that

01:16:20.400 whole time. And it's much easier to fall back to sleep when you have that reset.

01:16:24.300 So we don't want the activity to be too stimulating, but just mildly boring and entertaining enough.

01:16:30.560 Does that track?

01:16:31.340 Yep. One obvious thing we haven't talked about, and maybe it's so obvious we don't need to,

01:16:35.180 but just to close the loop on it is food and alcohol and how they pertain to this.

01:16:39.800 What's the checklist you run through with the clients?

01:16:41.580 So since we're dealing with so much life, I actually don't mess with their food. All I do

01:16:46.820 is say, hey, really, let's try to not eat within three hours of going to bed. Sometimes it's rare

01:16:51.500 that I'll have nighttime binge eating disorder to deal with at the same time or a blood glucose issue

01:16:56.820 that in diabetes that's poorly controlled at the same time. But I'm going to put those cases aside

01:17:00.860 for just a moment. So I generally will go with don't eat for three hours before bed. And when it comes

01:17:06.180 to alcohol, I tell my patients, look, this is five weeks of your life. I'm not going to drink

01:17:10.640 and you're not going to drink. So when I'm running a clinic, nobody's drinking. And the reason for

01:17:15.280 this is that in order for me to actually see what's going on with your sleep, I need to see

01:17:19.480 this with the least perturbation possible. Alcohol and marijuana are those things. Now,

01:17:24.660 if people are using a lot of marijuana or a lot of alcohol, I'm not here to put people into withdrawal.

01:17:29.700 So they just don't enroll until they're...

01:17:32.220 No, no, no. I'll let them in. So what I'll do is before people come to their first group,

01:17:36.160 I have them do a sleep diary so I can see what's going on. And before that, I will have done their

01:17:40.460 intake and I'll have them have told me their alcohol intake. And I'll have decided, all right,

01:17:44.000 here's what you're going to do. You're either going to not, or I just finished with some people.

01:17:48.120 One of them was drinking between 16 and 20 ounces of wine a night. It's huge. And I said, okay,

01:17:53.740 so you're going to drink two ounces of wine a night out of that same glass. And then, you know,

01:18:00.040 you're going to keep using that glass and you're going to drink something else, some other frou

01:18:03.220 frou drink. I don't care what it is, but I want it to be something that you don't drink during the

01:18:07.020 day. So I want it to be overpriced juice or overpriced bubbly water or something like this.

01:18:11.760 Something special.

01:18:12.240 Something special. And you're going to keep drinking it out of that wine glass. And I have them do that.

01:18:16.620 And I make sure they can do it before they start treatment. And they generally can,

01:18:20.120 because again, the other part that I have going for me is that people have been waiting so long

01:18:24.560 that by the time they get to me, they'll do what I say, which is just this lovely gift that I have.

01:18:31.020 But I'll make people be very consistent with that. They'll be like, oh, I have to drink two ounces

01:18:35.600 of wine a night. I'll say, yes, you do. You must. I want this consistent. That's the thing,

01:18:40.220 consistency. So if someone's saying, oh no, I drink three nights a week. And I'll say, all right,

01:18:44.320 cut it out. You're going to stop. I'm going to stop. We're all going to stop.

01:18:46.760 Are there any specific cognitive techniques that people are instructed to be working on

01:18:53.160 when they first wake up? No, nothing. There's nothing, no mind game to play. It's all behavior,

01:19:01.380 behavior, behavior. I'm all business. Yep. At CBT, I'm a purist and I don't involve the cognitive

01:19:06.720 techniques until week three of five with treatment. And that's when we get into things like scheduled

01:19:12.340 worry time, working with the thought records. And then also one of my favorite things to do with

01:19:18.800 patients who seem to wake up in the middle of the night, maybe at 1 a.m. they jolt themselves awake,

01:19:24.080 worrying about something in particular. I have a patient like that who every night in the middle

01:19:29.200 of the night wakes up at 1 a.m. and says, I'm very worried about thing A. I'll say, okay, thing A.

01:19:35.780 Here's what I'd like you to do with thing A. I would like you to track how worried you are about

01:19:41.320 thing A all day, every couple of hours. This is called tracking degree of belief in a thought.

01:19:47.620 And what you might find is that I'll build on this with an example of a patient that I had,

01:19:51.860 actually. This might be an easier way to explain it. I once had a patient with multiple sclerosis,

01:19:56.340 early 30s, pretty debilitating disease to have when you're that young, working a full-time job,

01:20:00.820 who used to jolt awake in the morning, every morning at 7 a.m., thinking, I'm never going

01:20:05.220 to make it through this day. My whole body hurts. This is a mess. I'm never going to be able to do

01:20:08.760 this. And she would lay in bed for two hours until like nine o'clock, thinking these thoughts,

01:20:13.200 just, oh, I can't do this. By nine o'clock, she'd get out of bed. She'd shower. She'd get to work by

01:20:18.000 10 o'clock because in the Bay Area, all these startups don't start till like 10. She'd get her coffee,

01:20:23.380 work with her assistant, do her meetings. And if I asked her, how much do you believe that thought,

01:20:27.460 I'm never going to make it through this day at noon? She'd probably say, oh, like 60%. Like

01:20:33.020 this afternoon is going to be rough. I don't know if I'm going to make it through. But if you ask her

01:20:36.160 at 5.30 when she's done working or whatnot, oh, how much do you believe that thought, I'm never

01:20:41.580 going to make it through this day? She'd be like, oh, I made it 0%. Day after day, she started realizing

01:20:46.260 like, oh, I don't believe this thought at 7 a.m. because it's true that I'm never going to make it

01:20:51.560 through this day. I believe this thought because it's 7 a.m. Once she was able to make that connection,

01:20:56.560 we were able to recapture her mornings. And at 7 a.m. she went and sat on her couch and she started

01:21:00.860 doing something she loved between 7 and 9, which for her was learning Italian with an app. She loved

01:21:06.560 it. And 7 to 9 used to be her most hated part of the day. But by the end of treatment, it was her

01:21:12.580 most beloved part of the day because no one was bothering her and she could learn Italian and

01:21:16.000 whatnot. And so one of the cognitive tools that I've built into CBTI in that cognitive package is

01:21:21.980 tracking how much you believe a thought over a given day. And if you believe a thought in different

01:21:27.840 levels throughout the day, how true can it really be? And it's really enlightening. And I would invite

01:21:33.040 you to notice what you're thinking about at 1 a.m. and then just see how worried are you or how much

01:21:37.100 do you believe this the next day at 3 p.m.? Oh, not at all. How come this deserves airtime at 1 a.m.

01:21:42.980 but not 3 p.m.? Let's talk about sleep supplements. So do you do a purge of supplements when people

01:21:52.260 come to you and they say, hey, I'm taking a pound of melatonin every night. I'm on an ashwagandha

01:21:58.740 drip. Just rattle them off. We could go through the list. Can I give you two links for the show notes

01:22:05.040 to studies of melatonin supplements that found that these melatonin supplements either had none of what

01:22:10.920 they said they had in them? Yes. I think we wrote a newsletter on one of them. Oh, great. Well,

01:22:14.500 there's been two. And when people come in and they say they're taking melatonin, I'm like, okay,

01:22:18.840 the alleged melatonin, how much of this are you taking? Let's assume that they're taking melatonin

01:22:23.000 because they're getting it from one of the companies that submits to third-party testing.

01:22:27.060 And so now they know they're doing it. And again, let's further posit that they're not taking a dose that

01:22:34.700 is deemed too high. So if you look at some of the sleep literature, there seems to be most people would

01:22:40.340 agree anything north of a milligram is probably just too much. Whereas kind of in the three to

01:22:46.040 600 microgram, there might be some benefit and more importantly, not just benefit, but actually

01:22:50.860 safety. You're not down-regulating melatonin receptors. You're offsetting the natural decline

01:22:56.460 in melatonin levels over time. I can tell from your face, you don't agree with any of this.

01:23:00.700 It's puzzling. So my face is also because it's hard to know where to go with this question because

01:23:04.300 some countries you need a prescription for melatonin. This is something prescribed by a doctor. It is

01:23:09.380 regulated. I don't remember all the countries off the top of my head, like Australia, New Zealand,

01:23:13.340 whatnot. You want that? You're not going to find it at their Walgreens. But in the U.S.,

01:23:17.040 taking too much can't kill you. So here you go. By the time someone gets to me, if they've got a huge

01:23:20.740 list of supplements and they still have a sleep problem, I say, okay, so clearly these aren't

01:23:24.500 doing what you want. They might be undermining what we want to do. I don't know what's actually in all

01:23:30.320 of those things because none of that's regulated. The data for things like ashwagandha are weak.

01:23:35.300 If you want to go Bradford Hill, we could. The data are also pretty weak for melatonin,

01:23:41.040 except in certain cases, which we can unpack a few of those with the explicit acknowledgement

01:23:46.800 that I'm not a physician. I've not been trained in the biological substrates, whatnot. But your

01:23:51.440 question is, do I take people off of this stuff? Yes. Get off that stuff. If you want to take it

01:23:55.920 after treatment with me again, great. But let's get off of it for now and let's see what your body's 0.99

01:24:00.540 actually doing. Because chances are you've been adding a supplement or two or whatnot over time

01:24:05.160 for years, and we don't even know what your body wants to do now. And you actually could be shooting

01:24:08.440 yourself in the foot with some of these things. Now, on the contrary, sometimes a patient will come

01:24:13.120 in and will say, oh, I'm taking a beta blocker for blood pressure. Now, you and I both know that's

01:24:16.780 like a fourth or fifth line treatment for blood pressure at this point. Nevertheless, beta blockers

01:24:21.800 inhibit melatonin secretion. And yet most prescribing doctors who are giving out beta blockers don't

01:24:27.900 realize that there's a significant risk of insomnia when you prescribe these to patients.

01:24:32.240 And I've had some patients who don't need treatment with me at all. They need a 0.5 milligram melatonin

01:24:39.020 pill every night, and that's it. And those are some of the most angry and satisfied patients ever.

01:24:45.240 They have one visit with me. It's done. They're furious that they've been suffering for 5, 10. I had one

01:24:50.480 patient who suffered for 30 years taking, oh gosh, metoprolol. He couldn't change his supplement

01:24:56.660 because something having to do with the vocal cords. He was a singer. Some of the other blood

01:25:00.440 pressure medications affect that. I didn't fully understand, but he would not change his blood

01:25:04.720 pressure med. So that was all that he needed. But do I think that the average healthy adult should be

01:25:10.700 taking melatonin? No, no. Now, there's probably some excellent data that you are much more aware of

01:25:17.080 than I am about how our melatonin secretion inhibition processes, whatnot, change as we age.

01:25:25.300 There may be some patients who benefit from taking melatonin, which is a hormone to induce sleep. But

01:25:31.040 remember, melatonin is like the guy at the start of the race. He's the guy with the gun. He fires the

01:25:36.260 gun. He doesn't have a car in the race. He's not helping you stay asleep. He's telling you when to

01:25:41.140 start the thing. So for a lot of adults, taking melatonin is really messing them up because they're

01:25:47.080 trying to go to sleep when their body isn't ready to go to sleep. They're forcing it to go to sleep.

01:25:50.460 Then they wake up in the middle of the night and they wonder why. And it's because, oh, you went to

01:25:53.960 sleep at the wrong time and your body's all kinds of confused. Yeah, interesting. So I really try and

01:25:58.600 take people off of these things so I can see what's really going on. And then if there's something

01:26:03.320 going on that looks like it might necessitate melatonin, I tag in one of my physician friends and talk

01:26:08.740 about it. So what about sleep medications? And let's talk about as many as you want. We can talk

01:26:16.460 about benzos. We can talk about trazodone. We can talk about Ambien. We can talk about the erexin-based

01:26:21.200 drugs. How many of the patients who come to see you are regularly taking one of these prescription-based

01:26:28.560 drugs for sleep? So a lot of people take over-the-counter drugs and prescription drugs for

01:26:35.420 sleep. And there was a huge shift that I noticed when COVID started. And there was a ban on flying

01:26:43.680 to different countries, Mexico and Europe. And it turns out there are a lot of people who will fly

01:26:48.880 to Mexico to get their Ambien and fly to Europe to get various sleep drugs that you can't necessarily

01:26:54.640 get here. All of a sudden, I saw a wave of patients dealing with withdrawal in the early months of the

01:27:01.260 pandemic because they couldn't go get more of their drugs. Oh my gosh, I'm screwed. What am I doing now? 0.98

01:27:05.160 How do I cope with this?

01:27:06.520 Why couldn't they get them here in that situation?

01:27:08.820 Ambien's prescription only.

01:27:10.220 They couldn't get a prescription while they were here?

01:27:12.140 Yes, because they were taking so much that they were well beyond what they could convince someone

01:27:17.780 to prescribe them. A lot of my patients are physicians. And a lot of physicians are pretty

01:27:22.820 reticent to go above FDA-recommended doses when it comes to Ambien. A lot of people don't realize

01:27:28.880 that I believe, I believe this is the case, Ambien is still the only drug that is differentially

01:27:34.420 prescribed to men and women. According to the FDA, the starting dose for women should be five

01:27:38.800 milligrams. Starting dose for men is five to ten for instant release. And then for extended release,

01:27:43.600 I believe, for women, it's 6.25. And then for men, it's 6.25 all the way to 12.5 because women 0.83

01:27:48.600 metabolize it less efficiently. So the people who I've seen, I've seen people taking 30 milligrams,

01:27:53.880 big doses. And gosh, this is a very loaded question. But there's a lot of patients who come

01:27:58.460 to me who will say, I've read something in the news. It turns out this medication I'm taking for

01:28:03.300 my sleep is bad for my brain. They're like, oh, you saw that, huh? And I want to quit immediately.

01:28:07.920 I need to quit by next week. Oh, okay. And you've been taking it for how long? Oh, 20 years. Okay,

01:28:13.560 right. So that never works. That never works. I wouldn't say that I have any sort of extreme

01:28:19.380 expertise in the different classes of sleep meds. But what I can tell you is the ones that people

01:28:24.460 most often are coming to me saying, I want to quit this. I hate being dependent on this. What

01:28:29.620 do I do? These are going to be the benzos, which doctors are becoming less and less hip to prescribing

01:28:34.840 for sleep. Ambien, the Sonata-Lanesta stuff. And then over-the-counter stuff like Benadryl,

01:28:42.120 maybe your occasional Doxepin. And then people are often prescribed Remeron for sleep and they run

01:28:47.640 into metabolic issues and they need to get off of it. So I think that covers the broadest swaths

01:28:53.680 that I see of things people wanting to quit. Now, the QVIC, it's some of these newer ones.

01:28:57.580 I don't see them as much yet. I'm sure it's coming. And what about Trazodone?

01:29:01.660 Trazodone is the one that I'm the least concerned about for a couple of reasons. I've not seen

01:29:06.800 compelling data that it negatively impacts the electrical quality of your sleep.

01:29:11.300 No. In fact, I've seen data that it does the opposite, that it's slightly positive.

01:29:14.780 Great. I'm looking for what's negative. I don't know if the study that you're speaking

01:29:18.940 of was statistically powered, if the primary outcome was improvements in sleep or decrements

01:29:24.260 in sleep. Now I'm trying to remember something that I wrote probably three years ago. I believe

01:29:29.640 the study looked at sleep duration as the primary outcome and a secondary outcome may have been

01:29:35.140 staging. Yeah. So I don't think it was powered for that, but I think they incidentally did find

01:29:39.100 an improvement. I think you've talked about extensively, like it's important to think about what was

01:29:42.840 a steady power to look at and all that. But I'm not the most worried about that also because

01:29:46.840 it's an antidepressant drug. And if someone's taking it and it is helping with their depression

01:29:52.720 and I take them off of it in the name of trying to help with their sleep, I have created a different

01:29:58.200 problem. Although the dose people take it, it tends to not have that effect. I mean, most people are

01:30:03.920 typically taking it at 25, 50, typically no more than a hundred, maybe at a hundred, depending on the

01:30:10.100 size of an individual. They're getting some of that benefit. I often see a hundred for sleep.

01:30:13.660 Yeah. And so for me, I'm thinking, Ooh, I don't know if that's just for sleep. And then I'm also,

01:30:18.180 if I see 50 even, and then I see another antidepressant, I think, Ooh, these could be

01:30:21.580 working together. You actually also have a diagnosis of depression. We need to think about

01:30:25.380 this carefully. If folks are showing up on 20 milligrams of Valium or Xanax or pick your favorite

01:30:33.020 benzo, do you have them go and do a taper detox with their physician before they come into the

01:30:40.020 CBTI program? No, I have them do it with me. So you will manage the medical withdrawal on that?

01:30:47.020 Let me explain exactly what I do. Scope of practice. So first of all, I always work with

01:30:51.760 the prescribing physician. I never start without making sure the prescribing physician is explicitly

01:30:56.980 aware of what I want to do. I talk with them. And this has to be one of your colleagues at UCSF

01:31:01.860 or whoever they're prescribing physician is. It's whoever is prescribing the medication to

01:31:04.880 this person. We now share a patient and have an obligation to. Every single time I have done this,

01:31:10.440 the physician has been in support of getting their patient off of benzos, except for one time,

01:31:16.580 which isn't even worth really getting into. But the point is, it's an overwhelming amount of support.

01:31:20.960 Yeah, I can imagine. Most of the time, these physicians have already tried to get their

01:31:24.280 patients to quit and to reduce. But in my opinion, they've tried to do it way, way, way too quickly.

01:31:31.860 And that's because there are physiological dependencies on these drugs and psychological

01:31:37.800 dependencies on these drugs. And we have to attend to both of them while we're doing this

01:31:42.520 taper process, or it's going to be a botch and the patient's going to relapse and we're going to be

01:31:46.920 back at square one or square negative one, unfortunately. So here's what I do. Let's take

01:31:53.040 a boring example. Pick your favorite benzo, favorite dose.

01:31:57.080 I don't particularly like them myself, but let's take Valium.

01:31:59.880 Valium, okay.

01:32:00.360 Long acting.

01:32:01.020 10 milligram?

01:32:01.660 Yeah, sure.

01:32:02.400 So let's say we've got a patient on Valium. They've tried to quit. They've occasionally abused.

01:32:07.420 They've gone up. They've split an extra in half. They've gone up to 15 sometimes, whatnot.

01:32:11.520 The first thing that I do with a patient is I say, all right, actually, for sake of better

01:32:15.860 example for sleep, can we do Ambien because it's a little more fun?

01:32:19.220 10 of Ambien.

01:32:20.240 Let's say 10 of Ambien every night at the beginning of the night. And then let's say sometimes they're

01:32:23.440 actually taking a fiver in the middle of the night when they wake up because they want

01:32:26.960 to get back to sleep.

01:32:28.000 I like the party dose.

01:32:29.080 Right. So let's say some nights it's 15, some nights it's 10. What do we do? So the first

01:32:33.940 thing I do is I take out the middle of the night dosing and I say, we're done with that.

01:32:37.200 You're limited to 10 a night and you got to take it before bed.

01:32:40.100 Yes. You have to take it before bed. You have to take it the same time every night. But if

01:32:42.960 you're going 15, five nights a week and 10, two nights a week, I'm going to make it a

01:32:46.280 12.5 before bed. Let's be generous. Start higher. So we'll agree on a dose that the

01:32:51.300 patient will take and it agreed upon time. So the prescriber and I agree on this. We're

01:32:54.360 like, okay, same page. This is what the patient's going to do. And they start doing that. Generally

01:32:58.240 the patient's like, no, no, no, I'm trying to quit. I don't want to take more. And I

01:33:01.080 say, no, no, before you quit, it must be stable. You cannot quit from a point of instability.

01:33:06.320 It will not work. I've seen people try and people say, oh, I want to quit. I want to go

01:33:11.080 from 10 to five. No, that's not how we roll. So let's say this patient's taking 12 and a

01:33:16.020 half and they're like, okay, I want to cut down. I'm like, all right. Okay. So how does going

01:33:20.420 from 12 and a half to five sound? And they say, oh my gosh, that's going to be really

01:33:24.180 scary. I don't think I can handle that. And what I actually have them do is I rate it on

01:33:28.080 a scale from one to 10 with 10 being the most anxiety provoking upsetting thing. And one

01:33:34.480 being not upsetting at all. This is called a subjective units of distress scale, suds, have

01:33:39.920 them suds it. So I say, okay, going from 12.5 to five, that sounds really terrifying now

01:33:45.020 because they've just done a week where they're consistent with 12.5 at the beginning of the

01:33:48.800 night. They've had no middle of the night crutch and they're not feeling great about that.

01:33:52.280 So then I say, okay, so how about going from 12 to 10? And they say, oh, not as bad, but

01:33:57.700 that's still like a six on my scale. And I do this process all the way until I get them

01:34:01.780 to a one. And I'll say, all right, so next week we're going from 12.5 to 12.

01:34:07.620 How are you even making that increment?

01:34:10.300 I can tell you exactly how we're doing that. We're going on the internet and we are buying

01:34:14.000 something called a gem scale. Now you and I both know that people who are wealthy enough

01:34:17.320 to have gems worth measuring aren't measuring their own. So the people who are buying those

01:34:20.760 scales are using them for other things. And so what my patients end up doing is they buy

01:34:24.440 these scales and they get a full-blown breaking bad setup in their bathroom. Like we're cutting 0.98

01:34:28.600 pills, we're weighing pills, we're doing math because the pill actually weighs more than

01:34:31.980 12 and a half because it's got binders and fillers. What percent do we need? And we kind

01:34:35.440 of make it fun. And they end up having to put the crumbly pill into a shot glass with some

01:34:39.580 water. We shoot it and the whole thing. We make a whole production out of it. But the point

01:34:42.760 just is. They're going from 12.5 to 12. And we do that for like three weeks. If they've

01:34:47.320 been on it for years, we're looking at three weeks. And the first couple of nights are

01:34:50.320 a little rough. There's a little stress.

01:34:51.840 If they're only doing a seven-week program with you...

01:34:54.560 Oh, no, no. This taper program we make and it will last a long time.

01:34:57.300 Before they enter the program.

01:34:59.420 No.

01:34:59.540 This is a separate issue.

01:35:00.320 This is a separate issue. And we do this after they've finished CBTI treatment. During CBTI

01:35:03.700 treatment, I stabilize them on their meds. And we just get it so they're not erratically

01:35:07.440 taking five different cocktails of things. When people come in to see me for treatment,

01:35:11.880 they'll say, oh, yeah. So Mondays, I do Ambien. Tuesdays, I do Trazodone. Wednesdays,

01:35:16.060 it's Benadryl. Because they have it in their head.

01:35:18.360 Why?

01:35:18.680 Because they think they don't want to get dependent on one. So they think that by doing

01:35:22.260 a rotating merry-go-round of these things that it's...

01:35:25.260 That's actually smart. I would have never even thought of that.

01:35:27.920 Oh, yeah.

01:35:28.760 Sinister.

01:35:29.380 It's working great.

01:35:30.140 Yeah.

01:35:30.480 So I generally work with the doctor and we decide, okay, here's the one you're going

01:35:33.260 to do. Here's the dose you're going to do. And you're going to be consistent

01:35:35.760 with this.

01:35:36.160 So vodka on Monday and then tequila on Tuesday, red wine on Wednesday, and then Chardonnay

01:35:44.180 Thursday. And this way, I'll never become an alcoholic.

01:35:46.480 Oh, figured it out, Peter. In short, I have people really stabilized during CBT. And sometimes

01:35:51.440 during week four, week three, four, they're ready to start this. And we start them on this

01:35:55.400 program. And once I have them in this way, they're able to do this on their own. So they'll

01:35:59.980 go from 12 to 12.5 for like three weeks and they'll be keeping sleep diaries. So they'll

01:36:03.720 see, oh, okay. And we'll get some confidence. And then they'll email me, you know, they'll

01:36:08.280 message me and they'll say, okay, so now what? And I'll say, all right, well, how are you

01:36:11.320 feeling? Like, what if we go down to 11.5? How does that sound? Sometimes that'll be too

01:36:15.400 scary. For some reason, crossing the five threshold is really scary. So we go from five

01:36:19.360 to 4.75 sometimes.

01:36:21.200 And just to be clear, this is psychological. There can't possibly be a physiologic difference

01:36:27.260 between four, 4.75 and five milligrams of Ambien. In fact, the medicine isn't even

01:36:32.600 homogeneously enough compounded within the capsule. So as long as everybody understands

01:36:38.400 that.

01:36:38.800 Probably not. But think some for tablets and I don't know about the requirements.

01:36:41.440 Yeah. Cause the binder and the active ingredient.

01:36:43.620 Yeah. And generic has to be 85% similar to the real deal. So there's all kinds of mess ups

01:36:47.620 here. Remember how I said there's a psychological part and the physiological part. This is a psychological

01:36:51.400 part that I think it's left out of a lot of the, oh, just cut it in half to start

01:36:55.760 decreasing your dose aspect, which is dealing with, okay, what can we physiologically do?

01:37:00.220 I'm talking about what can we psychologically do?

01:37:02.520 And do you think that this methodology of the incredibly slow taper with incredibly high

01:37:09.060 precision, do you think it works for opioids?

01:37:11.780 So I don't think I've ever seen that in my clinic. It's just not something I've had to

01:37:19.460 deal with.

01:37:19.740 Oh, I don't mean for sleep. I just mean in general. Or is the problem so grave that you have to be

01:37:24.720 a little more aggressive and switch them to a completely different class of drugs?

01:37:28.780 That's so far outside my area.

01:37:30.280 Okay, got it.

01:37:30.880 I can't speak to it. But what I can tell you is just that doing this method with the sleep

01:37:36.880 drugs slowly over time, people get more confidence and they can make larger reductions at a time.

01:37:42.360 And then importantly, Peter, when someone is tapering and something crazy in their life

01:37:46.420 happens, like a child gets diagnosed with cancer or something terrible happens, we stop the

01:37:51.820 taper and we stay where we're at. So your taper might look like this, but there's not a huge rush

01:37:57.440 to get off this thing. You've been on it for 20 years. Better to stably get off it. I always joke

01:38:01.980 with people like if you can lose 10 pounds in two days, how quickly do you think you can gain two

01:38:05.400 pounds? So when it comes to quitting these meds, slow and steady wins the race. Having people gain

01:38:10.360 the confidence that they can do it is such a big part of it. I know that one of the critiques I've

01:38:14.840 gotten from folks is like, well, wait a minute, some of these pills have coatings and da, da, da, da,

01:38:18.800 but it's a lot of it is psychological. So this works really well for a medication taper and people

01:38:25.900 can do it themselves. There's no like magic. I mean, I think we've covered a lot on CBTI and

01:38:33.920 let's now revisit the idea of the types of things that people should be on the lookout for that need

01:38:41.120 to be addressed first. So we haven't talked about sleep apnea. We haven't talked about restless leg

01:38:47.280 syndrome. What are the other things where you just want to have some sort of sign off that says,

01:38:54.540 hey, we've also confirmed that these things aren't present or what gets your suspicion roused that

01:38:59.640 says, hey, we got to look at something else because you're presumably not doing polysomnography on

01:39:04.600 everybody on the way in. How do you navigate that?

01:39:08.380 So I have the wonderful luxury of being able to look in people's charts and see who referred them to

01:39:13.580 me and why they are referred.

01:39:14.560 They can't be self-referred?

01:39:16.100 Everybody needs a referral of some kind and it can be from anybody, but any referral. A lot of my

01:39:20.520 referrals come from sleep disorder centers because they've already done all that work up and they

01:39:24.740 say, all right, it's none of these things. So here you go. If a patient tells me, I always ask a patient

01:39:30.380 like, oh, has your partner or anybody you've slept with ever told you that you snore or that you sound

01:39:34.980 like you're gasping for air in the middle of the night? I do have a bunch of those types of screening

01:39:38.560 questions. And I aggressively refer to colleagues with expertise in those areas before treatment

01:39:44.520 with me. A lot of times people have a CPAP and they say, oh, I don't really use it. I'm not sure

01:39:49.760 about that. And I say, well, I'm here to tell you that you should be sure about it and that you should

01:39:53.760 use it every single night. It doesn't fit. Cool. I'm going to make a call because we're going to get

01:39:58.300 it to fit. There's a different mask you can probably get. There's all these different issues that we can

01:40:02.320 tackle. It just sometimes takes making a phone call. And unfortunately, a lot of patients don't

01:40:08.940 have great follow through for their CPAP in terms of help using it and figuring it out. So sometimes

01:40:15.040 I have to just make that extra connection. The one thing I think I want to make sure that we put a bow

01:40:20.320 on also is this obsession with bedtime. I can make you wake up at any time by setting a very loud

01:40:28.240 alarm. I can anchor you into your day with a wake up time and that can be consistent every single

01:40:33.600 day. I cannot wave a magic wand and make you fall asleep at the same time every day. So when people

01:40:38.860 think, all right, I'm going to get a handle on my sleep, I'm going to go to bed at the same time

01:40:41.960 every night. No, no, no, no. Wake up at the same time every day. That's a much more important first

01:40:47.240 step. And if you're waking up at different times throughout the week, that is the first thing to fix.

01:40:53.740 Yeah. What degree of social jet lag do you tolerate? Just for folks listening, social

01:40:59.120 jet lag, meaning the experience of changing your sleep time during weekends, which could be akin

01:41:05.160 to jet lag if it differs by hours. In an ideal world, there would be zero, right? In an ideal

01:41:09.780 world, I wake up at seven o'clock in the morning every single day of the week. For an individual who

01:41:15.500 says, oh, but God, on the weekends, it's just so nice to not have to get up at seven. Do you say,

01:41:21.140 look, give yourself a 30 minute grace and that would still be considered perfectly healthy?

01:41:25.220 So during treatment, I tell people you need to wake up at the same time every day that ends in

01:41:29.440 DIY. So that means Monday, Saturday, Sunday. Yeah. That's all of them.

01:41:33.920 Yeah. That's during treatment. I have to check.

01:41:35.640 Yeah. Good. There is no room for negotiation during treatment. We're in the dictatorship.

01:41:40.840 But what I do teach people at the end of treatment is how to cope with the fact that life is going to

01:41:46.700 happen when treatment ends. It happens during treatment, but there's a lot that pauses during

01:41:50.620 treatment, to be honest. But let's say that you've got a major event on a Friday night. You're going

01:41:54.600 to a concert. Yes.

01:41:55.960 And you're going to be out way later than usual. What I tell people is, look, you need to pick

01:41:59.680 which day of that weekend do you want to suffer and which day do you want to feel good? Because

01:42:03.940 we can sleep in one day. You cannot sleep in two days in a row. That's going to take you off the

01:42:09.000 wagon. We're not doing it. So let's say Friday night you go to a concert and you want to feel good

01:42:13.320 on Saturday. Cool. Sleep in on Saturday. Sleep in by an hour on Saturday. Okay, fine. Go to bed on

01:42:19.380 Saturday night when you get tired. Spoiler alert, you're probably going to get tired past your usual

01:42:23.240 bedtime because you slept in. But then Sunday you have to wake up at your wake time and Sunday

01:42:27.440 you're going to suffer. But let's say you want to feel good Sunday. That means on Saturday you're

01:42:31.600 going to wake up at your usual time. Saturday is going to be a struggle bus, but you'll make it to

01:42:35.000 your bedtime and you'll go to bed at your bedtime. Then you'll feel better Sunday. So you just have

01:42:38.380 to choose. When do I want to do the suffering? The immediate day after?

01:42:41.040 So basically force the suffering into the narrowest place possible.

01:42:45.000 But you can choose because sometimes people don't want the suffering to be the next day.

01:42:48.380 They want it to be the day after. So you get to choose that. But I tell people, look,

01:42:51.640 don't sleep in more than one day in a row. It's going to mess you up. You're not really

01:42:55.000 getting quality sleep when you sleep in past your wake time. When it's been a pattern for

01:42:58.840 a long time, when you sleep in past your wake time, you're probably getting some extra stage

01:43:02.620 two sleep. You're not getting more deep sleep. That's for sure.

01:43:06.240 We're recording this on a Tuesday. Sunday, two days ago, I was flying back to Austin from LA

01:43:12.420 and the flight got delayed over and over and over and over and over again for reasons that are 0.90

01:43:21.260 so asinine they're not even worth describing. And then we finally got on the plane and taxied and

01:43:28.100 then the water was leaking out of the coffee machine. So we had to go back to get another

01:43:33.460 plane. I'm not making this up, but I can, I can only tell you how ridiculous this is. 0.85

01:43:39.520 The punchline of the story is we didn't get home till two in the morning, which is long past my

01:43:43.380 bedtime. So what would your strategy have been getting home at two in the morning prior to

01:43:50.900 Monday, a work day where you do have some leeway? I don't have to get up at six, which would be my

01:43:55.800 normal wake up time. Would you have said, just get up at six, stick with it and make it up by going

01:44:01.840 to bed a lot earlier Monday night? Or would you say sleep until eight? You'll probably feel better

01:44:07.220 than if you woke up at six. How would you handle that situation?

01:44:10.500 I'll say which day is more important for you to feel good on Monday or Tuesday.

01:44:13.660 Let's say I said Tuesday because I'm sitting down with you.

01:44:16.200 Well, then I would say probably try and not to sleep in too much so that you can go to bed at

01:44:20.760 your regular wake time on Monday. If you sleep in horribly on Monday morning, you're going to stay

01:44:25.280 up later Monday night and then you'll get up at your wake time today. You will have had shorter sleep

01:44:30.120 for today. It will have rolled all the way over.

01:44:32.320 That's actually what I did. So having not thought about this, I just slept until I think my wife

01:44:38.200 tried to get me out of bed at seven and I said, can you let me sleep till eight? So I didn't get

01:44:41.960 up till eight. But last night, you're right. I had a very hard time going to bed. It was like 11 o'clock

01:44:47.260 and I was still up meandering around.

01:44:49.400 Yeah. You just have to very carefully decide which day do you want to prioritize and that's how you make

01:44:53.540 that decision. So you have more control than you think is what's beautiful about that. And I just

01:45:00.000 remind people, you can never really make up for lost sleep that easily because sleep architecture

01:45:06.460 really matters. And when you're sleeping in, you're not getting more deep sleep. You're getting some

01:45:11.040 more maybe light sleep. And at worst, that's robbing you of maybe some of the deep sleep you

01:45:15.800 would have gotten the following night because you're on a circadian plan here. And we didn't

01:45:20.520 really talk about process S and process C. Maybe I can just briefly tell you what those two things

01:45:25.080 would be. Absolutely. Okay. So process S is sleep homeostasis. And that's this sleep pressure idea

01:45:31.420 that we are working on. Every day we build up sleep pressure until it's bedtime and then we

01:45:36.340 capitulate, we fall asleep. And then our sleep pressure drains throughout the night while we

01:45:40.360 sleep. And then in the morning, we build it up again the next day. And this is just adenosine

01:45:45.200 building up? Yeah. Think about it that way. And that's also why caffeine is problematic. So

01:45:49.300 caffeine blocks adenosine receptors. The caffeine crash when it wears off and then all the adenosine

01:45:54.360 floods the receptors and we experience that, oh, sleepiness. And that's why taking a nap is so

01:45:59.200 difficult because what napping does is it basically kind of deflates your balloon a little bit of your

01:46:04.080 sleep pressure. It robs you of some of that sleep pressure. So by the time you get around to your

01:46:07.720 normal bedtime, if you've taken a long nap, you've reduced how much sleep pressure you would ordinarily

01:46:12.240 have at that time. That's why napping can be dangerous. And then we have process C, which is the

01:46:16.820 circadian process. And that just marches on. It doesn't really care about your sleep pressure or how much

01:46:22.740 you've slept. I'm sure you've pulled an all-nighter, but when people pull all-nighters,

01:46:27.060 what they often will notice... How many all-nighters do you think I've pulled in my life?

01:46:30.220 Oh, hundreds. Yeah. I would need scientific notation to count them. It's so pathetic.

01:46:34.540 Yeah. It's a lot. The thing to note about that is that you're sleepy during the night when you're 1.00

01:46:39.180 pulling the all-nighter, but in the morning, you kind of have a burst of energy. And that's the

01:46:43.060 circadian part speaking up. And when we look at the sine curve of it, that's because your

01:46:48.300 temperature is coming back up. Your adrenal glands still make cortisol.

01:46:51.760 Right. So your circadian process doesn't really care much about the sleep pressure. It says,

01:46:56.740 oh, okay. If you line these two things up on a graph, they look like they talk to each other. They

01:47:00.200 don't. But these two processes really determine a whole lot about your sleep. And there are things

01:47:05.880 that we can do to support each of them. But CBTI really focuses on the sleep pressure aspect

01:47:11.780 by regularizing people's schedules. And then it supports the circadian aspect by some of these

01:47:19.560 little things that I talked about that I don't even know if you can't really call them standard

01:47:24.020 CBTI, like standardizing what time people are taking their medications, for example, doing things

01:47:29.340 that we know support circadian biology, not eating right before bed. In my perfect world, all of these

01:47:34.420 different Zykebers, which are timekeepers during the day, would be consistent from day to day. 0.71

01:47:39.040 You eat lunch every day at the same time, breakfast every day at the same time.

01:47:41.780 All of these things would support your circadian biology and probably improve your sleep.

01:47:46.640 Any rules about exercising? Do you have people that are showing up and you're going through your

01:47:51.780 intake and you realize based on their schedule, based on work, based on kids or other obligations,

01:47:59.240 the only time they're going to get their workout in is in the evening? And is that counterproductive?

01:48:04.520 Put it this way. If it is an issue, how do you adjust?

01:48:08.420 This is a really nuanced issue. I once had a patient who, a long time,

01:48:11.780 ago, who said, oh yeah, I take the 10 o'clock spin class in the Castro. I was like, oh, okay,

01:48:16.020 moving on. I assumed it was 10 a.m. I was wrong. And I learned that the next week when we were talking

01:48:20.780 about other things. But for some people, exercise at night is fine. For other people, it's super

01:48:27.940 stimulating. And it also really depends on what kind of exercise we're talking about.

01:48:31.740 I think one moderating variable here is also going to be level of fitness. If you take a person who's

01:48:37.380 extraordinarily cardiovascularly unfit and you put them in a spin class in the evening,

01:48:41.820 do you know it could take their heart rate quite a while to recover? You could probably provide me a

01:48:46.320 lot more information about that than I know. And what we know in order to fall asleep is that your

01:48:49.880 heart rate should be lowering. So if your heart rate is still elevated from a whole bunch of exercise

01:48:53.880 you just did, that's not going to help you. But if you're super fit and your heart rate recovers

01:48:58.160 really quickly, it might affect you less. So this matters. I think there was, for a long time,

01:49:03.940 this general suggestion to not exercise close to bedtime. I still think for the most part it applies.

01:49:09.700 But I think that it's important to think about what kind of exercise you're doing. If someone

01:49:13.260 tells me, oh, I'm going to a yoga class, I find this really relaxing and calming. It's a form of

01:49:17.560 stretching for me. Fine. Okay. This is the only time of day you can do it. You got a job, you got kids,

01:49:22.520 whatever. I'm not going to tell you to not go just because of the time of day that it is or

01:49:26.740 weightlifting or whatnot. But if you want to go to a HIIT class, I'm going to say, well,

01:49:30.580 can we not do it at 10 o'clock at night? I think it would really be great if we could move it earlier.

01:49:35.340 We try to do that. I do tell people, I have some patients who've come in and said, oh,

01:49:39.980 my body wants to wake up every day at seven o'clock, but I really want to go to this 5 a.m. spin class

01:49:45.580 every day. I'm like, okay, well, I understand. Exercise is very important. I'm a believer. Also,

01:49:51.760 your circadian biology has you going to bed at 11 and getting up at 7. And even if you're getting

01:49:58.420 up at 4.45 to get on your home spin bike to do this thing with this group, your body doesn't want

01:50:03.580 to go to bed until 11. And we're not going to be able to change that. So you're going to have to

01:50:07.180 make that cost-benefit analysis with, do you want to lose that much sleep to do that thing?

01:50:12.880 Yeah. My brother-in-law plays in a men's hockey league and you only get ice time late at night.

01:50:19.160 So I think they literally play Sundays at 11 p.m. or something. And he's always fried Monday because

01:50:25.760 pretty hard to play a game of ice hockey and then fall asleep after that. So I want to understand

01:50:32.860 more what the spectrum of CBTI looks like. I mean, your process sounds super dialed in,

01:50:40.700 but also it's quite bespoke. You've brought a lot of your own expertise to it and you've created a

01:50:46.780 system where you've got, we're going to do the intake. We're going to do these five sessions,

01:50:50.740 which I think are group sessions, the way you've described them. Then we do kind of the exit.

01:50:54.920 You bring so much rigor to it. Is that the way it is always done? Or are there CBTI therapists out 0.98

01:51:00.500 there who function like psychotherapists and they say, yeah, we're just going to engage with each other

01:51:05.840 until your problem is fixed. And we'll see each other once a week or maybe once every other week.

01:51:11.360 Everything you're doing sounds formulaic. And I say that not in a bad way. I think that's

01:51:15.280 probably a big part of its efficacy. Is that something people should expect

01:51:18.860 when they are going to a CBTI therapist? It's something people should ask for

01:51:22.980 before people start treatment. They fill out the Pittsburgh sleep quality index and they fill out

01:51:27.100 the insomnia severity index. And I tell them, look, we're going to fill this out when you're done

01:51:30.020 with treatment too. And we're going to see how this worked for you. We're going to actually take

01:51:34.100 measurements. What type of scores are you getting on the PSQI? I mean, it ranges from zero to 21.

01:51:39.680 I get all the way to 21. Yeah. And below five is considered no clinically significant sleep

01:51:45.760 problems. I relax that to six or seven, because if you have a prostate or if you're going through

01:51:48.980 menopause and have hot flashes, you're going to be elevated on that scale by no fault of your own

01:51:53.500 or your sleep's fault. And the insomnia severity index, I mean, yeah, we see all the way up to what

01:51:59.000 was it? 22, 23, something like that. So I see all the way up to the most severe levels in both of

01:52:04.800 these scales commonly. And the average point drops are huge in clinic. So I don't know if it was like

01:52:11.620 10 points in the insomnia severity index. Like it's very high, very responsive to this treatment.

01:52:16.580 But back to your original question is, I wish everybody did it by the book. I think there's a lot

01:52:22.020 of practitioners out there who want to do this by the book. I have a luxury to do it by the book

01:52:27.280 because I'm able to enlist help from my team to help me process sleep diaries every week and do

01:52:37.440 probably two hours of work outside of my clinic of prep for me. So they feed me my stuff that's been

01:52:45.120 built into the systems that I have. I'm prepping half an hour before clinic. I see everybody for an

01:52:50.220 hour and a half. And then I've got my notes, my templates and things. But I think that it is very

01:52:54.180 difficult to do CBTI when you're not seeing patients weekly because I look at weekly sleep

01:52:57.440 diaries and I make changes based on that. So when you find a CBTI therapist, I would say ask if you

01:53:02.200 can set up a time in the future with that therapist and see them weekly for a set of whatever, five to

01:53:08.160 eight weeks and put it on the calendar that way with them. If they say, oh, they don't have bandwidth

01:53:12.120 to do that for another month, say, okay, cool. I'll wait and then get on every week. And a lot of

01:53:16.780 practitioners also aren't going to necessarily score your sleep diaries for you. You can score them

01:53:21.220 yourself if you want to. I mean, it's not that difficult. If you just Google online, you can find

01:53:26.780 a sleep diary calculator and it's very easy to do the math yourself. There's a book that I really like

01:53:32.600 called Quiet Your Mind and Get to Sleep, written by Rachel Manber and Colleen Carney and Dick Bootsen

01:53:37.700 wrote the foreword. It's kind of a guided way through the treatment and you can use that workbook

01:53:42.760 yourself to do it. And you could also use that workbook when you're working with a provider.

01:53:47.320 But I think there are a lot of CBTI providers out there who can see you weekly and can do this.

01:53:53.700 You'll probably just have to do your back-end work with your calculations because they don't

01:53:57.420 have the billable time for that. They'll be busy during the sessions trying to teach you things.

01:54:01.460 I would also note that between my sessions with my patients, I make them watch very annoying videos

01:54:07.180 that I've made of myself giving a lecture about all of the science because I've found that if you

01:54:11.040 explain the science to patients, you'll get the adherence. Here's why we're going to do this.

01:54:16.020 People think, wait, I have problems sleeping. Now you're going to make me not go to bed?

01:54:19.660 This is not what I'm going for. And I have to explain to them, okay, here's why we do this

01:54:23.960 because this will ultimately get you where you want to go. But the principles of what I'm doing

01:54:29.020 are not at all bespoke. I'm doing the time in bed restriction, stimulus control, the cognitive

01:54:33.980 techniques, the relaxation techniques, and the sleep hygiene. Those are the five major components.

01:54:38.140 What is bespoke is the way that I set the wake time because that's not been standardized in

01:54:42.040 literature. The way I deal with standardizing medications, the way I deal with medication

01:54:46.320 tapers, some of the anxiety tools that I bring in like scheduled worry time, tracking due belief

01:54:51.800 during the day. I think that is actually pretty well incorporated into CBTI. But some of those

01:54:56.860 are a little bit more tilted toward my audience, which tends to be higher in anxiety. I build those

01:55:02.660 in. But otherwise, find someone on the website that we'll put in your show notes who knows how to do

01:55:08.600 CBTI. And I have a feeling you'll go far. The treatment works when you do it. And it doesn't

01:55:13.660 work when you don't do it, is what I tell all of my patients.

01:55:16.960 The book, Quiet Your Mind and Get to Sleep, you mentioned that that's something that people could

01:55:23.500 do in therapy. But you also mentioned that it's something people could just do on their own. So

01:55:27.320 if somebody is listening to this and they're thinking, A, I can't afford CBTI, or B, every practitioner

01:55:33.240 I've called said the soonest I can get in is nine months from now. If my choice is continue to

01:55:38.340 suffer or do something proactively, you would recommend that as a great strategy to start?

01:55:43.040 They can get that. They can try some of the apps. They're out there. I think they have less

01:55:47.400 traction currently. They're still in early stages, but try and help the rest app. But the Quiet Your

01:55:52.680 Mind and Get to Sleep book, people can do it by themselves. And I actually had a patient this

01:55:56.220 summer who was on the wait list. He got his intake and he was like, look, I'm fixed. I did the book.

01:56:01.380 It was awesome. But I still want to be in this group because I want to see what it's all about.

01:56:05.180 I'm not giving up my spot. And it was great having them in the group because they just

01:56:10.020 cheerlead everybody else and said, this works when you do it.

01:56:13.920 Any concerns with extreme temperature changes before bed? So people using sauna,

01:56:18.040 people using cold plunge, taking hot showers, hot baths. Subjectively, from my experience,

01:56:24.100 a sauna before bed really seems to help. Maybe it creates a bigger gradient in temperature drop as I

01:56:30.760 go from high body temp to low when I get into that super cold bed. But what is your experience

01:56:35.360 with that? And how do you manage it through the process?

01:56:37.400 Well, let's first take cold plunge before bed off the table. That's not a good idea because we know

01:56:41.860 that when you get in the cold plunge, it's immediately cold on your skin. But then once

01:56:45.120 you get out, your body is busy warming itself back up. And that's not what we want to be doing

01:56:48.520 right before bed. Then I'm going to come to the sauna part by saying that it's another

01:56:52.720 it depends. The outline that you just gave of the temperature gradient is beautiful. It makes a lot

01:56:56.800 of sense. For people who are naive to sauna, who get in a sauna and it increases their heart rate,

01:57:02.180 increasing your heart before bed. It might be the same problem as the exercise issue.

01:57:04.880 It might be the same problem as the exercise. Yeah, yeah, yeah. If they don't have the rapid

01:57:06.400 recovery. They don't have the rapid recovery. So that's something to learn about yourself.

01:57:10.540 And in fairness, I don't actually go straight from sauna to bed. It's usually sauna to 30 minutes

01:57:15.320 of Netflix to bed. That's going to be person to person. Another thing to keep in mind is that some

01:57:19.860 people who will go in the sauna at night then drink a whole bunch of water afterwards. Yes.

01:57:25.000 And then that ends up causing them to wake up more in the middle of the night. So it defeats the

01:57:28.560 purpose. That's a consideration also if that's an issue for you. But I would say just don't make it

01:57:34.220 too strenuous. Some people find that it's really helpful. I do best with it a few hours before bed

01:57:40.180 as opposed to right before bed. I think it's going to be a do what works situation because we don't have

01:57:45.900 enough data. But we are. I just started an NIH funded trial where we are looking at people who have

01:57:52.720 difficulty with falling asleep. And we are giving them whole body heating at home before bed. And

01:57:58.640 we're giving them cognitive behavioral therapy for insomnia through an app. And we're going to have

01:58:03.640 them do this whole home-based treatment that's going to combine a body-based heat treatment for 0.86

01:58:07.880 before bed with the CBTI treatment. And the idea here is what you explained, which is that by heating

01:58:14.120 you up right before bed, if we're heating up your hands and your feet, we're helping you actually

01:58:18.520 open the vasculature and dump some heat. It's going to create that gradient. And we think that

01:58:23.540 gradient might be important for people with the early kind of insomnia with falling asleep at the

01:58:27.120 start of the night. So we're going to see if that helps people using a sauna blanket type thing.

01:58:32.600 Ashley, someone listening to us for the last two and a half hours might assume that the only thing

01:58:36.740 you know about is CBTI. But it turns out that we've only scratched the surface of your area of

01:58:42.040 expertise. And there are other clinical areas that you have a lot of interest in that I think our

01:58:47.400 listeners would have interest in as well. The good news is we've, when I say we, I mean you,

01:58:52.700 you've delivered kind of a masterclass on a topic that I've wanted to know much more about. You know,

01:58:56.860 it's interesting. It's a bit of a black box because we send a number of our patients to CBTI therapy

01:59:01.900 around the country. And I would concur with what you said, which is based on their ability to comply,

01:59:09.640 the efficacy has been unparalleled, simply stated. As far as regular old doctors, I think we're

01:59:16.780 pretty good at helping people with sleep, given the nature of our practice and how much attention

01:59:21.100 we can pay. And therefore, I think by ourselves, we do pretty well. But when we can't, and we refer

01:59:27.180 to CBTI, I would have to think if there's been a patient who hasn't been helped. So that's great.

01:59:32.960 But truthfully, you've filled in all the gaps for me. And I think more importantly, I think you've

01:59:37.680 really helped listeners understand this. And I hope given people a lot of confidence,

01:59:43.320 because what I also take away from this is, there's really nobody who should be suffering

01:59:47.740 from insomnia. It's really not a necessary thing to suffer. There's things we might have to suffer

01:59:51.620 within life, but this isn't one. I think from very large percentage of the population, that's the

01:59:56.340 case. I'm afraid to say never, because you just never know. But there are so many, so many people,

02:00:01.840 countless, suffering from this who definitely don't need to be. The drawback is, we have kind of

02:00:08.060 run out of time to talk about a few other things that are really interesting, which is not uncommon

02:00:13.000 on this podcast, which means we're going to have to do a part two at some point to talk about eating

02:00:18.900 behaviors, thermal regulation, the impact that that has on depression or other things like that.

02:00:24.480 So apologies that maybe we spent more time on CBTI than we intended to. But as I kind of warned you

02:00:32.180 before we started, we love to just meander where the discussion goes. So is there anything else you

02:00:37.880 want to talk about on the CBTI front? I have a lot of notes on where I wanted to go, but I also

02:00:43.620 realized there's probably something I've forgotten, or there's an area you want to double click on?

02:00:48.420 No, I think it's important for people just to remember with this one that even if you don't

02:00:54.240 know what caused your insomnia, you can do this treatment. You don't have to have figured out,

02:01:00.680 oh, this is where it started, or this was the root of it all. You can start this treatment without

02:01:05.760 that knowledge, because this treatment is going to address what you're doing now that's actually

02:01:10.080 perpetuating the problem. And don't wait. There's never going to feel like a good time to do it.

02:01:16.000 Now is the best time. Your life is always going to be crazy. You're always going to have 50 more

02:01:21.180 things on the schedule than you wish you did. It's always going to be too busy. You're always

02:01:24.840 going to have events. Just do it now, because it's so difficult to live with insomnia and all of the

02:01:31.780 problems that it causes. I had this patient who was 87, who I finished treatment with last year,

02:01:37.660 and she just said, my, I wish I'd done this 40 years ago. Don't wait. Just do it. You won't regret

02:01:44.060 it. Are you under the impression that obviously people are waiting a long time to see you? That

02:01:49.700 probably speaks to how good you are and the resources that UCSF provides maybe in combination.

02:01:56.540 But if a person's listening to this and they're like, yeah, I wish I could work with Ashley,

02:02:00.940 but I just want to work with somebody. Do you have a sense of how large the CBTI community is

02:02:06.320 and how long a person should expect to wait? And do these therapists ever work via telemedicine

02:02:11.920 so that you have more opportunity to work with folks? I think that it is easier now to get than

02:02:18.000 ever, largely because of telemedicine. So I see patients all over California. I'm licensed in

02:02:22.900 California. Oh, so your eight people per bracket don't all physically come to San Francisco?

02:02:28.080 Nobody does. Great. I only see patients on Zoom now, which is actually a whole lot safer

02:02:33.120 because patients used to drive in, for example, from Fresno, they'd stay overnight in a hotel

02:02:36.720 in San Francisco. Yeah, they would just screw up the whole thing.

02:02:38.280 Screw up everything. Patients would have to fly in in some cases. It was nuts. But now I just see

02:02:43.140 people on Zoom, which is great. And there's a lot of versions of me who do that. By going to that

02:02:47.380 website, you'll be able to find a CBTI provider. And chances are they do telemedicine.

02:02:52.640 And there are just so many benefits. And one of the great pieces of news about that is that if

02:02:57.000 you live somewhere more rural now, it is instantly more accessible to you.

02:03:01.740 Although we have to hope that the providers, if you live in Iowa, we want to make sure they have

02:03:05.760 license in Iowa because you wouldn't be able to see somebody.

02:03:08.120 Right. They'll be licensed in Iowa. And there's also actually a growing and great thing called

02:03:14.060 PSYPACT, where I think 40 different states now are members of PSYPACT, where if you're licensed in

02:03:20.900 one state, you can be licensed in all of these states. Of course, California does not participate

02:03:24.220 because we're California. But it's getting easier and easier. And I do think that there's ways you

02:03:31.620 can start to do this on your own. If you get that book, if you try an app, you can actually do this.

02:03:36.800 You just have to remember that as special as each human is, you need to try and not feel like a

02:03:42.720 delicate flower with your insomnia. Just assume that you need to do this as it says you need to do it.

02:03:48.080 Well, Ashley, this was awesome. I learned a lot and I'm pretty sure everybody listening did. So

02:03:52.460 thanks for sharing and look forward to round two at some point next year.

02:03:56.060 Okay. Thanks.

02:03:57.800 Thank you for listening to this week's episode of The Drive. Head over to

02:04:01.920 peteratiyamd.com forward slash show notes. If you want to dig deeper into this episode,

02:04:08.720 you can also find me on YouTube, Instagram, and Twitter, all with the handle peteratiyamd.

02:04:14.040 You can also leave us review on Apple podcasts or whatever podcast player you use. This podcast is

02:04:20.980 for general informational purposes only and does not constitute the practice of medicine,

02:04:25.300 nursing, or other professional healthcare services, including the giving of medical advice.

02:04:30.340 No doctor patient relationship is formed. The use of this information and the materials linked to this

02:04:36.160 podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for

02:04:42.080 professional medical advice, diagnosis, or treatment. Users should not disregard or delay

02:04:47.240 in obtaining medical advice from any medical condition they have, and they should seek the

02:04:51.660 assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts

02:04:57.280 of interest very seriously. For all of my disclosures and the companies I invest in or advise,

02:05:02.620 please visit peteratiyamd.com forward slash about where I keep an up-to-date and active list

02:05:09.340 of all disclosures.

The Peter Attia Drive - March 24, 2025

#341 - Overcoming insomnia： improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia ｜ Ashley Mason, Ph.D.

Episode Stats

Summary

Transcript