#512 Sleep Optimization and CBT for Insomnia with Ashley E. Mason, PhD

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Furthermore, the views and statements expressed on this podcast are solely those of those that should not be interpreted to reflect official policy or position of any entity, aside from possibly casualty or more harmful as affiliate outreach programs. If indeed, there are any. In fact, there are none. Pretty much, we are responsible if you screw up. You should always do your own homework and let us know when we're going. Welcome back to the Curbsiders. I'm Dr. Matthew Frank-Watto, here with my great friend and America's primary care physician, Dr. Paul Nelson-Williams. Hi, Paul. Hey, Matt. How are you? I'm doing well, Paul. This is a topic near and dear to my heart. This is, we are talking about sleep and the ins and outs of CBT for insomnia with a great guest, Dr. Ashley Mason. Paul, before we introduce our co-host and our guest a little further, what is it that we do on Curbsiders? Why are we here? Matt, I'm so glad you asked. We are here because we are the internal medicine podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. It is almost 11 o'clock at night where we're at, which is ironic because we were talking about sleep tonight, Matt, and how to do it well. But before we get to that, I should say we are joined by the producer of this episode and also our co-host, Dr. Edison Yang. Eddie, how are you? I'm great. I'm glad to hear it. Matt, would you like to hear about our guest? I would love to hear about our guest. So we had the good fortune of speaking to the great Dr. Ashley Mason, Ph.D., an associate professor of psychiatry at the University of California in San Francisco, otherwise known as UCSF, Osher Medical Center for Integrative Health. As a researcher, she designs and tests interventions for depression, insomnia, and most recently, firefighter health. These interventions often involve thermal therapies and cognitive behavioral therapies, which we talk about in depth tonight. As a clinician, she provides CVTI, or cognitive behavioral therapy for insomnia, and group medical visits at the UCSF Osher Center. So she talks us through some of the two core tenets. We'll just sort of leave it as a teaser there of CBTI. We also talked a lot about sleep hygiene, her approach to how to address patients taking medications and supplements and substances to help with their sleep, and just general counseling for folks who have been struggling with insomnia. So it was a really high-yield episode for a problem that I think we hear a lot about in primary care. And a reminder that this and most episodes will be available for CME credit for all health professionals through vcuhealth at curbsiders.vcuhealth.org. All right, Ashley, we've been talking. You and I have been emailing for quite a while now. I'm glad that we're finally, we're here, we're doing this. This is a favorite topic of mine, sleep. But before we get to that, the audience wants to know what hobbies or interests do you have right now outside of your day job in medicine? Like, what are you into these days? Well, it's debatable if you can separate this out from my job, but I'm obsessed with saunas. I love going to the sauna. If you tell me, oh, there's this sauna out, I'm there. I'm ready to go. Let me just go get my stuff. We'll be there. Favorite weekend activity, favorite whenever I have time activity. I have so many questions, but I'm going to resist that a little bit. So you don't have a sauna in your house or you do have a sauna in your house? Because I know that's like a very popular thing these days. There's a sauna outside the house. It's like a barrel sauna. You throw wood in it. You light it on fire. You get in it. It's great. This is so outside my realm of experience. So I guess what is an ideal sauna experience looking like? So you have a weekend open. Someone tells you about the sauna. They're excited about it. This is the first time I've said the word sauna this many times ever in my entire lifetime. So what does the sauna date? Talk me through it because I have no context at all. So I want to share your enthusiasm. I am happy to spread the enthusiasm. There are so many sauna places to go, including ones that I've not gotten into yet, that I'm a little bit like, oh, I can't get a reservation there, in the Bay Area that I'm trying to go to. But if I have a free afternoon and you tell me that I can just go to a sauna and I can go in the city, I might go to like Alchemy Springs, which is one I love. It's like a giant 40-person sauna and they have cold plunges and you just go with your friends and you go in the sauna and you go in the cold plunge and your phone is like somewhere very far away. No one can reach you. There's no technology. You're just enjoying the heat and the cold. And then you go out for fabulous food afterward. And then you sleep like a baby, which is what we're here to talk about. And it's just lovely. So many people across so many cultures use heat therapies and heat modalities. I mean, everything from the sweat lodge to the Russian banya to the Turkish hamam there's the Korean kilns like there's there's heat practices across cultures probably for good reasons people have been enjoying them for hundreds and hundreds of years and it's just such an awesome way to spend an afternoon I fast I and I feel like just based on what I've heard from you on podcast I feel like body temperature stuff is just kind of a hobby horse years in the first place this actually does feel Kind of keeping that, I think more about it. You know, there's this like work-life balance thing that people talk about that I've heard of it, but it makes no sense to me. I don't know what that really means. Or like work-life separation. I'm like, what are we talking about here? Because research is me-search. Like I'm very interested in these things. And yeah, I study heat in the lab. I give people hyperthermia treatments in the lab, but also I go do hyperthermia in the wild. I just love all of it. All right. Well, let me ask my, thank you for all that. Let me ask our other usual favorite question. I would love to hear about any meaningful advice or feedback that you have either received or that you like to give as part of your career or training. My favorite piece of advice that I have to remind myself of almost daily in my job is that whenever you're presented with a situation, you have a choice. You can be right or you can be effective. And a lot of the times, being right is like scratching a mosquito bite. It feels so good for just like a moment and then you instantly regret it. Instantly regret it. The long-term outcomes of just being effective are better. And a nice example of this is when a mistake has been made. You have a choice. Do you need to identify who made the mistake? Make sure they know they made the mistake. and then resolve the mistake? Or can you skip the first two parts and just be like, all right, here's what we need to do now. Chances are your relationship with the person is going to be way better if you just skipped to here's what we need to do now. So whenever you're confronted with a situation where you have a moment, you can think, okay, I could be right or I could be effective. What do I want to do? that's my best advice for anyone in academic medicine that might save me a lot of headaches with my children at home i was thinking yeah it's also good with family members yeah well it's i feel like i've been thinking about something similar a lot to like i think public health messaging like i feel like it's applicable like across like huge domains there's plenty like you can apply it almost anywhere in medicine or in life so that is that is terrific yeah okay we have a lot of sleep to talk about eddie would you would you uh do us the honors of reading our case from cash slack we have miss ima up all night is a 62 year old female with obesity hypertension anxiety and chronic low back pain she describes herself as a lifelong bad sleeper she knows she should get eight to nine hours per night so she gets in bed around 9 p.m even though when she's not tired. She wakes up around 3 to 4 a.m. feeling hot or with her mind racing most nights and reads in bed or listens to an audiobook for 45 minutes or so until she falls back asleep again. And she wakes up around 6.15 a.m. and lingers in bed checking the news and email until around 7 a.m. She sleeps better if she has one to two glasses of wine in the evening or sometimes she takes an over-the-counter antihistamine or 10 milligrams of melatonin. She heard you run a sleep program and wants to know how she might improve her sleep, where do you start with someone like her? Can I interject for a second? So, Paul, number one, what do you think of that name? It's solid, yeah. See, I told you we're wearing him down, Ashley, with these puns. And then second, I feel like this case might be triggering for you. There's a lot of things in there, or maybe not triggering for you, but we tried to make it so there were some teaching points here. So back to Eddie's question. Where do we start? It's juicy. So my first question is a basic safety question. Is this patient's hypertension controlled? We could say it's controlled, yeah. We could say it's controlled. Can we assume she's on medication or other, you know, this is not an emergent situation with hypertension. No, we'll say this is just like every internal medicine patient pretty much has hypertension. when we give you a case like this. Unless we say it's uncontrolled, we'll assume it's controlled. Okay. So I'll zoom out a little bit. The first thing I would ask with a patient like this is I'd want to know what are her goals. Right? Because reading this, you might think you know what her goals are, but might be quite surprised. Her goals are often not predictable. Some people say, I want to fall asleep faster. I want to stay asleep longer. I want to be less anxious about my sleep. Some people say I want to feel rested all day during the day. Sometimes people say goals that are reasonable. Sometimes people say goals that are highly unreasonable. And for the highly unreasonable goals, I have this magic wand that viewers can see that I keep on my desk and I can wave every now and then when I have a wish for someone. However, getting an understanding of what their goals are first is really important. So I typically start with that just to set the tone of what are we doing here. And I also assess readiness. So how ready is this person to make changes that they're going to need to make to get to their goals? I always joke with people, you know, if you lose 10 pounds in two days, how quickly do you think you can gain 10 pounds back? Probably two days. So when people come at me and want a quick fix for their sleep, I say I've got real bad news for you. This is going to take time and work because you've not been sleeping well for a very long time. So we're going to need some time to fix this. So I kind of gauge where people are at. But sometimes, I mean, most of the time by the time people get to me and get off the wait list and they're waiting for months and months, they're ready to do their sleep. But if I didn't have a wait list and I had people who were just kind of coming in with a whole host of problems, I'd really want to make sure that this is something they want to work on and that there isn't a higher priority item on their list. That's a good point. Because for us in primary care, it may be just something that they mention offhand and it's not like the top of their bill for the day. Like they want us to address their chronic pain or they want us to address something else. So let's assume, though, that she's wanting to come in and she's saying, you know what, I want to start working on the sleep thing. I would want to fill in some gaps in that story. So I'd want to understand, I think she said she gets in bed at like 9 o'clock. I'd want to know how long it takes her to fall asleep. What is she doing in bed before she falls asleep? I'd also want to know a little bit more about when she's waking up hot. One of the pearls I give a lot of internal medicine residents or other residents that I teach here at UCSF is that a lot of times people tell you they're hot at night, And if I had a nickel for every time I took away someone's down comforter and changed it out with cotton blankets, I might have $12.50. Like I might have a lot of, you know, like tens of cents, right? Hundreds of cents. Because your body is actually supposed to be its coolest at night and its warmest during the day. And if you are sleeping in the equivalent of your ski jacket, because if you go look at what's in your ski jacket, it's probably down or something similar. If you're basically sleeping in that, you could be giving your body a mixed signal. And that mixed signal is that it's warm. I'm warm. Oh, it must be time to be awake. And you may be waking yourself up in the night because you can't cool down. So I often will switch out cotton sheets and cotton blankets the first time I ever encounter a patient. This is during their intake. I'll say, all right, before you start treatment with me, you need to go online, buy some cotton sheets and cotton blankets. And guess what else? You can get flannel cotton, which is so much cheaper than those really expensive things. And cotton blankets are cheap. People often don't know what a cotton blanket is. If the word duvet is in there or quilt or coverlet, it's not a cotton blanket. Cotton blanket is a very specific definition. And I can send you after this, like, some links to this is a cotton blanket. So I would ask her about her bedding. If she said it was down or not cotton blankets and such, I would make her switch that out immediately. I'd want to know a little bit more about how many nights she's actually drinking and how many nights she's actually using over-the-counter meds and how many nights she's actually using melatonin. Because there's this interesting thing that I see these days, which is patients coming in and saying, okay, so Mondays, I do Benadryl. Tuesdays, two glasses of wine. Wednesdays is melatonin. Thursdays is Ambien. And then we start it over just so that I don't get addicted to anything. I just rotate, which is creative. Creativity points for sure. Also, not a great solution, not a long-term plan. So I typically will ask about those kinds of gaps in an intake with someone like this. And then what I would do is I would, there's value in filling in those gaps, but there's extra value in having a patient like this do something called the consensus sleep diary. This is a paper diary. I can send you one of these to put in the show notes if you want that folks could download and have their patients do. Yeah, please. But it's basically the equivalent of a seven-column document for seven nights. where people wake up in the morning and then they write down all the stuff that happened last night. And they do this for seven days in a row. People often ask me, well, can't my wearable do that? The answer is no, your wearable can't do that. Wearables are not useful for this because I want you to be able to see all seven nights in concert. We're going to use that when we get back together after this first appointment. and wearables are the most accurate for the best sleepers and the least accurate for the worst sleepers. If you're someone who wakes up in the middle of the night for a few hours, there's good odds that your wearable device thinks you took two naps, right? So these things are not optimized for poor sleepers and the algorithms aren't built around them either. So I often tell people, look, just during sleep treatment, take that thing off. We're not going to worry about it. We're going to use what you are experiencing and what you report. So that's where I would start with this person, just to get a whole bunch more information. Now, if we're assuming I get more than 14 minutes with her, which is my rough estimate of what someone like you might get with her, depending on the setting. Is that right? Well, I'm recently in, like, the concierge space, so I spend a lot more time now. But, Paul, what about you? Whereas I just perpetually run late. So maybe a little bit more than 14 minutes, but yeah, not much time to focus on sleep for sure. Okay. Now that the holidays are over, you might be feeling like you've got a big spending hangover. All those drinks, the holiday food, the gifts, it all adds up. Luckily, Mint Mobile is here to help you cut back on overspending on wireless this January with 50% off unlimited wireless plans. Look, I have an expensive wireless bill. I got six people in my household. I am looking to save some money. 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This episode is brought to you by FIGS. Listen, curbsiders, I've been wearing FIGS scrubs for going on six years now. And if you're like me, around that time, you started to notice, why is everyone in the hospital looking so good these days? What's going on? And then you probably realized that it was because they were wearing these new, really great-looking scrubs, figs scrubs. That's right, figs. Everyone else was still wearing those stiff, itchy, boxy scrubs that don't fit right, don't look good on anyone. And when figs came around, it was a total game-changer. I've been wearing figs for over five years now, and when I'm wearing scrubs, that's all I wear. I have five pairs. I can wear one pair each of the weekdays that I'm working, and it's great. It's so comfortable. People are actually jealous that I get to wear them to work because it's like wearing your most comfortable piece of clothing every day. Now it's a new year. It's a new you, or at least a new uniform. 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Actual insomnia disorder we know responds really well to something called cognitive behavioral therapy for insomnia. And one component of cognitive behavioral therapy for insomnia is sleep hygiene. I feel like everybody's heard of sleep hygiene. And a lot of people think, oh, you know, my sleep would be so much better if I just cleaned up my sleep hygiene. But sleep hygiene is typically the control group when we're looking at cognitive behavioral therapy for insomnia and showing it's massively better than that. So I wouldn't just rely on that. But a few pearls of sleep hygiene that you can give some folks that have outsized benefits can be like the one that I just said about bedding. Cooling down the room from 65 to 68 degrees Fahrenheit instead of being warmer. Using dimmer lights at night. A lot of people find that wearing those orange glasses, and I mean orange glasses, they have to be ugly. If they're not orange and ugly, they're likely not doing the job. Some people find that wearing these glasses before bed in the one to two hours before bed can help them fall asleep faster. That's not CBTI. It's been found in some studies. I wouldn't say it's a robust evidence-based practice, per se. If you talk to some circadian biologists, they might say, of course it is. But I'm a human. I don't study the mice. Humans. Humans is what I do. in 2016 the American College of Physicians said hey cognitive behavioral therapy for insomnia is the first line treatment for insomnia disorder this is what you're supposed to try first so if this lady who you just described wants to fix her sleep your first step is not going to be writing her a prescription for sleep drugs it's going to be writing her a referral for cognitive behavioral therapy for insomnia and in this moment you can give her some different sleep hygiene things which I can go over in more detail now. I'm not sure if you want to dive right into those or if you'd rather segue into going over exactly what is CBTI. Paul, what do you want to do? I think, yeah, I think we should probably get the fundamentals first. Actually, even before we explain what CBTI is first, I had a question about our particular case, actually something you had said. So I appreciate your sort of patient-centered way of saying, what is this patient's goals for what they're trying to accomplish here? And I guess, reading this case, the patient wanting to get eight to nine hours per night, I don't know if that equates to I just don't want to be tired anymore and if that's the same thing. But I guess I'd like to hear, A, how you ask about the patient's goals, and then, B, like so many things, we probably also have goals for our patients. So how much sleep should we tell this patient she should be getting? Because I feel like that's also a fundamental question I get. How much should I be sleeping? And I don't know that I have. It's easy to say eight hours, but I'm not sure that's necessarily practical or even true. Sorry, I'd like to hear how you assess goals and sort of what goals we should be kind of going through with the patient, if you're comfortable talking to them. Yeah. You know, patients seeking sleep treatment come in shitting all over themselves. I should be doing this. I should be doing that. I shouldn't be doing this. I mean, they're just shitting everywhere. And so one of the first things I do is I say, okay, says who? And I take the example of a short sleeper. There's a very large difference between someone who says, look, I sleep six hours a night. I wake up, I feel refreshed, that's all I can do. You give them an eight-hour opportunity to sleep, they're going to sleep six hours, great. But then you take someone else who's only sleeping six hours because she's working three jobs trying to support two kids and also trying to, like, have a life and only sleeping six hours, so she only gets time to sleep six hours. If you look at the health outcomes of those two people, they're very different. And when you look at the epidemiological literature and you see, oh, there's a bell curve. People sleeping very little seem to have bad health outcomes. People sleeping a lot seem to have bad health outcomes. Well, in the short sleep people, we're merging the people who are naturally short sleepers and the people who only have six hours a night to sleep. And then we're looking at people who are sleeping 11, 12 hours a day. Why are they doing that? they're probably sick right people at the end of life people who are dealing with major illness they're sleeping a lot so we see this bell curve and i explain to people because most of the people who come in to see me are coming in because they have a sleep problem or they've been convinced they have a sleep problem one of my favorite stories is from a patient i once had who got into my clinic and I said, okay, so tell me about this. And she's like, well, everything was going fine. And then I joined this study and the study gave me this bracelet to wear, this whoop bracelet to wear. And I opened the app in the morning and it said to watch out. It said that I was not sleeping enough. It started to lay out a plan for me. And I said, okay, okay. All right. So, So tell me how you're feeling. And she said, oh, I'm feeling great. Like, I have a job. She was in her 70s and a job that involves memorizing a lot more stuff than what I do. That's for sure. And I said, okay, and that's going fine. Oh, yes. And you fall asleep fine. Oh, yes. And you wake up feeling fine. Oh, yes. Do you wake up during the night? No. And I said, I think we know what we need to do here. I think we need to take that bracelet off and things will get better. And behold, weeks later, without the bracelet, I'm much less upset about this now. Things are fine. Thank you. Didn't need treatment, right? Just happened to naturally not sleep eight hours. So when people tell me, oh, I need to sleep eight or nine hours, I say, who says? And people will say, oh, you know, but I did when I was younger. And then I bust out this graph that shows that as we age, our sleep changes. And I say, you know what? I know what happened here. I definitely know what happened here. You got older. Time passed. We know what happened. It must have happened to you. It happens to me, all of us, right? And I go over the fact that as we age, we do seem to get less deep sleep. As we age, we do seem to have more wake time after sleep onset or WESO, which is what you'll see in the literature. These are commonly observed things. And so a lot of what I end up doing at the beginning with negotiations is debunking myths. And I say, let's make a deal, you and me. Okay. Let's forget about the number of hours. And instead, let's focus on the quality of your sleep. Would you ever have nine hours of tossing, turning, garbage sleep, or seven hours of awesome, not waking up a whole lot, maybe wants to pee, not stressful sleep? Most everyone's going to choose the seven hours. So we really focus on quality over quantity. Because as soon as you start putting numbers on things like that, then people start doing competitive sleeping. It gets a little bit nuts. So I try and debunk that at the outset. I get them to agree to focus on quality over quantity. And I also debunk this idea that every morning you should wake up feeling refreshed. I'm like, yeah, that's in the movies. it's normal for people to feel groggy up to 30 to even 60 minutes after you wake up in the morning it's called sleep inertia right and a lot of times people will a lot of times people present for sleep treatment right after they retire which is so entertaining to me or at least it was at first and I was like this is weird patients will come in and they'll say you know what I'm supposed to be golfing and having brunch like I had all these plans this was going to be awesome and now I can't sleep. And it's like, well, yeah. You no longer have to wake up at the same time every day, eat lunch at the same time every day, see the same people every day, be in the same place every day. Your routine is completely gone, which has completely messed up your sleep. And so when people come in and they have some of these expectations around sleep, I have to say, look, circumstances have changed. So your sleep has changed. We're going to have to rebuild some things, get your sleep back on track. you lost like something something happened right so yeah i go after the hours thing go after the lifestyle thing and then people want to wake up feeling refreshed and i can laugh and we'll just say hey remember you have you used to wake up at 7 a.m with an alarm so you can get to work by 7 45 and you didn't really think about how refreshed you were you just went to work but what were you saying sorry no i i think that's i think that's fantastic to to point that out because that is one of the most common things. I think people, they have it in their head seven to nine hours or eight to nine hours. And it's just, it changes throughout the lifespan. It's good to point that out. And I saw some things about like in some native cultures, their sleep kind of shifts depending on the time of year, like if it's more light out or not. These are cultures with like no screens or anything where they're just sort of, you know, living more natural lifestyles, I guess you could say, not necessarily modern lifestyles. So I always think that's interesting. And they're not sleeping like 10 hours a night from what I read. No, I agree with you. And I would also like to highlight that in our modern society, at least here in the U.S., we've kind of favored the early morning larks and demonized the night owls. And what I, what I'm, let me unpack those terms for a minute. Night owls are people who like to go to bed later and wake up later in the morning. Larks are people who like to go to bed earlier and wake up earlier. And you might wonder, well, why do we have multiple types of people? Why not? And also, why isn't it so easy to change? Well, if you think back to kind of what you were describing, Matt, being back out on the prairie, if we all went to bed at the same time and we all woke up at the same time, the odds of a lion successfully eating us are higher. It's nice to have some night elves out there, making sure that the lion is not coming while all you delicate flowers go to bed early. And then you wake up early to make sure that we can sleep and no lions are coming now, right? So this kind of diversity of sleep phenotypes probably was evolutionarily adaptive for groups of humans in the wild. And now, unfortunately, we have this society that is pretty much built for morning people. You know, pretty much. There's some jobs that are not. But I think those are probably in the minority. And, you know, unfortunately, a lot of people then have to change what their natural sleep window is. And it's much harder to do than people think. Just becoming a morning. If you're a person who naturally goes to bed at midnight and gets up around 7 or 8, becoming a person who enjoys getting up at 5 a is likely not in the cards for you That just too much We can maybe shift it 30 45 minutes But it is challenging And that why we get the sleep diary from this patient I want to see what are they naturally doing before I tell them what to do. I tell her, don't change anything. You go to bed when you want. You wake up when you want. And then I get this nice seven-day picture of what's happening for this patient before I've intervened. I think the chrono, so this chronotype is the term I've heard people put on this. And I think I've seen, I've definitely seen people in clinic where they were, it was someone who was being forced to get up at five. And I said, well, what did you like to do? Like, what would you do if you had your choice? And she goes, well, I normally go to bed at midnight and I wake up at, like you said, seven or eight. and the job was creating the sleep problem, which is easier said than done to fix that situation because your job, you might not have the option to shift the time that you're working. So it was an issue, but at least it gave the patient insight into why it was happening. Yeah, and a lot of times when it comes to sleep problems, there's a lot of anxiety. I always joke that my favorite patients are anxious people who can't sleep. They're the only people who I treat. Anxious people who can't sleep, they're on time. They do their homework. They've got their MyChart thing is done. They're like A plus, right? It's just they're great. And a lot of times when people can't sleep well, they don't understand why. It's just the angry sleep gods that have decided I don't sleep well. But as soon as you can look at their sleep diary and say, oh, look, you slept in a lot this day. And then the following night you couldn't fall asleep probably because you didn't have enough sleep pressure, which we'll define in a little bit. And once you can start to show people patterns like, oh, now you see why you didn't sleep well, now you have power and control because you see what happened and you can prevent it from happening or you can let it happen and at least know why you didn't sleep well. Knowing why you didn't sleep well takes a lot of the anxiety out of it. When you don't know why, it's scary. Yeah. Yeah. And the more anxiety, the more it promotes wakefulness and it's counterproductive. All right. Well, I think we were going to define cognitive behavioral therapy for insomnia, and then we can keep digging into the treatments. Yes. Let's define cognitive behavioral therapy for insomnia. And there's a few different components of this that we should... Well, let's just put this into the five-part framework, right? So there's something called stimulus control, which we'll define in a second. There's what's now called time in bed restriction. cognitive tools, relaxation tools, and sleep hygiene. These look like the five buckets. And if you're going to take these five buckets and you're going to say, Ashley, which are the two non-negotiable buckets? The two non-negotiable buckets are stimulus control and time in bed restriction. You cannot not do those. If you don't do one of those or both of those, the thing falls apart. So stimulus control. Let's start there. Stimulus control means reserving your bed only for sleep and sex. A lot of times when people are struggling with sleep, they've started trying stuff like listening to podcasts in bed, reading in bed, watching TV in bed, having dinner in bed, working in bed, living in bed, just in case anytime they might be sleepy, they can fall asleep at that given moment because they're so anxious about not having enough sleep that they better be there. They better be ready. But that means we associate the bed with watching TV, podcasts, working, watching TV, all these things. And that's not what we want to do. Everybody who was this podcast, I think, might remember the Pavlov dog thing with the bell, right? You ring the bell when you give the food. If the dog starts to associate the bell with the food, you can ring the bell. The dog salivates with no food. Magic, right? So if we start associating the bed with all kinds of things that aren't sleep, that weakens the bed as a cue for sleep. We want to strengthen the bed as a cue for sleep. So I tell people, nothing in bed except for sleep or sex, and this isn't very hard. And I also tell people, look, if you're not sure if something is sleep or sex, just send me a message. I'll get back to you. Within 24 hours, I will have it clarified. They're almost always cut and dried cases of yeses or noes. Only a few precious gems have been like, well, well. Those could be pretty interesting emails, I'm guessing, but we don't. This is a family-friendly podcast, so we'll. Family-friendly, right. They're great, great emails. So that's numero uno. But keep in mind, I don't tell people that. I wouldn't tell Mrs. I'm up all night, right, that at the first thing, because I want that diary first. I want that first without my intervention to see what's the lowest hanging fruit. Because if I start intervening before I get that baseline, I won't know the first great place that I want to really put my cards. And ultimately, everybody gets the same thing. It's just there's a little bit of differential degree of emphasis for certain people where I'm like, oh, that's a really big thing for you. I got to punctuate it a little bit. The other key ingredient to cognitive behavioral therapy for insomnia is something called time in bed restriction. This used to be called sleep restriction, which sounds more severe. So we kind of trade it up. Time in bed restriction. And it is exactly as it's described. We are restricting the amount of time that you get to be in bed. Well, what does restricting mean? Well, I am restricting how long you get to be in bed to match how much sleep your body can produce. How am I figuring that out? Well, here's where there's two ways that you can do this. I'm sure there's more ways you can do this. The standard way in cognitive behavioral therapy for insomnia is to have Mrs. I'm up all night, fill out that sleep diary, figure out on average how much sleep she's getting per night, and then say, okay, you're getting seven hours a night. You get to go to bed at 12 and get up at 7. I don't do it that simply. Rather, what I do is they, and I've talked about this with tons and tons of colleagues, and everyone's like, oh, yeah, that lines up. Like, that makes perfect sense. You're doing the same thing. You're just doing it stepwise. So I'm going to have this patient fill out that sleep diary, and I'm going to look at her seven wake-up times from that first diary that she did. And let's say that she woke up at 6 o'clock, 6 o'clock, 7 o'clock, 7 o'clock, 7 o'clock, 8 o'clock, and 8 o'clock, right? So seven mornings of times that she woke up. I am going to pick a wake time for her, although I'm going to let her pick it. I'm going to say, what time would you like to wake up? And she's going to say, oh, I'd like to wake up at 9.30 in the morning. and I'm going to say, well, you woke up at 6 a.m. and 6 a.m., then 7 a.m., 7 a.m., 7 a.m., and then 8 a.m. and 8 a.m., so on zero days did you actually wake up at 9.30. And having this diary is so powerful because she can look down and she can see that. And she'll say, oh, yeah, I can't sleep until 9.30. So then we both mutually decide, yeah, that's not a good idea. So let's choose a time you can actually sleep until most of the time. So then we look at her diary and I say, all right, we need to pick a time that you made it to. You had to have made it at least half, like more than half of the week, so four of the mornings. Right? So did she make it to 8 a.m. four mornings? No, she only made it two mornings. Did she make it to 7 a.m. four mornings? Well, she made it to 7 a.m. three mornings. So the two days that she made it till 8 a.m. and then the three days that she made it till 7 a.m. means that she made it to 7 a.m. at least five days. So I say, all right, 7 a.m. it is. You're going to wake up every day for the next seven days at 7 a.m. And seven days, I would say, Saturday, Sunday, any day ending in D-A-Y, right? Seven days. You have to wake up at that time. Then she's going to do another diary. She'll bring in that diary. And I tell her, look, you can go to bed anytime you want this coming week. But you can't go to bed until you're sleepy because you cannot do anything in bed except for sleep or sex. So go to bed when you're sleepy. And then you have to wake up every day at 7 a.m. And then I use that diary to figure out how much is she sleeping each night. And then I use that to determine her time in bed restriction. Let's say she's on average was sleeping seven hours each night. Then what you do is you add a half an hour and you give them that. So seven and a half hours in bed, that's what she would get. And I would work backwards from the wake time, which is 7 a.m. Her bedtime would be 11.30 p.m. If you're wondering some of the mechanics of this, there's a great book called Quiet Your Mind to Get to Sleep. I can give you the link to it. It's like $15 on Amazon. I didn't write it. But it's a great book, and it describes a lot of this. But you do time in bed restriction with this patient. And I appreciate that this is not exactly doable in a primary care doctor's office because you're not seeing a patient every week. This is why you have to refer out for CBTI. But my major goal in explaining how this works to primary care, internal medicine, and family doctors is just so you know what you're referring your patient to do. And you can kind of set them up for success. And setting them up for success really means starting them off with this understanding that, look, You're going to have to make some changes to your bedtime routine, the times that you sleep. And one of the best things that you can start to do with your patient when you refer them to CVTI is try to get them to be consistent with their medications. If they're doing the medication merry-go-round, Benadryl one night, Ambien one night, Melatonin one night. Have them get consistent. Use the same thing in the same dose at the beginning of the night each night. We really try to avoid reactive medication use. And this is outside of CBTI. CBTI actually has nothing to say about medications. People just tend to use less medications when they get successful treatment with CBTI. But a lot of times people come in and they're using medications in ways that kind of counter CBTI and make it harder to do. So if you can get your patients to be stable on their meds and not taking them in the middle of the night reactively when they wake up, you're setting your patient up for the best outcomes from CBTI. So those are the first two big ones, stimulus control and time in bed restriction. Hey, Curbsiders. Have you ever chosen a CME conference because of the destination only to be disappointed by the education once you got there? That's where Continuing Education Company really stands out. They host conferences in places clinicians genuinely want to visit, like Hawaii, Alaska, the Florida Keys, Kiowa Island, Nashville, and New Orleans, but they pair those destinations with education that actually delivers. 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See for yourself why Continuing Education Company is considered a leading source for medical education. Visit cmemeeting.org forward slash curbsiders to learn more. That's cmemeeting.org forward slash curbsiders. So two things. I want to ask something about stimulus control. But before I do, to please our semen overlords, I just want to say diphenhydramine and zolpidem. But then also, with the stimulus control, I guess I want to ask, I'm asking your permission to be strict, I guess. But, like, how strict are we in terms of what patients are allowed to do in bed? Like, TV, I have found patients so hesitant to give up. Like, oh, no, I always watch TV in bed. Even before I was having trouble sleeping, you know, I have a timer. It's no problem. Like, I try, it just, it's, I feel like I make no headway. So I'd love to hear some of the evidence for that or how you counsel patients about that or how I can talk to them in a way that I will see more believable because I have a hard time getting people to let go of screens while in bed, and I know that's something that seems to be hard to palm when we're talking about insomnia. Okay, I'll take that one. So when you're seeing a patient who's coming in with sleep difficulties, one of the things I really don't care about is, well, what started this? I mean, I do ask that at the end of my intake. End of my intake. I say, oh, do you think anything caused this? And people will say, oh, yeah, it started on December 30th, 1979, when I got my mother-in-law present and she hated it. And I was just distraught. Right. And I'll be like, oh, okay. Oh, believe me, the specificity that I have gotten in my intake forms, unbelievable. I almost feel like I could write a haiku with some of this stuff. It's so good. But oftentimes what start, what precipitates a sleep problem and what perpetuates a sleep problem are different things. So things that often will start a sleep problem, losing a job, getting a divorce, unexpected death, expected death of a loved one, you name it, super stressful event. Everybody's coming in with a certain number of factors that predispose them to having sleep problems. Everyone's got a small level of it. But let's say the threshold for insomnia is up here. Okay. Then you have an acute event. Boom. puts you over the threshold. There you are. You're over the threshold. And to cope with that, you start doing things like popping a diphenhydramine or a zolpidum or taking naps or having an extra glass of wine to help yourself get to sleep or knock out a little bit early or maybe some extra energy drinks or caffeine. You start doing all these things to compensate. Meanwhile, the thing that puts you over the edge, you maybe lost a job, maybe you got a new job. That's not so stressful anymore. So that's come down. But all these perpetuating behaviors, all these things you're doing that you did to try to help yourself that are actually perpetuating the problem are still going on. So the thing that starts the insomnia and the thing that perpetuates the insomnia, different buckets, different buckets. And when people say, oh, yeah, I've always done this. And I say, oh, yeah, well, in college you could drink like a six-pack of beer and you could still wake up at 7 in the morning and go to the gym and be fine, right? Like, can you do that now? People are like, oh, no, I can't do that now. That wouldn't work. Right? So things change. We age. Just because you've always done something, that might be something that's now got you over the threshold. Can't just do it. I've heard about these sleep timer things. I've had patients who are just like, oh, this is how I calm myself down. And I say, well, then we need to work on that during the day. because if you're not able to calm yourself down during the day, then we're going to have to deal with it during time that you should be sleeping or that you could be sleeping. And this kind of slides us into the cognitive tools that I can get to, but I think you had another question. You said you had two questions, Paul. Was there another one? Oh, now doing memory testing. No, I think you covered it. Oh, no, I wanted to make the generic point and then also the stimulus control. So you covered both. You did great. I actually I was going to just mention with stimulus control the other part of that is is getting out of bed right if they wake up like in the middle of the night and they're like fully activated or they can't sleep for 30 minutes 20 20 30 minutes whatever the cutoff is that's that is that part of stimulus control they have to get out of bed at that point too. Yes. Great. Glad you asked this. So, yes, if you wake up in the middle of the night and you have the thought, gee, I really can't get back to sleep three times. It's time to get out of bed. Or if it's been 20 minutes, time to get out of bed. And it's not the end of the world, guys. You can go to the bathroom. You can read a boring book. I tell people activities in the middle of the night are things that you should be embarrassed about if your boss saw you doing them during work. So reading a trashy magazine, you know, doing a crossword puzzle when you were supposed to definitely be doing something else at work, right? These are the kinds of things that you would be embarrassed doing at work, so do them in the middle of the night. They're supposed to be slightly fun, slightly boring, not too engaging. Don't start a movie for three hours in the middle of the night. I tell people, look, if you start Dances as the Lulls or some other long movie in the middle of the night, then you're going to want to stay up and finish it having revenge fun because there's never enough time for fun during the day, and we have to fight the revenge fun. So if you want to watch TV in the middle of the night, I tell people, pick a show with 20-minute episodes, sitcom, think like Seinfeld, like some of these older shows that were like, what, 22 minutes or something. Watch one episode and then check in with your body and think, am I sleepy enough to go back to sleep? And then go back to bed. The parallel I like to make is rapidly falling out of style because video games have changed. Back in the 90s, does anybody remember when we had those video games with cartridges and they would go into those big machines? And whenever they would freeze, you'd have to take them out and blow out the game and then put it back in to restart. You'd lose your place and it was, oh, but oh, well, it's what we had. That's kind of like doing a reset and going back into bed. And if you get out of bed and go back to bed, you've got better odds of falling back asleep a lot of the time than if you just lay there tossing and turning. You want to do a reset. And this also kind of brings us backwards to the beginning of the night when I always want to make sure people know that humans, we're kind of like airplanes. Have you ever been on an airplane that's about to land, and then all of a sudden the pilot goes, just kidding, and then you go back up into the air, and everybody grips their seats and goes, whoa, and he's flying back, and nobody knows what's going on, and then 12 minutes later, after an agonizing silence, when you think maybe there's no landing, the pilot comes back on, And he says, well, folks, the wind was blowing a little bit and we saw a bird. So we're going to do a new approach. And, you know, like that, that is us, right? We have got to land the plane at the beginning of the night. We're not a toaster that you unplug. As soon as you unplug a toaster, if you turn it on, it will not toast. It is done. We humans, you cannot just unplug us. You have to land us like a plane. The approach has to be just so to go to bed. So I tell everyone, make a one-hour winds-down routine before bed that you can do anywhere. You can do it in a hotel room. You can do it at your mother-in-law's house. You can do it at your house, right? It might involve things like a face mask, brushing your teeth, reading a book, putting on your pajamas, laying out your clothes for the next day, right? Some sort of behavioral routine that's going to send your body a message. Hey, we're doing this now. We're getting ready for the thing, the thing where we get unconscious. We're going to go do that. So you can tell anybody to just make this routine. And a lot of times you'll get a sense of where the problem is. Some people will say, oh, no, I have to work up until five minutes before I go to bed, and then I want to go to bed. And it's, okay, well, I think we know what the problem is here. Right? This isn't necessarily a sleep problem. This is like a I'm working when I should be doing the other thing problem. Yeah. You're coming right out of the trenches and trying to go to bed when your adrenaline from being in email work is still high. You mentioned the light blocking, these ugly orange glasses people might be wearing before bed. It is hard to avoid TV in the hour before bed if that's like, let's say, I'll use myself as an example. The kids get to bed at 8. I like to go to bed at 9. So between 8 and 9, my kids are reading books upstairs, and my wife and I try to grab like 45 minutes of television, and then I'm usually getting tired and going to bed. Is that a mistake? Should we not have any television within that hour of – and then do you differentiate between handheld and like the television screen? I was reading about this that maybe there's some difference, but I want to know your thoughts. So I have some thoughts. This is outside of CBTI, but this is based on different literatures. And the first to most bluntly answer your question, I'm not worried about the TV that you're watching. I would say make sure that the light that you have on in the room is lamps, not overhead lights. I'm much more concerned about that than you watching a show before bed. The difference where I draw the line is as soon as you're using a handheld screen, you're not just watching it, you're interacting with it. We didn't evolve for the neural experience of interactive screens. I mean, this is just, they're so stimulating. And I don't know that research has done a fantastic job yet of separating out the effects of sheer blue light, just blue light exposure at night, versus the interactive nature of these devices and just how they affect our brain chemistry. These shiny things, these iPads, these computers, one of my go-to examples is when you go to Las Vegas, and I don't mean to pick up Vegas. It's a lot of fun. It's great. It's wonderful. But when you go to Vegas and you walk through some of those casinos and you see folks sitting at the slot machines, people generally don't look like they're having a good time. They're kind of glazed over and they're just like pulling the thing and pulling the thing. Like something's going on in their brains, right? It's not and it's probably not good, right? We didn't evolve to deal with some of these experiences that we're confronted with now in everyday technology. TV, I'm less hateful of it right before bed just because it's not an interactive screen that's giving you one of these feedback devices devices or worse, a lot of the apps and things on screens were literally designed to keep you glued to them and keep your brain spinning in certain ways. So I do tell people, look, if you're going to read, just try and read books. And, you know, people say, what about a paperweight Kindle? I'm like, okay, I surrender. If we can't do real books, okay, paperweight Kindle it is. But I really try to tell people, look, if we can avoid the backlit screens, a good thing, the interactive ones. I know, it's tough. Yeah, I have a dim, the lights are all dimmed. It's a calming TV show, recently British, the British baking show, very calm show. And paper books with, I have those little book lights that clip to the top of the book. I tell patients, too, to try to use those. That's fine. I do tell people, too, in the middle of the night, if you want to read, We don't read about pandemics, global warming, politics. Like there's a whole, and I tell people, if you're not sure if it's appropriate for the middle of the night, send me a message and I'll clarify it's a good activity. I've had people say, oh, okay, what about like planning out? And I'm like, nope, planning. Anything productive in the middle of the night is a no. We do not want to associate being awake in the night with being productive. Got it. Yeah. You were going to mention the cognitive, and I think you were kind of leaning into the scheduled wary time. Yes, I'll lean into this stuff now. So part of CBTI is cognitive tools. There are a whole host of cognitive tools that CBTI has borrowed from different areas of cognitive and behavioral therapies, particularly for anxiety disorders and depressive disorders. And they're super useful because they're tools to work with your thoughts. Many of you probably have patients who tell you that they wake up in the middle of the night with their head spinning, a busy mind, thinking of all the things they need to do or all the things they wish they said or should have said or could have said or should say tomorrow. There's this whole huge list of different types of thoughts people experience in the middle of the night. And I always like to remind people that, you know, if we're really busy during the day, and if we avoid dealing with stuff during the day, our brains are so smart. And they will say, oh, okay, I see you don't have time to worry about this right now because you're trying to help the kid with homework, figure out carpool, decide if that permission slip really should get signed, whatever you're trying to do. You're not dealing with it then. And then as soon as your head's on the pillow and you wake up to use the bathroom and then you go back to bed, your brain says, oh, I see you're not doing anything right now. Now might be an excellent time to worry about whether you said something upsetting at that meeting yesterday. Right. So then and then you're off to the races. Then you're just going. Right. All kinds of stuff. So the first thing I like to do in the cognitive tool section is I like to talk about with patients about what those thoughts really are for them. Do they spend a lot of time ruminating about things that already happened or worrying about things in the future? And giving patients this language that differentiates ruminating from being about the past, worrying from being about the future, helps them understand, okay, in the middle of the night, I tend to do one of these two things. And a lot of people will do both, but there's generally a predominant flavor, if you will. And there's a whole host of cognitive tools that you can use and that patients can use that are featured in that book, Quiet Your Mind to Get to Sleep, which I swear, I've said it a bazillion times everywhere. but I have nothing to do with it other than I think it's a great book. Yeah, and I've read it, and it basically teaches you how to do cognitive behavioral therapy on yourself if you want to. Yes, it's a workbook. Yeah, it's a workbook. And there's a whole suite of cognitive tools that we can consider, but I'd like to talk about one of my favorite ones that you can probably knock out with patients in a quick visit. if a patient comes in and tells you you know i am in the middle of the night i am just so worried about my something my house burning down i am certain that my house is on fire somewhere it's going to burn down something's going to happen and then you ask them okay okay so that's that's a big problem at like two in the morning for you. And then you say, okay, so what do you do generally in the afternoons around like three or four? Oh, I take my dog for a walk in the park across the street. Oh, okay. How worried are you at that time about the house burning down? Well, it's really not a concern then. Just really, you know, not worry about then. And you help people start to connect the dots. Well, okay, so you're 100% sure that this is happening at two in the morning, but you're, you're like 10% sure it's happening at four in the afternoon. If we believe a thought at different levels throughout the day, how true can it be? If you can get a patient to have a, have a, this like this small shift to realize when you're like, Oh, I don't think my house is going to, it's too, I don't think my house is going to burn down because I think it's going to burn down. I think that because it's 2am and that's what I do at 2am. I think that. you can have this entire different relationship with your thoughts. And I once had a patient who's told me that I have her permission to tell the story, but it's just so powerful. It was just that she used to hate waking up at seven in the morning and then just being in pain for a couple of hours after she woke up because she had a chronic illness. And then she'd finally get up and she'd go to work. But for those two hours, she would be sitting there having this thought, I'm never going to make it through this day. But if you asked her at lunch, like, okay, you think you're going to make it through this day? She'd be like, oh, probably. You ask her at dinner, like, oh, you're going to make it through the day? She's like, oh, yeah, I did it. And once I had her track her degree of believing that thought, I'm never going to make it through the day, for a whole week, she had this moment of like, oh, I only believe this at 7 a.m. So, of course, she had to follow the rules and start getting out of bed at 7 a.m. She couldn't just be in bed awake being miserable because that's not sleep or sex, right? So she'd get out of bed at 7 a.m., she'd go to the couch, and she'd start doing her app on her phone, learning a language with one of those apps. And it became her favorite part of the day from 7 to 9. She didn't have to be at work until like 10. It was like she had a great job. But from 7 to 9 became her favorite part of the day where she went on the couch and did her language learning. And eventually she went on a foreign trip and sent me a postcard. She's like, I learned the language. Very exciting. It's very exciting for her, right? But there was just this huge shift for her realizing like, oh, I don't believe this because it's true. And this is something you can talk about with your patients. There's a one page handout for tracking your degree of belief in your thought in that in that workbook and in like 50 other cognitive behavioral therapy workbooks. Easy tool to use. And then there's other tools like cognitive distortions checklists where you can give patients a whole list of things and examples of things that are, you know, everything from should statements. Do you should all over yourself or should all over other people? Or are you fortune telling? Are you mind reading? any thought that fits one of these cognitive distortion categories can probably be worked on with a cognitive and behavioral tool that's in the suite of cognitive and behavioral therapies. And a lot of patients realize that once they start using these tools, they can much more easily work with their ruminations and their worries. But let's go back to the time of day issue. When you have a patient who comes in and starts telling you all this stuff they're worried about, and you have this internal monologue of like, oh, you don't need to worry about that, right? Like, there's a moment for a lot of people. And even if you ask those people, like, oh, do your friends worry about a lot of things? They'll say, oh, yeah, but they shouldn't. They should just stop that. But me, on the other hand, right? If I told every patient who came in and started telling me all these things they're worrying about, and I said, okay, well, just stop it. They wouldn't like me very much. I wouldn't be a very effective therapist. There's a great Bob Newhart skit, I think it is, on SNL where he plays a therapist, and, like, a patient comes in. He's like, I can fix your problem in two words. So she gets a pen and she's ready to write it down. He's just like, stop it. Just get out of my office, right? And so what I do is the opposite. I say, okay, you're very worried about all these things that you think are going to happen in the future that you're worried about. What do we do with very important things? We schedule time to do them. So I have them get out their calendar and literally schedule worry time every day for the next seven days. Like anything that ends in DIY, again, same joke, right? Saturday, Sunday, we do it every day. I have them schedule worry time. And then let's say this person schedules worry time from 4.30 p.m. to 5 p.m. A worry pops up at 9.15 a.m. Oh, my gosh. I did not figure out what kind of goodie bags I'm going to get for my daughter's birthday party. Oh, shoot, shoot. Right, and you start, like, spinning out. Instead of doing that, you just say, you write this down on a little list. You say, goodie bags. And you're like, okay, well, I can't worry about that now because I have time scheduled later to worry about that. And believe me, the last thing you want to do is get to your worry time and have nothing left to worry about because you're already worried about it. So you tell people, save up all the things you're going to worry about and worry about them during the worry time. And you can use the different cognitive tools to more effectively worry about them And then instead of having worry all over your day spread out it condensed And the quality of the rest of the hours of your day is so much better You're never going to be able to convince your patients to stop worrying, but you can convince them to compartmentalize it. And this can really improve their quality of life. And by doing it during the day, it's less likely to wake them up in the middle of the night. And if you have that kind of patient, if you've ever had, this story will track onto certain kinds of patients. If you ever had an early flight to get up for, Matt, Paul, Eddie, early flight. Sure. Right. Okay. And you go to bed the night before and you're thinking, all right, I have to turn off the air conditioning, take out the trash, lock the door, turn on the front porch. You've got this list, right, of things you've got to do before you leave for the airport, before you get in that cab. and a lot of times there are people whose every night is like that and one of the things they can add to their hour-long bedtime routine is the to-do list, the brain dump. Just dump it all out. All those things you're trying to remember for tomorrow, dump them on a piece of paper because that way when your head hits the pillow, instead of reciting the whole list, the list is very short. I need to look at that pad of paper. I need to look at that pad of paper. I need to look at that pad of paper. That's it. So, mini crash course on some of the cognitive and behavioral techniques. There's a lot that patients can benefit from there that seemingly can have nothing to do with sleep, but that can be very much affecting sleep. All right, Ashley. So let's say Ms. Imatt takes the most diligent sleep diary you've ever seen. Like, it is studious, it is complete, it is detail-oriented down to the second, and she comes back with this data, with these data, I should say, and is now interested in sort of more concrete ways to kind of perhaps work on her sleep. So I guess before we get too deep into it, I would like to hear, we touched on some general principles of sleep hygiene. You said the first visit, you don't really sort of stress those. You just want patients to sleep as they normally do so they can document, and then you can kind of attack. So when you do go to revisit sleep hygiene and recognizing everyone's different, what are the high yield points or the points that you make every single time other than getting rid of down? I will say, by the way, pulmonologists are going to love you because it's down pillows we've already thrown out for ILD, so it's exciting to come back and, once again, just sort of rail against a specific type of bedding. It's a really niche thing that we seem to be doing. But what else? What other sort of general counseling points do you always hit with patients? And then, you know, otherwise, how do you explore those things? Yeah. So aside from keeping the room cool and the bedding, which we've already talked about, I really focus on landing the plane, which we just talked about also. I tell people to try and finish their last meal at least two or three hours before bed. A lot of your patients probably have some type of indigestion, whether it's GERD, some type of reflux. This is just a high-yield item for a lot of people who think they struggle with sleep in the beginning of the night. And they're already on a meprizol. They're already sleeping on a wedge. They're already doing some of those things. It turns out they just need to finish eating a little bit earlier. That's some nice low-hanging fruit. The consistent wait time, which we already went over, that's arguably part of time in bed restriction, not just sleep hygiene. I do also try and remind people that exercise is very important. Also, it's great to not do it right before bed. I once had someone who I was doing an intake with, and I said, oh, what do you do for exercise? He said, oh, I do it with the 10 o'clock spin class in the Castro. And I said, oh, okay, cool, cool, cool. And about a week later, I was just like looking over the thing. I was like, wow. So it looks like you couldn't get to bed in time. He's like, well, I was still, you know, I was getting back from spin class. I was like, oh, you met 10 p.m. spin class on the Castro. Right. So really try and buy a cardiovascular exercise toward the morning. If someone wants to do yoga nidra in the evening, I'm like, I'm here for it. That's fine. But I try and move the vigorous exercise to earlier in the day, because, again, vigorous exercise heats up your core body temperature, which is not what we want when you're trying to fall asleep. When you're trying to fall asleep, we want your core temperature to be dropping. which generally means that your skin temperature is warming. You're experiencing vasodilation so that you can dump heat from the core, which is why often taking a brief warm shower or brief warm bath before bed can actually help you fall asleep. This is not just an old tale. And we're doing a clinical trial right now in my laboratory, actually. That's an NIH-funded trial where we're giving people cognitive behavioral therapy for insomnia digitally, and then we're giving them a passive body heating treatment using a sauna blanket before bedtime. Half people get randomized to get that, half people don't get that. And we're looking at whether adding 15 minutes of passive body heating in the hour or two before bed helps people fall asleep faster. Do you have an acronym for this trial? And then if not, we should probably connect offline. Do you have a trial name yet? This is going to be critically important coming up. We do. In fact, I believe that having a study name is so critical for every single study, and there also must be acronyms. Otherwise, what's the point? And for this study, we call it sauna and lifestyle every evening practices for sleep, the sleep study. All right. Yeah. Pretty good. I have other study names, too. They all have acronyms, the social study, the engine study. I mean, I've got them all. I feel like you could even get sauna in there just because there's this, as for sleep, I feel like there's lots of things you could do. This is good. This is fertile stuff. I'm sorry. I think this is important. I mean, our last one was called Heatbed. Excellent. Excellent. And that was like hyperthermia for the experience of depression. Like it was a whole, I'm drawing a blank, but I can get it for you. But Heatbed was pretty good. Ashley, I should tell you that Paul's a big trial head, as I've coined the term. and that means that he really gets off on hearing about the name of a trial and then he gets really angry if they kind of crammed in the acronym. So you've done well with yours. Clearly, it's high-quality science for practicing. I can tell. I don't even need it in the method section. I mean, another one we're about to do is sauna for offline connections and interactive authentic living, and that's called the social study. Very nice. We're studying sauna for loneliness. in young adults. Because they're in one of these 40-person group saunas, so they're meeting people there? They'll get to go with a friend. I like it. This is great. Me too. Real world research. Just a way to get funding to go to saunas is another question I might ask. You know, unfortunately, I don't actually get to go, but if we can create sauna culture in young people, what a great thing to do. No phones, no booze. It's just like a healthy way to go out with your friends at night. But, yes, we have an acronym for it. All right. So we're taking warm showers. We're taking warm showers, vasodilating. So blood goes to the skin that's dropping our core temperature. Yes. And I've also heard people say, like, I would be made fun of maybe by my wife. I'm going to say it's by my wife for wearing warm socks to bed because I can't fall asleep if my feet are cold. And then I heard, I don't remember if it was you or somebody else, say, yeah, actually, that helps because you're shunting blood away from the core, right, to your hands and feet. if you warm your hands and feet, but you tell me. It was me. It was me. There's actually data on this showing that people with circulatory disorders that limit circulation to their hands and their feet have more trouble falling asleep at the start of the night. And when you actually resolve these disorders, their early insomnia, which is falling asleep at the start of the night, resolves in small studies. But there's also common sense. If you've ever tried to fall asleep with really cold hands and really cold feet, you've known that it doesn't work. It's really hard to do. Just go camping and try it. I mean, I don't go camping, but other people could. I mean, I have a place to sleep. If aliens ascended the earth and saw us going involuntarily sleeping outside, they would be confused, just like if they saw us on treadmills. But back to the sleep hygiene, the other component you need to know is caffeine. I tell folks, look, the half-life of caffeine is four-ish to six-ish hours. Of course, there's variability there, so please don't pin me on that. But everyone is different, and I don't think anyone is immune to the effects of caffeine. Last I checked, there's no caffeine immunity. People will say, oh, I can drink a whole jug of coffee and then go right to sleep. Well, it's probably affecting your sleep architecture. Sleep architecture is how you cycle through the various stages of sleep. And remember, there's REM sleep, rapid eye movement sleep, and non-rapid eye movement sleep. And those are different types of sleep. We cycle through different stages of non-rapid eye movement sleep with stages of REM sleep throughout the night. And caffeine can mess these up. They can keep you up at the beginning of the night. It can make it harder to fall asleep. If you wake up in the middle of the night, it can do all kinds of things. and for people's caffeine cutoff time 11 a.m is almost the latest i do for almost anybody unless they're really phased delayed and going to bed really late like 2 a.m or something but most of the time i tell people look you can have all the caffeine you want before 11 a.m and don't have extra if you don't sleep well that's it that's a thing that we've had to really add in the last what 10 years since all these energy drinks became famous and now you can go get like granola bars with caffeine in them. It's nuts, right? So caffeine is on the list of sleep hygiene. Stopping work at least a couple hours before bed. And I feel the hypocrisy while I say that is palpable. I can feel it in my body right now. But really trying to get people to stop working. Your husband's in the background like, yeah, I would love it if that was the case. and then there's you know email falls into that category social media oh don't do it in the middle of the night don't do it before bed it's really not helping anything if you ever been scrolling on social media put your phone down and thought I feel great or like I feel better probably not probably not that's probably probably no I tell people to really try and avoid using their phone before bed. It's just not a winning strategy. We've already talked about cooling down your room. With napping, I would also put a caveat on napping because there's naps that are problematic and there's naps that aren't problematic. If you've got a patient coming in, no problems with sleep at night, tells you they take a nap every day, please be with them. Cool. No problem, right? You do you. But if you have a patient coming in saying, oh yeah, I take a two-hour nap in the afternoon, can't get to sleep at night at all. We'll say, well, I know. We know why, right? I always tell people for the daytime who have trouble sleeping, if you have to take a nap because you have to, like, operate heavy machinery, like a car, or, like, argue with a teenager, or do something really, you know, like, ugh. You get a 25-minute nap-ertunity, meaning you set an alarm for 25 minutes, then you can get into bed and try to sleep, although it's really not trying because we don't try. Sleep is letting go. But you get into bed, You have 25 minutes. The alarm goes off. The jig is up. You're out of bed. It's an opportunity. And by doing that, you're probably not going into deep sleep. You're probably staying in NREM stages one and two sleep, and then you're waking up. And if you were in NREM stages one or two, and I came over and I poked you, you'd just kind of be like, wow, why'd you wake me up? If you were in NREM stage one and I poked you, you'd say, I wasn't sleeping. Yeah. But if you were in NREM stages three or four, you would kind of be like, oh, why'd you do that? You'd be grumpy, you know, not grouchy. You'd be grouchy, not happy. So you really don't want to get into that kind of deep sleep during the day because when you deep sleep during the day, it's going to take away from your sleep pressure at night. We should probably define sleep pressure for a moment here. Sleep pressure is the pressure that you develop throughout the day that helps you fall asleep at the start of the night. while you sleep, your sleep pressure drops, and you wake up in the morning, you don't have any left. And then all day you build it up again, and that's what helps you fall asleep at the start of the night. If you spend out some of that taking a two-hour nap, you've got less at the start of the night. Right? And one of the common topics amid sleep pressure is caffeine. And I'm going to butcher this because it's very simplistic, and I'm sure that there are people listening to this who are going to say that adenosine receptors are much more complex than I'm making them out to be, but this is how I talk about it with patients, and they understand it. I ask if anybody's ever seen hockey, like a hockey game on TV or whatever. People will always say yes. I've never really had people say they don't know what this means. And I say, imagine the goalie who's trying to keep the pucks out, right? Keeping the pucks out. That's like caffeine. When you drink caffeine, what it's doing is it is guarding your adenosine receptors, and the adenosine is coming in and it's blocking the adenosine from getting in the receptors, blocking it, blocking it, blocking it. And then as soon as the caffeine wears off, it's like the goalie skates off the rink and says, peace, I'm out, I'm done here. And then the adenosine rushes to fill in those receptors. And then you experience that thing called the caffeine crash. You've experienced a breach, like, oh, you kind of like feel it wear off. All day, what that caffeine is doing is it's blocking those, it's kind of blocking your buildup of sleep pressure. And then you kind of get it all of a sudden. And there's this giant temptation to try and drink more caffeine or eat a bunch more sugar to ward off that crash. Don't do it. Don't do it. All your caffeine done before 11. Don't have extra. Yes. And then, of course, we can get on to my spiel about supplements and medications, which is off-label from sleep hygiene. I'd say that those are my greatest sleep hygiene hits. Before we get to supplements, I did want to end. Thank you for the sleep hygiene summary. That's great. I do want to ask, in terms of the time in bed restriction and even the stimulus control, do any of the techniques that you talked about change depending whether or not we're talking difficulty of sleep initiation versus someone who has trouble staying asleep? Because I feel like I hear different flavors of difficulty sleeping, and more often than not it's the patients who get up multiple times or have a hard time kind of falling asleep after they wake up, which feels kind of different than someone who has a hard time falling asleep in the first place. Do these tools apply across the board? Do you alter your approach depending on what issues they have, Or I guess how do you address variations in insomnia? Let's give a couple quick definitions. So the three types of insomnia we're talking about are early insomnia, difficulty falling asleep at the start of the night, middle insomnia, waking up in the middle of the night, being up for a while, then going back to sleep, or late insomnia, waking up early in the morning, never, ever getting back to sleep. Beautifully, CBTI is for all of these people. when people wake up in the middle of the night maybe they've run out of sleep pressure and they need to build up some more sleep pressure to get back to sleep maybe they're waking up and then they're getting stuck on a thought pattern there's all types of things that can cause people to have difficulty with sleeping but the beauty of CBTI is that it works on all of them so I take all comers in my clinic, all three types yes I was going to say about the sleep pressure that book you were referencing, it has a really nice depiction of if your sleep pressure just goes up in a straight line, and then if you take a nap, it kind of dips down, and then it'll start to go back up after the nap, but it's not going to reach the same height it did if you didn't take that nap. And I feel like for people that wake up in the middle of the night, that's the most common that I get in my clinic. People are complaining, and I think people are so worked up or so tired by the end of the day that they can fall asleep and they get that initial block of, like, core sleep and their sleep pressure goes down enough that then their brain's like, oh, they wake up and they're like, oh, I'm in my place where I worry. Let's get going. And then they're just, like, off to the races, and they're trying to force themselves back to sleep, which doesn't work because, as you said, sleep is passive, and that creates the problem. So that's the most common complaint I get from people. Well, here's a couple off-label comments based on my clinical practice. One thing I've learned with countless patients at this point is that, and I don't know if anybody actually knows the answers to some of these questions because they haven't necessarily been studied, but that linear relationship that you were describing, I'm not convinced that it's linear. You might earn one, like if you're awake from 1 p.m. to 1.10 p.m., if it's a one-to-one ratio of earning sleep pressure, let's say that's 10 minutes you've earned, 10 minutes of sleep pressure there. I've had other patients who find that if they go to bed at 9 p.m., they wake up too early. They're screwed. But if they go to bed at 9.15 p.m., they can sleep an hour longer. They earned more sleep pressure later at night when they were fighting to stay awake harder because they were more sleepy. They were working harder against the system from 9 p.m. to 9.15 p.m. And therefore, instead of waking up at 4 a.m., which they would do if they went to bed at 9 a.m., they might make it all the way until 5 a.m. if they go to bed at 9.15 p.m. And a beautiful case of a patient who found this out. She was phase advanced, and she also said I could share a story. And she found that if she went to bed at 8.50 p.m., no good. But if she could make it until 9 p.m., boom, she got an extra hour of sleep. Something magic about those 10 minutes. And they were hard 10 minutes. She's fighting it, right? Yeah. But if she could just make it, she'd get way more sleep in the morning. And so a lot of times people will go to bed early at night when they're feeling exhausted, fatigued. somewhat sleepy but if they can just stay awake a little bit longer they'll be less likely to wake up in the middle of the night now the other thing I will tell patients is the more stress and anxiety and not dealt with worry you have the more sleep pressure you need to keep yourself asleep because those things work against sleep pressure so you have a choice you can build up more sleep pressure or you can tamp down some of the worry and anxiety so you don't need as much. And that's what a lot of the drugs that we're probably about to talk about, probably about to talk about, help deal with. They help simulate some of that sleep pressure, right? In one way or another, because a lot of these drugs have different mechanisms. People trying to force themselves to stay up, I guess the risk there is like, they fall asleep for an hour on the couch, and then they're just... Yeah, and you don't want that. So it's a delicate dance. And that's why instead of giving people a wake time and a bedtime at the first visit, which is commonly done in CBTI, I always do just a wake time first so that I naturalistically see when people get sleepy given that wake time instead of giving them both at the same time. And we actually did just publish, a medical student published data from my clinic. Gabriela Gutierrez just published a paper on my most recent 200 patients to come through my clinic and our outcomes from CBTI. So doing it this way really does work. Yeah. And it's less hard for the patient because if you miss, and what I mean by miss is if you give the patient a wake time that ends up being a miss, then you've given them a bedtime, they're more likely to drop out and quit because it was totally, totally a bad fit. But if you don't give them, if you give them a wake time that's not exactly perfect and then they still get to wiggle around at their bedtime, you can fix it. they're not as likely to quit. Well, I think we should talk about substances. So, Ms. Ima, she's doing all the sleep hygiene stuff. She's working the CBTI. But remember, she's been cycling through the OTC, antihistamine, melatonin. She's throwing some glasses of wine in there. So how do we fix this issue? Okay. Let's start by talking about what some of these substances do to your sleep. once patients understand more about what some of these substances do to their sleep they're much less attached to using them the interesting thing about alcohol which i'll start with is that it really does kind of help you fall asleep faster it helps you get unconscious faster and then it helps you fall asleep faster and one of the jokes i like to make with patients is if i went outside the hospital onto the sidewalk and I saw someone get, you know, just walk into a, walk into this giant, very poorly placed like pole outside of our building that it's easy to walk into and knock themselves out. And they were lying there on the sidewalk. The patient and I, we would, we, everybody would know this guy is not asleep. He just got knocked out by this poorly placed pole. But boy, does he look like he's asleep, right? Hmm. So you have to remember that when you go to sleep as the effect of a substance, there's real odds that it doesn't look like sleep necessarily would if we hooked you up to an EG cap and we were measuring you, right? Because the guy who got into a war with the PG&E paddle and pole and lost outside the office, you know, he's unconscious. He's not sleeping. So I tell people, look, the thing about alcohol is, yeah, you'll get unconscious faster. You fall asleep faster. It might not affect your deep sleep too much at the beginning of the night, but then it's going to cause you to lose REM sleep. It's going to cut your REM sleep short, and it's going to cause you to wake up more in the second half of the night. And it just so happens that the second half of the night is really when you do more of your REM sleep. quick segue is that is to say that most of your slow wave sleep the deep sleep is in the first half of the night most of the REM sleep is in the second half of the night why well one of the evolutionary explanations is just that REM sleep is actually not very deep sleep it's lighter sleep it's easier to wake up from that now your body's paralyzed because you don't want to be acting out your dreams and that was an evolutionary gift to us right so we're not acting on our dreams during REM sleep but back out on the prairie like we talked about before if you go to bed at the start of the night, you want to get your deep sleep then. The harder to wake you up from sleep then, because you're pretty sure there's no lion around to eat you. But as the night goes on, you know, who knows? Lion might be here. So better to get our lighter sleep earlier in the morning. And if you look at what brainwaves look like between REM sleep and being awake, there's more in common than there is in common between deep sleep and being awake, right? So back to the story, alcohol messes with your REM sleep. It causes you to wake up more and it fragments your sleep. It's not doing great things for your sleep. If a patient comes in and says, oh, I'm drinking one or two nights a week, I ask them to stop drinking for the five weeks that they're in treatment with me. I say, look, you haven't been sleeping well for 50 weeks, 500 weeks, whatever it is. Give me five weeks, five weeks. Come on. Is this worth it to you? Now, in contrast, if someone comes in and says, yeah, I drink a bottle of wine a night. We're not going cold turkey on that. That's a bad idea. Bad idea. I don't do alcohol withdrawal stuff. Not a thing. Now, if it was a bottle, I think actually I'd probably be pulling in a colleague and doing some substance abuse work first. But let's say it was like two glasses of wine a night that someone was drinking every night. I would say, okay, we need to cut that down. I want it to be like three-ounce pour a night. That's it. Three-ounce pour. And then once you're done drinking your three-ounce pour every night, you need to fill your wine glass with overpriced bubbly water or whatever it is that you don't normally drink during the day. It has to become your nighttime-only fancy beverage, and you have to drink it out of your wine glass because the behavior has to be there. And I've treated two sommeliers in the past, and, you know, you can imagine. They're like, I'm pouring LaCroix in my $250 wine glass. Yes, that's what we're going to do. Both of them, by the way, came around, and, you know, it's amazing. These people spit out money for a living. They taste the wine, but, like, they're literally, like, spitting out really expensive things. So it was a hurdle to overcome, but the point just is that alcohol was not helping them. And just because you used to be able to drink a whole bunch and it didn't affect your sleep, I'm doing air quotes right now, and it can be now. So I would target that. And you didn't mention anything. Okay, supplements. We'll go to that first. Sure. There's a lot of common supplements people talk about with me. You know, people say, what about magnesium? And I'm like, great. That's my preferred placebo. Just get one that's NSF certified and go nuts. You know, if you're taking too much magnesium citrate, you will know. You will be in the bathroom and you will figure it out quickly. You don't need me to tell you, right? But most Americans are probably magnesium deficient. But as you all know, drawing a magnesium lab is pointless. It changes every, what, number of minutes? It's not something that people really just do to determine if they're deficient in the world. So if people want to take that, I'm over it. Okay. Going on. Yeah. Now, if people come to me and they say, oh, but ashwagandha or glycine, and I'm just like, well, we don't have great data. Also, that stuff could be expensive. and if it worked, you wouldn't be here doing an intake appointment with me. Right? Also, these supplement manufacturers, some of them get NSF certification, NSF certification for sport. There's some that do good stuff. Right. But I'm not convinced that supplements are going to solve this problem. And there are supplements that will make this problem worse. And I think, why don't we go to melatonin next, and then let's cover marijuana, because we have to cover marijuana. Sure, sure. Even though some of your listeners will be in states where it may not be legal or used that much yet. But there are states where providers are actually, I think, recommending this to patients. And I really want to be able to give my two cents on that. But melatonin is a supplement that a lot of patients will come in and say, oh, yeah, like my doctor said to take that. And I just kind of think, oh, I'm so sorry. Who's your doctor? I need to send them a message, right? There are very few patients who actually, and I hate to use the word need, but have a very, very good shot of needing to be on melatonin. And those are patients taking beta blockers. Anything ending in allol, I always check, is that a beta blocker? Propanolol, metoprolol, you know, allol. Beta blockers actually do inhibit melatonin secretion by the pineal gland. That's real. And there is a, there are clinical trial data showing that giving these patients two and a half milligrams of melatonin before bed can really help with their difficulties with sleep onset. These patients typically have what's called a ferroli insomnia. It's actually on the box. It's in the label that these drugs can cause sleep problems. And I had one patient who's given me permission to share his story who I didn't take with and at age 35 said he was diagnosed with high blood pressure and was put on a blood pressure medication at this time a beta blocker and believed his insomnia to have started because of his distress about having been diagnosed with high blood pressure. Oh, I saw this man decades later, decades later. So sad. And he could not change his medication. He had to be on this particular medication for a whole host of reasons. He couldn't use any of the ACE inhibitors or other blood pressure medications. And all he needed was a melatonin supplement. Two days later, this man did not need treatment at all. He continued. He finished because he wanted to. But his overwhelming emotions, he said at the end, were, I am very, very satisfied. I am very, very angry. I am very angry. So if you have a patient who's on a beta blocker and who is having trouble falling asleep at the start of the night, I'll give you guys a link to the article of this clinical trial so that physicians can read it themselves and see. But that is an appropriate use. Have you heard of that, Paul? I knew that beta blockers had insomnia as a potential side effect. I had no idea of the mechanism, and I have not been prescribing melatonin. Yeah. So I think up to a third of people who are prescribed these drugs experience this. Now, my understanding as a non-physician is that beta blockers are now considered maybe a fourth-line treatment for blood pressure management. There's other options that are more commonly used, but beta blockers are still commonly used for other things. Paul, what would you put this at? Yeah, no, we've talked about this a bunch. Yeah, it's sort of last line at this point now. We've talked to blood pressure gurus about this, and really it's not one to reach for unless you have one of those other indications that you're talking about. So, yep, you're going to say that's exactly right. And for coronary artery disease now, the long-term use of beta blockers kind of being taken out. So the two main reasons now are heart failure, AFib, that I would see patients on it off the top of my head, I guess sometimes for migraines, people take them too. I mean, professors take them for public speaking, but that's about what I commonly will see with people who say, oh, I take those occasionally, and I'm like, occasionally, interesting. I've recently learned a little bit more about that. But you're mentioning about heart disease is an important one. So actually, okay, let me back up a little bit. Melatonin is a hormone. It's a hormone that you can buy at Walgreens in the United States. If you go to many countries in Europe, you need a prescription for melatonin. You cannot just go buy it in a store. Now, in the U.S., you can't really overdose on this stuff and hurt yourself too much. So I guess, you know, here we are. You can just go buy it. However, there have been at least two studies that have tested a large number of brands of melatonin and found that these bottles have things in them that they don't say they have in them. I believe one study found that one brand had CBD in it. One brand had actual serotonin in it. And sometimes melatonin has anywhere from 40% of what it says to 448% of what it says in the bottle, some ridiculous range. And a key thing that important to remember that I learned about from Michael Grandner who just awesome is that when a melatonin supplement is manufactured by one of the larger manufacturers they are targeting the actual pill to have what the bottle says it has in it on the day of its expiration So that might be in two years three years So the people designing the supplement are then taking into account the degradation factors And let say you got a pill that says it's got five milligrams in it. Well, when it starts out, it might actually have seven. But in two years, it's going to have five, because that is what the testing standard is. So there's a lot to be aware of when it comes to some of these doses. And then if we talk about what is an appropriate dose, in the stores you'll see things like 5 milligrams, 10 milligrams. An appropriate dose for using melatonin, which is typically the appropriate use cases when you're trying to shift your circadian rhythm to be on a new time zone for travel, is about 0.5 milligrams. 0.5 milligrams. And that's taken at the time you're going to bed. No, that's like three to four hours before your target bedtime at wherever your destination is. So, unfortunately, there's a lot of misuse of melatonin going on. And recently in the news, there was this huge flashy headline of this abstract that found, They looked at like five years of health records for like some like 130,000 adults who used melatonin for at least a year. And they matched them to another 130,000 or something. And these were people who were quite sick. And they looked at these people in terms of likelihood of having heart failure, requiring hospitalization, dying from any cause. And what they found was that they looked at this exposure group, which is people who were prescribed at least one milligram of melatonin, and they compared that to people who were not prescribed that. And they found all these outcomes that were worse. But the issue here is that the people who were not prescribed melatonin could have been buying it from the store. How often are people prescribed melatonin? They didn't even control for that. And then they also, people who are more sick or who may be having some of these problems may then be told to take melatonin by their physician. So this abstract got all kinds of headlines. It was not peer-reviewed. It was just published before peer review. And way, way, way more data actually show that melatonin has beneficial properties to people with heart failure and other heart problems. So it was an unfortunate state of affairs that threw melatonin under the bus. I, of course, love any opportunity to talk about the proper use of melatonin and the fact that most people actually should not be taking this. And if you think about what melatonin is, it's the hormone of darkness. it's the hormone of darkness so if you look at mice and rats and and animals that are awake in the night their melatonin is still high at night but they're awake we associate it with restfulness and being asleep so it's it's it's this unfortunate state of affairs that people seem to think that this is a good thing to take for their sleep when in reality it's like giving your body a message Like, hey, do the sleep thing now. And your body might think, okay, okay, so hormone of darkness, okay, so we're going to do the thing now. And you might go to sleep now and then run out of sleep pressure because you went to bed at the wrong time. You might wake up and think, oh, why am I awake right now? Well, we went to bed early. We spent it out early. So when people say, oh, I'm going to try some melatonin for sleep, I say, no, you're not. Like, don't do that. Really. It's not a good plan. And unless you are on a beta blocker and you haven't tried this yet, you should try this in a controlled fashion. Make sure you get an NSF certified, you know, manufacturer. Unfortunately, sometimes these are hard to find in the lower doses. But I have found a couple that I have patients using that I know work. And my litmus test for if brands work is if they work on the beta blocker people in one night, you know. yeah i i paul do you get the person that takes the melatonin like they they tell you they wake up in the middle of the night and they take the melatonin no no i've not encountered that i yeah and and i clearly i i was thinking people take it like an hour or so before bedtime i didn't realize it was three or four hours before your intended bedtime to take it so even i you know that's for a 0.5 milligram dose now some people take a larger dose right at bedtime like the study that I was talking about the 2.5 milligram or people take a 3 milligram, and that's more of a knock you out situation. Got it. More so than if you take a 0.5, you're telling your body like, oh, it's time to start making, like it's kind of like getting you started. Like it's time to start secreting that. Whereas if you just take a whack-a-moe dose, like, oh, here it is. We're going to take it. Right. Right? So it's a different way of thinking about it. I had a patient who was accidentally taking his child's pediatric melatonin dummies, and he's like, and I have to admit, I have never slept better. So just apropos of the lower doses being more effective for some folks, I think about that story all the time, and it just makes me smile. Yeah. I mean, it is interesting. Some people do find, like, you know, and I'd be curious to know more about that person's circumstances because I think it is a great tool that we can use appropriately. I just think that it's more commonly used inappropriately. And then if we make a catch-all for all of the other supplements, like glycine, I mean, I have seen patients spending hundreds of dollars that they really don't have to be spending on some of these supplements. That, you know, does it really cross the blood-brain barrier? Does it really do that? I mean, my biggest refrain is just when people say, oh, I'm taking all these things. And I'm like, okay, and you're here. And you said things have never been worse. and you're desperate and you'll try anything. So one of the tries that I'm going to ask you to do is to stop taking all this stuff. Put it in your, you can start taking it again in five weeks if you hate me and you don't want to take it. But almost always, by the time patients are done with CBT-I, they're like, oh, sweet, I'm saving money. And the people who are really saving the money are the people who are not buying all the expensive booze. Booze is expensive. So a lot of times people will be like, oh, I've lost a few pounds, saved a few dollars, I'm sleeping better. I don't know why I wouldn't just keep doing this. Paul, we went into the wrong field. I feel like all her patients are happy and satisfied. She's getting good outcomes for them. I can't always say that for my patients, but I'm trying. Well, let me say this. Other people, two things. One, I only treat anxious people who can't sleep because I've decided that they're the best and that this is still fixable, so I love it. I don't do anything else. You guys are doing everything. Some of the problems we get thrown at cannot be fixed. That is true. You guys are, like, my hat's off. I could not do that. But to tidy up on the alcohol thing is that I ask people to stop drinking for the five weeks they're with me, but then when they're done, they get to do an experiment, and they get to bring alcohol back. And then I say, keep a sleep diary and see how it affected you. And a lot of times people find that alcohol does not affect you just one night. alcohol can affect your sleep up to two nights. Now, again, this is an extrapolation based on the literature. This is not the CBTI literature. But if you think about it, the first night after you drink, your REM sleep gets compromised. There's documented cases of what's called REM rebound when you've missed that on REM sleep in other contexts, right? And when you have REM rebound, then you're displacing N2 sleep, which is a type of non-REM sleep. And a non-REM phase two sleep is important for certain types of emotional and other types of memory consolidation, right? So alcohol consumption, I always tell people, look, count on it. Like, let's assume it messes with your sleep or affects your sleep two nights. So if you're drinking every other night, by definition, almost all of your sleep is affected. And when people start drinking again, they often will realize, you know what? That really nice glass of wine on Friday, totally worth it. That cheap wine every night with dinner, not worth it. Right? So I tell people, look, all you're doing by cutting it out for this short period of time while you're fixing your sleep is learning the price of admission. All right. So I want to hear about marijuana. I would not be doing my job if I did not say Hormone of Darkness was the name of my goth man after college. But, yeah, tell us more about cannabis because I have a ton of patients that use either marijuana or CBD products or some sort of variation on that theme, and it's where it helps with sleep. So what is your spiel with that, and how do we do counseling regarding the use of marijuana for sleep? Because I feel like that's a real common – it's one of the most common reasons I hear that it's used in my patient population. When it comes to marijuana, we know less than we would like to because it's been illegal for so long that it's been very hard to study. now we're starting to get to study it more in the laboratory I do not personally study this I'm grateful that other people do let's get CBD out of the way from the get go the jury is still out we don't know don't know if it's really hurting I think that if it was really helping I would know because the wait list wouldn't be like years if it was the magic bullet we would have We would have heard about this. But unfortunately, I don't think that's the case. Here's why THC is scary. THC does help people at the beginning. It does help you. People feel like it helps them become unconscious faster. But when they use it within three hours of bedtime, they actually have close to 60% increased risk of wake time after sleep onset and more stage one sleep. And remember, stage one is sleep is the kind of sleep where if Matt was in stage one sleep and I went up and poked him, he would say I wasn't sleeping. And there have been studies showing that plasma THC levels tested against polysomnography show a dose-dependent relationship. So the more that it's in your plasma, the more wake time you're going to have after you fall asleep. And the problem is that even though it acutely helps you, in the beginning you do get more deep sleep, you get less REM sleep, which is a little bit of a mixed finding. But what's not so mixed is that with chronic use, you get tolerance to those effects. And then you need more. And when there was a study last year that showed that when people use it more than 20 days a month, which sounds like a lot, but a lot of people are using it that often for sleep, they do have more wake time after sleep onset, even as time goes on, not just acutely but chronically. and it messes with your sleep architecture because of this. So when you start to lose some of some stages of sleep, get more of one, get less of the other, and then it starts fluctuating, you're changing this beautiful dance that our bodies do during sleep, fluctuating in and out of these different stages. You're supposed to get light sleep, you're supposed to get deep sleep, and you're supposed to get REM sleep, and you're supposed to get it in a certain order. and when that gets compromised there's a lot we don't know about what that does to your health but chances are it's not great it's not necessarily good for you and if you give me a patient taking 5mg oh another pearl I think is that solpidum starting dose folks know what this is? starting dose for men or women there are you just won the prize so it does differ between men and women and this is the thing that i've learned is not widely known the starting dose for women is five the starting dose for men is 10 i think everybody should start at five personally but um that is something to know women should never don't start women at 10 if you bring me someone using thc every night for sleep and you bring someone me using you bring me someone using zolpidum every night for sleep the person on zolpidum is i can get them it's much easier to quit zolpidum i know this sounds crazy but the withdrawal effects from marijuana are i mean so sleep problems is one of the most enduring features of marijuana withdrawal no matter like kind of what time of day you're using it, people will report this. People get less deep sleep during withdrawal. They get more REM sleep. And that comes with, unfortunately, more weird and unpleasant dreams. And you know they're weird and you know they're unpleasant because you're waking up more. And when you wake up during REM sleep, which happens, that's when you're remembering those dreams. And it's really unpleasant. People will report just this is just they don't want to go to sleep because they don't want to deal with these dreams. and um it's the what when you're when you're quitting the marijuana and you start experiencing more rems because again rem was suppressed when you're using marijuana and now you're having rem rebound during withdrawal and rem rebounds can be days and days and days it's not just one night it can keep going and unfortunately we don't really understand how long that withdrawal is For some people, apparently, in the literature, it can be 30 days. I've had patients, it's months. Months. And it's very hard. So I really recommend not starting THC for sleep. There's better options, like cognitive behavioral therapy for insomnia. And if you want to go a substrate route, there's better substrates to use than marijuana. If you want to use a medication, there are better options. this argument that, oh, it's natural. It's a plant. It's natural. Tobacco's natural. It's a plant. Opium, also a plant. Arsenic, natural substances, right? The list goes on. So this whole natural versus not natural argument has got to die. Please help me kill it. So, so, so. What are the better options you were mentioning? Okay. I am not a physician. I'm not a physician. There are known risks of not sleeping. There are some risks that have been found with various sleep drugs. We know that some sleep drugs, for example, Z drugs, those can reduce, for example, your REM sleep duration. Right? But if you've got a patient who's like, well, I've been on this for a number of years, haven't gotten any therapy, but it's helped me go from, you know, it's gotten me to be able to sleep again. Does this mean I'm going to get dementia? My answer is no, no. I know you see headlines freaking you out about that. No. I mean, there are, when you look at the brain of someone using a Z-drug, Zolpidum, Z-drug, you will see or you can see that there's reduced slow wave activity and like suppressed power in certain ranges of sleep. So sleep may not look like what natural sleep might look like. and we don't necessarily know how bad that is. People assume like, oh, this is terrible. I've seen a headline. I need to get off this drug immediately because I'm going to get dementia if I don't. I've already been on it. And I tell people, slow your roll. You've been on this for 10 years. You're still fine. We can get you off of this, but we're going to do it very slowly. And I'll segue to that in a moment about how I help people get off of drugs. But some of the drugs that you may see people on, I think we talked about diaphanhydramine earlier, which is an antihistamine. I'd like to point out that this is a medication used for allergies. And here we are. It's an allergy medication. It's a sedating antihistamine. It's not intended for long-term use. I don't recommend that for a long-term solution. When patients come to me and say, oh, I'm using trazodone, for example, I'll say, okay, well, that's also an antidepressant. It can be used for sleep. And you have to be really careful when you take someone off of a drug like that because depression and sleep problems are highly comorbid conditions. And if you are effectively treating someone's depression with trazodone and they want to get off of it because they've heard it's a sleep drug, you need to reeducate your patient and say, okay, here's the risks, right? This is really important to talk about. I don't, I think all of us know that you're not supposed to be prescribing benzodiazepines to your patients for sleep. That's not what we're supposed to be doing. I don't prescribe anything because I'm not a physician. I'm a psychologist. But, and I understand that you often inherit patients who are already on them and say, Oh, my other doctor was giving me this and this is what I do. it's not a great long-term solution for sleep it does impact your sleep architecture it reduces slow wave activity i think the studies with slow wave activity have been with temazepam and these drugs all work differently some of them not all the work differently but a lot of them do work differently whether they're adrenergic receptor modulating or whether they're you know dealing with the wake-promoting system, these drugs work differently. I think one area of drugs right now, and I always know that these podcasts get recorded and they stay on the Internet forever and things could change. So keep this in mind. But I am seeing in my clinic and in the sleep medicine clinic at UCSF, CSF, I am seeing more patients who have the ability to use dual Rx and receptor antagonists or DORAs. I'm seeing more patients using some of these. Unfortunately, because there's no generics, they're still expensive. I think we're almost at the 12-year mark, so we should be getting close for all the lawsuits to have expired or whatever so you can get a generic one. I think these drugs for me in my clinic have been the easiest ones to help people get off of. So when people use these for a period of time, these have been ones we've been able to get off of much more easily than marijuana, than Z drugs, than benzos, than doxapin. And so if a patient is just saying, look, I've got to use one, which is rare for me. It doesn't happen very much. Most of the time patients get to me and they're like, look, I want off. I'm like, okay, we're going to make a plan for you to get off. We've got to talk to your doctor about it. Got to make sure they agree with it, and then we'll do the thing. But for the rare patient who's just like got to be on something, I've got to start something, And this, I think, is one of the better options, the Doras and probably Trazodone. Trazodone, you do see with some people, they get, I hate the word hangover, but it's the best way to describe it, just like a morning foggy thing that we don't really seem to see with the Doras. And that's probably because they work differently. They're antagonizing the weight-promoting orexin system, whereas trazodones, it's like a histamine serotonin and an adrenergic receptor modulator. So the drugs just work differently. All that to say, 99% of the time I have patients coming and saying I want to quit drugs. And the first thing I do is I say, does your physician or your prescriber know you want to quit the drugs? Actually, before that, I say, does your physician or prescriber know you're taking the drugs? because some of my patients, they'll go to Mexico, they'll buy themselves a whole bunch of Ambien, they'll come back, they'll do that twice a year, and they'll be like, well, he didn't really want to give it to me, so this is what I do. But now I really want to stop taking it because I saw this thing in the news, and so first thing we do is we disclose to our doctor that we're taking the drug, make sure we know, right? And I talk about why that's important because I'm a psychologist and safety and ethics and my license and the law. And then I talk about how we're going to reduce the medication. Is this a good time to go into that? I think so, yeah. And this will probably be, yeah, I think that's the last thing we have to cover. Cool. So this is something you can absolutely do with your patients, and it is something you can initiate in an appointment with your patients, and then you can probably deal with MyChart messaging back and forth to get the job done with them. They actually find this kind of fun. and what I do with them is I use something called the subjective units of distress scale, or the SUDS scale. Paul, this has to have come up in addiction medicine for you, at least some, but I don't know, maybe, maybe not. Yes, yeah, that's all sounds like a lot of this minor. Great, great. So what I do with the SUDS scale goes from 0 to 10 or 0 to 100, whatever floats your boat, is I say, okay, let's imagine that 10 is the most stressful thing that you could do. You really don't want to do it awful, terrible. and I have them give them an example. And then I'm like, all right, let's do a one, something that is, like, positively not stressful. Sitting on the beach with tacos, you know, not stressful, great. So we make their scale. And everybody's scale is a little bit different. And, you know, I get a few examples going on the scale. And then let's take a patient, let's take a classic, let's take a classic, zolpidum 10 milligrams, patient coming in, saying, look, I just saw this in the news. I really want to quit this. I've been on this for 15 years. And I say, okay, all right, okay. And let's assume the doctor knows, has already given their blessing for me to help them taper off. We're all in cahoots. Everybody's in agreement. What I do is I say, okay, so 10 milligrams. So how stressful would it be to go from 10 to 5? And the patient says, oh, my gosh, that's a 10. Tried that before. Worst rebound insomnia ever. It was terrible. I tried it. Can't do that. That's a bad idea. We're not going to do it. So that was a 10. And I was like, okay, we're not doing it. We're not doing it. Don't worry about it. and then I say, what if we went from 10 to like 9.75? And then typically the patient will laugh at me, say, ha, ha, ha. Well, they don't make that pill size. Also, that's a joke. And then like, well, great. Joke's on you. We're doing that. And since you've rated that a one, we're doing that, and here's how we're going to do it. I have them buy what's called a gem scale from Amazon. and you and I and everybody know that anybody who is wealthy enough to have gems is not weighing them on a $20 scale that they bought on Amazon. That's not happening. You and I both know what that is. That's a scale. It's a drug scale. It's a drug dealer scale. It is what it is. I said it. I said what I said, and I have the patient buy it on Amazon, and then I tell them, look. Okay, immediately go into a watch list. Oh, yeah. And then it's even more fun. Then we get a mirror, like a mirror and a razor. And I'm like, all right, get out your bandana, full breaking bad setup. And then I'm like, get out your calculator. Because, of course, these pills, this 10 milligram pill does not weigh 10 milligrams. The 10 milligram pill might, let's just for round numbers, say it weighs 20 milligrams because it's got fillers, dyes, colors, whatever in it. So we have to calculate how much he's got to shave off. in order to get to 9.75 milligrams. And then guess what? That's what he's doing for two weeks. Two weeks. Comes back after two weeks and says, hey, that was a joke. And I'm like, cool, so how scary would it be to go to 9.5? Generally, that's a one. We do that again for two weeks. And if you keep doing this, remember, this guy's been on it for 15 years. Who cares if we take a long time? Then typically he'll go to 9.5. Then he'll be like, you know what? Next time, let's go from 9.5 to 9. Now we're talking. Now we're starting to go down by half a milligram every two weeks. Something magical happens at five milligrams. Whenever they cross the five milligram threshold, there's like this like rebound several nights of drama that happens, and I get a message saying, oh, God, it's happening. And I'm like, no, no, just ride it out. Take an extra week. And as people are tapering, if something stressful happens, I say, look, let's just take an extra week at that level before we go down again. So it looks like steps. Some steps are larger than other steps. If you've got a stressful life event, we stay at that step until there's not. And I almost never do it faster than every two weeks because people do need a few nights to adjust each step. I say, look, it's going to be psychological for a few nights. We know it's not physiological because it's almost nothing, right? So you just got to like mentally get there for two days and then you'll be back. And this works for so many drugs, even the ones, you know, I always check with the physician. But most of the time, even if the bottle will say, oh, you can't cut it or whatever. I talked with the doctor. I'm like, well, can we cut this one? And they're like, well, actually, you can. This isn't, you know, an issue for this one. Even this extended release pill is not necessarily an issue for this. So, you know, I always check with the doctor about what we can do with what pill. And some of them are powders. And you open them and you can just dump out a little bit and then put it back together. But this method, this slow and steady wins the race is what I remind patients. Like, look, you've been on this for 15 years. You're not going to get off of it in five days or five weeks. And most patients have already tried to quit themselves before they tell you. They've tried because they'd rather come back and tell you, oh, I already quit that. Right. But if they're coming back and they're like, you know, I want to try, they've probably already tried. Yeah. So, yeah. That is, I think that's a brilliant approach to that. And it is common to find the patient that's been on Zolpidem for 10 years or more. Or Alprazolam for 10 years or more. You know, there's all these medications. I think we need to start wrapping up. And, I mean, we've gone through so much. This has been amazing. All high-yield stuff. Why have to plug a few things, right? Yeah, you get the plug things. How about we usually ask you, before plugs, any favorite take-home points you want the listeners to remember. They're probably going to have to listen to this twice. I would recommend that for people because you're going to pick things up. So do that space learning. But what are the take-home points, like two or three, that you really like? Wake up at the same time every day. Okay. It's going to make you, by default, start to get sleepy at the same time every night. It's the magic thing. I can wave this wand, make you wake up at the same time every day with an alarm. I cannot wave this magic wand and make you fall asleep at the same time every night. Focus on the wake time, not the bedtime. If you pick one thing, start having your patients just wake up at the same time every day. You don't need supplements for sleep. All right. And what are we plugging today? We're plugging cotton sheets and cotton blankets for the world. Please. I don't care what brand. Please. And get rid of your duvet, your comforter. put it on the couch snuggle with it during TV time another couple things that I was thinking about is if you have patients with tinnitus which is a big sleep killer for some people I've had some patients have a lot of benefit from using these things called Oslo earbuds not my company I don't work with them, nothing of that but I mean hey I'd love to someday call me right but at the same time these earbuds They do this little noise thing, this white noise thing, and it helps patients with tinnitus sleep. Patients with tinnitus are at high risk for using benzos for sleep, and if I really want to keep them off. So these seem to help because they're really comfortable and they make a nice white noise. And the last thing I'll plug is just, and I do advise this company, so I want to be really transparent about that, but I know CBTI can be hard to find. So this group of Argentinians approached me a couple of years ago, and they're like, we want to make a digital version of CBTI, and we want to make it good. And I said, cool, as long as you promise not to sell out and always be available. Because a lot of the digital CBTI platforms, they are good, but they've been taken off the market and customers can't get them. They're sold to insurance companies now, and so you can't just go out and get them. So they're gone, right? and you read the clinical trials and you were like, oh, I want to go find that digital CBTI for my patient. You can't. But the one that I've been helping is the – it's called REST. And this is a tailored CBTI approach that does do the stepped wake time, then bedtime approach. And they've kept it affordable. And they're going to have an area – they have an area for clinicians where you can go and, like, try it, get a deep discount for your patient and that whole thing. They've designed it with busy primary care people in mind to try and give them an option, especially since insurance doesn't cover CBTI for a lot of patients, which drives me crazy. So I just want to, even if you don't use the REST app, just digital CBTI and even the book that we talked about, Matt, self-guided CBTI, it can work. So even if you can't get an individual therapist or a group therapist like me who can do CBTI for you, So digital CBTI can work. A book can work. You can do this. It's not rocket science. It's not that hard. And you can fix your sleep. Sleep can be fixed. It's not an impossible problem. This has been another episode of the Curbsiders, bringing you a little knowledge food for your brain hole. Yummy. Great. Thank you for preempting the holes that Matt has now been shouting out recently, Eddie. Still hungry for more? Join our Patreon and get all of our episodes ad-free, plus twice-monthly bonus episodes at patreon.com slash curbsiders. You can find our show notes at curbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox. This includes our Curbsiders Digest, which recaps the latest practice-changing articles, guidelines, and news in internal medicine. And we're committed to high-value practice-changing knowledge, and to do that, we want your feedback, so email us at askcurbsiders at gmail.com. Reminder that this and most episodes are available for CME credit for all health professionals through vcuhealth at curbsiders.vcuhealth.org. Special thanks to our writer and producer for this episode, Dr. Edison Jang. And to our whole Curbsiders team, our production is done by PodPaste, Elizabeth Proto does our social media, Jen Watto runs our Patreon, Chris Bichumanchu moderates our Discord, Stuart Brigham composed our theme music, and with all that, until next time, I've been Dr. Matthew Frank Watto. I've been Dr. Edison Jang. I like the sound of that, Eddie. and as always I'm me Dr. Paul Nelson-Williams thank you and goodbye