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Episode 42: The Science of Sleep with Dr. Aric Prather
35 Plays1 year ago
Joe and Rolf talk to Dr. Aric Prather, a clinical psychiatrist at UCSF and author of the new book "The Sleep Prescription: Seven Days to Unlocking Your Best Rest" about why sleep is important, the relationship of stress to sleep, and how to tune your body and environment to get a great night's sleep.
Special Guest: Aric Prather.
Recommended
Transcript
Introduction to Dr. Eric Prather's Work
00:00:08
Speaker
Welcome to Cognation. I'm Joe Hardy. And I'm Rolf Nelson. On today's episode, we have a special guest, Dr. Eric Prather, who is a professor of psychiatry and behavioral sciences at the University of California, San Francisco, where he co-directs the Aging Metabolism and Emotion Center. He is also a licensed clinical psychologist who helps lead the UCSF Insomnia Clinic, where he practices cognitive behavioral therapy to treat patients with insomnia.
00:00:39
Speaker
So he's got a robust research program as well as a clinical program. And he also recently wrote a book. So we're going to talk a bit about his research and, you know, a little bit about what he does in
Journey into Sleep Research
00:00:52
Speaker
the sleep clinic. I think this is going to be an interesting topic for anyone who sleeps, which hopefully is everyone listening. Welcome, Eric. It's great to be here. Thank you.
00:01:02
Speaker
Yeah, Eric, you want to tell us a little bit about sort of your background, how you got into what you're doing and sleep research.
00:01:09
Speaker
Yeah, I'm happy to. So I've been at UCSF for kind of over a decade now. But my interest in sleep really started when I was in graduate school. So I completed my graduate training at the University of Pittsburgh, which in Pittsburgh, Pennsylvania, which actually has like a really kind of long standing historic sleep medicine interest and kind of center there.
00:01:34
Speaker
My training was specifically in something called psychoneuroimmunology, which is kind of a subfield of psychology and psychiatry that's interested in kind of psychological and behavioral
00:01:50
Speaker
factors that influence the immune system. And so when I started graduate school, I was really actually focused on stress and how it impact the immune system. And so we do a lot of research where we bring people into the laboratory and stress them out, kind of draw their blood and then take it into the lab and try to
00:02:08
Speaker
understand what's happening with their cells or kind of proteins that were being produced and stuff like that. And then as I was continuing to do that, I was starting to hear more about and read more about kind of these effects of sleep on the immune system. And interestingly,
00:02:27
Speaker
in the human literature, when you deprive individuals of sleep, they show a lot of the same sort of changes in the immune system that you see in the context of acute stress. And, you know, that was kind of interesting that that was going on in that sleep field. You know, for me, it was there was this clear connection between stress and sleep. Right. I mean, it's this bidirectional process. And so it seems strange to me that there are all these folks in the kind of the stress field kind of focusing on the immune system in the sleep field, focusing on the immune system. And so
00:02:55
Speaker
know, I wanted to try to bridge that. And so, you know, as I kind of went through my graduate training, you know, I started talking to more and more sleep researchers, we integrated some sleep measures into the studies we were running.
Clinical Work at UCSF and Insomnia Clinic
00:03:07
Speaker
And that really kind of kicked it off for me, I kind of, you know, my, my dissertation was on
00:03:15
Speaker
sleep and its impact on vaccination response, specifically antibody response to the hepatitis B vaccination series. And, you know, for many people who do, who have done dissertations, like oftentimes, like you do it doesn't work out, you move on, kind of figure something out. Mine actually was like very enlightening. And, you know, there was kind of this strong signal of kind of sleep duration predicting how well people responded to the hepatitis B vaccination series. And so I kind of carried on with that, you know, I mean,
00:03:42
Speaker
We ran other studies around vaccinations, looking at other studies, looking at kind of susceptibility to infectious illness. And that kind of success kind of bred more and more investment in this area. And then as a clinical psychologist,
00:03:57
Speaker
you know, I certainly appreciated the role that sleep played and kind of mental health and our physical health and where it may be a leverage point to kind of improve lots of other things in people's lives. And so, you know, after graduate school at Pittsburgh, you have to do as a clinical psychologist, you have to do kind of a one year internship where you just do clinical work to graduate. And so I and it's a match system. So you kind of like
00:04:21
Speaker
you know, visit a bunch of places, you rank them and then the schools rank you and then you get this letter, an email that just says like, you're going here. And so I ended up matching at Duke University Medical Center. And so we moved for one year to Durham, North Carolina. And it turned out at Duke, there was a
00:04:40
Speaker
supervisor there named Jack Edinger, who had been a pioneer in cognitive behavioral therapy for insomnia. So I got training in that. And so then I was like, Oh, wow, I have like all this sleep research, I know how to affect the immune system. And now we know what we can do with this, how we can impact people's lives with this kind of first line treatment for insomnia. And so, you know, when I went to UCSF,
00:05:02
Speaker
over the period of time that I've been there, we've kind of continued with this sleep work.
Interplay of Stress and Sleep
00:05:06
Speaker
We certainly do a lot of work on sleep and stress still and how it impacts kind of biological factors related to aging and kind of the immune system, but also kind of helped build this insomnia clinic so that we could get people the sleep they need.
00:05:20
Speaker
I wonder if you could talk a little bit more about your thinking on the relationship between sleep and stress. In your book, you talk about how stress can affect sleep and how sleep can also affect stress levels too. Though sometimes the relationship might not be as strong as people think that you can endure stressful events and they can be absorbed and not necessarily affect your sleep, but sometimes they can. So what's your thinking on this?
00:05:50
Speaker
Yeah, I mean, it was, so clearly we know that they're linked, right? And the insomnia literature is kind of built on this idea that, you know, there's a stressor that happens to people and, you know, that creates a period of sleep loss. And then there's kind of these perpetuating factors, these behavioral changes that kind of drive insomnia. And that feels, I mean, that feels pretty natural to people. They, you know, say I can't sleep because I'm so stressed out.
00:06:16
Speaker
Yeah, right, exactly. And so, but interestingly, if we kind of measure and this is our group has done this, but there's lots of kind of research studies around the country that have looked at this daily level stress and how well it predicts their sleep at night. And it turns out that
00:06:33
Speaker
you know, in many cases, kind of the amount of stress that someone experiences doesn't seem to be a very strong predictor of their sleep at night, with a couple of exceptions. So, you know, if the stressor is really big, right, like you get into like a car accident, or, you know, you know, something very, you know, you lose your job, right, those those kind of those will have reverberations throughout the day, throughout the night, right, it'll kind of get your mind really active and likely impact your ability to sleep.
00:06:58
Speaker
Or if the stressor happens kind of really close to bedtime, right? So we we've run experimental studies where we kind of stress people out right before bed and see what happens. And it turns out that, of course, you know, you do something really bad to someone right before they go to sleep. Like it's harder to sleep.
00:07:15
Speaker
And related to that, it's particularly hard for people that are high ruminators, right? They already have this tendency to kind of, you know, rethink, replay these experiences. And so that active mind will certainly get in the way. But when they're kind of more modest stressors or kind of like daily hassles, it doesn't seem to make as big of a deal. And I think that's really largely due to the way in which sleep is regulated, right? We have kind of these strong underlying biological processes that
00:07:43
Speaker
you know, ensure that people fall asleep, right? That kind of gate the experience of sleep and these environmental factors that really tell your body what's supposed to happen. And so, you know, little things may not make as big of a deal because those things play such an important role for people who, for sleeping.
Experimental Studies on Sleep and Stress
00:08:02
Speaker
I think
00:08:03
Speaker
You know, there may be exceptions where if someone's kind of already a little anxious or, you know, more likely be a ruminator, like those things that it may make those daily hassle stressors more powerful. But I think in general, and this is what the data suggests that it's not as strong in that direction now.
00:08:18
Speaker
The other direction in which sleep impacts how people experience stress, um, seems to be much stronger. And, and again, it's, this has kind of been done in like a numerous different kind of daily diary type studies where people kind of fill out, you know, questionnaires throughout the day, they kind of measure their sleep using say wrist actigraphy, which is kind of like a souped up fitbit type model to get kind of research grade measures of sleep behavior. And in those instances, uh, across the board in general, that.
00:08:48
Speaker
if people get less sleep than they typically do, they tend to be more reactive to stressors during the day. And in fact, their threshold for what they consider to be stressful is lower as well. So kind of little thing, I always, I always think of it as like little things feel like big things when you don't get the sleep you need, right? Kind of impacts your brain. Experimental studies suggest that, you know, people have, you know, are more reactive to threat
00:09:15
Speaker
Um, you know, there, there's kind of some neuroscience around kind of, you know, downregulation of the prefrontal cortex and, and all these sorts of things that seem to kind of put people on edge for, for stressors, because we just don't have kind of the capacity to cope in the same way that we do when we do get the sleep we need.
00:09:32
Speaker
I think that's interesting, too. Yeah, that for most people, an average day that they think of as, you know, a workday or a stress day, we've got a few things on your mind. And, you know, if they didn't happen your bedtime, if you're not sort of unusually, you know, prone to rumination that that your sleep may be okay, and that you can you can get by.
00:09:52
Speaker
Yeah, and I think also in terms of what you were saying there about the impact of sleep than on stress and reactivity distress, what I was thinking about when I was reading the book was, I mean, obviously it's hard to untangle
00:10:07
Speaker
what the causal relationship, causal direction, right? So I'm sure there's some good research there in terms of really pulling apart like what's driving what, right? Because you could imagine there might be a third factor, right? There's some underlying causes affecting both your stress response and your sleep response. So I'm wondering there, like what are some of the ways that you can know that it's actually sleep
00:10:30
Speaker
or lack of sleep that's driving the stress response versus some, you know, other causal factor, you know, that might be in your life.
Logistical Challenges in Sleep Studies
00:10:39
Speaker
Yeah. I mean the, you know, the primary way in which people attack this is with experimental studies, right? So where they manipulate the amount of sleep that someone gets. And so, so bring them into the lab and actually like poke them, they'll let them sleep. Is that kind of how it works? Yeah. Well, I mean, yeah.
00:10:55
Speaker
You know, they're different. Right. I mean, you know, right. So there's the kind of like the biggest hammer of kind of just not letting someone sleep all the time at all. Right. And so we're running a study right now where we are doing a full night of total sleep, a total sleep deprivation. And
00:11:11
Speaker
And I'll be honest, it's challenging. It's challenging for people. They're randomized to this, whether they get to sleep or not in the lab. And we have to do a lot of prep for these individuals so that they're prepared for this. What exactly would you do if you came to the lab and were told you weren't able to sleep? What would you do with your time? Make a list, make a plan. Because we have had instances where people come in and they're randomized to sleep deprivation. They're like, I'm out. I'm not doing this.
00:11:40
Speaker
We're like, well, what do you mean? That was the whole study. They're like, well, there was a 50-50 chance and I lost. Because it is challenging and we've certainly had instances where people have gotten four hours in and they're just like, I can't stay up anymore. You need to let me out of the study. And so we of course do that, but it's a lot of investment on our time and things like that for the study.
00:12:05
Speaker
But, you know, so that's one instance. Other examples are where they do kind of they make people stay up till, say, three in the morning. Right. So that so it's kind of partial sleep deprivation. Oftentimes studies will do this for multiple nights. So they'll kind of it's like a partial sleep restriction study. So they do three nights of like four hour sleep opportunities.
00:12:25
Speaker
um or they'll do um you know where they let people go to bed it so they'll or they'll wake them up at three right so they'll let them go to sleep and then they'll wake them up at three and those are ways to try to get at kind of specific deprivation so if you if you you know when you go to sleep the first half of your night is disproportionately slow wave sleep kind of that deep restorative sleep and so um and there's some circadian
00:12:50
Speaker
uh, rhythmicity to that. Um, and so if you deprive people of that first half of the night, you're actually shorting them a little bit on that slow wave sleep, where if you deprive it in the second half of the night, you're, you're more likely to short people on kind of REM sleep, which, which happens disproportionately in the second half of the night. So that actually, you know, that's both kind of cumulative sleep deprivation over days, but also in the, in the acute setting can be kind of try to get at some of the specificity about what it is, what is it about sleep that, that might be important. Right.
00:13:18
Speaker
Um, and then, you know, and then more recently people have been moving into models where they try to get people to do sleep deprivation at home. Right. And so, so we've kind of worked with the, in this space and it's, it's really hard to know if people are really being sleep deprived, but we'll do things like people have to check in every 15 minutes or every 30 minutes, right? Either by text or by email so that.
00:13:39
Speaker
you know that they're like alert during this during at least those times like you can't know for sure um an alternative would be you know if we could put people to send people home with um you know single lead EEG that they can wear so we can actually track brain activity around sleep and wake um you know
00:13:56
Speaker
And I think as those devices become more easily accessible and cheaper, that's what people will move towards as a way of way of getting kind of in home kind of polyseminography, which is, you know, the gold standard for understanding sleep physiology.
Roles and Impacts of Sleep Stages
00:14:10
Speaker
That's yeah, I mean, that that makes a lot of sense. It's it's
00:14:15
Speaker
must be challenging as a researcher to have to also be up all night watching people do it. It's funny. I have to say, I think part of it is for me, as I mentioned in the beginning, I didn't come into sleep as a sleep researcher. I've always tried to maintain though I'm slipping farther down into the
00:14:39
Speaker
the sleep world where I'm kind of seen as this sleep person. But I had always thought about, I'm interested in sleep because it's important for health. And I really care about health. But sleep is something that we know how to work on. We have tools to move it around. And so that's a really great entry point. And people don't mind talking about sleep. It's unlike talking about depression or anxiety. It's a great entry point.
00:15:07
Speaker
to understanding someone's life. And my clinical experience is if you give someone their sleep back,
00:15:14
Speaker
so much of their life improves. It's amazing. And so in a lot of ways, it's kind of selfish. I'm like, I like how I feel when I give people their sleep back. And so that's why I keep doing it. But you're right. Doing sleep research is challenging. I, thankfully, am not the person that's in the lab staying up all night. I'm very much not a night owl. I go to bed early. I like sunrises. I'm just not for that world. But thankfully, we have people on staff that do do it.
00:15:44
Speaker
And I'm so grateful to them, especially our coordinators who are also not sleep techs. They don't stay up all night, but they do have to do these really hard hours to manage this. And just kind of getting this stuff off the ground has been hard. It was only a couple of years ago, maybe five years ago, where I started doing in lab work.
00:16:07
Speaker
And so bringing people into the sleep lab, measuring it part and largely due to for this kind of this research study that we've been running over the last five years. And, you know, I, I thought I knew what I was getting into. And I, you know, it's been like a little bit of a learning curve. And I've been really grateful to like, I've had postdocs and stuff who have come from kind of, you know, hardcore sleep medicine training programs that have kind of disabused me of some of the things that I thought were kind of like,
00:16:33
Speaker
how things worked. They're like, no, this is not how you do it. I'm like, okay, great. Well, glad you're here. Thank you for helping me. This is interesting. You've gotten into the sleep research when I think it's been a really hot topic recently. I think it's something that a lot more people are aware of. Matthew Walker's book has been on the bestseller list and I think a lot of people are familiar with some of the basics of why sleep is important. It seems like you jumped into the right time.
00:17:04
Speaker
So you were talking about relationship of stress and sleep. And so different sorts of sleep. So whether it's deepwave sleep or REM sleep or lighter cycle sleep, is there an importance for one or the other in
Effects of Sleep Deprivation on Health
00:17:22
Speaker
general? What are people lacking that causes stress? And how does this relationship work?
00:17:29
Speaker
something that you can recover from fairly quickly, or is it cumulative? I guess that's too many questions in one. But they're all really great questions. In a lot of ways, we speculate on what is important. Sleep architecture, and I think
00:17:52
Speaker
that's one of the kind of innovations that I think will happen over the next five so years as people start to look at kind of much more granular ways of understanding kind of, you know, EEG and kind of like a high dimensional way, because I think there's a lot there that we don't quite understand. But, you know, I mean, I think in general,
00:18:20
Speaker
slow wave sleep is thought to play an important role in kind of recovery and restoration. And there is some evidence to support that. I think one of the things that is most notable is that when people are sleep deprived, the first thing that happens as soon as they go to sleep is they drop in a deep sleep. And so the interpretation has been, well, that's the thing that the body is prioritizing. That
00:18:46
Speaker
That's like the first thing it wants to get off its plate because it hasn't had the sleep that an individual is needed. Yeah. Like a sort of a rebound. Exactly. Exactly. And, you know, I mean, we, we are learning more about what other aspects of, of sleep do, right? So like REM sleep has been kind of implicated in, um, kind of emotional memory consolidation and, and certainly kind of sleep spindles seem to play an important role in learning and, and, and, and those sorts of things. And so they are.
00:19:15
Speaker
you know, people are identifying kind of markers within the sleep architecture that seem to be particularly relevant to cognition. You know, there's been growing interest in slow wave oscillations and people trying to develop devices that can try to gate those to improve, say, cognitive function and stuff like that. And
00:19:36
Speaker
There has been a little bit of success in that arena. I think it's just another example of how we're trying to dig deeper into the brain electricity outputs that we can actually use for specific outcomes.
00:19:56
Speaker
And so, I mean, that's my answer to that.
Health Risks of Chronic Insufficient Sleep
00:20:01
Speaker
I'll admit, there were a lot of questions in there, and so I'm not exactly. Yeah, I was just sort of personally curious about, let's just give an example. Say you stay up until 3 AM and get up at 6 AM. So subjectively, you probably feel crappy, you feel a little stressed out.
00:20:20
Speaker
Um, and maybe your cortisol levels are elevated. I don't know what else goes along with this, but, um, what might you see from something like that? Yeah. I mean, you know, people, you know, so subjectively, obviously people feel kind of down. Um, they more fatigued. Uh, oftentimes an individual's mood is a little bit, um, you know, impaired, uh, you know, with that one. Yeah. Yeah.
00:20:46
Speaker
I mean, though, though I will say that, you know, oftentimes when we deprive people of sleep at night, they actually get kind of giddy towards the early part of the morning. Right. So there is this like shift in in kind of affect that way. And then people often get like a like a like a second wind, which is driven by kind of your circadian uptick of alertness that happens.
00:21:06
Speaker
But certainly people often show changes in autonomic functioning, so their heart rate variability might be a lower, their cortisol might be higher. But then there's all these cognitive changes, so that people have difficulty potentially with word finding, attention, reaction time. Brain fog is something that we see commonly when people that have insomnia that report chronic
00:21:34
Speaker
difficulties in sleeping. And so that's, you know, in the acute setting, you had asked about kind of whether it was a cumulative effect. You know, so when people sleep, our, you know, I take the stance that, you know, our body tries to compensate for that, right? I mean, you know, we do, when people have a bad night of sleep, the next night tends to be better. You know, they fall asleep faster, their sleep might be deeper, as a way of trying to make up for that loss.
00:22:02
Speaker
But, I mean, the population level data suggests that chronic insufficient sleep is a risk factor for a whole host of negative health outcomes from cardiovascular disease and metabolic conditions like type 2 diabetes and then growing evidence that it may be implicated in the early development of neurodegenerative diseases.
00:22:25
Speaker
you know, among other things, right? So like our work has shown that people are more susceptible to infections and obviously that's taken on a whole new life with a pandemic. And so, you know, and the idea is that, you know, there is a wear and tear that happens on the body that you're, you know, when you, and you know this, when you deprive someone of sleep, you know, you see you arrive at eight hours of sleep, right? And then you let them sleep for as long as they want. They don't sleep for 16 hours.
00:22:52
Speaker
like your body, you know, it changes the way in which someone makes up that sleep. And the thought is that perhaps over time, there's just a cumulative cost. And the cost is in the currency of health, right? And so that would be, you know, how we're doing that. Now, like, it's not to say that our population level data is perfect, because honestly, it's usually like a one item question.
00:23:15
Speaker
that is just asked to thousands and thousands of people.
Social Factors and Sleep Disparities
00:23:18
Speaker
So we, you know, we have good statistical power, but the kind of the way in which it's, you know, we're not measuring sleep per se, we're measuring kind of self-reported experience of sleep on average, right? And we know that sleep is so variable over time. I mean,
00:23:31
Speaker
There was stuff in the news just recently about social jet lag, and social jet lag might be something that predicts long-term health as well, and it's incredibly common. That really gets at this variability that people have during the week that is not captured typically in these one-item measures.
00:23:52
Speaker
on the whole, though, if you kind of take the literature, you know, as as kind of a big why in a wide net, it certainly suggests that people who get, you know, less than seven hours, people, especially on the short end of like six, five hours on average, those are the ones that are at risk for lots of things. So yeah, so not only are you feeling crappy in the morning, but it is cumulative, and you're going to experience a lot of negative health consequences over your life. And yeah, I think that's something
00:24:19
Speaker
people are starting to pick up on too and why people are seeing sleep as a more central component of overall health.
00:24:29
Speaker
Yeah. And I think also, isn't it the case that like, uh, or it seems like, let me ask the question. It seems like people are experiencing more problems with sleep today than they were like in the past, like certainly like the, the, the distant past, right? Like, uh, you know, our human beings have evolved. We need to sleep. Uh, but somehow many, many people experience problems with this in a modern society and
00:24:59
Speaker
Do you have thoughts on why that is today? Well, first of all, is it true that it's worse today than it was 400 years ago? It does seem like it's worse today. I don't know for certain that it's different than 400 years ago.
00:25:15
Speaker
Um, the records are, are less clear, I guess, but, but, um, but I mean, over, you know, there's certainly evidence to suggest that say insufficient sleep, right? So that's, that's like one thing that we can agree upon in that because we have a definition. Um, and so in that case, those are the center for disease control. It's, it's less than seven hours.
00:25:39
Speaker
of sleep for an adult. Right. And so people are sleeping, they're considered to have getting kind of have sleep insufficiency. And that has increased over the decade for sure. The percentage of adults that even just over the last 10 years. Yeah, yeah. And I mean, it's not, you know, it's, it's, you know, it's something like, you know, like in the 30%, I don't know the exact percent, but it's, you know, it's, but you know, if you scale it up to like the size of the population, it's really a lot, right? Like, it's like almost like 100 million people.
00:26:06
Speaker
Um, and so that are, that are, you know, chronically getting insufficient amounts of sleep.
Rising Awareness of Sleep's Importance
00:26:11
Speaker
Like the reason for that, I think is complex. I mean, and I think, um, it's not only complex and what's causing it because, but I also think it, it is, um, I like to say like sleep opportunity is not evenly distributed across the population, right? There are like certain segments of the population that are more affected than others.
00:26:32
Speaker
And so there are like social determinants that kind of drive those changes or drive those proportions. What would be an example of a disparity there?
00:26:42
Speaker
Yeah, so I mean, there's a strong racial disparity in sleep duration. And so, and this is a lot of the work that we are currently doing, where, you know, black Americans are significantly more likely to be short sleepers, compared to white Americans. And, you know, and that and those those disparities, those racial sleep disparities map onto
00:27:07
Speaker
similar racial health disparities that we see in the population. So it raises this idea like, oh, well, we know that sleep is related to cardiovascular risk. We know there's disparity in cardiovascular disease outcomes by black and white groups and by sleep groups. Maybe this is one of the contributing factors. It's certainly not the only thing. But we've been trying to understand these racial health disparities, particularly with a lens of focusing on sleep.
00:27:34
Speaker
Um, but I, and so that, so that's an example, but, um, you know, I think there are lots of different things that contribute to, um, kind of this lack of sleep. I mean, I think some of it is kind of societal norms, right? About kind of the, the priority of productivity over rest.
00:27:50
Speaker
I think that's like a very Western type thing and I don't think anyone would necessarily dispute that as something that might contribute to it. I think there are obviously certain policies that kind of contribute to this challenge.
00:28:06
Speaker
You know, workplace policies around commuting times or for shift workers and kind of the number of hours that they can work perhaps might contribute to insufficient amounts of sleep. School start times is certainly something that we talk a lot about in the sleep community that contribute to insufficient sleep among adolescents.
00:28:27
Speaker
there's often just the tendency for people to put sleep on kind of the last thing on their list to kind of get done. And then there's this kind of emerging phenomenon of revenge bedtime procrastination that people are actually putting off sleep, right? And I think that really speaks to kind of the lack of autonomy that people might feel that they have in their lives. And that, you know, that speaks to kind of what, you know,
00:28:57
Speaker
what what someone's daytime is like right and it's like it ends up being at a cost of sleep but the that's not because they don't want sleep or don't appreciate sleep it's like
00:29:07
Speaker
it's just really hard to manage all the things that are going on in our lives. You know, I think, yeah, I think there's lots of different things. I mean, and you're also right that kind of the interest in sleep has grown over time too. And I think that's a really great thing. I mean, when I started doing this, I mean, you know, I feel like you were kind of like clawing our ways to like, try to get up seat at the table. But just this year,
Improving Sleep with a Seven-Day Model
00:29:32
Speaker
you know, the American Heart Association has kind of these seven things that are important for heart health. And this year, they added sleep as an eighth one, like they for years, they had had just seven and sleep finally made it on. And that's a really big deal for people that kind of study cardiovascular disease and and want to get this information out to people that are worried about their heart health. Right. But, you know, I think
00:29:55
Speaker
the development of wearable technology that is focused on sleep has really captured the imagination of people, right? They like contract their sleep, they know their experience, but they, they can see the data and the kind of the moving from kind of the niche quantified self movement into population level is made a big deal. I think, you know, books like Why We Sleep, you know, that that really was a game changer for the sleep field. I mean, you know, Matt,
00:30:22
Speaker
Walker, who I like, you know, have had the luxury of like working with over the years, you know, it's incredible. I mean, it, you know, it's not that it hasn't kind of made some people anxious about their sleep, because that's absolutely also true. But I mean, I think, you know, in general, it has, you know, raised the profile of sleep as a discipline as and as like a key piece of our well being and health in ways that other things haven't. And so that's, that's really exciting, too.
00:30:52
Speaker
Yeah, and I think people are more aware of things like sleep hygiene, keeping regular hours, and some of the things that you point out in your book. So we had an episode a while ago on the effects of blue light on sleep.
00:31:10
Speaker
I like the perspective that your book takes, because I think this is probably closer to the truth, that blue light is not going to be a decisive factor likely in your sleep. It could be a small contributing factor. It will affect melatonin levels. But there are probably a lot of other things that are going to have much more effect. So to focus on this exclusively and think that if you're just filtering out blue light, you can still look at Twitter and all that stuff.
00:31:40
Speaker
Um, is probably the wrong way to think about it. Yeah. So, I mean, right. So I want to say there is absolutely evidence that blue light exposure can, you know, down regulate melatonin secretion. And for people that are really sensitive to that, it can make, it can be a, it can make a big difference in kind of their circadian rhythm and the quality of their sleep.
00:32:01
Speaker
I guess, yeah, my response has historically been that, you know, like an industry was created around blue light and like keeping it out of people's eyes, right? And I think there's in a lot of ways that that is what drives some of the discussion around how important this is because, you know, the content
00:32:27
Speaker
that people are consuming is much more likely to be impacting their ability to sleep. Things like social media, the internet, everything that Blue Light is on, particularly on our devices, they exist to kind of keep people engaged, right? Like they're developed to keep you coming back. The number of hours that my wife spends watching TikTok at night is like,
00:32:55
Speaker
That's all I have to see every single night to know. It's working, even if the night shift filter is on. And it's really- So it's really more the thoughts-racing, cognitive sort of effect that, you know, it's both. Because we know there's regulation of melatonin, but- Yeah.
00:33:14
Speaker
But I think that fits with experience, too. People may be less aware of the blue light sometimes, but they're very aware of what they're thinking about when they're looking at social media and those thoughts racing, rumination. Yeah, I mean, I think that's part of it. But I mean, I think it's just like the reward processing, like those dopamine hits, like at every video that you see or whatever.
00:33:39
Speaker
Um, it's like not even, it's not even like conscious thinking. It's like engagement, right? Like it's, and like that is incompatible with sleeping. Um, and so, you know, that's why, you know, I think almost by definition, right? Yeah, exactly. And so like, you know, I mean, it's, we, you know, want to make sure that everybody has, you know, if they're doing devices, if they, you know, if they, if they are sensitive to blue light, like putting these night shift filters on, I mean, it's great that we have them.
00:34:05
Speaker
but to assume that that's gonna solve the problem is faulty. And so kind of really focusing on what content people are consuming with the goal towards winding down, right? Like kind of something that's kind of like facilitates relaxation versus something that like you're like, can't wait for the next thing so that you can kind of, and the hours go by all of a sudden. Yeah, well, that might be a good lead into starting to talk about, we've talked a bit about sort of
00:34:36
Speaker
the study of sleep and some of the problems associated when you don't get enough sleep and some of the causes of preventing sleep, things like that, might be good to start to get into your book and talk a little bit about some of the ways that you can help yourself get better sleep.
CBTI as First-Line Insomnia Treatment
00:34:55
Speaker
Yeah, yeah, absolutely. And yeah, I provide like a little context. So this book is part of a series and so,
00:35:06
Speaker
So and they're all developed around this like seven day model. And so there's like one on love by John and Julie Gottman, who are kind of like very famous for doing kind of couples work. And then my co conspirator and in the lab that we run, Alyssa Apple wrote one on stress, right. And so these are all kind of, it's kind of set up that way.
00:35:28
Speaker
And so given that model, what I attempted to do was distill principles from cognitive behavioral therapy for insomnia to kind of help people understand kind of both the science of sleep and what regulates it, but what things we can do in our lives that can put us in the best position to get a good night's sleep. And so whenever like the seven day thing comes up, I always kind of like
00:35:57
Speaker
bristle a little bit because it's you know that it's it's it's like the expectation isn't necessarily I mean for some people that might be true but it's it you know and that's why the the last chapter is called you know this is the beginning not the end because when we do this in clinic it's not seven days right like it's like five weeks or something and all the work happens in between our meetings
00:36:17
Speaker
And so each one of those seven days have kind of a tool that we layer on in clinic each week, but we did it in kind of in a more contracted period for this. But with them all layered on and with the sleep diary that is included in the book that people can use to track their sleep,
00:36:36
Speaker
It can provide an insight into how that individual's sleep is regulated and using the tools can hopefully get their sleep back on track. Yeah. That makes sense. Maybe you take a step back and talk a little bit. You mentioned cognitive behavioral therapy for insomnia. Maybe you mentioned a little bit about what that is. Then you talked about the sleep diary. That seemed like a really important thing in the book. Maybe you can talk about what that is and why that's important.
00:37:04
Speaker
Yeah, absolutely. So, um, you know, cognitive behavioral therapy for insomnia. So that, I mean, for, so CBTI is what people say. Um, you know, there's lots of cognitive behavioral therapy models, right? For depression, anxiety.
00:37:18
Speaker
you know, panicked of sort or what have you. And this one is sort of similar, though there's a big emphasis on the behavioral component. And so, you know, that's what we tend to lead with, though the cognitive part is kind of interspersed throughout for sure. And CBTI is kind of well recognized as the first line treatment for insomnia. So like the American College of Physicians recommends is every kind of like recommending body knows that this is true, though
00:37:47
Speaker
you know, admittedly, rarely is it the first thing that people try. Right? I mean, they go to their primary care physician, they have insomnia, and like the primary care physician, understandably, doesn't know where to send someone for CBTI. There's just not enough providers and, you know, the digital tools that are coming out aren't kind of easily accessible currently, and all those sorts of things. And so they end up kind of being on medication, typically. But, you know, what CBTI does is it really addresses the underlying
00:38:15
Speaker
processes that often go awry when people have insomnia. So kind of, um, you know, this is in the context of, so there's always the sleep hygiene component that everyone, most people have heard about, but there's also, um, around kind of sleep, like scheduling, um, kind of your wake time and trying to set in line your, the two primary regulatory mechanisms of sleep, which are your circadian rhythm and your homeostatic sleep drive, which we, we might get into, but, um, but then also really trying to.
00:38:44
Speaker
Um, help make things more predictable for your body. So one of the things that happens with people with insomnia is they spend a lot of time in bed, not sleeping. And that actually plays an important role in kind of fracturing the relationship between your body and the bed, because the bed is actually, it turns out to be like a really incredible, important environmental trigger for bringing on sleepiness.
00:39:08
Speaker
But when people spend lots of times in bed, not sleeping, it, your body gets confused basically. And so there's this conditioned arousal that develops. And so we kind of work on scheduling people, sleep better, um, uh, you know, working on that condition arousal, uh, and then, you know, true, true, you know, providing people with strategies for managing stress for, you know, facilitating relaxation.
00:39:31
Speaker
Um, and then, you know, oftentimes we end up actually moving people's bedtimes back later to amplify that homeostatic sleep drive. So that, which, which is kind of our drive, our need to sleep, which often helps people kind of be reacquainted with that feeling of sleepiness. So, you know, oftentimes people that I meet with insomnia, even though they have really bad nights of sleep all the time, they don't ever describe themselves as sleepy. They just feel tired.
00:40:00
Speaker
They can't remember the last time they felt sleepy. By working on these strategies, we can try to leverage the biology to bring back that experience of sleepiness.
Using Sleep Diaries in CBTI
00:40:13
Speaker
It's such a welcomed friend that they haven't seen in so long.
00:40:18
Speaker
Um, and, and then, so those are the behavioral components and the cognitive components. So there's the strategies for helping people more manage their worry and, and, and things like that. But there's also, you know, when people have really bad nights of sleep, they, they begin to really think the worst, right? I mean, they, they really begin to, to catastrophize about kind of what happens if they don't get a night of sleep, they use a lot of mental effort during the day trying to figure out like, Oh my God, like,
00:40:44
Speaker
Should I go to this thing tonight or not? Because I don't know if I'm going to be able to sleep. And those types of that kind of anxiety really feeds on itself and ensures kind of a bad night of sleep, right? So we kind of go through kind of cognitive strategies to try to understand like, what is the real evidence around these cognitions? How do they make you feel? If we thought about it a different way, would that kind of change the outcome? And that that's really in line with kind of like classic cognitive behavioral therapy. And so
00:41:09
Speaker
And it does seem like, you know, addressing those cognitions seem to be kind of the things that stick with people for the long-term. And so it's really important to address those. Oftentimes when we do the behavioral strategies and people begin sleeping better, they grow in confidence, right? They begin to do it on their own. They begin going like, oh, you know, I guess I can sleep. It's not lost to me. And then it's a matter of kind of working on kind of, you know,
00:41:37
Speaker
A bad night doesn't mean you're going to be an insomniac again. Everyone has bad nights, but when you have insomnia, it feels like you're the one that is broken versus reflecting on the fact that sleep is variable. That's CBTI. One of the pieces that's really critical to it is the sleep diary.
00:41:57
Speaker
And that's because, and this is something like I say commonly is, sleep is really universal, but it's also really personal, right? There are like specific things to you. We know how sleep works, but there are things that are like specific to your life that will be critical for understanding how to get your sleep back on track. And a lot of it has to do with kind of how variable sleep is from night to night. And so the sleep diary typically has information about kind of when people go to bed,
00:42:25
Speaker
what time, how long it takes them to fall asleep, how many times they wake up in the middle of the night, how long they're awake in total, and then what time they wake up in the morning and kind of the quality of their sleep. Sometimes we have evening components about like what medications you took, how much alcohol you had, you know, your whether you exercise or not, those those kind of things, which also can be important information. But you know, what we do is we kind of track that over the course of the week to really understand, you know, both kind of where people are at baseline,
00:42:53
Speaker
and how much time they're spending in bed not sleeping so that we can kind of shift their sleep schedule. But also it allows us to, as we layer on these treatment strategies,
00:43:07
Speaker
what effect are they having, right? So we layer them on and then we can see over time, like, oh, we move this thing, you know, your sleep on average improves. It also helps us, I think it helps individuals get some insight into their sleep because when you have a bad night of sleep, you know, that's the thing that sticks in your mind.
00:43:26
Speaker
Right. But if when you see it all laid out across the week and you average it, then you begin to see like, Oh, look, like I had a bad night, but on average, my sleep is actually pretty good. Right. And it doesn't take away from the fact that, you know, a bad night is terrible. Right. Like no one likes that. I mean, I'm sure all of us on this call have had like some nights of insomnia where we're like, had to get through the day. But, you know, when you can see that it's that on par, you know, you're, you're doing okay.
00:43:55
Speaker
you know, on average and you're kind of moving towards something, you can kind of track it over time, that that also builds confidence, that helps kind of, you know, chip away at some of those negative cognitions. So I think the sleep diary is critical and often, you know, largely because people are just like not good reporters of their sleep, right? Like we kind of have this recency effect where we like, you know, remember like last night maybe, or we, you know, often hold on to exceptions.
00:44:21
Speaker
as our metric of what our sleep is like. I'll just say one more thing that oftentimes with people in insomnia, their catastrophic thinking is often tied to the worst night of sleep they've ever had. That's the thing that they fear, understandably, but it's so rare.
00:44:40
Speaker
And so they, but that's what they think is gonna happen. And at the same time, they've also probably had an exceptional night of sleep, right? We all know that kind of sleep, like where you fall asleep and you wake up in the same position that you like went to sleep in and like you didn't wake up at all and you feel like a million bucks and it's like, and so then that becomes like their metric for like what a good night of sleep is. And so, but they're both exceptional, right? On both sides. And so the sleep diary actually allows us to see kind of the variability
00:45:05
Speaker
and kind of helps people kind of shift their mindset around what are the expectations for what healthy sleep looks like.
Regulating Sleep with Consistent Wake-Up Times
00:45:16
Speaker
So, okay, so there's lots of different components to this. And I think in your book, you talk about kinds of treatments that go from relatively minor to pretty major life shifts. I think you mentioned a patient that you had that had to switch jobs in order to
00:45:35
Speaker
in order to change your sleep cycle, and it can be a fairly major shift. I'm wondering, of all these different treatments or things that can be done, what the first advice that you give to people, and I guess one of the things that you were pushing strongly in the book, and which maybe people are less aware of, is
00:45:59
Speaker
getting up at the same time or being consistent about getting up in the morning can have an enormous effect. And that's not as intuitive as having lots of sleep or our general thoughts about sleep. So why is getting up at the same time important?
00:46:19
Speaker
Right. Right. And that's I mean, that's definitely how we start out the book. And in fact, that's that's like always the first thing that I tell people if they're having trouble with their sleep. And and it has to do with the two things. I mean, so one, when people get up at the same time each day, it helps in train your circadian rhythm. And that's really important for kind of kind of a well regulated system because the circadian rhythm is such an important piece of of kind of sleep regulation.
00:46:50
Speaker
Also, it focuses on something that we can control. One of the things that people with insomnia often hear is that they should also have a bedtime that they go to sleep at every night.
00:47:06
Speaker
that actually puts a lot of pressure on someone with insomnia. If you say, okay, you need to be asleep by 10, they're gonna be sitting and watching the clock tick by and realizing, oh my gosh, three more minutes, two more minutes, one more minute, and that can actually amplify.
00:47:21
Speaker
um, the anxiety around sleep. And so, you know, we focus on setting a standard wake up time, one, because it kind of sets your in line your day, right? Like your circadian rhythm, it also kind of sets the, when you, when your sleep drive will begin, right? So your homeostatic sleep drive, I talked to, talk about it like a balloon that like fills up with sleepiness and, you know, the sleepiness that at the neurochemical level seems to be a denosine.
00:47:47
Speaker
that builds up in the brain across the day. But we we use similar amounts of energy from day to day. And so if you get up at the same time every day, you're more likely to get sleepy around the same time each night. And so your bedtime will become more will become regulated that way. But, you know, it's a great
00:48:03
Speaker
principle that you can you can enact that that we typically can control have control over and makes seems tough to wake up at you know the sick you know whatever time you choose to wake up consistently at that time but so I so I will say that like
00:48:21
Speaker
you know, I get obviously, as you might imagine, like get a fair amount of pushback and like, well, like, I like to sleep in on the weekends, like, what are you talking about? And I get I totally get that. And, you know, that does speak to kind of the type of sleep debt that people are carrying, right? That and it and it's, you know, that's another thing that we can, you know, people can potentially address like, why, why do you need to sleep in? But, you know, these kind of recommendations are really for people that
00:48:46
Speaker
are having trouble with sleep. So if you have a sleep debt and you have the opportunity to sleep in on the weekend, we know that sleep debts aren't great and this social jet lag aren't great. But if you need more sleep, you can get it. But if you're having trouble sleeping,
00:49:03
Speaker
Like this is something that you can take control over that is focused in the morning, which is less close in time proximally to like the thing that you're fearing, which is like bedtime, right? So it's like the first thing you can do when you wake up in the morning that can set things in motion that you can then layer on throughout the day is a good strategy. But yeah, obviously, not everybody, it is hard.
00:49:29
Speaker
Like you say, you may have those ruminations at night that may be a little more challenging to control, at least in the morning. However painful it is, you're awake and you can get up and get out of bed. It is under your control.
00:49:42
Speaker
Yeah, and I mean, I think it does raise an important thing, because I mean, raising rumination, like people can have bad nights of sleep, but then they still have to get up at the same time each day, right? And I think that's one of the things that's important to address because for people that have insomnia, when they have a bad night of sleep, right, especially on the extreme end, they may sleep in like several hours later to kind of make up for that, right? If they have the opportunity. I mean, I've had, certainly had patients that like will just cancel off work.
00:50:10
Speaker
because they had a bad night of sleep and then sleep in longer. And that just reinforces this anxiety. It throws off the system. And then it kind of, it also has implications for that following night because you've now like slept in a lot later, your rhythm is thrown off, and then it makes it harder to fall asleep that night. But if you get up at that same time, despite having a bad night, you know, your body will take care of
Environmental Cues and Stimulus Control in Sleep
00:50:32
Speaker
you, right? Like you'll, you'll,
00:50:34
Speaker
One of the important shifts that people have to make in, um, in treatment for insomnia, at least with CBTI is, you know, it's not about tonight's sleep, right? Like we can, we can only do so much to like put ourselves in the best position to sleep well. Um, but we're working towards improving our sleep on average, right? That like, if we do these things on average, our sleep will get better, but we can't put all the pressure on tonight.
00:51:02
Speaker
And maybe that's a little harder for people to see those slightly longer term consequences than
00:51:08
Speaker
what they're feeling immediately, which is horrible. Yeah, I mean, that's where the sleep diary is important, because then you can actually see it. And you can see that even if you had a bad night of sleep, you can see in the data that in most cases, people have a better night the next night, and that their average will improve. And the metric that we often use is something called sleep efficiency. And so that's the amount of sleep that someone gets for a given opportunity.
00:51:37
Speaker
And so if you go to bed at 10 and get up at 6, so that's eight hours and you're asleep that whole time, full eight hours, it's like 100% efficiency. But if you're awake for four of those hours, then your efficiency is 50%. And so what we want to try to get people up to is like 85%, if they're under 65. And once we get to 65, then it's like 80% is kind of more normative.
00:52:02
Speaker
And when we do that by kind of pushing their bedtime later, so we're like constraining the denominator, right?
00:52:10
Speaker
Um, which will increase the efficiency, but, and so that will kind of cut out some of that wakefulness, um, trying to get to sleep, or it'll cut out some of that wakefulness in the middle of the night. Um, because people often will just spend extra time in bed because, um, of this fear of, you know, people will give themselves like 12 hours in bed to get that eight hours. But, you know, guess what? You can't make 12 hours of sleep. And so you're kind of assuring yourself that for most people, it's like four hours of wakefulness somewhere in that window. And that's what we want to try to try to work on with people with insomnia.
00:52:40
Speaker
is starting to get a couple of hours of that really good sleep and then maybe extending it past then. So they start out, it's a little tough going to bed later and then as they're able to control some of these things, then being able to gradually increase their sleep time with the same efficiency.
00:53:00
Speaker
So what we do is we'll constrict it. It's called time and bed restriction or sleep restriction, some people call it, and to increase their efficiency. And then once we're able to do that, we will slowly move their bedtime a little bit earlier, a little bit earlier, a little bit earlier, but we'll continue to track it with the sleep diary
00:53:20
Speaker
until we get to some kind of optimal level where they're still having high efficiency and they're getting more sleep. Even in that contracted amount, you know, people tend to report kind of feeling better because their sleep is in kind of like one big bolus compared to that same amount of sleep broken up, right? Like there's something about the continuity that's really important.
00:53:40
Speaker
Um, and so, you know, oftentimes though, even when we do this procedure and then we move people's bedtimes earlier slowly, it ends up being later than they were before, right? Like people often as, as a way of trying to get their sleep on track will go to bed earlier. And so, you know, we ended up finding it in the data and that's, you know, then we have to kind of come up with some kind of.
00:54:04
Speaker
you know, compromise about like, okay, well, this is what the data suggests. Like, are you able to just stick with this? Or if your sleep gets off track, like move it back to this, you know, things like that. Yeah. It seems like one of the themes that comes out of this is actually related back to the sleep hygiene idea of not spending a lot of time in bed, not sleeping. So when you're in bed, you want to be sleeping. What's the, the theory behind that?
00:54:27
Speaker
I seem to remember there was some idea that has something to do with conditioning. So is it like operant conditioning, classical conditioning? How does that work? Yeah, it falls under the umbrella of classical conditioning. I mean, you think of Pavlov's dog and the idea that you're kind of pairing
00:54:47
Speaker
um, the feeling of sleepiness with the bed. Right. And so when people are sleeping well, you know, they feel sleepy when they go to bed, but kind of the actual, the process of getting in bed is like a hammer that comes down on someone that like allows your body to let go and allows you to sleep.
00:55:06
Speaker
And then the opposite happens when people have sleep disturbances, particularly in the context of insomnia. And so often I will have patients that say, you know, I was feeling really sleepy, then I got in bed and my brain woke up.
00:55:21
Speaker
And that's like the conditioned response that has developed from kind of so much time, kind of having difficulty sleeping and being in bed. You've kind of like, you know, fractured that relationship that was so important for bringing on that experience of sleep.
Establishing Bedtime Routines
00:55:36
Speaker
Because, you know, honestly, like sleep is doesn't, you know, it's so critical for our health.
00:55:41
Speaker
But in a lot of ways, it doesn't seem like the most adaptive thing that you can be doing. It's like you drop off from the world. You're in this vulnerable state. But these environmental things really help tell you when you should be doing that.
00:55:58
Speaker
Um, and the bed is, is, is that thing. And so, um, when we try to address this problem, um, we actually kind of, first we have to break the relationship of the kind of distress and the bed, right? So we like, when people are kind of spending excess time in bed awake, not sleeping.
00:56:17
Speaker
Like more than 20 minutes, for instance, we'll have people like get out of bed. And again, this is actually a really hard thing to get people to do. Like no one wants to do this, but get out of bed. And then they kind of go somewhere quiet, you know, try to facilitate kind of sleepiness on their part, kind of whatever works for them. But, you know, we usually give like a list of different things like reading or like listening to music or podcasts or whatever, things that are like, but they aren't so engaging that you're going to like stay up all night doing it.
00:56:45
Speaker
until you begin to feel sleepy again and then you want to repair that feeling with the bed. And it does. In the initial times, it's definitely this back and forth. It's kind of like a dance. You get out of bed, you feel sleepy, you get back in bed, your brain wakes up.
00:57:00
Speaker
And I always say that, well, so that's really good evidence this is a problem, right? There it is. You've just experienced this problem in an acute setting. Clearly, we need to address this. And then they get back into bed, and then they get back in. But over time, you rebuild this relationship. And for some people, it doesn't take long at all. But for others, it's a little bit more of a challenge. And it's really foundational to how insomnia works. And so that treatment is called stimulus control.
00:57:27
Speaker
But and it really is an important part of how we get people sleeping better. Yeah, that is a fascinating one that people normally would be unaware of that this is going on, that when they enter the bed, their body's doing something in reaction to that that has something to do with sleep, preparing them for it or stopping them from it. And just maybe being aware of that connection is helpful.
00:57:57
Speaker
Yeah, yeah. So that if you're just lying in it too long without sleeping.
00:58:02
Speaker
Yeah, I mean, it does take a little bit of one convincing, right? I mean, especially as it gets towards the winter, like no one wants to do it. And and there are ways to adapt it. Right. I mean, like I see lots of like our clinic is is housed in neurology. And so, you know, we get people with like lots of chronic pain conditions or kind of other things that keep that. I mean, we're living in San Francisco where, you know, your bed is your couch, is your table, is your office desk. You know, it's
00:58:27
Speaker
often hard to find another place. But this is where maybe adaptations to this approach are things like sitting straight up in bed, moving to the other side of the bed, flipping over to the foot of the bed. Anything that really tells your body, look, this is not my sleeping position, can be effective in retraining this experience.
00:58:53
Speaker
But, you know, it often takes time and kind of figuring out what works for people. So what is... An interesting aspect is that your role is a motivational speaker to these people because it does seem like you sort of need to convince people of the importance of sleep, not everybody's aware of it, and then convince them to stick to these somewhat difficult regimens.
00:59:19
Speaker
But with the hope that it's going to be doing a lot more good for them once they once they can get through it. Yeah, you know, I mean, like, I guess I'm at the luxury of like when people come to our clinic, they are acutely aware of how important sleep is. Right. Like they like are because of this. Yeah. Yeah. But but I mean, you know, in general, I think this is where, you know, there's been a lot of great
00:59:46
Speaker
work and getting the message out around the importance of sleep. And so people are kind of more aware of it and kind of the collective consciousness, but then often don't know what to do about it. And, you know, our role as clinicians and behavioral sleep medicine researchers is to try to stave off any impulse to kind of immediately reach for medications.
01:00:13
Speaker
What's one more example of some of the advice that you give to folks?
01:00:21
Speaker
Yeah, I mean, you know, and again, like in in clinic and in this book, I talk about it more as like a recipe than a menu. Right. Like it's it's like it works better in combination. And then there's then you need to give it time to bake. Right. It's not like a one off thing. But but but I mean, I think so there's so so we mentioned kind of a couple of things already. So
01:00:46
Speaker
the getting up at the same time and then we talked about kind of not spending excess time in bed, not sleeping and that strategy. I think the other thing that's really important is creating a
01:00:58
Speaker
kind of clear transition, you know, that oftentimes people treat their brains like it's their laptop, that they can just close down and then it's like asleep for the night. And a lot of that is a function of our busy lives, but we do need to kind of mark these transitions for kind of, you know, towards rest and restoration.
01:01:22
Speaker
And in part, it's to kind of allow your body to wind down to kind of amplify that parasympathetic nervous system that's so important for kind of facilitating sleep and in creating, again, more environmental cues
01:01:39
Speaker
that help your body know what's happening. So, you know, like I, our brains are like just they're like predicting machines, right? They're like taking in so much information and trying to kind of make predictions about how best to use metabolic resources. And I don't think sleep is any different that, you know, we need to be able to kind of make things as predictable as possible. And so for some people, it's things like,
01:02:02
Speaker
You know, people have their own kind of ritualistic bedtime routines typically. And I think that's partly why, as you know, getting back to our beginning of our discussion around stress and sleep, why stress doesn't play as big of a role is because we have these rituals that help regulate the sleep process. But, you know, I mean, kind of dimming the lights, kind of, you know, putting away your work,
01:02:22
Speaker
kind of getting into your pajamas, brushing your teeth, doing whatever with, you know, if you have a partner, like spending time, you know, whatever it is that you do, like those things, that consistency and pairing it with like the sleep experience is really important. Right. Like it's like, and I think it's super unrecognized as like such a key thing. Like I think we, you know, readily as humans think that we're kind of in control of all of these things that go on in our world. But it turns out like
01:02:47
Speaker
our brain is reacting to lots of things in the environment that tell us what to feel and what to
Developing Lasting Sleep Habits
01:02:53
Speaker
do next. I think the transition is a real critical part of that. One of the things that people will need to be doing if they're changing these behaviors is to acquire a habit that's going to be a lasting habit. There's various research about how long it takes to acquire a habit. I'm curious as to
01:03:17
Speaker
as to what you see as the amount of time that it might take someone to get into a place where they're comfortable going forward and they won't revert back again. You always have regressions, there can be life events or things like that, but maybe
01:03:35
Speaker
You know, some research has suggested a couple months of repeated practice so that it'll become automatic enough that it continues. Just curious as to how you see patients after...
01:03:48
Speaker
Yeah. Yeah. I mean, that's a great question. And I mean, I think the unfortunate reality is that people that have insomnia are at increased risk of having insomnia again. It seems to be like a predisposition in some cases. But I think that's why CBTI is particularly effective. And the data would support this, that in the long term, people outperform
01:04:14
Speaker
with respect to sleep, having this treatment compared to kind of a medication, right? Because you actually learn tools for the next time. I mean, I think for most people, this treatment is effective. Certainly, I think the
01:04:35
Speaker
the data would suggest that it's on average 60% of people find this effective, which is much higher than sleep medications. Though I think for certain clinics, it's even above and beyond that because that's the average and all people
01:04:52
Speaker
carry this out the same. But it typically takes five, six weeks of doing this. My experience is that the time and bed restriction is like the thing that is the most powerful because it's so deeply embedded in our biology. And so people are able to do it. If people are able to kind of put their bedtime much later than it used to be, and again, this is all kind of
01:05:18
Speaker
Determined by their sleep diary. So it's personalized in that way though. We never restrict time in bed below five hours You know if people are able to do that, you know, they can have you know rapid success You know, but I mean it is also true that these other pieces have to be incorporated I always say that like you could do all these things and then if you had an espresso right before bed like it probably wouldn't matter but And then and then I will say like I guess in my experience probably
01:05:48
Speaker
You know, every two months, someone that I had seen in the past like emails me and needs to get like a refresher, right? Because like life happens and you know, people feel confident when they leave. We go over all the kind of tools and we talk about like next steps and what you would do if this or that happened. But like, look, it's, it happens. And I mean, the good news is that like, these are tools.
01:06:12
Speaker
And that these are things that, you know, people have had experience potentially mastering. And so there's no reason to think that they can't just get back on track. Well, out of the habit at some point, but you know how to get back on again if you need to. Yeah. And then, you know, I honestly like, and I don't know, I mean, this is just my personal feeling, but like,
01:06:32
Speaker
Like life is hard. Like I don't have value judgment on like what you can and cannot do. Like I just want to like give people the information based in like the sleep science, like try to meet people halfway to like improve it a little bit. And if that's what they, that feels like the right place for them right now and they're satisfied, like that's, that's fine.
Potential Pitfalls of Over-Focusing on Sleep
01:06:51
Speaker
And you know, if, if they feel differently in the future, like I'll just be sitting in front of this computer still then too. So, you know, we can always get, get back into it because you know, I like,
01:07:00
Speaker
people have to manage a lot of things. And I mean, I feel I think the anxiety about their sleep can can oftentimes just make and not kind of doing everything perfectly can actually do more harm than good. And so, you know, I try to be like as compassionate as possible. It must be hard for you sometimes seeing, you know, knowing the long term health benefits and, and
01:07:27
Speaker
knowing that a good night's sleep can put a lot of these things back together and improve daily life in so many different ways that it must be, I don't know, must be. It's funny that you say that because I really do. I think about this a lot because we try to get people to focus on how to improve their sleep. That's all our research is about is
01:07:53
Speaker
what happens when you don't get the sleep you need? And if we improve your sleep, look how much better things are. But then in clinic, you're trying to get people to stop worrying about your sleep. That's the problem. You're worrying about it so much. And so it's this delicate balance. I'm a strong sleep advocate. I think it's the thing that people can do. It's the glue that holds our life together.
01:08:21
Speaker
But also when people are hyper focused on it, it completely undermines the whole system. So I always say, no one ever wonders even how sleep works until it stops. And then you become so focused. And so through these sleep diaries and through the cognitive strategies that we use, we try to get people to recognize that look, sleep isn't
01:08:45
Speaker
the end all and be all of your life. Lots of things go into whether you have a good day or a bad day. It's not just about sleep. And trying to deliver that message, it's like dialing it back for people with insomnia because it is clearly one of the contributors to their problem.
01:09:04
Speaker
Well, that seems like maybe a good place to start to wrap it up here. Thinking about the future and thinking about where things are going on the research side. Eric, I'm curious if there's anything you're really excited about in terms of whether it's your own research or things you see going on in the field, advances that are happening, things that might be better in a couple of years than they are today.
01:09:29
Speaker
Yeah, no, that's a great question. I think technology will certainly contribute to some of the advancements around understanding sleep architecture and all of the deep electrical signals that we can get around the brain and what that might mean for sleep and for health.
01:09:50
Speaker
And so I'm excited about learning more about that as people work in that space. And I think we're learning more and more about the role of sleep and neurodegenerative diseases. So certainly the most exciting discovery in the last five years in sleep has been around the glymphatic system and the importance role that sleep plays in helping clear out metabolites in the brain that
01:10:18
Speaker
are linked to the pathophysiology or the pathology of Alzheimer's disease, things like beta amyloid and stuff like that, that sleep plays a clear role. So rather than being this population link, there's a clear mechanism that might be at play, which is a great advance.
01:10:41
Speaker
One, on the clinical side, really interested in testing digital therapeutics to scale up these types of treatments and who they work for and who they don't. Can we move the science and the treatment along?
01:10:57
Speaker
in those with those tools. And then, you know, you know, my, my, my heart is always in the on the immune side of things. And so, you know, we're doing studies, we launched a really large study around the COVID-19 vaccine. And so we've been following people, like measuring their sleep and lots of other characteristics over time. And
01:11:17
Speaker
follow them through their vaccination series and their booster series. And we're going to try to understand some of the links between these psychological behavioral factors in particular sleep and how that might impact immune function. And then we moved into, in the context of insomnia, trying to understand the link between insomnia and cardiovascular disease. And so I've been working with some
01:11:37
Speaker
nuclear medicine folks using pet MRI imaging to understand the impact of insomnia on inflammation around the heart as a way of trying to understand the pathway of how insomnia and maybe hyperarousal of the sympathetic nervous system might impact the types of immune cells that get lodged in the arterial areas that will drive
01:12:05
Speaker
atherosclerosis and things like that. And so we're continuing to follow up on all those things, which is really exciting in a lot of team science, which is kind of like my jam.
Future Directions in Sleep Research
01:12:15
Speaker
Well, this has been a fascinating discussion. So again, Dr. Eric Prather, new book out, The Sleep Prescription, Seven Days to Unlocking Your Best Rest. We really appreciate your work and
01:12:28
Speaker
stopping by to talk to us. Yeah, thanks for having me. Are there any other places people should go to look for you, like social media or anything like that? Yeah, I mean, I'm on Twitter for as long as it lasts. I'm not sure. At Eric Prather. After that, I don't know. Get back on MySpace. We'll see you on MySpace.