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

25:20But one of the hallmarks of cognitive behavioral therapy for insomnia is your bed is only for sleep. There are two things you're allowed to do in bed. I always tell my patients, you're two things that you can do in bed are sex and sleep. If you're not sure if something counts, message me and I'll clarify it for you real quick, whether it counts in one of those two buckets. But we really want to just associate the bed with sleep. And to be clear, just going back to this study, was there a belief or were some of these guys studying in bed? They were studying in their dorms in their beds and everywhere else.

25:53I mean, everywhere. So this wasn't specifically a study focused on sleep per se. it was just focused on this associative pattern that became the bedrock of this treatment. And we can go back even further and we can look at Pavlovian conditioning, the dog and the bell and the food. And we don't need to go over what that whole thing was again right now. But the point just is that the dog came to associate the bell with getting food. And a lot of times when people are struggling with sleep, you know what they're doing in their bed? They're reading. They're scrolling. They're watching TV. They're listening to podcasts.

26:26They're doing like everything. A lot of people by the time they get to me, they're camping out in their bed just in case they're able to sleep. Oh, I'm going to go have a snack in bed because if I'm sleepy enough, I'll roll over and take a nap and I'll get some x -rays ease. So people have moved so much of their lives into their beds that it's completely dissociated from sleep. That's one of the bed rocks. And then another bed rock is what we now call time and bed restriction. This used to be called sleep restriction, but I I don't know where along the way in the last number of years it went from being called sleep restriction to time and bed restriction, but whoever made the change, I'm still not sure who made that change.

27:03I'm thankful to them for it because the other key component of CBTI is that we restrict the amount of time that a patient is in bed to match how much time their body can actually produce of sleeping. A lot of times people with insomnia will say, okay, I need to be in bed for at least 12 hours if I want to get 7 hours of sleep. I know it's hard to believe, but it's true. And we just obliterate that notion. And this is another core and very old part of CBT that dates back what? 1970s, 80s. But when you take those two parts, then you start to add in some of the cognitive components that have been around also for decades, the cognitive therapies part, the air and back stuff with cognitive restructuring, which is where we take a thought.

27:49Have you ever heard that phrase? Don't believe everything you think. So you take a thought and on the classic thought record tool, you'll have patients write down the thought, write down how they feel, write their feelings from say 0 to 90%. And then we have them write down what's the evidence for this thought if you had to go to court right now and there was a judge and a jury and what have you. And you had to present evidence for your thought. What would you be able to present? That evidence for a thought is not another thought. It's not a belief. It's evidence. Last time I slept six hours, I got a worst grade on a test or something.

28:25That would be evidence. You got a worst grade in test. But then we look at all the evidence for a thought. We look at all the evidence against a thought. Like oh, last time you didn't sleep so well, you didn't get fired. Still did find in school, whatever the thing. And then we create a balanced thought, which is even though I'm not going to be as well rest it, I'll still get through this day. Then we have people re -rate their emotions, re -rate how much they believe this new thought, this whole song and dance. This is the cognitive component, and that's kind of the bedrock of so much of cognitive therapy.

28:56Of course, people have so many negative thoughts about sleep and dysfunctional thoughts about sleep that aren't true or that are catastrophizing and whatnot. That is also blended in to the treatment. And then we have relaxation techniques, which are things like progressive muscle relaxation that came along as well. And those are part of the treatment. Progressive muscle relaxation will be like where you squeeze your hands and let go and squeeze your hands and let go and then squeeze your arms and let them go and move through your whole body to get out of your head and into your body. And I don't know what order those actually were packaged into CBTI.

29:31But I can tell you the first two, the stimulus control and the time and bed restriction. Those are among the earliest, earliest parts of CBTI. And what we know from dismantling studies is, when you take either of those out of the treatment, no dice. Yeah, I want to talk about both those a little bit more. I want to bracket sleep hygiene and come back to it because I think again, the temperature and all that light stuff, we shouldn't gloss over that even though it's easy to take for granted. And I know that many people listening to this podcast will have heard other content where we talk about it, but I'd love to have it all in one place.

30:02I think the time and bed restrictions pretty interesting and in talking with sleep physicians Who also implement this it seems quite draconian at the outset it can be remarkably Difficult they're giving people five hours in bed max and they're really trying to force sleep pressure How do you navigate that and how do you decide how hard to squeeze the tube of toothpaste? Let me draw a line in the sand between what CBTI says broadly as a treatment and then how I've actually implemented it in my clinic. So what CBTI will have you do is they will have you, and I say you as the royal you, your patient, they will have you felt something called a sleep diary, and this is a paper diary that covers seven days because if I asked you how well you slept four nights ago, it's like a food frequency questionnaire and epidemiology.

30:52Totally. Total waste of time. total. So you have to do it every morning. Okay. And of course, I'm not obsessed with it being exact because I'm much more interested in the picture pattern of it. If you asked someone to fill it out for just one day and then worked with that, you'd have a totally distorted picture you wouldn't know what you're working with. But what classic CBTI does is they'll take that seven day sleep diary. And then they will actually use the time you got in bed, time you fell asleep, how many times you woke up, how long you were awake, what time you woke up, it has all of these different questions in it and you can use that to calculate how much time a person was sleeping on average over the course of the week.

31:30And what CBTI does is it says, you patient, why don't you pick what time you want to get up every day? And then you would ostensibly pick a time. The CBTI clinician, let's say your sleep blog said you were naturally sleeping six hours a night. The clinician would add 30 minutes to that and make it six and a half hours and then work backwards from your chosen wake time. So let's say you chose a wake time of 7am. I would work back six and a half hours to get to a bedtime for you of 12 .30am. And of course, that's the bedtime of your childhood dreams. Imagine going to sleep over and your friend's mom saying, all right, kids, you can't go to bed until after 12 .30am.

32:09Kids, love it. Adults think this is torture because it is. That's what classic CBT .I would do. 6 hours being the number? 6 .5. You get that half hour of grace. As far as I know in CBTI, almost nobody's restricting less than 5 .5 hours. 5 .5 seems to be the floor. I've not seen people restricting to 5. There are a subset of people, and I don't know the data on this because I don't even know if the data exists on this, who are what we call genetically short sleepers, and these people know who they are. They have always been like this. and it's not upsetting and distressing and causing them grief.

32:47We're not talking about those people. Okay, so that's what CBTI will do. And just to be clear, let's say five and a half is the floor. Six is typically what you would do, so six and a half in bed. Well, no, if your body is producing six hours of sleep, I add 30 and I get six and a half. If your body is producing only five and a half, I add 30 and you get six. So I do this computationally for each person. I see. So when I bring my sleep log to you, you've seen that for the past week I've been spending 12 hours in bed, but by my recollection, because I'm looking at the clock when I'm not sleeping, I'm only getting six and a half hours of sleep in the 10 or 12 hours I'm laying there, you're gonna say, oh okay, that's your sleep time.

33:30Take that, add 30, that's your time in bed, work, I got it. Yes, yes. And here's where what I do is slightly different, but also the whole theoretical underpinning is not disturbed at all, by the way that I do this. So how many times have you had a patient come to you and say, oh, I really want to be that person who wakes up at 5am gets a go on my day. I want to get my exercise in. I want to get my meal prepping, do all this stuff. I'm like, okay, cool, cool. So you want to be a 5am person. What time do you get up now? All like 11. I'm like, okay. All right. So this whole part in CBTI where people choose their wake time, that's not a thing for me.

34:06In my clinic, we play a game called Democracy Within a Dictatorship. What that just means is that instead of just letting patients cart -blanch choose their wake time, I actually look at their sleep diary and I let them think they're choosing their wake time. And if I agree with it, they will have chosen. If I don't, the dictator comes in. And I look at their diary and if they are getting up at 7am, 6am, 7am, 7am, 6am, 6am, 6am, 6am. I will say, well, we have no evidence that you can sleep until 830. That's not realistic. But we have evidence that you can sleep until 6, because four of the last seven days you made it until 6.

34:49So 6 o 'clock is your wake time. And this is not anywhere in CBTI. I've spoken with a lot of my colleagues who do CBTI and asked them how do you choose a wake time, and there is no standardized method. But by using this method, I'm definitely making sure that I'm at least gating the patient's sleep at a reasonable time. Because if I let that patient just choose 8 .30 AM as their wake time, and they were only producing six and a half hours of sleep. They're going about at one in the morning. They're going to bed at two in the morning, and they're getting up at 8 .30. Because they chose their wake time as 8 .30, but really they're gonna wake up at like six or seven, and they're not even gonna cash in on the full six and a half hours that they should be getting in bed.

35:27So I've added in this component of my own of setting their wake time to be a much more reasonable time. And then what I do before giving them a bedtime, I give them a week at that wake time. And I see how much sleep is your body producing with this new wake time. Now, let's say you're doing the sleep log and they're spending, you know, eight hours in bed, getting four hours of sleep. Let's say they're getting five hours of sleep, eight hours in bed, and then they're taking an hour nap a day. So they're removing all their sleep pressure during the by taking that nap, but they kind of need to take the nap because they're not getting enough sleep.

36:05So they're in this vicious cycle. So do you add the hour of nap time back to sleep and say, actually, you're getting six hours of sleep, let's do the exercise based on five plus one, plus a half, 6 .5? No, no, no, no, no, no. We want to extinguish that sleeping during the day thing. So there's a difference between a person without insomnia healthily using naps, and then there's a person with insomnia who's napping to compensate for what's not happening at night. So I think that to best explain this, I should just finish this example of the wake time thing because this directly ties in. If I'm setting their wake time and then I'm seeing how much time they're actually producing sleep, that first week when I give them the wake time, I don't give them a bedtime.

36:43I don't even do time and bed restriction that first week because for some people setting a wake time solves the issue, which is kind of nuts, but one or two of every eight patients who I see, because I see patients in groups of eight. We'll have a huge improvement from just having a consistent wake time because their body actually recalibrates and they start getting sleepy at a more consistent time each night because they're not doing it. And I do say in that first week, I take away the naps. I say, I don't care how you slept last night. You need to just stay awake until you're ready to go to sleep, no naps for now.

37:16Now, when I have patients, mmm, probably older patients like 80 and up, I'll be okay with a nap, but I'll often, at this stage, I'll say, look, you have an opportunity of 25 minutes. And a 25 -minute nap opportunity means you set the alarm for 25 minutes, you get in bed, and it's going to go off 25 minutes later, and that's when you get up. I don't care how long you actually slept during that time, because I don't want you going into phase three or phase four, slow wave, deep sleep during the day, because that's what's going to really mess you up at night. A stage two sleep nap is not really an issue during the day as much.

37:54It's not going to be so bad. But at this stage of the person within Tommy that we're talking about, I don't want them taking a one hour nap in the day. And they come back that second week having done the wake time that I said, and I then recompune how much time and bed they're spending. And then I still use that wake time, and I then calculate their bedtime. And then the true time and bed restriction begins week two. Okay, but just to be clear, if you have someone who is using a nap to compensate for their insomnia, step one is just kill the nap. Kill the nap. And then let the cards settle where they may for a week, recalculate actual sleep time, and then go through the exercises described.

38:32I've made this point on a podcast before I think, but just want to get your blessing. When we're on bow hunting trips, you are going to bed insanely late and waking up insanely early. It's just the nature of when you get back to camp and eating and then you got to be up super early. So I've never been on one of these trips where I could actually be in bed for more than five and a half, six hours in a night. So the strategy is to get that sleep, but then I always try to get a 90 minute nap at around one in the afternoon. And the reason I pick 90 is to get a full sleep cycle. And I tend to function incredibly well under those circumstances because remember you're also very physically active, like this is demanding time.

39:16So would I be better off not doing that nap midday? Oh, that's a bow hunting trip and you don't have insomnia. That's not a problem. Okay, all right, got it. Yeah, totally different monster. And I tell people to, a lot of last few years, people have had serious illnesses, they've had COVID, they've had whatever, when you're sick, all bets are off. What I tell people is, if you need a nap when you're sick, you need a nap when you're sick, but we maintain stimulus control. You don't nap on the couch, we're only napping in bed. And if you're awake and feeling sick, then you can be on the couch, not in bed.

39:45While we're on that topic, what do you say to the legions of people watching who fall asleep watching TV on the couch? Oh, the worst. A lot of people fall asleep on the couch because they're just so overtired that the ship has sailed. Their body's ready to go to bed and they're just letting it and they're not getting up and doing the thing. I tell people, look, if you want to prioritize your sleep, pay attention to your body. When you're watching TV, do you notice that you're starting to nod off? Do you notice your eyelids feeling heavy or your hands feeling warmer? Are you starting to sag a little bit?

40:19Okay. These are indicators that it's probably time to get off the couch and go to bed. For people who can't figure that out, I say, okay, you want to watch TV at night, sit in a stool. You're going to figure it out real fast. What about just the social dynamic of it, which is when you have a couple, not that I'm saying this should experience it all. And one part of that couple, they want to be together and watch TV. But one member of that team falls asleep immediately while the other does not. And the one that does not tries to tell the one that is to go to bed, but that one wants to be with the other.

40:53I don't know if you can ever imagine a scenario like that. Yeah. I'm just making it up. Okay. Good. I'm glad you're making that one up. I have a lot of these couple of issues that come up in sleep clinic. This is not uncommon. Because what's more intimate than being completely unconscious next to another person if you think about it evolutionarily? That's probably the riskiest thing you can do. So there is this desire for closeness in lots of couples and it becomes a challenge when one of the members of the couple has a sleep problem. And the first step is remembering this is not necessarily permanent.

41:24We need to go about fixing this now and then we can find a new winning solution. So in the interim, I'm assuming you've already tried maybe watching something different on TV that might be more exciting to the second partner, etc. It's not about the boringness of the show per se. Doesn't appear to be. Okay, good. So if that's the issue, then I would say, hey, if this is a priority, what are we going to do? We're going to schedule it. We're going to schedule time to be on the couch together at a time when I can definitely be awake and be spending meaningful time with you. The problem is sometimes other members of the family who tend to be smaller also tend to be occupying all of the bandwidth during those earlier hours when the member of the family in question is able to be awake.

42:13This is a hard problem to scale, but what I would just say is if you're actually ready to go to bed and your body is saying that you need to sleep, you should probably do that. But it's more likely that then you'll be awake the next day and be a more pleasant, exciting partner to be around and be able to have more meaningful experiences with your partner that way. Otherwise, I tell people, look, this is an issue. If it's a really an issue, we're going to get a babysitter, figure it out. There are ways to get around these things. People just often want it to work like they see in the movies. Like, oh, this should be easy.

42:51Obviously, I'm talking about my wife here, so I'll stop double speaking. But if my wife falls asleep every single time on the couch, but then when said Netflix is over and we go up to bed She falls right back asleep and it doesn't seem to keep her awake. Is it pathologic? This isn't necessarily a problem, but what I would say is we sleep more deeply at the beginning of the night We experience more slow wave sleep in the first half of the night and more REM sleep in the second half of the night I think other podcasts guests you've had can definitely go into the neurobiology of this much more deeply but a way that I like explaining this has to do with evolution.

43:26If you think about it, when we're deeply, deeply asleep, we're kind of tuned now. And on the prairie, when we figured, okay, it's safe to go to sleep right now, our body's prioritized getting that really deep sleep when we knew it was safe. And then as the night goes on, we sleep more and more lightly, which makes sense because, hey, there could be lions and tigers around or whatever that are gonna come and eat us. So evolutionarily speaking, it was adaptive to sleep more deeply in the first half of the night. Now, if your wife is falling asleep on the couch and getting some of that sleep at that stage of the night and maybe getting more interrupted aspects of that because there's noise from the TV or whatnot.

43:59It could be disturbing the quality of that's the drawback. Yeah, it makes sense. To that effect on the prairie, it also makes sense that evolutionarily there's diversity in people who are night owls and early morning larks. We needed that diversity in order to keep the tribe safe from the threats on the prairie. Some people were staying up late. Okay, no lines. Some people were up early. Okay, no lines. And there's nothing pathologic about being a person who's going to be more likely to fall asleep earlier, be a person who's more of an idol. And it's very hard to change that. A lot of patients want to change it.

44:30Broadly, two to three different archetypes of that. I know there's a circadian rhythm test you can take online that gives you a sense of it. I almost think it's so self evident if you pay attention to your patterns. It is. I'm really a clinician. So I deal with what's in front of me all the time. I'm not so concerned about these tests. I'm more concerned about what's the problem that's messing up your life right now and how can we work around that? Let's go back to sleep hygiene for a second. We talked about temperature. Nowadays we have these incredible devices that can cool our mattresses and things of that nature.

45:04Obviously we have air conditioning that can cool the room. Do you have a preference for one or the other? I mean, clearly not everybody needs to buy a mattress cooling device if they can afford it. that shouldn't be an impediment to sleep. Do you have a room temp set? We typically talk about the mid -60s. Is an ideal room temp do you adhere to that? Yes, mid -60s is terrific. If people say, oh, if this is just too cold, I say, well, what's too cold? And often they will say my feet. And we have wonderful solutions for that. They're called socks. We can get really thick socks. I'm also not opposed to, you know, those tiny little heating pads, you can get there like this big foot and half by a foot or something.

45:39Putting one of those in the foot of your bed, it's gotten an auto shut off, it shuts off after like an hour or something to fall asleep with, I don't have a problem with that. There's no issue there. But yes, a cool room is definitely key and insert my refrain about down comforters, duvets, etc. Get cotton blankets, get cotton sheets. Let's talk about light. Do we need to have it so pitch black you can't see your hand in front of your face? Do we need to block the moonlight? How dark do we need it to be? This is a common question. If you close your eyes right now, you'd be able to tell that it's light in this room.

46:13We can sense light through our closed eyelids, and many women would tell you that their eyelids seem to get thinner as they age. So I think an eye mask is a great addition. This is for a lot of people with early morning awakenings. Eye masks can be a game change because they don't realize that what's causing their early morning awakenings is a little bit of light getting into the wrong part of their eye, indicating it's time to be awake right now. I don't know the details on what wavelength of light that is or what necessarily the light is coming from whether it's a light outside from the sun or the moon or whatever it might be.

46:48But the point just is a lot of folks with early morning awakening can really benefit from having something covering their eyes, whether it's a sleep mask or there's like hats that go down here now. I'm a big fan of making your room dark. I am one of those people who travels with a role of black electrical tape because you go to a hotel room and there's like 50 ,000 lights everywhere. You wouldn't just get relief from the eye mask in this. I do. But I'm one of those people who rips my I'm ask off in the middle of the night and I've tried every single I'm asking it's coming off so I Like to wear it.

47:20I start with it. I try and keep it on as much as I can But I also if there's egregious lights in a room. I cover the moon luck meeting like you're gonna cover the alarm clock And or whatever the oh yeah, no, there's none of that in my room My trick is I unplug alarm clocks because I realize sometimes they're so complicated that they just go off And all the night and I didn't realize it and yeah Oh, totally. And the microwaves are the worst. Those are the blinking time. But you mentioned the cooling mattress stuff, which I'm intrigued by, but I also am concerned about. It seems that a lot of these mattresses have settings where you can make it cooler, but also you could make it warmer.

47:54And I worry about two things. One is I worry about messing with our circadian temperature biology because you remember in the 1980s for a hot minute when electric blankets were really popular. And all of a sudden they're not. They're starting to see associations between electric blanket use and some cancers. And at the time, there was a lot of speculation that this was related to EMF. But the great thing that time does is it gives us more perspective. And there are some indications that actually that might have been messing with circadian temperature, and that might have been part of the issue.

48:27We know that night shift work is carcinogenic. Do we though? Yeah. Night shift work's been declared a carcinogenic. Well, I mean, no disrespect to the WHO. I don't know what I believe that they say. I know that there's an association between night shift work and cancer, but do we really know that it's causal? I think if we go Bradford Hill on this, and we look at temporality, I think that there are age -matched case control studies where they can look at people going through different control for history effects to see our people getting more and less cancers. It is tricky because, for example, you look at firefighters.

49:02There are way more likely to get cancer. They work way more, they have way more chemical, but they've way more other things in the mix. But I think that some of the more classic studies have also been done with hospital workers, also confounding effects. How do we get around the confounding effects of the obvious dietary shifts that occur in people when they're working under those conditions? I mean, if I think back to how I ate in residency or how I eat after a night of poor sleep, I mean, to me that would be more the cause I'd put more of that on kind of the metabolic ill -health that might result.

49:36But carry on. Yeah, I think that it's often hard for people to sleep during the day. Making that change from going to sleeping at night to being a person who sleeps during the day, for some people it's not even possible. You talk to some night shift workers, they sleep very little because they just can't sleep during the day. They're not able to flip their circadian biology. But there's a whole history, and I know we'll probably talk about thermal stuff in a bit, but of looking at disruptions in circadian temperature as one of the most common circadian disruptions in mental health disorders. But going back to the cancer thing, what would be the believed mechanism of action?

50:16I would talk to an oncologist about that, and I would probably talk to a circadian biology person about that. But what I can just speak to is just my understanding that electric blankets are no longer here with us and very common because there were these observed ill health effects, whether they're due to EMF or whether they're due to messing with your body temperature at night. But what concerns me about some of the exogenous interventions like mattresses that might heat up is they're supposed to be a normal circadian temperature rhythm that we do during the day and during the night. And when we start imposing things on that, some of these mattresses can actually be set to cycle different temperatures during the night and all these things.

50:59Yeah, so the one that I use just by full disclosure, I'm an advisor to that company. The one that I use, you change how cold it is throughout the night. So I think I run it as I think the settings go from zero to minus ten. Minus ten is the absolute coldest. Zero is no temperature. Is that like a point scale or is that degrees? No, it's a point scale. Yeah, yeah, yeah. Yeah. So I think I get in and I have it at minus five and then I run it down to minus 10 and then I bring it up to minus five in the morning. Something to that effect. So I'm taking it from cold to really cold up to cold. Right.

51:34Okay. So where my concern is just that you're saying people would heat themselves with these things. Yes. But that gets to the point which we know we don't want to be warm. We don't want the debate. Right, but a lot of people get in bed and they don't like feeling cold, because it is easier to fall asleep when your hands and your feet and your skin is warmer. So people will maybe mistakenly do this for more of the night than they should. And I'm just concerned that our circadian temperature rhythm is an exquisitely controlled system. And a 10 point scale on a device, I think, pills and comparison to the complexity of what our bodies need to do in terms of temperature during the night.

52:14The good news is if you can keep your room at 65, none of this matters. And the biggest challenge honestly is hotels for most people is where you have the hardest time. Hotels are the worst. And there are some mattresses now. They're just hot. There's a short list of mattresses that I just tell people, like, look, that's going to be a hot mattress. Don't get that. And you want to be really careful to make sure that you can be cool in your bed. And I think the easiest way to do that if you don't have the money to splurge on Something that's going to be a mattress that's going to definitely be cool would be keeping your room cool What about Blue light before bed.

52:48I've looked at these data quite a bit and I would say that six years ago I was in the camp of Every light had to be read so you know I had to have my phone shifted into a red light phase my computer shifted into a red light phase I had all of these apps that managed all of this stuff so as soon as the sun went down, Blue Light was being removed from my electronics. And I have to say, I sleep subjectively and objectively better today. I say objectively if you can believe what a sleep tracker tells you, but we can rack at that and come back to it we should never taking Blue Light out of my devices, but instead paying attention to what I'm consuming.

53:32In other words, my new hypothesis has become, it's not the blue light that is the problem, it's the stimulus that often comes with the blue light. In other words, not looking at social media, regardless of light color, is a far greater positive impact on my sleep than looking at those things, but just making sure that there's no blue light coming through. So let's talk about that. What is the role of minimizing blue light when it comes to preparing for sleep? First, I want to completely agree with you. We didn't evolve for the neural experience of Instagram. We're not ready for that. I think regardless of what color light you're getting your Instagram on, that's probably not helpful before you go to bed.

54:16So I think that you're entirely right. I think the larger problem is not necessarily the blue light, but is the thing that we're interacting with, whether It's an iPad or a phone or a computer because typically those things are going to involve social media work email All of these other things that I think are much more potent disruptors of sleep than the blue light itself I must caveat this though. I have had a few patients who they were not using Instagram before bed They were not doing email before bed none of this nothing stress forced No, but I just finished with a patient recently like this who found that using orange colored glasses and I'm talking orange colored glasses Not those beautiful blue light blocking glasses that are clear lenses that I'm not sure what they're really doing sometimes I'm talking ugly motor cycle looking orange lenses I found that a handful of patients wearing these two hours before bed.

55:12It completely immediately, ameliorates their sleep onset insomnia such that they were able to almost immediately quit Ambien. The beauty of these interventions is if you can isolate them to one change at a time, you can be empirical about it and something like wearing glasses is benign. I mean, you're only out the money you spend on them and if it works, great. And if you really want to test it, take them off and see if your symptoms return. And then if they don't, maybe it fixed you, maybe it wasn't that who cares if they return and you can fix it. Yeah, like I try not to be terribly dogmatic about this stuff, but I also think that when people go to great lengths to remove blue light without removing stimulus, they're missing the boat a little bit.

55:57And for me, social media is not much of a stimulus. I actually don't pay that much attention to it, but work is. So for me, the single worst thing I can do right before bed is look at email. Whereas watching TV, it's a total beautiful way for me to be distracted by watching something mindless on Netflix for an hour. And as long as I don't go and check my email and see what got sent to me in the last hour, it'll be great. It doesn't matter that I just finish watching a big bright screen of Netflix. It doesn't seem to impact me. Well, one is much more interactive and stressful and one is very passive.

56:32when you're just watching a movie that has nothing to do with you, no bearing on your life. What I would say back to your, what I'm going to call AB testing, whenever you want to test one of these individual, what I call low hanging fruit interventions, you want to collect your own data on a paper sleep diary for two weeks. Make the change, you must do it for two weeks. And there's a few more low hanging fruit pieces of sleep hygiene. By the way, do you have a nice template? We have one that we give our patients. Again, it's super low tech, it's a piece of paper. So low tech. Do you have one on your UCSF website?

57:01I can make it public. Yeah. Yeah. Yeah. Okay. We'll link to it in the show notes. Yeah. Easy to do. We'll link ours as well, but yours is probably better. Ars is like boxes you color in. Oh, yeah. And it's like you put C when you had caffeine, A when you had alcohol, E when you exercise. So we're documenting when did you exercise? When did you have food? Alcohol, caffeine, and when were you in bed and when were you sleeping? Who? By the shading. Yours might be even more high -tech than mine, but what I will tell you is Mine is just enough to get the information that I will definitely act on and nothing else, but I will tell you, can I go over a couple more pieces of low -hanging on sleep hygiene?

57:37Okay, so back to the glasses. If you are a person who has trouble with what we call early insomnia, so difficulty falling asleep at the beginning of the night, and you're already not looking at your email, not doing Instagram, you're just annoyed that you cannot fall asleep at the beginning of the weeks and see what happens. It's so easy to do. To be clear, is there a particular brand? I have no affiliations with any of these things. I can tell you there's some really nice ugly ones from lowbluelights .com, I think, crystal in business. But they look like motorcycle goggles. I do think that the wrap around feature is important because if we're going for it, let's go for it.

58:16It's a worthy thing to do. Another important thing to do is to talk to your physician. I'm not a physician, but that I work with a ton of them. And I learned this from an anesthesiologist's all medications have circadian effects, all of them. Somehow it's probably not known for all of them how they do, but they do. Make sure you are taking your medications at the same time every day and at the right time of day. For example, I once had a patient coming in saying they were taking 450 milligrams of bupropion for depression before bed. No. That's gonna be a pretty stimulating dose of something to take for bed.

58:51So make sure that you go over your medications with your doctor and that you're taking them at the optimal times of day and be really consistent with your medications. And another one that is a particularly low -hanging piece of fruit is something called decaffeinated coffee. Turns out there are speculations that decaffe coffee can have as much as 15 to 30 % of the caffeine that regular coffee has. I haven't found that reference. I've dug. I've tried to find one that will show that. I haven't found exactly that. But there are some data from 2006 that were published saying that 15 -ish percent.

59:27But then again, more recent data have shown that Starbucks, I think, says that their 12 -ounce has 155 milligrams of caffeine, but outside laboratory testing found 310, something like that. So when you're decafinating coffee that's much more caffeinated than you started with, this can make an absolutely huge difference. I tell people, we're done with caffeine by 11. That's my 11am. That's my standard. unless we've got an extreme phase delay or phase advance, I should define those terms. A phase delay is when you go to bed really late and you wake up really late. A phase advance is when you wake up really early and you go to bed really early.

1:00:02So someone who's waking up at like 3 .30 in the morning and going to bed at like 8 p .m. that would be a phase advance. Phase delay would be like, I'm going to bed at 3 a .m. and I'm waking up at 10 a .m. So in those cases, I might do something differential with the caffeine, but for most people who are neither of those, I'll cut it off at 11. That includes your caffeinated coffee and your decaffeinated coffee. And I never take people's caffeine away. Caffeine withdrawal is not something I want to deal with in my clinic and I don't think it's necessary. You can cause a lot of damage taking me away someone's coffee.

1:00:36People really don't like that. Billy puts them in a bad mood and it's not necessary. So I tell people do not change how much coffee you're drinking. Put it all before 11. Just move it all. What fraction of people are such rapid caffeine metabolizers that they seem immune to caffeine and sleep? I think that that person doesn't actually exist. I need to be convinced what the normal caffeine half -life is four to six hours. So even if we take someone who's four hours, that means after four hours you still have half of a cup of coffee and after eight hours you still have a quarter of a cup of coffee and if you have that coffee at 2 p .m.

1:01:15and that coffee actually had 310 milligrams of caffeine in it and it was only a tall coffee from Starbucks. There's a lot of contingencies to build in here, but I could tell you people, someone will both just know, actually stops using decaf coffee after dinner and it's a world of difference for their sleep quality. People will say, oh no, I fall asleep just fine, it doesn't affect me. Well, it is affecting you. It's affecting the electrical quality of your sleep throughout the whole night And I would refer you to talking to a sleep neurologist to interpret some of those sleep studies and talk with you more about that.

1:01:51For my purposes, all I need to know is the person who's trying to fix the insomnia is, oh, you're having two decaf coffees after dinner every night. That could add up and that could be doing something and that could make your sleep less restful. Okay. Low hanging fruit. Just stop it at 11. Stop it. Do the experiment at a minimum. Okay, so those are three. But don't reduce it. Is the key thing. Anything. Any other really obvious things to AB test for two weeks? No, I think that that's the major part. I will tell people also, people like to fall asleep with podcasts on, don't do that. Including this one, right?

1:02:26Right. Yeah. This is an easy one to fall asleep too, but I don't know. I hope that people aren't falling asleep listening to this, although if this helps them sleep. One of the things I want to talk about is on the relaxation techniques. Where does or does mindfulness -based practice come into it? So anyone who's done mindfulness -based meditation probably appreciates how difficult it is. It's not like transcendental meditation where you're focusing on a mantra. You're instead focusing on a sensation, typically breathing. But body awareness is a thing that you wanna focus on. Is that counterproductive or is it productive as you're laying there awake?

1:03:02So my unsatisfying answer to so many questions is always gonna be it depends because there's moderator variables. And when it comes to CBTI, what we know is that what's been tested is progressive muscle relaxation, which you could argue is a form of a body scan, which is part of many mindfulness practices where you scan your whole body, you think about your hands, you notice how they're feeling, are they warm, are they soft, why not, and you move through your whole body. With progressive muscle relaxation, you squeeze your hands and you let them go. You squeeze them and you let them go. It's more of an active process that you're paying attention to throughout your body.

1:03:35Doing this in bed right before you fall asleep for a few minutes is fine. That's the one exception to the sleep and sex rule. I tell people that it's also fine to practice this in other parts of your house. You don't have to just be in bed. But the body scan and mindfulness in general has been studied in combination with CBTI. And what the data have shown is somewhat fascinating. There's no actual differential improvement on sleep duration or metrics of sleep. But people like the mindfulness stuff. They report they're more happy with it. They like doing that. But in terms of actual improvement on sleep outcomes, I don't think it really adds too, too much to CBTI.

1:04:16The effects with CBTI are pretty whopping. When it's done well, 50 to 60 % of people can get remission and 70 % can get clinically meaningful improvement to their sleep. So in the world of psychological treatments, that's really good. But to circle back to your question, mindfulness is great. I think there's a lot of practical uses for it for helping yourself when you're in psychological states. You don't want to be in. It's a great way to be in life But when it comes to sleep, do I need you to start a mindfulness practice to improve your sleep? No So you mentioned 50 to 60 percent of people are going to have a remission closer to 50 but yeah 70 % will have a meaningful clinical improvement of the 30 % that do not.

1:05:02Why? When does the treatment fail? The treatment fails when people don't do it. So in other words, we're really saying 30 % of people are not able to adhere to the treatment. I wouldn't go that far. There are some people who are genetically short sleepers. And at some point this may become distressing for them. I had a story of a patient who was in her 70s came to me saying, I have a huge problem. My sleep is not good. And I asked her, okay, so tell me all about this. She was like upper 70s had a volunteer job really active full workout plan I'm like you're crushing it lady. What's the problem exactly?

1:05:38She says well I joined this study and I had to wear this wearable device and I woke up in the morning and it says that things are not going well every morning Morning after morning and it says I'm at risk for different things I'm not gonna say which wearable company was and I said okay There's an amazing treatment for that. Can I see the wearable device? Can I please just have that wearable device? Here's my vice grips. Exactly. This was a while ago, but I took it away from her and the wearable devices now are not doing this. This was gosh, seven, eight years ago. I made a note to ask you this question.

1:06:12When do you tell people? Because we do this with our patients, which is take the tracker off. We're doing a six month tracker holiday done with the tracker. done. So is that main stay part of your treatment is like let's get all that anxiety out of there. For people with insomnia, I tell them, yes, coming to me in my clinic, the people who have bothered to wait a year and a half to get into the clinic, those people, yes, I am telling them that. And so to go back to your 30 % of people, the genetically short sleepers who become distressed about their sleep are not going to be helped by CBTI. They're not.

1:06:49Maybe they shouldn't be helped. Maybe there's nothing to fix. Correct. Correct. But they're presenting, so I'm putting them in the group. And then yes, we know that there's such a huge body of data on CBTI at this point. It's just wonderfully studied. And we know that when people don't do the treatment, it doesn't work. Adherence is a major, major component. Duration of treatment also matters. It seems that if you do four or more sessions with a therapist doing the CBTI, your outcomes are going to be way better than if you try and cut it way short with one or two. My treatment is five sessions.

1:07:18I do an intake. you get five treatment sessions and then I do a follow up where we just tidy things up. And the space between them is a week. Always one week. I am militant about this. If you're going to miss a week, you can't be in it. You have to wait for the next cycle. Given that people are waiting a year and a half to see you, tells me that there's a mismatch on the supply demand curve. Why is that the case? First of all, there is a great directory. Can I give you for the show notes? Yes. So there's actually a way you can look up. We use it ourselves in practice. This is exciting behavioral sleep medicine.

1:07:50Yeah, yeah. So that is how you would find a provider who definitely knows how to do CBTI. One of the major problems comes down to psychologists and providers taking insurance. A lot of the best folks there in private practice, they don't take insurance and you could be paying hundreds of dollars a session to see them. And they're pretty backed up as it is and they don't take insurance. I am fortunate I get to work at UCSF at the Oshar Center for Integrative Health and we take Medicare and all kinds of insurance so people can pay minimal or non -existent copays to see me. And there are other CBTI providers at UCSF, their waitlists are long, long, long too.

1:08:31In fact, in order to see patients now with any volume, I don't see individual patients. I see eight patients at a time and group medical visits. And I do it 90 minutes every week, all eight patients in that 90 minutes to get it done. So what will it take for AI to replicate what you are doing to scale this much more? Because a lot of this, a lot of the work I do can be done by an AI. How much of the art and science of this is teachable to LLMs and at least is another offering. I'm not saying it should ever displace what you're doing or what a therapist is doing, but if we have a backlog of people for years, shouldn't we have an alternative which might say, look, there's an online course that you can do that will give you 70 % of the value of what you might get sitting in the group with Ashley.

1:09:24Hey, if you can find a way to replace me, I'm here for it. We'll just come up with an alternative to scale. Here's the issue. There are some CBTI apps, smart phone apps and the range is out there. And I've had patients who've tried these while they're waiting. Yes, exactly. And they'll come in and they'll say, oh, it might have helped a little bit. And I think the major issue is that many, many people with sleep problems think that their sleep problem is unique. It's special. This can't be treated by just a generic app. My problem is different. And the joy of me having a group is that people can hear that everybody's problems are different and I'm gonna treat you all the same way.

1:10:01You all are going to do the same things. You might do it at different times, but you're all going to do the same things. I think that there is a world where AI can help with the personalization aspect. I'm actually helping a company that's making an app. It's called REST. They are integrating AI to use, for example, the way that I calculate someone's wake time, which is not something that's in standard CBTI. They're incorporating that and they're able to actually do more tailoring. And I'm excited to see where it goes. But I think that the biggest fly in the alignment with this is going to be getting patients to look at the fact that they have been assigned to wake up at the same time every day for the next seven days and think, oh gosh, I only wake up at 5 a .m.

1:10:43two days a week. Normally now I have to do it every day. Getting them to really do it is going to be hard. Before my patients enroll in my clinic, they watch a 10 minute video and it's a really scary video. In that video, I'm basically saying, look, this is gonna be hard. You're gonna hate me. You're going to want to make a dart board with my face on it and play darts on it. You are going to suffer in the beginning of this treatment. But guess what? You have been suffering for months or years. Now you're going to suffer for five weeks. You're going to do it my way. And if you don't like it, you can go back to your way.

1:11:15This is five weeks of your life. How bad can it be? How much worse can it get? So I do one of these kind of pep talk videos. There's just something about knowing that someone else is actually really paying attention to one of the biggest problem, if not the biggest problem in your life at that moment. Sleep is a 24 hour day problem. This is not just a problem at night. It is affecting you all day. It is intensely personal. So it's a lot to trust an algorithm or an app to know, oh, okay, I really should do these things. I think it's a big ask and it's hard. By the way, when you're giving them that boot camp speech is the time and bed restriction typically the thing that causes the most distress?

1:11:55They don't know about that at that stage. People are in the dark at that stage. I just say, look, we're going to do this thing. It's going to be really hard. You're going to get worse before you get better because everybody sleeps less the first couple of weeks while we're getting all these things lined up. And for some people, what ends up being the hardest is the wake time because they're used to just sleeping in whenever they can or catching up on those hours when they can. For other people, ooh, the super late bedtime that I give them, that's what crushes them. I'm like, oh my gosh, I have to stay up until then.

1:12:27But the great news is that we dial it back over time. And I don't think we talked about this part with time and bed restriction, which is just that there's a benchmark for efficiency, sleep efficiency. And we define sleep efficiency as the amount of time that you're in bed sleeping divided by the entire time that you're spending in bed. And the benchmark is 85%. So each week, I'm actually calculating sleep efficiency from people's paper, sleep diaries. And once we do time and bed restriction, if they are above 85%, I'm move their bedtime back 15 minutes. And then if that's the same for another week, you move back another 15 minutes.

1:13:00And people say 15 minutes, what? Who cares? I'm like, oh, you'll care. After four weeks, that's an extra hour every night. That's huge. And are people able to, with a high enough fidelity, report awake time in bed? For example, like if I were doing this, let's assume I've got a clock next to my bed that I can look at, because you have to do that for this purpose. You have to have some device to keep track of time. So, I get in bed because my time in bed tonight is 11 and my wake up time tomorrow is 5 .30. Okay, so I get in bed, it's 11. Check. Okay. How do I know what time I fell asleep? Let's just say I didn't have an issue falling asleep.

1:13:38How do I know if it's 11 .15 versus 11 .30? I'm looking for the difference between five minutes and 50 minutes for that time to fall asleep thing, right? And in the middle of the night when you're waking up, guess what? If you're not getting late, you're getting out of bed. So you can look at the clock and be like, all right, I'm out of bed. And then you have to go do what I call a very fun and potentially embarrassing activity. Embarrassing, meaning if your boss caught you doing this activity during the work day, you should feel embarrassed. So for example, reading people magazine or reading some trashy magazine, you wouldn't want to be caught at your desk doing that at work.

1:14:12That's exactly what you should be doing in the middle of the night. So person wakes up at two in the morning and they can't go back to sleep. Get up, go and do something that is not productive, not rewarding in the way that, hey, this is, I'm building a pattern around getting up and doing something I like. Right. So I wouldn't be able to get up and play chess. I wouldn't be able to do the online chess thing that I love. Maybe, maybe not. I mean, I tell people they can play solitaire. Okay. Adult coloring books are all the rage. I couldn't check email. No, it worked. Work -related work is a definite no.

1:14:44What about scrolling social media? No, no. We don't like that. Although that meets the criteria, if you wouldn't be in a bar, it's catching you doing it. We don't do social media or interactive. Read for pleasure. That's fine. But we don't read about global warming, current events, politics, pandemics, those things are off the menu. Stock trading? How if it's stressful? I wouldn't do that. Okay, so there's a narrow subset of activities that you are gonna get out of bed to do. Yeah. Mm -hmm. Stuff that's kind of boring, but entertaining enough. because we don't want you to get a habit of looking forward to doing something in the middle of the night.

1:15:18This happens with parents, like a parent, for example, who might be busy all the darn day with their kids and their families' needs and everything else. Then in the middle of the night they wake up and it's like, oh, this is me time. This is when I'm gonna do all these really fun things that I don't get to do during the day. We don't wanna make a habit of you time being between three and four a .m. That's really when you want you to be sleeping. Sometimes you have to schedule that stuff during the day, But we want the stuff in the middle of the night to be mildly boring into that end back to your blue light thing I don't mind if people watch for example an episode of mash or Gilligan's island or sex in the city or some other sitcom I like 20 minute episodes because then you can generally turn it off Checking with your body think am I ready to go back to sleep and then you can go back to sleep Do you remember in the 90s if you played video games ever how we had those like cartridges and you go Put them in and sometimes you have to take them out and Blow them out to put them back in and reset them because they would freeze that's what you're doing.

1:16:13When you get out of bed in the middle of the night, you do it in activity, you're resetting and then you're going back to sleep. Instead of just having stewed in bed that whole time, and it's much easier to fall back to sleep when you have that reset. So we don't want the activity to be too stimulating, but just mildly boring and entertaining enough. Is that track? Yep. One obvious thing we haven't talked about, and maybe it's so obvious we don't need to, but just to close the loop on it as food and alcohol and how they pertain to this, what's checklist you run through with the clients. So since we're dealing with so much life, I actually don't mess with their food.

1:16:46All I do is say, hey, really, let's try to not eat within three hours of going to bed. Sometimes it's rare that I'll have nighttime binge eating disorder to deal with at the same time or a blood glucose issue that didn't diabetes that's poorly controlled at the same time, but I'm going to put those cases aside for just a moment. So I generally will go with, don't eat for three hours before bed. And when it comes to alcohol, I tell my patients, look, this is five weeks of your life. I'm not going to drink and you're not going to drink. So when I'm running a clinic, nobody's drinking. And the reason for this is that in order for me to actually see what's going on with your sleep, I need to see this with the least perturbation possible.

1:17:21Alcohol and marijuana are those things. Now, if people are using a lot of marijuana or a lot of alcohol, I'm not here to put people into withdrawal. So they just don't enroll until they're... No, no, no, no. I'll open it. So what I'll do is before people come to their first group, I have them do a sleep diary so I can see what's going on. And before that, I will have done their intake and I'll have told me their alcohol intake and I'll decide it, all right, here's what you're gonna do. You're either gonna not, or I just finished with some people. One of them was drinking between 16 and 20 ounces of wine a night is huge.

1:17:53And I said, okay, so you're gonna drink two ounces of wine a night out of that same glass. And then you know what, you're gonna keep using that glass and you're gonna drink something else. Some other proof of drink, I don't care what it is. But I want it to be something that you don't drink during the day, so I want it to be overpriced juice or overpriced bubbly water or something like this. Something special. Something special. And you're going to keep drinking it out of that wine glass. And I have them do that. And I make sure they can do it before they start treatment. And they generally can.

1:18:20Because again, the other part that I have going for me is that people have been waiting so long that by the time they get to me, they'll do what I say, which is just this lovely gift that I have. But I'll make people be very consistent with that. They'll be like, oh, I have to drink two ounces of wine a night. I'd also say, yes, you do, you must. I want this consistent, that's the thing, consistency. So if someone's saying, oh no, I drink three nights a week and I'll say, all right, cut it out. You're gonna stop, I'm gonna stop, we're all gonna stop. Are there any specific cognitive techniques that people are instructed to be working on when they first wake up?

1:18:55No. Nothing. There's nothing, no mind game to play. It's all behavior behavior. I'm all business, yep, it's CBT, I'm a purist. And I don't involve the cognitive techniques until week three of five with treatment. And that's when we get into things like scheduled worry time, working with the thought records. And then also one of my favorite things to do with patients who seem to wake up in the middle of the night, maybe at 1 a .m., they jolt themselves awake, worrying about something in particular. I have a patient like that who every night in the middle of the night wakes up at 1 a .m., and says, I'm very worried about thing A.

1:19:33I'll say, okay, thing A. Here's what I'd like you to do with thing A. I would like you to track how worried you are about thing A all day, every couple of hours. It's called tracking degree of belief in a thought. And what you might find is that I'll build on this with an example of a patient that I had actually. This might be an easier way to explain it. I once had a patient with multiple sclerosis, early 30s, pretty debilitating disease to have when you're that young, working a full -time job, who used to jolt awake in in the morning, every morning at 7 a .m. thinking I'm never gonna make it through this day.

1:20:06I hope body hurts, this is a mess, I'm never gonna be able to do this. And she would lay in bed for two hours until like nine o 'clock, thinking these thoughts, just, oh, I can't do this. By nine o 'clock, she'd got out of bed, she'd shower, she'd get to work by 10 o 'clock cause in the Bay Area, all these startups don't start till like 10, she'd get her coffee, work with her assistant, do her meetings, and if I asked her, how much do you believe that thought I'm never gonna make it through this day at noon? She'd probably say, oh, like 60%, like this afternoon's gonna be rough. I don't know if I'm gonna make it through.

1:20:35But if you ask her at 5 .30 when she's done working or whatnot, oh, how much do you believe that thought I'm never gonna make it through this day? She'll be like, oh, I made it 0%. Day after day, she started realizing like, oh, I don't believe this thought at 7am because it's true that I'm never gonna make it through this day. I believe this thought because it's 7am. Once she was able to make that connection, We were able to recapture her mornings and at 7 a .m. she went and sat on her couch and she started doing something She loved doing seven and nine which for her was learning Italian with a nap.

1:21:06She loved it and Seven to nine used to be her most hated part of the day But by the end of treatment it was her most beloved part of the day because no one was bothering her and she could learn Italian and whatnot And so one of the cognitive tools that I've built in to CPTI in that cognitive package is tracking how much you believe a thought over a given day. And if you believe a thought in different levels throughout the day, how true can it really be? And it's really enlightening. And I would invite you to notice what you're thinking about at 1 a .m. And then just see how worried are you or how much do you believe this the next day at 3 p .m.

1:21:39Oh, not at all. How come this deserves air time at 1 a .m. but not 3 p .m.? Let's talk about sleep supplements. So do you do a purge of supplements when people come to you and they say, hey, I'm taking a pound of melatonin every night. I'm on an ashwagandha drip. Just rattle them off. We could go through the list. Can I give you two links for the show notes to studies of melatonin supplements that found that these melatonin supplements either had none of what they said they had in the court? Yes, I think we wrote a newsletter on one of them. Oh, great. Well, there's been two. And when people come in and they say they're taking melatonin, I'm like, okay, the alleged melatonin, how much of this is it?

1:22:20Are you taking? Let's assume that they're taking melatonin because they're getting it from one of the companies that submits to third party testing. And so now they know they're doing it. And again, let's further pos it that they're not taking a dose that is deemed too high. So, if you look at some of the sleep literature, there seems to be most people would agree anything north of a milligram is probably just too much. Whereas kind of in the three to six hundred microgram, there might be some benefit and more importantly not just benefit, but actually safety. You're not down regulating melatonin receptors.

1:22:54You're offsetting the natural decline in melatonin levels over time. I can tell from your face, you don't agree with any of this. It's puzzling. So my face is also because it's hard to know where to go with this question, because some countries you need a prescription from melatonin. This is something prescribed But by a doctor, it is regulated. I don't remember all the countries off the top of my head, like Australia, New Zealand, but not you want that, you're not going to find it at their Walgreens. But in the US, didn't too much, can't kill you, so here you go. But the time someone gets to me, if they've got a huge list of supplements and they still have a sleep problem, I say, okay, so clearly these aren't doing what you want.

1:23:25They might be undermining what we want to do. I don't know what's actually in all of those things because none of that's regulated. The data for things like ashwaganda are weak if you want to go Bradford Hill, we could. the data are also pretty weak for melatonin, except in certain cases, which we can unpack a few of those, with the explicit acknowledgement that I'm not a physician, I've not been trained in the biological substrates, whatnot, but your question is, do I take people off of this stuff? Yes, get off that stuff. If you want to take it after treatment with me again, great. But let's get off of it for now, and let's see what your body's actually doing, because chances are you've been adding a supplement or two or whatnot over time for years, and we don't even know what your body wants to do now.

1:24:07and you actually could be shooting yourself in the foot with some of these things. Now, on the contrary, sometimes a patient will come in and will say, oh, I'm taking a beta blocker for blood pressure. Now, you and I both know that's like a fourth or fifth line treatment for blood pressure at this point. Nevertheless, beta blockers inhibit melatonin secretion. And yet, most prescribing doctors who are giving out beta blockers don't realize that there's a significant risk of insomnia when you prescribe these to patients. And I've had some patients who don't need treatment with me at all. They need a 0 .5 milligram melatonin pill every night, and that's it.

1:24:42And those are some of the most angry and satisfied patients ever. They have one visit with me. It's done. They're furious that they've been suffering for 5, 10. I had one patient who suffered for 30 years taking, oh gosh, Metoprolol. He couldn't change his supplement because something having to do with the vocal cords he was a singer. Some of the other blood pressure medications affect that. I didn't fully understand, but he would not change his blood pressure med. So that was all that he needed. But do I think that the average healthy adult should be taking melatonin? No, no. Now, there's probably some excellent data that you are much more aware of than I am about how our melatonin secretion, inhibition processes, what not change as we age.

1:25:25There may be some patients who benefit from taking melatonin, which is a hormone to induce sleep. But remember, melatonin's like the guy at the start of the race. He's the guy with the gun. He fires the gun. He doesn't have a car in the race. He's not helping you stay asleep. He's telling you when to start the thing. So for a lot of adults taking melatonin is really messing them up because they're trying to go to sleep when their body isn't ready to go to sleep They're forcing it to go to sleep. Then they wake up in the middle of the night and they wonder why and it's because Oh, you want to sleep at the wrong time and your body's all kinds of confused.

1:25:56Yeah, interesting. So I really try and take people off of these things so I can see what's really going on. And then if there's something going on that looks like it might necessitate melatonin, I tag in one of my physician friends and talk about it. So what about sleep medications? And let's talk about as many as you want. We can talk about benzos, we can talk about trasidone, we can talk about ambion, we can talk about the erexan -based drugs. How many of the patients who come to see you are regularly taking one of these prescription -based drugs for sleep? So, a lot of people take over the counter drugs and prescription drugs for sleep.

1:26:36And there was a huge shift that I noticed when COVID started. And there was a ban on flying to different countries, Mexico, and Europe. And it turns out there are a lot of people who will fly to Mexico to get their ambient and fly to Europe to get various sleep drugs that you can't necessarily get here. All of a sudden, I saw a wave of patients dealing with withdrawal in the early months of the pandemic because they couldn't go get more of their drugs. Oh my gosh, I screwed. What am I doing now? How do I cope with this? Why couldn't they get them here in that situation? Ambience prescription only.

1:27:10They couldn't get a prescription while they were here. Yes, because they were taking so much that they were well beyond what they could convince someone to prescribe them. And a lot of my patients are physicians. and a lot of physicians are pretty reticent to go above FDA -recommended doses when it comes to Ambien. A lot of people don't realize that I believe, I believe this is the case. Ambien is still the only drug that is differentially prescribed to men and women, according to the FDA that starting dose for women should be 5 milligrams, starting dose for men is 5 to 10, for instant release, and then for extended release, I believe for women it's 6 .25 and then for men it's 6 .25 all the way to 12 .5 because women metabolize it less efficiently.

1:27:50So the people who I've seen, I've seen people taking 30 milligrams, big doses. And gosh, this is a very loaded question. But there's a lot of patients who come to me who will say, I've read something in the news. It turns out this medication I'm taking for my sleep is bad for my brain. They're like, oh, they saw that, huh? And I want to quit immediately. I need to quit my next week. Oh, okay. And you've been taking it for how long? Oh, 20 years. Okay, right. So that never works. That never works. I wouldn't say that I have any sort of extreme expertise in the different classes of sleep meds, but what I can tell you is the ones that people most often are coming to me saying, I want to quit this.

1:28:27I hate being dependent on this. What do I do? These are going to be the benzos, which doctors are becoming less and less hip to prescribing for sleep, ambion, the sonotal lannusthus stuff, and then over the counter stuff, like Benadryl, maybe your occasional docks of pin, and then people are often prescribed have remoron for sleep and they run into metabolic issues and they need to get off of it. So I think that covers the broadest swaths that I see of things people wanting to quit. Now the cubic, it's some of these newer ones. I don't see them as much yet. I'm sure it's coming. And what about trasidone?

1:29:01Trasidone is the one that I'm the least concerned about for a couple of reasons. I've not seen compelling data that it negatively impacts the electrical quality of your sleep. No, in fact, I've seen data that it does the opposite, that it's slightly positive. Great. I'm looking for what's negative. I don't know if the study that you're speaking of was statistically powered. If the primary outcome was improvements in sleep or decrements in sleep. Now, I'm trying to remember something that I wrote probably three years ago. I believe the study looked at sleep duration as the primary outcome and a secondary outcome may have been staging.

1:29:36Yeah. So I don't think it was powered for that, but I think that incidentally did find an improvement. I think you've talked about extensively. It's important to think about what was a study power to look at and all that. But I'm not the most worried about that also because it's an antidepressant drug and if someone's taking it and it is helping with their Depression and I take them off of it in the name of trying to help with their sleep. I have created a different problem. Although the dose people take it it tends to not have that effect. I mean most people are Typically taking it at 25 15 typically no more than a hundred maybe at a hundred depending on the size of an individual they're getting some of that benefit.

1:30:12I often see 100 for sleep. Yeah. And so for me, I'm thinking, ooh, I don't know if that's just for sleep. And then I'm also, if I see 50 even and then I see another anti -depressant, I think, ooh, these could be working together. You actually also have a diagnosis of depression. We need to think about this carefully. If folks are showing up on 20 milligrams of volume or San ex or pick your favorite benzone, do you have them go and do a taper detox with their physician before they come into the CBTI program? No, I have them do it with me. So you will manage the medical withdrawal on that? Let me explain exactly what I do.

1:30:48Scope of practice. So first of all, I always work with the prescribing physician. I never start without making sure the prescribing physician is explicitly aware of what I want to do. I talk with them. And this has to be one of your colleagues at UCSF or whoever they're prescribing physicianists. Whoever's prescribing the medication to this person, we now share a patient and have an obligation to. Every single time I have done this, the physician has been in support of getting their patient off of benzos, except for one time. Which isn't even worth really getting into, but the point is it's an overwhelming amount of support.

1:31:20Yeah, I can imagine. Most of the time these physicians have already tried to get their patients to quit and to reduce. But in my opinion, they've tried to do it way, way, way too quickly. And that's because there are physiological dependencies on these drugs and psychological dependencies on these drugs. And we have to attend to both of them while we're doing this taper process, or it's going to be a botch and the patient's going to relapse and we're going to be back at square one or square negative one, unfortunately. So here's what I do. Let's take a boring example, pick your favorite pencil, they were dose.

1:31:57I don't particularly like them myself, but let's take volume. Okay. 10 milligram. Yeah, sure. So let's say we've got a patient on valium, they've tried to quit, they've occasionally abused, they've gone up, they've split an extra 1 ,5, they've gone 15 sometimes, what not. The first thing that I do with a patient is they say, all right, actually for sake of better example for sleep, put it to Ambien because it's a little more fun. 10 of Ambien. Let's say 10 of Ambien every night at the beginning of the night and then let's say sometimes they're actually taking a fiver in the middle of the night when they wake up because they want to get back to sleep.

1:32:27I like the party dose. Right, so let's say some nights it's 15, some nights it's 10, what do we do? So the first thing I do is I take out the middle of the night dosing and I say we're done with that. You're limited to 10 a night and you got to take it before bed. Yes, you have to take it before bed, you've taken the same time every night, but if you're going 15, five nights a week and 10, two nights a week, I'm going to make it a 12 .5 before bed. Let's be generous. Start higher. So we'll agree on a dose that the patient will take and it'll agree upon time. So the prescribed one I agree on is like, okay, same page this is what the patient's going to do.

1:32:56And they start doing that. Generally, the patient's like, no, no, no, I'm trying to quit. I don't want to take more. And I see, no, not before you quit, it must be stable. You cannot quit from a point of instability. It will not work. I've seen people try. And people say, oh, I want to quit. I want to go from 10 to five. No, that's not how we roll. So let's say this patient's taking 12 and a half. And they're like, okay, I want to cut down. I'm like, all right. Okay, so how does it going from 12 and a half to five sound? And they say, oh my gosh, that's going to be really scary. I don't think I can handle that.

1:33:25And what I actually have them do is I rate it on a scale from one to 10 with 10 being the most anxiety -provoking upsetting thing and one being not upsetting at all. This is called a subjective units of distress scale Suts have them suds it so I say okay going from 12 .5 to 5 that sounds really terrifying now Because they've just done a week where they're consistent with 12 .5 at the beginning of the night They've had no middle of the night crutch and they're not feeling great about that And then I say, okay, so how about going from 12 to 10? And they say, oh, not as bad, but that's still like a six on my scale.

1:33:59And I do this process all the way until I get them to a one. And I'll say, all right, so next week we're going from 12 .5 to 12. How are you even making that increment? I can tell you exactly how we're doing that. We're going on the internet and we are buying something called a gem scale. Now you and I both know that people who are wealthy enough to have gems worth measuring aren't measuring their own. So the people who are buying those scales are using them for other things. And so what my patients end up doing is they buy these scales and they get a full -blown, breaking bad setup in their bathroom.

1:34:28We're cut in pills, we're weighing pills, we're doing math because the pill actually weighs more than 12 .5 because it's got binders and fillers. What percent doing it? And we kind of make it fun. And they end up having to put the crumbly pill into a shot glass with water. We shoot it in the whole thing. We make a whole production out of it. But the point just is, they're going from 12 .5 to 12. And we do that for like three weeks. If they've been on it for years, we're looking at three weeks. And the first couple nights are a little rough. There's a little stress. If they're only doing a seven week program with you, Oh, no, no.

1:34:55This taper program we make and it will last a long time. But before they enter the program, this is a separate issue. This is a separate issue and we do this after they've finished CBTI treatment. During CBTI treatment, I stabilize them on their meds and we just get it so they're not erratically taking five different cocktails of things. When people come in to see me for treatment, they'll say, oh yeah, so Monday's I do Ambien. Tuesday's I do Trasidone. Wednesday's has been a drill, because they have it in their head. Because they think they don't want to get dependent on one. So they think that by doing a rotating merry -ground of these things That's actually smart.

1:35:26I would have never even thought of that. Oh, yeah, well, it's a stir -up. Working great. Yeah, so I generally work with the doctor And we decide okay, here's the one you're gonna do here's the dose you're gonna do and you're gonna be consistent with this So vodka on Monday and then tequila on Tuesday Red wine on Wednesday and then shard and a Thursday and this way I'll never become an alcoholic Oh, figured it out, Peter. In short, I have people really stabilized during CVT and sometimes during week four, week three four, they're ready to start this and we start them on this program. And once I have them in this way, they're able to do this on their own.

1:35:59So they'll go from 12 to 12 .5 for like three weeks and they'll be keeping sleep diaries, so they'll see. Oh, okay, and we'll get some confidence. And then they'll email me, you know, they'll message me and they'll say, okay, so now what? And I'll say, all right, well, how are you feeling? Like, what if we go down to 11 .5, how does that sound? Sometimes that'll be too scary. For some reason, crossing the five threshold is really scary, so we go from five to 4 .75 sometimes. And just to be clear, this is psychological. There can't possibly be a physiologic difference between four, 4 .75 and 5 milligrams of ambient.

1:36:30Correct. Right. In fact, the medicine isn't even homogeneously enough compounded within the capsule. So as long as everybody understands that. Probably not. But think some of our tablets and I don't know about the requirements. Yeah, because the binder and the active ingredient... Yeah, engineering has to be 85 % similar to the real deal. So there's all kinds of mess ups here. Remember how I said there's a psychological part in the physiological part? This is a psychological part that I think it's left out of a lot of the, oh, just cut it in half to start decreasing your dose aspect, which is dealing with, okay, what can we physiologically do?

1:37:00I'm talking about what can we psychologically do? And do you think that this methodology of the incredibly slow taper with incredibly high precision? Do you think it works for opioids? So I don't think I've ever seen that in my clinic. It's just not something I've had to deal with. I don't know for sleep. I just mean in general. Or is the problem so grave that you have to be a little more aggressive and switch them to a completely different class of drugs? That's so far outside in the area. I can't speak to it. But what I can tell you is just that doing this method with the sleep drugs slowly over time, people get more confidence and they can make larger reductions at a time.

1:37:42And then importantly, Peter, when someone is tapering and something crazy in their life happens, like a child gets diagnosed with cancer or something terrible happens, we stop the taper and we stay where we're at. So your taper might look like this. But there's not a huge rush to get off this thing. You've been on it for 20 years, better to stably get off it. I always joke with people like if you can lose 10 pounds in two days, how quickly do you think you can gain two pounds? So, when it comes to quitting these meds, slow and steady wins the race. Having people gain the confidence that they can do it is such a big part of it.

1:38:13I know that one of the critiques I've gotten from folks is like, well, wait a minute. Some of these pills have coatings and da -da -da -da -da -da, but it's a lot of it is psychological. So this works really well for a medication taper and people can do it themselves. There's no, like, magic. I mean, I think we've covered a lot on CBTI and let's now revisit the idea of the types of things that people should be on the lookout for that need to be addressed first. So we haven't talked about sleep apnea. We haven't talked about restless legs syndrome. What are the other things where you just want to have some sort of sign off that says, hey, we've also confirmed that these things aren't present.

1:38:57or what gets your suspicion rouse that says, hey, we got to look at something else because you're presumably not doing polysomniography on everybody on the way in. How do you navigate that? So I have the wonderful luxury of being able to look in people's charts and see who referred them to me and why they are referred. They can't be self -referred? Everybody needs a referral of some kind. And it can be from anybody, but any referral. A lot of my referrals come from sleep disorders centers because they've already done all that work up and they say, all right, it's not an escape. So here you go.

1:39:28If a patient tells me, I always ask a patient, like, oh, has your partner or anybody you slept with ever told you that you snore? Or that you sound like you're gasping for air in the middle of the night? I do have a bunch of those types of screening questions and I aggressively refer to colleagues with expertise in those areas, but for treatment with me. A lot of times people have a CPAP and they say, oh, I don't really use it. I'm not sure about that. I say, well, I'm here to tell you that you should be sure about it and that you should use it every single night. It doesn't fit. Cool. I'm going to make a call because we're going to get it to fit.

1:39:58There's a different mask you can probably get. There's all these different issues that we can tackle. It just sometimes takes making a phone call. And unfortunately, a lot of patients don't have great follow -through for their CPAP in terms of help using it and figuring it out. So sometimes I have to just make that extra connection. The one thing I think I want to make sure that we put a bow on also, is a subsession with bedtime? I can make you wake up at any time by setting a very loud alarm. I can anchor you into your day with a wake -up time, and that could be consistent every single day. I cannot wave a magic wand and make you fall asleep at the same time every day.

1:40:38So when people think, all right, I'm going to get a handle on my sleep, I'm going to go to bed at the same time every night. No, no, no, no, wake up at the same time every day. That's a much more important first step. And if you're waking up at different times throughout the week, that is the first thing to fix. Yeah, what degree of social jet lag do you tolerate just for folks listening social jet lag, meaning the experience of changing your sleep time during weekends, which could be a kin to jet lag if it differs by hours. In an ideal world, there would be zero, right? In an ideal world, I wake up at seven o 'clock in the morning every single day of the week.

1:41:14For an individual who says, oh, but God on the weekends, it's just so nice to not have to get up at seven. Do you say, look, give yourself a 30 minute grace and that would still be considered perfectly healthy. So during treatment, I tell people, you need to wake up at the same time every day that ends in D .A .Y. So that means Monday, Saturday, Sunday. Yeah. That's all of them. Yeah. That's during treatment. I have to check. Yeah. Good. There is no room for negotiation during treatment. We're in the dictatorship. But what I do teach people at the end of treatment is how to cope with the fact that life is going to happen when treatment ends.

1:41:48It happens during treatment, but there's a lot that pauses during treatment, to be honest. But let's say that you've got a major event on a Friday night. You're going to a concert. Yes. And you're going to be out a way later than usual. What I tell people is, look, you need to pick which day of that weekend do you want to suffer and which day do you want to feel good? Because we can sleep in one day. You cannot sleep in two days in a row. That's going to take you off the wagon, we're not doing it. So let's say Friday night you go to a concert and you wanna feel good on Saturday. Cool, sleep in on Saturday, sleep in by an hour on Saturday.

1:42:17Okay, fine, go to bed on Saturday night when you get tired, spoil or alert, you're probably gonna get tired, past your usual bedtime because you slept in. But then Sunday you have to wake up at your wake time and Sunday you're gonna suffer. But let's say you wanna feel good Sunday. That means on Saturday you're gonna wake up at your usual time. Saturday's gonna be a struggle of us, but you'll make it to your bedtime, you'll go to bed at your bedtime then you'll feel better Sunday. So you just have to choose, when do I want to do the suffering? The immediate day after? So basically force the suffering into the narrowest place possible.

1:42:45But you can choose because sometimes people don't want the suffering to be the next day they want it to be the day after. So you get to choose that, but I tell people, look, don't sleep in more than one day in a row. It's going to mess you up. You're not really getting quality sleep when you sleep in past your wake time. When it's been a pattern for a long time, when you sleep in past your wake time, you're probably getting some extra stage two sleep. You're not getting more deep sleep. That's for sure. We're recording this on a Tuesday, Sunday, two days ago, it was flying back to Austin from LA, and the flight got delayed over and over and over and over and over again for reasons that are so as to mind, they're not even worth describing.

1:43:24And then we finally got on the plane and taxied, and then the water was leaking out of the coffee machine. So we had to go back to get another plane. I'm not making this up, but I can only tell you how ridiculous this is. The punchline of the stories we didn't get home till two in the morning, which is long past my bed time. So, what would your strategy have been getting home at two in the morning prior to Monday a work day, where you do have some leeway. I don't have to get up at six, which would be my normal wake -up time. Would you have said, just get up at six, stick with it, and make it up by going to bed a lot earlier Monday night?

1:44:03Or would you say sleep until 8, you'll probably feel better than if you woke up at 6. How would you handle that situation? Also, which day is more important for you to feel good on Monday or Tuesday? Let's say I said Tuesday because I'm sitting down with you. Well, then I would say probably try not to sleep in too much so that you can go to bed at your regular wake time on Monday. If you sleep in horribly on Monday morning, you're going to stay up later Monday night. And then you'll get up at your wake time today and you will have her head shorter sleep for today. It will have rolled all the way over.

1:44:32That's actually what I did. So having not thought about this, I just slept until I think my wife tried to get me out of bed at seven and I said, can you let me sleep till eight? So I didn't get up till eight. But last night you're right at a very hard time going to bed. It was like 11 o 'clock and I was still up meandering around. Yeah. You just have to very carefully decide which day do you want to prioritize and that's how you make that decision. So you have more control than you think is what's What's beautiful about that and I just remind people you can never really make up for lost sleep that easily because sleep architecture really matters and when you're sleeping in you're not getting more deep sleep you're getting some more maybe light sleep and at worst that's robbing you of maybe some of the deep sleep you would have gotten the following night because you're on a circadian plan here.

1:45:19And we didn't really talk about process S and process C. Maybe I can just briefly tell you what those two things would be. Okay. So, process S is sleep homeostasis, and that's this sleep pressure idea that we are working on. Every day we build up sleep pressure until it's bedtime, and then we capitulate, we fall asleep, and then our sleep pressure drains throughout the night while we sleep. And then in the morning, we build it up again the next day. And this is just a dentists scene building up? Yeah, think about that way. And that's also why caffeine is problematic. So caffeine blocks adenosine receptors.

1:45:51The caffeine crash when it wears off, and then all the adenosine floods the receptors, and we experience that, oh, sleepiness. And that's why taking a nap is so difficult, because what napping does is it basically kind of deflates your balloon a little bit of your sleep pressure. It robs you of some of that sleep pressure. So by the time you get around your normal bedtime, if you've taken a long nap, you've reduced how much sleep pressure you would ordinarily have at that time. That's why napping could be dangerous. And then we have process C, which is the circadian process. And that just marches on.

1:46:19It doesn't really care about your sleep pressure or how much you've slept. I'm sure you've pulled an all -nighter, but when people pull all -nighters, what they often will notice. How many all -nighters do you think I've pulled in my life? Oh, hundreds. Yeah, I would need scientific notation to count them. Yeah, it's a lot. The thing to note about that is that you're sleepy during the night when you're pulling the all -nighter, but in the morning you kind of have a burst of energy. And that's the circadian part, speaking up. And when we look at the sine curve of it, that's because your temperature is coming back up.

1:46:49Your adrenal glands still make cortisol. Right. So your circadian process doesn't really care much about the sleep pressure. It says, okay, if you line these two things up on a graph, they look like they talk to each other. They don't. But these two processes really determine a whole lot about your sleep. And there are things that we can do to support each of them. But CBTI really focuses on the sleep pressure aspect by regularizing people's schedules. and then it supports the circadian aspect by some of these little things that I talked about that I don't even know if you can't really call them standard CBTI, like standardizing what time people are taking their medications, for example, doing things that we know supports circadian biology, not eating right before bed.

1:47:32In my perfect world, all of these different zykaburs, which are timekeepers during the day, would be consistent from day to day, you'd lunch every day at the same time, and breakfast every day at the same time. All of these things would support your circadian biology and probably improve your sleep. Any rules about exercising, you have people that are showing up and you're going through your intake and you realize based on their schedule, based on work, based on kids or other obligations. The only time they're gonna get their workout in is in the evening and is that counterproductive. What do this way?

1:48:05If it is an issue, how do you adjust? This is a really nuanced issue. I once had a patient who a long time ago who said, oh yeah, I take the 10 o 'clock spin class in the Castro. I was like, okay, moving on. I assumed it was 10 a .m. I was wrong and I learned that the next week when we were talking about other things. But for some people exercise at night is fine. For other people it's super stimulating and it also really depends on what kind of exercise we're talking about. I think one moderating variable here is also gonna be level of fitness. If you take a person who's extraordinarily cardiovascularly unfit and you put them in a spin class in the evening.

1:48:42Do you know it could take their heart rate quite a while to recover? You could probably provide me a lot more information about that than I know. And what we know in order to fall asleep is that your heart rate should be lowering. So if your heart rate is still elevated from a whole bunch of exercise you just did, that's not going to help you. But if you're super fit and your heart rate recovers really quickly, it might affect you less. So this matters. I think there was for a long time this general suggestion to not exercise close to bedtime. I still think for the most part it applies, but I think that it's important to think about what kind of exercise you're doing.

1:49:13If someone tells me, oh, I'm going to a yoga class, I find this really relaxing and calming. It's a form of stretching for me. Zada, Zada. Fine. Okay. And this is the only time a day you can do it. You got a job. You got kids, whatever. I'm not going to tell you to not go just because of the time a day that it is or weightlifting or whatnot. But if you want to go to a hit class, I'm going to say, well, How can we not do it at 10 o 'clock at night? I think it would really be great if we could move it earlier. We try to do that. I do tell people, I have some patients who've come in and said, oh, my body wants to wake up every day at 7 o 'clock, but I really want to go to this 5 a .m.

1:49:45spin class every day. I'm like, okay, well, I understand. Exercise is very important. I'm a believer. Also, your circadian biology has you going to bed at 11 and getting up at 7. and even if you're getting up at 4 .45 to get on your home, spend bike to do this thing with this group, your body doesn't want to go to bed until 11, and we're not going to be able to change that. So you're going to have to make that cost -benefit analysis with, do you want to lose that much sleep to do that thing? Yeah, my brother -in -law plays in a men's hockey league and you only get ice time late at night. So I think they literally play Sundays at 11 p .m.

1:50:22or something. And he's always fried Monday because pretty hard to play a game of ice hockey and then fall asleep after that. So we're not understand more what the spectrum of CBTI looks like. I mean your process sounds super dialed in, but also it's quite bespoke. You've brought a lot of your own expertise to it and you've created a system where you've got we're going to do the intake. We're going to do these five sessions, which I think are group sessions the way you described them. Then we do kind of the exit. You bring so much rigor to it. Is that the way it is always done? Or are there CBTI therapists out there who function like psychotherapists?

1:51:02And they say, yeah, we're just going to engage with each other until your problem is fixed. And we'll see each other once a week or maybe once every other week. Everything you're doing sounds formulaic. And I say that not in a bad way. I think that's probably a big part of its efficacy. Is that something people should expect? when they are going to a CBTI therapist. It's something people should ask for. Before people start treatment, they fill out the Pittsburgh Sleep Quality Index and they fill out the Insomnia's Vary Index. And I tell them, look, we're going to fill this out when you're done with treatment, too.

1:51:31And we're going to see how this worked for you. We're going to actually take measurements. What type of scores are you getting on the PSQI? I mean, it ranges from zero to 21. I get all the way to 21. Well, yeah. And below five is considered no clinically significant sleep problems. I relax that to six or seven, because if you have a prostate If you're going through menopause and the pot flashes, you're going to be elevated on that scale by no fault of your own or your sleep's fault. And the Assamnias severity index, I mean, yeah, we see all the way up to what was it? 22, 23, something like that.

1:52:01So I see all the way up to the most severe levels in both of these scales, commonly. And the average point drops are huge in clinic. So I don't know if it was like 10 points in the Insamnias severity index. It's very high, very responsive to this treatment. But back to your original question, is I wish everybody did it by the book. I think there's a lot of practitioners out there who want to do it, this by the book. I have a luxury to do it by the book because I'm able to enlist help from my team to help me process sleep diaries every week and do probably two hours of work outside of my clinic of prep for me.

1:52:43So they feed me my stuff that's been built into the systems that I have. I'm prepping half an hour before clinic. I see everybody for an hour and a half and then I've got my notes, my templates and things. But I think that it is very difficult to do CBTI when you're not seeing patients weekly because I look at weekly sleep diaries and I make changes based on that. So when you find a CBTI therapist, I would say ask if you can set up a time in the future with that therapist and see them weekly for a set of whatever five to eight weeks and put it on the calendar that way with them. If they say, oh, they don't have bandwidth to do that for another month, so okay, go all wait and then get on every week.

1:53:16And a lot of practitioners also aren't going to necessarily score your sleep diaries for you. You can score them yourself if you want to. I mean, it's not that difficult. If you just Google online, you can find a sleep diary calculator and it's very easy to do the math yourself. There's a book that I really like called Quiet Your Mind and Get to Sleep written by Rachel Mandor and Colin Carney and Dick Bootson wrote the forward. It's kind of a guided way through the treatment and you can use that workbook yourself to do it And you could also use that workbook when you're working with the provider But I think there are a lot of CBTi providers out there who can see you weekly and can do this You'll probably just have to do your back end work with your calculations because they don't have the billable time for that They'll be busy during the sessions trying to teach you things I would also note that between my sessions with my patients.

1:54:04I make them watch very annoying videos that I've made of myself giving a lecture about all of the science because I've found that if you explain the science to patients, you'll get the adherence. Here's why we're going to do this. People think, wait, I have problem sleeping. Now you're going to make me not go to bed. This is not what I'm going for. And I have to explain to them, okay, here's why we do this because this will ultimately get you where you want to go. But the principles of what I'm doing are not at all bespoke. I'm doing the time and better strictions stimulus control, the cognitive techniques, the relaxation techniques and the sleep hygiene.

1:54:36Those are the five major components. What is bespoke is the way that I set the wake time because that's not been standardized in literature. The way I deal with standardizing medications, the way I deal with medication tapers, some of the anxiety tools that I bring in like scheduled worry time, track and roof leaf during the day. I think that is actually pretty well incorporated into CBTI. But some of those are a little bit more tilted toward my audience which tends to be higher in anxiety. I build those in. But otherwise find someone on the website that will put in your show notes who knows how to do CBTI and I have a feeling you'll go far.

1:55:11The treatment works when you do it and it doesn't work when you don't do it is when I tell all of my patients. The book, quiet your mind and get to sleep. You mentioned that that's something that people could do in therapy, but you also mentioned that it's something people could just do on their own. So if somebody's listening to this and they're thinking, A, I can't afford CBTI or B, every practitioner I've called said the soonest I can get in his nine months from now, if my choice is continue to suffer or do something proactively, you would recommend that as a great strategy to start. They can get that.

1:55:43They can try some of the apps. They're out there. I think they have less traction currently. They're still in early stages, but try and help the rest app. But the quiet you're mind to get to sleep book, people can do it by themselves. and I actually had a patient the summer who was on the wait list. He got his intake and he was like, look, I'm fixed. I did the book, it was awesome. But I still want to be in this group because I want to see what it's all about. I'm not giving up my spot. And it was great having them in the group because they just cheerlead everybody else and said this works when you do it.

1:56:13Any concerns with extreme temperature changes before bed? So people use insana, people use in cold plunge, taking hot showers, hot baths, Subjectively from my experience, a sauna before bed really seems to help. Maybe it creates a bigger gradient in temperature drop as I go from high body temp to low when I get into that super cold bed, but what is your experience with that and how do you manage it through the process? Well, let's first take cold plunge before bed off the table. That's not a good idea. Because we know that when you get in the cold plunge, it's immediately cold on your skin, but then once you get out, your body is busy warming itself back up and that's not what we want to be doing before bed.

1:56:49But then I'm going to go into the sauna part by saying that it's another, it depends. The outline that you just gave of the temperature gradient is beautiful. It makes a lot of sense. For people who are naive to sauna, who get in a sauna and it increases their heart rate, increasing your heart. It might be the same problem as the exercise. It might be the same problem as the exercise. Yeah, if they don't have the rapid recovery. They don't have the rapid recovery. So that's something to learn about yourself. In fairness, I don't actually go straight from sauna to bed. It's usually sauna to 30 minutes in that flex to bed.

1:57:16That's gonna be person to person. Another thing to keep in mind is that some people who will go in the sauna at night, then drink a whole bunch of water afterwards. Yes. And then that ends up causing them to wake up more in the middle of the night, so it defeats the purpose. That's a consideration, also, if that's an issue for you. But I would say, just don't make it too strenuous. Some people find that it's really helpful. I do best with it a few hours before bed, as opposed to right before bed. I think it's gonna be a do -what -work situation because we don't have enough data. But we are, I just started an NIH -funded trial where we are looking at people who have difficulty with falling asleep and we are giving them whole body heating at home before bed and we're giving them cognitive behavioral therapy for insomnia through an app and we're going to have them do this whole home -based treatment that's going to combine a body -based heat treatment for before bed with the CBTI treatment.

1:58:10And the idea here is what you explained, which is that by heating you up right before bed, if we're heating up your hands and your feet, we're helping you actually open the vascular chair and dump some heat. It's going to create that gradient and we think that gradient might be important for people with the early kind of insomnia with falling asleep at the start of the night. So we're going to see if that helps people using a son of blanket type thing. Actually, someone listening to us for the last two and a half hours might assume that the only thing you know about a CBTI, but it turns out that we've only scratched the surface of your area of expertise.

1:58:42And there are other clinical areas that you have a lot of interest in that I think our listeners would have interest in as well. The good news is we've, when I say we, I mean you, you've delivered kind of a masterclass on a topic that I've wanted to know much more about, you know, it's interesting. It's a bit of a black box because we send a number of our patients to CBTi therapy around the country. And I would concur with what you said, which is based on their ability to comply, the efficacy has been unparalleled, simply stated. As far as regular old doctors, I think we're pretty good at helping people with sleep, given the nature of our practice and how much attention we can pay.

1:59:22And therefore, I think by ourselves, we do pretty well. But when we can't, and we refer to CBTI, I would have to think if there's been a patient who hasn't been helped. So that's great. But truthfully, you've filled in all the gaps for me, and I think more importantly, I think you've really helped listeners understand this and I hope given people a lot of confidence because what I also take away from this is there's really nobody who should be suffering from insomnia. It's really not a necessary thing to suffer. There's things we might have to suffer within life, but this isn't one. I think from very large percentage of the population, that's the case.

1:59:56I'm afraid to say never because you just never know, but there are so many, so many people countless suffering from this who definitely don't need to be. The drawback is we have kind of run out of time to talk about a few other things that are really interesting, which is not uncommon on this podcast, which means we're going to have to do a part two at some point to talk about eating behaviors, thermal regulation, the impact that that has on depression or other things like that. So apologies that maybe we spent more time on CBTI than we intended to, but as I kind of warned you before we started, we love to just meander where the discussion goes.

2:00:36So is there anything else you want to talk about on this CBTI front? I have a lot of notes on where I wanted to go, but I also realized there's probably something I've forgotten, or there's an area you want to double -click on. Now, I think it's important for people just to remember with this one that even if you don't know what caused your insomnia, you can do this treatment. You don't have to have figured out, oh, this is where it started or this was the root of it all. You can start this treatment without that knowledge because this treatment is going to address what you're doing now that's actually perpetuating the problem.

2:01:12And don't wait. There's never going to feel like a good time to do it. Now is the best time. Your life is always going to be crazy. You're always going to have 50 more things on the schedule than you wish you did. It's always going to be too busy. You're always going to have events. Just do it now because it's so difficult to live with insomnia and all the problems that it causes. I had this patient who was 87, who I finished treatment with last year. And she just said, my, I wish I'd done this 40 years ago. Don't wait. Just do it. You won't regret it. Are you under the impression that obviously people are waiting a long time to see you that probably speaks to how good you are and the resources that UCSF provides maybe in combination.

2:01:56But if a person is listening to this and they're like, yeah, I wish I could work with Ashley but I just want to work with somebody. Do you have a sense of how large the CBTI community is and how long a person should expect to wait and do these therapists ever work via telemedicine so that you have more opportunity to do work with folks? I think that it is easier now to get than ever, largely because of telemedicine. So I see patients all over California. I'm licensed in California. So you're eight people per bracket don't all physically come to San Francisco? Nobody does. Great. I only see patients on Zoom now, which is actually a whole lot safer because patients used to drive in, for example, from Fresno.

2:02:35They'd stay overnight in a hotel. Yeah, I would just screw up the whole thing. Screw up everything. Patients would have to fly in in some cases. It was nuts. But now I just see people on Zoom, which is great. And there's a lot of versions of me who do that. By going to that website, you'll be able to find a CBTI provider and chances are they do telemedicine. There are just so many benefits. And one of the great pieces of news about that is that if you live somewhere more rural, now it is instantly more accessible to you. Although we have to hope that the providers, if you live in Iowa, we wanna make sure they have licensed in Iowa because you wouldn't be able to see somebody.

2:03:08Right, they'll be licensed in Iowa. And there's also actually a growing and great thing called SciPact where I think 40 different states now are members of SciPact where if you're licensed in one state, you can be licensed in all of these states. Of course, California does not participate because we're California, but it's getting easier and easier. And I do think that there's ways you can start to do this on your own. If you get that book, if you try it at, you can actually do this. You just have to remember that as specialists each human is you need to try and not feel like a delicate flower with your insomnia Just assume that you need to do this as it says you need to do it.

2:03:48Well actually this was awesome I learned a lot and I'm pretty sure everybody listening did so thanks for sharing and look forward to round two at some point next year Okay, thanks Thank you for listening to this week's episode of the drive head over to Peter atia MD dot com forward slash show notes If you want to dig deeper into this episode, you can also find me on YouTube, Instagram, and Twitter all with the handle Peter at the MD. You can also leave us a review on Apple podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice.

2:04:30No doctor -patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis or treatment. Users should not disregard or delay an obtaining medical advice from any medical condition they have and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously for all of my disclosures and the companies I invest in or advise, please visit peteratiamd .com forward slash about where I keep an up to date and active list of all disclosures.