October 13, 2024 • 29 mins
10/13/24
The Healthy Matters Podcast
S03_E24 - Insomnia... and How to Fix It.
I’m sure most of all of us would agree that sleep is precious…
But sooner or later we all run into issues falling asleep, staying asleep, or waking up too early. Of course, missing out on quality sleep can have direct consequences on how well we function in our daily lives, but did you know it can have real consequences on your physical and mental health as well? So, when is it actually insomnia versus just a restless night? How many hours of sleep should I get each night? How long does the average person need to fall asleep? And maybe most importantly - what’s the ideal length of a nap?
On the final episode of Season 3 of our show, we’ll look into the world of restful sleep with sleep psychologist Dr. Mark Rosenblum. Dr. Rosenblum is also a specialist in Cognitive Behavioral Therapy for Insomnia (CBT-I), which has been proven to show even better results than most of the medications prescribed for this condition, and without the hefty side effects. So tune in and find out what causes insomnia, when it’s time to get help, and what the best methods are to make sure you’re able to get a proper dose of restful, delicious sleep. We hope you’ll join us, and as always, thanks for listening!
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
Welcome to the Healthy Matters podcast with
Dr. David Hilton , primary carephysician and acute care
hospitalist at HennepinHealthcare in downtown
Minneapolis, where we cover thelatest in health, healthcare
and what matters to you. Andnow here's our host, Dr. David
Hilton .
Speaker 2 (00:18):
Hey everybody, it's David Hilden and welcome to
episode 24, the final episodeof Season three of the Healthy
Matters podcast. Thanks forjoining us today. We're gonna
talk about insomnia and themost effective treatment for
insomnia, which is cognitivebehavioral therapy for
insomnia, otherwise known asCBTI . To help me out today, I
(00:39):
have Mark Rosenblum. He is adoctor of psychology and an
expert in insomnia and thetreatments of insomnia. He is a
colleague of mine here atHennepin Healthcare in downtown
Minneapolis in our sleepcenter. Mark, thanks for being
here. Well, thank you
Speaker 3 (00:52):
For having me. I appreciate it. So
Speaker 2 (00:53):
You've been doing sleep medicine for some 20, 30
years, I don't know, a longtime. Mm-hmm ,
and treating patients whoexperience insomnia. So could
you start us out, lay thegroundwork, the basics of
insomnia. What is insomnia? Howis it defined, and what are the
various types?
Speaker 3 (01:09):
Well, when we break down insomnia, we , we break it
down between the symptom versusthe condition. The symptom of
insomnia is something that mostpeople are familiar with.
Troubles falling asleep,trouble staying asleep, or
troubles waking up too early inthe morning. When it
transitions to a condition,usually it involves a few more
factors. First of all, youstart having some daytime
consequences. A person isstruggling more at work, maybe
(01:31):
at school , um, in theirrelationships. Secondary is it
ha it takes on a chronicfeature to that. For example,
most people, upwards to 50% ofpeople will have insomnia
symptoms At times. They may bethere for a day or two and they
resolve in contrast thecondition which goes on and on
until it's treated. We thinkeven upwards to 10% of the
(01:52):
population struggles with that.
Yeah,
Speaker 2 (01:53):
I can imagine that darn near everybody listening
says, yeah, I had troublefalling asleep last night, or I
woke up at 2:00 AM and I wasanxious about something. So, so
I think it's something that agreat number of people have
experienced. But you'redistinguishing that with,
when's it a problem that youneed to have addressed? That's
what you mean by a condition.
Yeah,
Speaker 3 (02:09):
So, so a symptom oftentimes, like I said, could
be for a single night here orthere. There are sometimes
though the symptoms can go onand on because they're
secondary to another situation.
So for example, let's saysomeone's going through a lot
of stress in their life, arelationship stress, job
stress. That would still be aninsomnia symptom though that
could go on for a while . Andin those situations treating it
(02:30):
still has some value typically.
But like you said, thecondition is really that one
that just seems to go on and onand on until it's resolved or
treated.
Speaker 2 (02:38):
Could you break down these types of insomnia's force
? Are they caused by differentthings? So what , what do they
look like? So
Speaker 3 (02:44):
Troubles falling asleep. The , the way we
demarcate it from let's sayjust a , a normal night of
sleep is anytime it takes morethan a half hour to fall
asleep. And if this happensmore than three times a week,
we now consider that aproblematic type of insomnia
here. Oftentimes what you seeassociated with that is some
situational stress. Again, weall have stress. Stress is a
normal thing, but sometimesthat stress is so high that it
(03:07):
seems to interfere with ourability to fall asleep. Middle
of the night insomnia is alittle more complicated. People
are waking up. Again, it's asimilar time duration for more
than 30 minutes. But this caninvolve again, regular stress
too. But there can be othersleep conditions that seem to
fuel that, that would alwaysneed to be teased out when that
occurs. And the early morninginsomnia is kind of interesting
(03:27):
too, 'cause we'll sometimes seepeople again with the stress,
but also a little depressiontied into that as well. So
Speaker 2 (03:32):
How does that differ the waking up too early from
just the middle of the nightone ? Do they have a different
pattern to them?
Speaker 3 (03:38):
Well, what differentiates them typically
is just about the person'sability to get back to sleep
because it is normal to wake upduring the night. Most people
do, but for some reason, somepeople have a harder time
getting back to sleep in themiddle of the night, whereas
other people have a harder ,harder time to get back to
sleep if they wake up tooearly. You know, and , and one
of the features of thatoftentimes is when someone is
aware that it's, let's say,within an hour of their
(04:00):
expected wake up time, thatseems to put them in a kind of
a dynamic where either theygive up trying to sleep or they
feel a lot of pressure get backto sleep, which then interferes
with it.
Speaker 2 (04:08):
And listeners, don't worry in just a short bit on
this episode, we're gonna talkwith Dr. Rosenblum about ways
to manage these conditions andwhat treatments are available.
So stay tuned for that. Solet's go back to the first kind
for just a little bit if wecould, I bet there's a medical
name for that. When you can'tfall asleep.
Speaker 3 (04:25):
Well, in , in the name of insomnia has evolved
over the years. Back in the daywe used to refer to like this
chronic insomnia or troublesfalling asleep as a primary
insomnia. And then if it wascaused by some other factor,
we'd call it a secondaryinsomnia. These days, to be
honest with you, we really kindof lump it all together because
it doesn't seem to affect howwe treat it as long as it's a
(04:45):
chronic condition. So you
Speaker 2 (04:46):
Said 30 minutes. I tell you, if I'm lying there
for 30 minutes and can't fallasleep, I'm gonna be pretty
anxious. Just on that factalone, I think last night , uh,
my head hit the pillow and Iwas out in about 30 seconds. So
what is considered normal? Howlong are you supposed to lie
there before you fall asleep?
Is 30 minutes the time.
Speaker 3 (05:04):
So anything under 30 cons minutes is considered
within normal limits. And thatsometimes is something that,
that people react with .
Similar to what you said, it ,it feels too long. And then it
triggers some anxiety about thesleep itself, which then feeds
into the insomnia. So anythingunder 30 minutes. And actually
when it's a a few minutes, whatthat suggests to us is you are
(05:24):
really sleepy when you go tobed. Most people take at least
five to 15 minutes to fallasleep. So kudos to, you're
going to bed when you're in areally sleepy stage. Well
that's
Speaker 2 (05:32):
'cause I was up till 1:00 AM the past four nights
for work thing . So Ithink maybe it's my own fault.
Which brings up a question. Uh, bring , uh, what to what
degree do your own behaviorscontribute to this type of
insomnia? You know, is itsomething you could have done
something about or is it just afact of your life that you
can't fall asleep? Well,
Speaker 3 (05:51):
We can see a variety of behaviors that increase the
risk of that. So for example,you have some people burning
the midnight oil, like that's
Speaker 2 (05:57):
What I've been doing all
Speaker 3 (05:57):
Week. Yeah. And you see this a lot for college
students, for example, who areare studying for their finals
up until, you know, the middleof the morning. Also, sometimes
what you'll see is people thatdon't really have a regular
routine and there's somethingabout the aspect of routine
that seems to feed into thebetter chance of falling asleep
at night. We see when peoplehave a lot of variety in their
routine, they can have a littlemore difficulties. And then the
(06:18):
last trap that I think thatpeople get into are people who
are watching TV in bed or ontheir phones in bed as they try
to sleep at night. And what isinteresting about that is
oftentimes the reason they'reinitially doing it is they
think it's gonna help themsleep. And at some point it
probably was, but over time itweakens the association between
bed and sleep and actuallyfeeds into the insomnia. So
Speaker 2 (06:38):
Me watching a very intense episode of The Bear
last night on TV where they'reyelling and screaming at each
other that maybe didn't helpeither. It
Speaker 3 (06:45):
It may have not helped
Speaker 2 (06:46):
. So
there are some things and we ,
we will delve into that alittle bit more. What about the
middle of the night business?
Maybe I'm wrong in this, but itsounded a little bit more
sinister or it sounded just alittle bit more like that might
represent some other conditionsthat you have to deal with. Is
that, am I missing that or?
Well,
Speaker 3 (07:02):
Troubles falling asleep is typically insomnia
when people wake up in themiddle of the night. There can
be a variety of other sleepdisorders that also lead to
that behavior. You see peoplewho have things like restless
leg syndrome , uh, sleep apneato name a few here. So there
could be , uh, numerous reasonswhy people wake up. But if
there is also troubles gettingback to sleep, that would be
more the traditional insomnia.
(07:23):
So essentially there could besituations that are
multifactorial with the middleof the night insomnia. Yeah.
Speaker 2 (07:27):
And I, I treat adults. I'm an internal
medicine doctor and so I treatmostly adults and , and even a
subset of adults I treat mostlyolder adults. Is it true or is
it not true that, that yoursleep shortens or gets
different as you get older?
Because I can tell you thatdarn near every adult man over
a certain age gets up in thenight to go pee. They had ,
(07:48):
they have to urinate and thenusually they get right back to
sleep. But is it true thatolder adults experience
insomnia more or if an olderadult is not sleeping as well,
is that something they shouldhave looked at?
Speaker 3 (07:58):
Yeah, it , it is more common and I really liked
how you phrased it. Does theirsleep change as they age? There
used to be this myth out therethat people would just need
less sleep as they age. So kindof kinda whitewash all these
sleep needs or sleep healthconcerns as people age. But as
people age, there are a varietyof reasons why they have more
sleep issues. You named one for, for males they feel like they
have to get up more to gourinate, but there could be
(08:20):
other reasons as well too. Aspeople age, the more sedentary,
which isn't helpful for sleep ,uh, oftentimes they lose the
structure. Let's say they had acareer and they were go waking
up the same time each day,going to bed at the same time
each day, wrapping that aroundtheir career and sudden that's
lost. So there's a variety ofreasons and then also we, we do
find that people seem to spendless time in their deep
(08:40):
restorative sleep as they ageas well too. So there's a host
of reasons why sleep justbecomes more problematic as we
age versus the myth that it'speople just don't need as much
sleep. Is
Speaker 2 (08:49):
There a correct number of hours to sleep? I get
to ask this all the time.
Speaker 3 (08:52):
Yes and no. Like a lot of things, right? So we
used to have this number ofeight hours that was around and
I suspect everybody's certain ,well you need eight hours of
sleep as an adult. But itwasn't really backed by
anything empirical. It was moreanecdotal, if anything. And I
suspect what was based on theidea as an adult , uh, your
sleep cycles last about one anda half to two hours. So some
people were going through foursleep cycles and it turned out
(09:14):
to be eight hours. When we lookat the data for adults, the
average adult obtains about 7.3hours of sleep a night. That's
Speaker 2 (09:21):
Pretty specific there, Dr. Rosenberg.
Speaker 3 (09:22):
Well that's what I'm saying. It's not , not saying
Speaker 2 (09:24):
It's optimal. 7.3 hours is what the average adult
gets.
Speaker 3 (09:26):
Yeah. Based on our, our , well the data we have
now, again, that is alwaysevolving, but um, it doesn't
mean that's optimal. That'sjust what is happening. A big
thing that we pay attention towithin sleep health is just not
how much sleep a person isgetting, but how are they
feeling in the morning? I'drather have a patient get six
and a half hours of sleep andfeel rested in the morning than
get 8.00 hours of sleep andfeel lousy. Yeah ,
Speaker 2 (09:48):
That makes perfect sense. I think I would go for
10 hours if I could andI never had that in ages, but
I, I think I need more than I'mgetting. Do you , is that a
over generalization or, or itsounds like maybe people need
to get a little bit more thanthey are in general. Oh
Speaker 3 (10:02):
Yeah. I mean there , there is a, a widespread
understanding that in today'ssociety, in western society
we're not getting enough sleepand we're now looking at it in
the same light that we look at,let's say with obesity , uh,
smoking cigarettes. In that aspeople do these things
chronically and repeatedly,they oftentimes can pay a , a
price in their health or theirmental health or even how they
(10:24):
function on a day-to-day basis.
What
Speaker 2 (10:25):
Does the medical science support about the
long-term effects of poorsleep?
Speaker 3 (10:30):
Well, if we're just gonna simplify it, I talk about
insomnia or insufficient sleep.
We know there's a greater riskfor heart disease, there's a
greater risk for diabetes,there's a greater risk for
obesity. There's abidirectional relationship
between untreated insomnia andsubstance use disorders,
especially alcohol. Um, there'sa bidirectional relationship
between depression andinsomnia. You mean
Speaker 2 (10:52):
It's causative and it's a result?
Speaker 3 (10:54):
Yep , it's a loop and as well as generalized
anxiety disorder. And then ifwe take it a step further, it
affects us how we function on aday-to-day basis. We find that
people have lower workproductivity, a greater risk
for motor vehicle accidents. Soas I was mentioning earlier, it
really cuts through a lot ofdifferent areas of health in a
similar weight as smoking or orobesity. Before
Speaker 2 (11:13):
We get into CBTI , which I'm gonna do in just a
moment, is the amount of sleepthat is required differ by age
of life. We've talked aboutolder adults, but then we
always hear about teenagers andkids. Just, I don't wanna skim
over that. Is it differentbased on age, how much a person
might need? Everyone knowstheir teenager slept in until
noon may . Is it maybenot the teenager's fault? Do
(11:35):
they need more sleep or is yourkid just a slacker,
Speaker 3 (11:37):
? Well, you
know, it's possible to be both.
It doesn't have to be one orthe other . Your
Speaker 2 (11:41):
Kid can be a slacker and it's still necessary, but ,
Speaker 3 (11:43):
But we are finding that teens need about nine
hours sleep a night. That'swhat the data is supporting.
And in fact, there's been amovement nationally to shift
star times in high schools toaccommodate that, which I think
is a terrific concept becausewhat what was happening before
and it still happened a lot oftimes you're having these sleep
deprived teens go to school,they're tired, they're probably
more irritable, more down,harder time focusing far from
(12:07):
optimal as a learningenvironment. Yeah .
Speaker 2 (12:08):
Cut your teens some slack maybe a little bit. Hey
Mark , I got a question oncefrom a listener about napping.
And personally I could take anap anytime , any day I could
fall asleep anywhere. And I,and this listener asked ,
what's the ideal length of timefor a nap? So
Speaker 3 (12:24):
Like a lot of things it , it's a more complicated
answer even though it's asimple question. When we talk
about naps, the thing we wewanna be mindful of is the
state of sleep we're in. So ittakes about 30 to 40 minutes
before we get into the deepersleep in , in most cases. So
anytime a nap under that , that30 minute threshold for most
people, they're okay. Where wealways wanna be careful is we
don't wanna net sleep too muchor nap too much where we're
(12:47):
using up the deep restorativesleep. 'cause that's the one
that can have an impact on thefollowing night. Okay,
Speaker 2 (12:52):
So you don't wanna sleep too long because you
don't wanna get into the deepersleep in your neck . Correct.
So the ideal length is what
Speaker 3 (12:58):
I usually say 20 to 30 minutes.
Speaker 2 (13:00):
You talked about the states of sleep , I would call
the the napping the state ofbliss is what I'd call it.
We're gonna take a quick nap. Imean we're gonna take a quick
break and when we come back I'mgonna ask Dr. Rosenblum to
share some success stories thathe's had with his patients and
also to share some practicaltips that you can use right now
if you're having troublefalling asleep or staying
(13:20):
asleep. So stick around, we'llbe right back
Speaker 4 (13:25):
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(13:48):
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Speaker 2 (14:03):
So we're back talking with Dr. Mark Rosenblum
about insomnia. Mark, whatmight people not know about
insomnia who are really worriedabout it?
Speaker 3 (14:12):
Well what we're finding, one of the key
features that underlies theperpetuation chronic insomnia
is people often develop ananxiety or fear about not
sleeping. We all have a badnight of sleep now. And then
for the person with the sleepanxiety that we're referring
to, that sleep anxiety getshigher or stronger the longer
this insomnia goes on. So aftertwo nights the sleeping anxiety
(14:34):
is at one level, but by threenights it's even higher and it
just keeps building andbuilding. And oftentimes
people, while they're awarethey're having it, they're not
always aware that's the reasonor one of the main reasons
they're not sleeping.
Speaker 2 (14:46):
Let's shift a bit now to the treatments and we're
gonna introduce the concept ofCBTI , which stands for
cognitive behavioral therapyfor insomnia. What the heck is
that?
Speaker 3 (14:56):
So cognitive behavioral therapy for insomnia
is really the outcome of thedevelopment of a variety of
different insomnia , uh,treatments that focus on
behavioral or cognitions. Andthey all were developed in
different schools. And so themain techniques that make up
cognitive behavioral therapyfor insomnia now include
something called sleeprestriction , uh, stimulus
control, cognitiverestructuring. And we find each
(15:19):
of them on their ownempirically show improvements
in sleep. And when we pull 'emtogether, we have an approach
that has outcomes that aretypically better than even the
prescription sleep medications.
Speaker 2 (15:30):
The thing that I get asked for almost the most in my
primary care practice is canyou give me a pill to go to
sleep? And listeners, CBTI is amore effective treatment than
anything that comes in a pillform. So that was some kind of
eggheady terms you used inthere, some technical terms
about, you know, aboutall the parts of CBTI . Let's
break those down. Sure.
Speaker 3 (15:48):
So sleep restriction typically involves condensing
the window of sleep temporarilyand shifting the bedtime later
temporarily. And takingadvantage of the fact that as
we restrict ourselves oursleep, we naturally get sleep.
Here it's not essentiallyrocket science, but it , it
seems to be a very effectiveway to enhance our sleepiness.
And what happens then is peoplestart going to bed in a
(16:10):
sleepier state and havingbetter success, we can see a
pretty quick turnaround in howquickly they're falling asleep
and how much they're sleepingthrough the night. And once a
person has better sleep qualityand also feels more in control
of their sleep, well thengradually and incrementally
move that bedtime earlier.
Speaker 2 (16:25):
So how long do you have to do that? The sleep
restriction?
Speaker 3 (16:29):
I will see improvements between session
one and two if someoneimplements sleep restriction
along with maybe a few other ,uh, sleep really
Speaker 2 (16:35):
Right at me In between sessions one and two
with you?
Speaker 3 (16:37):
Yeah. And and the way I've, over the years,
because I've been doing thisnow for almost 20 years now,
towards the tail end of thefirst week after the first
session, you start seeing atrend in improvement. And by
the time they come back for thesecond session, which is
usually a week or two later,we're oftentimes already seeing
improvements in a person'ssleep.
Speaker 2 (16:52):
Wow. Wow . That that would be wonderful because you
don't see that in anythingelse. Okay. That's sleep
restriction. What's the secondcomponent? So
Speaker 3 (17:00):
Stimulus control is essentially an adult version of
sleep training. So tounderstand stimulus control,
it's best to understand how welearn to sleep when we're
infants 'cause we all wentthrough that to some capacity
or we, we took care of our ownkids. 'cause there's a
transition phase where aninfant goes from having an
irregular and erratic sleepschedule to sleeping through
the night with scheduled naps.
(17:21):
And it's largely based ondifferent learning theories we
have in psychology while stealmis control borrows from these
same learning concepts andessentially retrains an adult
to sleep , meaning that they'regoing to bed and they feel
drowsy naturally as they go tobed and then they fall asleep
in a timely way. So
Speaker 2 (17:37):
Just gotta emulate your six month old .
Speaker 3 (17:39):
Basically though though we tend to be a little
more complicated than the sixmonth old ,
Speaker 2 (17:43):
I would imagine
Speaker 3 (17:44):
Because of what goes on between our ears,
essentially we , we tend tothink our way in and out of ,
in a lot of things in life,including sleep.
Speaker 2 (17:51):
So in CBTI , you talk this through with your
patients about ways that theycan retrain themselves.
Speaker 3 (17:58):
Absolutely. And, and then there is a third component
that that ties into this stuffreally nicely called
restructuring our sleepreframing. And we find for the
vast majority of people withchronic and repetitive
insomnia, they start thinkingabout the sleep and insomnia
while they're awake at night ina way that makes it even harder
to sleep. So they start gettingincreasingly frustrated or
panicked or irritated or theybecome really preoccupied about
(18:21):
the next day , gosh, what'swork gonna be like? So with
cognitive restructuring oressentially teaching people how
to think differently about theinsomnia while they're in the
midst of it, and then I'll addto that is I'll teach 'em about
how sleep works and as theystart getting, you know, an
understanding of how this allcomes together, they can have
what we call like an aha momentand it , and it kind of can
pull this together and you cansee that sleep anxiety drop and
(18:42):
then they start sleeping betteragain.
Speaker 2 (18:43):
So compare that if you will to medications. So
people in our society, it's nottheir fault. Our society is
kind of into medications.
That's what I do for a livingmore than I wish I did. How
does sleep medications work andthen how does that differ from
what you do? Well
Speaker 3 (18:59):
And so first I wanna to defend these people because
by the time they come to theirprovider, there is that anxiety
or panic about not sleeping. Sothey're desperate. Mm-hmm .
and , andmedications is probably what
they're more familiar with. Butthe interesting thing is when
we compare the data and we'vehad uh, numerous times they've
done comparisons. There's anorganization called the Agency
for Healthcare Research andQuality. A federal agency back
(19:20):
about seven or eight years agoran some data and they found
the medications work about 60to 65% of the time
Speaker 2 (19:27):
Sleep medicines do .
Yeah , yeah .
Speaker 3 (19:28):
And in contrast, when we look at the data for
CBTI , we're at about 75 to80%. So one of the points that
is helpful I think to convey isthat our data is better, but
what is also helpful tounderstand is really what the
medications are doing. Andthat's usually one of two
things. They're either creatinga drop in a person's anxiety or
arousal or they're creatingmore sedation. And these are
(19:49):
two things we can do withoutmedications. I can make my
patients more sleepy by justhaving them go to bed later
temporarily. Mm-Hmm, . Okay . I can
make them more relaxed by doingthe cognitive reframing or
sometimes we'll also integratesome relaxation techniques. So
the CBTI can actually targetthe same things though though
it does take a little morework, but overall it tends to
be more effective andhealthier.
Speaker 2 (20:10):
That's really interesting to me. You said you
can make people more, you know,you so you can address the
sleepiness issue that themedications kind of claim to
do. And the most popular sleepaid medicines that you can buy
at your local drugstore areantihistamines. You know,
they're just, we're using 'emfor some side effect and they,
they might make you more sleepyor they reduce your, they
sedate you kind of, or theymake you less anxious. You can
(20:32):
do all those things without amedication and have better
success than any of thosepills. And the data supports
that.
Speaker 3 (20:38):
Yeah . And the data supports that. And also, you
know, medications have adifferent target than cognitive
behavioral therapy forinsomnia. The target for a
sleep aid be at theantihistamine or the
prescription sleep aid is toaddress a single night of
sleep. Mm-Hmm . Okay . So ifsomeone has maybe acute
insomnia or just a singlenight, perhaps that's a good
fit. But when it's a chronicproblem, people are now using a
(20:58):
one night at a time approachfor a chronic problem. And as
such, people are taking thesesleep aids indefinitely for
years. But
Speaker 2 (21:05):
These also have lots of side effects too. Uh,
there's all kinds of sideeffects too. Uh, even the over
the counter ones, folks, youcould , there are side effects
to over the counter sleep aids.
Older adults can have troubleswith their bowels, they can
have troubles with B anddehydrated all from these sleep
aids. And the prescription onesalso have quite a few side
effects. Some of them arelegendary that you might have
(21:25):
read about. We're not gonna getinto that in much more detail,
but is there a downside to theCBTI that you're talking about?
I mean, what would the sideeffect be? Is there a downside?
Speaker 3 (21:35):
Well, there are what we call contraindications and
what a contraindication meansis this somewhat has some other
health issue that maybe someaspect of CBTI should not be
done. So sleep restriction,which is one of the tools we
don't typically recommend itfor some of the they history of
bipolar disorder , um, seizuresor we call parasomnias. Um , in
(21:55):
all those situations, if we dosomething that amplifies
sleepiness, be it through sleeprestriction or a medication,
you can increase those symptomsor those health risks. What's
Speaker 2 (22:04):
A parasomnia?
Speaker 3 (22:05):
That's a terrific question. So that's
Speaker 2 (22:07):
A whole nother episode, isn't it? That's
Speaker 3 (22:08):
A whole nother episode. But so our body is
supposed to do certain thingswhile we're awake and do
certain things while we'reasleep. And in a parasomnia
these signals get crisscrossed.
Probably the most commonexample that people are
familiar with is someone whosleepwalk, we're not supposed
to walk while we're sleeping.
We're our muscles are supposedto be flacid and we're not
supposed to be moving. Butthere's a variety of other
conditions too where our bodykind of gets the signals get
(22:29):
crisscrossed and we find whensomeone does anything that
amplifies sleepiness, likesleep restriction or the sleep
medications, you can get eitheran occurrence of it or a more
frequency if it's alreadyexisting. And, and for people
that sometimes heard of some ofthese sleep medications, some
of these stories that you'retalking about, oftentimes
that's what's happening isthey're amplifying their, how
sleepy they are and then you'retriggering these parasomnias
and so they're out walking intheir sleep or driving their
(22:51):
car or what have you. Little
Speaker 2 (22:52):
Practical things about CBTI before I ask you to
give some tips for what peoplecan do right now, but when you
do engage in CBTI , what canyou expect? You talked about
sessions. Is this an ongoingthing? Does it go forever? How
many sessions is it? How dothey access it? Things like
that.
Speaker 3 (23:07):
So even though most of the time it's administered
by a psychologist, it it , it'sgonna have a much different
feeling or structure to it incomparison to traditional
therapy, which can go on formonths, even years. CBTI is a
brief treatment. Um, it usuallytakes somewhere between three
to six sessions and when youget in with a sleep
psychologist, you're not gonnabe delving into , uh, your deep
(23:28):
history typically. Usually it'sas a behavioral treatment,
people are assignedrecommendations or homework. Uh
, oftentimes they'll tracktheir sleep using a sleep blog
and when they come back wereview it and keep modifying it
so it moves pretty quickly.
And, and like I said, usuallytakes between three to six
sessions. The , the target forCBTI and we don't always reach
the threshold is actually tocure the insomnia to resolve
(23:50):
it. And so, you know, I tellpeople what if I , when I try
to like kind of simplify it, Isimplify it as basically we're
retraining you to sleep. Sojust like it can take a little
time with a treating an infantand it's , it's
sometimes a little frustrating.
It doesn't always happen rightaway, but it has a lot of the
same goals. We're trying toretrain someone to sleep and as
such we could , we can actuallyget to the point they don't
(24:11):
need further treatment
Speaker 2 (24:13):
And you can access that through your healthcare
system if you happen to be inMinneapolis. I encourage nobody
more than the sleeppsychologist at Hennepin
Healthcare right here indowntown Minneapolis. Okay.
Practical tips. If someone'shaving sleep problems right
now, they're not yet engaged inCBTI . What, what tips could
you give people who arelistening if they're having
(24:33):
some trouble falling asleep,what behavioral things could
they do?
Speaker 3 (24:36):
Well, I find it's helpful to, to think about this
in the same way you think abouthow you'd want your own kids to
sleep if you have kids. So forexample, with our kids, we want
them to go to bed and wake upat the same time each day. Well
, we wanna do the same thingfor ourselves because our sleep
operates a lot like our needfor food. And just like if we
ate meals at all differenttimes of the day, our appetite
would be irregular. If we sleepat all different times, it's
(24:58):
gonna create a , anirregularity of when we're
sleepy. The second thing is tolimit to what we do in bed to
sleep and intimacy. If we thinkback again how sleep training
works for an infant, wewouldn't give our infant all
these different things to do intheir bath , in our crib in an
effort to intimate sleep or weactually discourage that . So
you really wanna be only in bedfor sleep and intimacy at
(25:18):
night. And, and the third one,and this is more of I think a,
a modern manifestation isreally get off the internet in
that hour or so before bedtime.
And, and this ends up not justaffecting insomnia, but we're
seeing now people staying ontheir phones for hours and
hours, which at that pointthey're not getting enough
sleep. Not because they cansleep, but they're just not
using their opportunity tosleep.
Speaker 2 (25:39):
Those are great tips and I, I don't think I do any
of 'em. Mark , I think I havesomething to work to do on
there. You know, regularschedule , um, uh, the bed for
sleep and intimacy only andless screen time right before
bed. Those are fantastic tips.
What about alcohol and exerciseright before bed? Those are two
things I get asked a lot. Youshouldn't drink right before
bed, you shouldn't exerciseright before bed. True. Or is
(26:00):
that a myth? So
Speaker 3 (26:01):
Let me get into the weeds a little if I may. You
may. Um , . So foralcohol, yeah, we don't wanna
drink alcohol close to bedtime,which ironically at one point,
and this is maybe 15 years agoor so, it was one of the most
common ways people on their owntry to rectify their insomnia.
And while at times it can helpfall asleep a little bit with a
small amount, alcohol is adepressant. So what happens is
(26:22):
it messes with our respiratorysystems of sleep and we tend to
have a lower quality of sleep,more awakenings and feel less
rested in the morning. Sousually the benchmark we say is
we encourage no alcohol withintwo hours of bedtime. Exercise
is interesting because back inthe day, old sleep hygiene
discouraged any exercise in theevening. And this was largely
based on the idea that when weexercise our body's physiology
(26:45):
changes in a way that makes itless likely to sleep. But where
we've evolved in that over timeis a little bit, first of all,
it doesn't take our body a fullevening to cool down . For most
people it takes a couple hours.
Second exercise, especiallycardio is in a very effective
tool to deal with stress. Sowe're now actually encouraging
some of our patients, if theyhave a lot of day-to-day stress
(27:05):
is to do some modern intensecardio two to three hours for
bedtime. That's a great bit of, uh, advice to give. Thank you
for all of that. Before I letyou go, mark , what final
thoughts would you leave withour listeners? Well , what I'd
really suggest for people is tothink of their sleep health in
the same light that they thinkof weight loss and smoking. In
that if you take care of yoursleep health proactively ahead
(27:27):
of time, that will help youacross the board in so many
areas of your health. So whatI'd really encourage people is
not wait to the point that youneed to see a sleep specialist,
but see what you can do now toreally make sure that you get
the quality and quantity ofsleep you need to maintain good
sleep health. I feel sofortunate to get to work with
colleagues across medicalspecialties. Mark , thank you
(27:47):
so much. This has been anincredibly helpful show. Thanks
for being with us and thank youfor having me. Well, that's a
wrap on season three of thepodcast and I can't stress
enough how thankful I am forall of you who are listening
and supporters of the podcast,three seasons in the books.
Thank you for downloading.
Thank you for listening. Thankyou for telling your friends
(28:08):
about the Healthy Matterspodcast and don't lose any
sleep. We'll be back for seasonfour in the next two weeks with
a new episode. So please joinus for that. Thank you for
listening and in the meantime,be healthy and be well.
Speaker 1 (28:23):
Thanks for listening to the Healthy Matters podcast
with Dr. David Hilden. To findout more about the Healthy
Matters podcast or browse thearchive, visit healthy
matters.org. Got a question ora comment for the show , email
us at Healthy matters@hcme.orgor call 6 1 2 8 7 3 talk.
There's also a link in the shownotes. The Healthy Matters
(28:45):
Podcast is made possible byHennepin Healthcare in
Minneapolis, Minnesota, andengineered and produced by John
Lucas At Highball Executiveproducers are Jonathan , CTO
and Christine Hill . Pleaseremember, we can only give
general medical advice duringthis program and every case is
unique. We urge you to consultwith your physician if you have
a more serious or pressinghealth concern. Until next
(29:06):
time, be healthy and be well.
Welcome to the Healthy Matters podcast with
Dr. David Hilton , primary carephysician and acute care
hospitalist at HennepinHealthcare in downtown
Minneapolis, where we cover thelatest in health, healthcare
and what matters to you. Andnow here's our host, Dr. David
Hilton .
Speaker 2 (00:18):
Hey everybody, it's David Hilden and welcome to
episode 24, the final episodeof Season three of the Healthy
Matters podcast. Thanks forjoining us today. We're gonna
talk about insomnia and themost effective treatment for
insomnia, which is cognitivebehavioral therapy for
insomnia, otherwise known asCBTI . To help me out today, I
(00:39):
have Mark Rosenblum. He is adoctor of psychology and an
expert in insomnia and thetreatments of insomnia. He is a
colleague of mine here atHennepin Healthcare in downtown
Minneapolis in our sleepcenter. Mark, thanks for being
here. Well, thank you
Speaker 3 (00:52):
For having me. I appreciate it. So
Speaker 2 (00:53):
You've been doing sleep medicine for some 20, 30
years, I don't know, a longtime. Mm-hmm ,
and treating patients whoexperience insomnia. So could
you start us out, lay thegroundwork, the basics of
insomnia. What is insomnia? Howis it defined, and what are the
various types?
Speaker 3 (01:09):
Well, when we break down insomnia, we , we break it
down between the symptom versusthe condition. The symptom of
insomnia is something that mostpeople are familiar with.
Troubles falling asleep,trouble staying asleep, or
troubles waking up too early inthe morning. When it
transitions to a condition,usually it involves a few more
factors. First of all, youstart having some daytime
consequences. A person isstruggling more at work, maybe
(01:31):
at school , um, in theirrelationships. Secondary is it
ha it takes on a chronicfeature to that. For example,
most people, upwards to 50% ofpeople will have insomnia
symptoms At times. They may bethere for a day or two and they
resolve in contrast thecondition which goes on and on
until it's treated. We thinkeven upwards to 10% of the
(01:52):
population struggles with that.
Yeah,
Speaker 2 (01:53):
I can imagine that darn near everybody listening
says, yeah, I had troublefalling asleep last night, or I
woke up at 2:00 AM and I wasanxious about something. So, so
I think it's something that agreat number of people have
experienced. But you'redistinguishing that with,
when's it a problem that youneed to have addressed? That's
what you mean by a condition.
Yeah,
Speaker 3 (02:09):
So, so a symptom oftentimes, like I said, could
be for a single night here orthere. There are sometimes
though the symptoms can go onand on because they're
secondary to another situation.
So for example, let's saysomeone's going through a lot
of stress in their life, arelationship stress, job
stress. That would still be aninsomnia symptom though that
could go on for a while . Andin those situations treating it
(02:30):
still has some value typically.
But like you said, thecondition is really that one
that just seems to go on and onand on until it's resolved or
treated.
Speaker 2 (02:38):
Could you break down these types of insomnia's force
? Are they caused by differentthings? So what , what do they
look like? So
Speaker 3 (02:44):
Troubles falling asleep. The , the way we
demarcate it from let's sayjust a , a normal night of
sleep is anytime it takes morethan a half hour to fall
asleep. And if this happensmore than three times a week,
we now consider that aproblematic type of insomnia
here. Oftentimes what you seeassociated with that is some
situational stress. Again, weall have stress. Stress is a
normal thing, but sometimesthat stress is so high that it
(03:07):
seems to interfere with ourability to fall asleep. Middle
of the night insomnia is alittle more complicated. People
are waking up. Again, it's asimilar time duration for more
than 30 minutes. But this caninvolve again, regular stress
too. But there can be othersleep conditions that seem to
fuel that, that would alwaysneed to be teased out when that
occurs. And the early morninginsomnia is kind of interesting
(03:27):
too, 'cause we'll sometimes seepeople again with the stress,
but also a little depressiontied into that as well. So
Speaker 2 (03:32):
How does that differ the waking up too early from
just the middle of the nightone ? Do they have a different
pattern to them?
Speaker 3 (03:38):
Well, what differentiates them typically
is just about the person'sability to get back to sleep
because it is normal to wake upduring the night. Most people
do, but for some reason, somepeople have a harder time
getting back to sleep in themiddle of the night, whereas
other people have a harder ,harder time to get back to
sleep if they wake up tooearly. You know, and , and one
of the features of thatoftentimes is when someone is
aware that it's, let's say,within an hour of their
(04:00):
expected wake up time, thatseems to put them in a kind of
a dynamic where either theygive up trying to sleep or they
feel a lot of pressure get backto sleep, which then interferes
with it.
Speaker 2 (04:08):
And listeners, don't worry in just a short bit on
this episode, we're gonna talkwith Dr. Rosenblum about ways
to manage these conditions andwhat treatments are available.
So stay tuned for that. Solet's go back to the first kind
for just a little bit if wecould, I bet there's a medical
name for that. When you can'tfall asleep.
Speaker 3 (04:25):
Well, in , in the name of insomnia has evolved
over the years. Back in the daywe used to refer to like this
chronic insomnia or troublesfalling asleep as a primary
insomnia. And then if it wascaused by some other factor,
we'd call it a secondaryinsomnia. These days, to be
honest with you, we really kindof lump it all together because
it doesn't seem to affect howwe treat it as long as it's a
(04:45):
chronic condition. So you
Speaker 2 (04:46):
Said 30 minutes. I tell you, if I'm lying there
for 30 minutes and can't fallasleep, I'm gonna be pretty
anxious. Just on that factalone, I think last night , uh,
my head hit the pillow and Iwas out in about 30 seconds. So
what is considered normal? Howlong are you supposed to lie
there before you fall asleep?
Is 30 minutes the time
Speaker 3 (05:04):
So anything under 30 cons minutes is considered
within normal limits. And thatsometimes is something that,
that people react with .
Similar to what you said, it ,it feels too long. And then it
triggers some anxiety about thesleep itself, which then feeds
into the insomnia. So anythingunder 30 minutes. And actually
when it's a a few minutes, whatthat suggests to us is you are
(05:24):
really sleepy when you go tobed. Most people take at least
five to 15 minutes to fallasleep. So kudos to, you're
going to bed when you're in areally sleepy stage. Well
that's
Speaker 2 (05:32):
'cause I was up till 1:00 AM the past four nights
for work thing
Which brings up a question. Uh, bring , uh, what to what
degree do your own behaviorscontribute to this type of
insomnia? You know, is itsomething you could have done
something about or is it just afact of your life that you
can't fall asleep? Well,
Speaker 3 (05:51):
We can see a variety of behaviors that increase the
risk of that. So for example,you have some people burning
the midnight oil, like that's
Speaker 2 (05:57):
What I've been doing all
Speaker 3 (05:57):
Week. Yeah. And you see this a lot for college
students, for example, who areare studying for their finals
up until, you know, the middleof the morning. Also, sometimes
what you'll see is people thatdon't really have a regular
routine and there's somethingabout the aspect of routine
that seems to feed into thebetter chance of falling asleep
at night. We see when peoplehave a lot of variety in their
routine, they can have a littlemore difficulties. And then the
(06:18):
last trap that I think thatpeople get into are people who
are watching TV in bed or ontheir phones in bed as they try
to sleep at night. And what isinteresting about that is
oftentimes the reason they'reinitially doing it is they
think it's gonna help themsleep. And at some point it
probably was, but over time itweakens the association between
bed and sleep and actuallyfeeds into the insomnia. So
Speaker 2 (06:38):
Me watching a very intense episode of The Bear
last night on TV where they'reyelling and screaming at each
other that maybe didn't helpeither. It
Speaker 3 (06:45):
It may have not helped
Speaker 2 (06:46):
we will delve into that alittle bit more. What about the
middle of the night business?
Maybe I'm wrong in this, but itsounded a little bit more
sinister or it sounded just alittle bit more like that might
represent some other conditionsthat you have to deal with. Is
that, am I missing that or?
Well,
Speaker 3 (07:02):
Troubles falling asleep is typically insomnia
when people wake up in themiddle of the night. There can
be a variety of other sleepdisorders that also lead to
that behavior. You see peoplewho have things like restless
leg syndrome , uh, sleep apneato name a few here. So there
could be , uh, numerous reasonswhy people wake up. But if
there is also troubles gettingback to sleep, that would be
more the traditional insomnia.
(07:23):
So essentially there could besituations that are
multifactorial with the middleof the night insomnia. Yeah.
Speaker 2 (07:27):
And I, I treat adults. I'm an internal
medicine doctor and so I treatmostly adults and , and even a
subset of adults I treat mostlyolder adults. Is it true or is
it not true that, that yoursleep shortens or gets
different as you get older?
Because I can tell you thatdarn near every adult man over
a certain age gets up in thenight to go pee. They had ,
(07:48):
they have to urinate and thenusually they get right back to
sleep. But is it true thatolder adults experience
insomnia more or if an olderadult is not sleeping as well,
is that something they shouldhave looked at?
Speaker 3 (07:58):
Yeah, it , it is more common and I really liked
how you phrased it. Does theirsleep change as they age? There
used to be this myth out therethat people would just need
less sleep as they age. So kindof kinda whitewash all these
sleep needs or sleep healthconcerns as people age. But as
people age, there are a varietyof reasons why they have more
sleep issues. You named one for, for males they feel like they
have to get up more to gourinate, but there could be
(08:20):
other reasons as well too. Aspeople age, the more sedentary,
which isn't helpful for sleep ,uh, oftentimes they lose the
structure. Let's say they had acareer and they were go waking
up the same time each day,going to bed at the same time
each day, wrapping that aroundtheir career and sudden that's
lost. So there's a variety ofreasons and then also we, we do
find that people seem to spendless time in their deep
(08:40):
restorative sleep as they ageas well too. So there's a host
of reasons why sleep justbecomes more problematic as we
age versus the myth that it'speople just don't need as much
sleep. Is
Speaker 2 (08:49):
There a correct number of hours to sleep? I get
to ask this all the time.
Speaker 3 (08:52):
Yes and no. Like a lot of things, right? So we
used to have this number ofeight hours that was around and
I suspect everybody's certain ,well you need eight hours of
sleep as an adult. But itwasn't really backed by
anything empirical. It was moreanecdotal, if anything. And I
suspect what was based on theidea as an adult , uh, your
sleep cycles last about one anda half to two hours. So some
people were going through foursleep cycles and it turned out
(09:14):
to be eight hours. When we lookat the data for adults, the
average adult obtains about 7.3hours of sleep a night. That's
Speaker 2 (09:21):
Pretty specific there, Dr. Rosenberg.
Speaker 3 (09:22):
Well that's what I'm saying. It's not , not saying
Speaker 2 (09:24):
It's optimal. 7.3 hours is what the average adult
gets.
Speaker 3 (09:26):
Yeah. Based on our, our , well the data we have
now, again, that is alwaysevolving, but um, it doesn't
mean that's optimal. That'sjust what is happening. A big
thing that we pay attention towithin sleep health is just not
how much sleep a person isgetting, but how are they
feeling in the morning? I'drather have a patient get six
and a half hours of sleep andfeel rested in the morning than
get 8.00 hours of sleep andfeel lousy. Yeah ,
Speaker 2 (09:48):
That makes perfect sense. I think I would go for
10 hours if I could
I, I think I need more than I'mgetting. Do you , is that a
over generalization or, or itsounds like maybe people need
to get a little bit more thanthey are in general. Oh
Speaker 3 (10:02):
Yeah. I mean there , there is a, a widespread
understanding that in today'ssociety, in western society
we're not getting enough sleepand we're now looking at it in
the same light that we look at,let's say with obesity , uh,
smoking cigarettes. In that aspeople do these things
chronically and repeatedly,they oftentimes can pay a , a
price in their health or theirmental health or even how they
(10:24):
function on a day-to-day basis.
What
Speaker 2 (10:25):
Does the medical science support about the
long-term effects of poorsleep?
Speaker 3 (10:30):
Well, if we're just gonna simplify it, I talk about
insomnia or insufficient sleep.
We know there's a greater riskfor heart disease, there's a
greater risk for diabetes,there's a greater risk for
obesity. There's abidirectional relationship
between untreated insomnia andsubstance use disorders,
especially alcohol. Um, there'sa bidirectional relationship
between depression andinsomnia. You mean
Speaker 2 (10:52):
It's causative and it's a result?
Speaker 3 (10:54):
Yep , it's a loop and as well as generalized
anxiety disorder. And then ifwe take it a step further, it
affects us how we function on aday-to-day basis. We find that
people have lower workproductivity, a greater risk
for motor vehicle accidents. Soas I was mentioning earlier, it
really cuts through a lot ofdifferent areas of health in a
similar weight as smoking or orobesity. Before
Speaker 2 (11:13):
We get into CBTI , which I'm gonna do in just a
moment, is the amount of sleepthat is required differ by age
of life. We've talked aboutolder adults, but then we
always hear about teenagers andkids. Just, I don't wanna skim
over that. Is it differentbased on age, how much a person
might need? Everyone knowstheir teenager slept in until
noon
(11:35):
they need more sleep or is yourkid just a slacker,
Speaker 3 (11:37):
It doesn't have to be one orthe other . Your
Speaker 2 (11:41):
Kid can be a slacker and it's still necessary, but ,
Speaker 3 (11:43):
But we are finding that teens need about nine
hours sleep a night. That'swhat the data is supporting.
And in fact, there's been amovement nationally to shift
star times in high schools toaccommodate that, which I think
is a terrific concept becausewhat what was happening before
and it still happened a lot oftimes you're having these sleep
deprived teens go to school,they're tired, they're probably
more irritable, more down,harder time focusing far from
(12:07):
optimal as a learningenvironment. Yeah .
Speaker 2 (12:08):
Cut your teens some slack maybe a little bit. Hey
Mark , I got a question oncefrom a listener about napping.
And personally I could take anap anytime , any day I could
fall asleep anywhere. And I,and this listener asked ,
what's the ideal length of timefor a nap? So
Speaker 3 (12:24):
Like a lot of things it , it's a more complicated
answer even though it's asimple question. When we talk
about naps, the thing we wewanna be mindful of is the
state of sleep we're in. So ittakes about 30 to 40 minutes
before we get into the deepersleep in , in most cases. So
anytime a nap under that , that30 minute threshold for most
people, they're okay. Where wealways wanna be careful is we
don't wanna net sleep too muchor nap too much where we're
(12:47):
using up the deep restorativesleep. 'cause that's the one
that can have an impact on thefollowing night. Okay,
Speaker 2 (12:52):
So you don't wanna sleep too long because you
don't wanna get into the deepersleep in your neck . Correct.
So the ideal length is what
Speaker 3 (12:58):
I usually say 20 to 30 minutes.
Speaker 2 (13:00):
You talked about the states of sleep , I would call
the the napping the state ofbliss is what I'd call it.
We're gonna take a quick nap. Imean we're gonna take a quick
break and when we come back I'mgonna ask Dr. Rosenblum to
share some success stories thathe's had with his patients and
also to share some practicaltips that you can use right now
if you're having troublefalling asleep or staying
(13:20):
asleep. So stick around, we'llbe right back
Speaker 4 (13:25):
When head up in healthcare says we are here for
life. They mean here for you,your life and all that it
brings. Hennepin Healthcare hasa hospital HCMC and a network
of clinics both downtown andacross the west metro. They
provide all the primary careand specialty care you would
expect to find. But did youknow they also have services
like acupuncture andchiropractic care available at
(13:48):
many of their primary careclinics and at their
integrative health clinic indowntown Minneapolis? Learn
more@hennepinhealthcare.org.
Hennepin Healthcare is here foryou and here for life.
Speaker 2 (14:03):
So we're back talking with Dr. Mark Rosenblum
about insomnia. Mark, whatmight people not know about
insomnia who are really worriedabout it?
Speaker 3 (14:12):
Well what we're finding, one of the key
features that underlies theperpetuation chronic insomnia
is people often develop ananxiety or fear about not
sleeping. We all have a badnight of sleep now. And then
for the person with the sleepanxiety that we're referring
to, that sleep anxiety getshigher or stronger the longer
this insomnia goes on. So aftertwo nights the sleeping anxiety
(14:34):
is at one level, but by threenights it's even higher and it
just keeps building andbuilding. And oftentimes
people, while they're awarethey're having it, they're not
always aware that's the reasonor one of the main reasons
they're not sleeping.
Speaker 2 (14:46):
Let's shift a bit now to the treatments and we're
gonna introduce the concept ofCBTI , which stands for
cognitive behavioral therapyfor insomnia. What the heck is
that?
Speaker 3 (14:56):
So cognitive behavioral therapy for insomnia
is really the outcome of thedevelopment of a variety of
different insomnia , uh,treatments that focus on
behavioral or cognitions. Andthey all were developed in
different schools. And so themain techniques that make up
cognitive behavioral therapyfor insomnia now include
something called sleeprestriction , uh, stimulus
control, cognitiverestructuring. And we find each
(15:19):
of them on their ownempirically show improvements
in sleep. And when we pull 'emtogether, we have an approach
that has outcomes that aretypically better than even the
prescription sleep medications.
Speaker 2 (15:30):
The thing that I get asked for almost the most in my
primary care practice is canyou give me a pill to go to
sleep? And listeners, CBTI is amore effective treatment than
anything that comes in a pillform. So that was some kind of
eggheady terms you used inthere, some technical terms
break those down. Sure.
Speaker 3 (15:48):
So sleep restriction typically involves condensing
the window of sleep temporarilyand shifting the bedtime later
temporarily. And takingadvantage of the fact that as
we restrict ourselves oursleep, we naturally get sleep.
Here it's not essentiallyrocket science, but it , it
seems to be a very effectiveway to enhance our sleepiness.
And what happens then is peoplestart going to bed in a
(16:10):
sleepier state and havingbetter success, we can see a
pretty quick turnaround in howquickly they're falling asleep
and how much they're sleepingthrough the night. And once a
person has better sleep qualityand also feels more in control
of their sleep, well thengradually and incrementally
move that bedtime earlier.
Speaker 2 (16:25):
So how long do you have to do that? The sleep
restriction?
Speaker 3 (16:29):
I will see improvements between session
one and two if someoneimplements sleep restriction
along with maybe a few other ,uh, sleep really
Speaker 2 (16:35):
Right at me In between sessions one and two
with you?
Speaker 3 (16:37):
Yeah. And and the way I've, over the years,
because I've been doing thisnow for almost 20 years now,
towards the tail end of thefirst week after the first
session, you start seeing atrend in improvement. And by
the time they come back for thesecond session, which is
usually a week or two later,we're oftentimes already seeing
improvements in a person'ssleep.
Speaker 2 (16:52):
Wow. Wow . That that would be wonderful because you
don't see that in anythingelse. Okay. That's sleep
restriction. What's the secondcomponent? So
Speaker 3 (17:00):
Stimulus control is essentially an adult version of
sleep training. So tounderstand stimulus control,
it's best to understand how welearn to sleep when we're
infants 'cause we all wentthrough that to some capacity
or we, we took care of our ownkids. 'cause there's a
transition phase where aninfant goes from having an
irregular and erratic sleepschedule to sleeping through
the night with scheduled naps.
(17:21):
And it's largely based ondifferent learning theories we
have in psychology while stealmis control borrows from these
same learning concepts andessentially retrains an adult
to sleep , meaning that they'regoing to bed and they feel
drowsy naturally as they go tobed and then they fall asleep
in a timely way. So
Speaker 2 (17:37):
Just gotta emulate your six month old .
Speaker 3 (17:39):
Basically though though we tend to be a little
more complicated than the sixmonth old ,
Speaker 2 (17:43):
I would imagine
Speaker 3 (17:44):
Because of what goes on between our ears,
essentially we , we tend tothink our way in and out of ,
in a lot of things in life,including sleep.
Speaker 2 (17:51):
So in CBTI , you talk this through with your
patients about ways that theycan retrain themselves.
Speaker 3 (17:58):
Absolutely. And, and then there is a third component
that that ties into this stuffreally nicely called
restructuring our sleepreframing. And we find for the
vast majority of people withchronic and repetitive
insomnia, they start thinkingabout the sleep and insomnia
while they're awake at night ina way that makes it even harder
to sleep. So they start gettingincreasingly frustrated or
panicked or irritated or theybecome really preoccupied about
(18:21):
the next day , gosh, what'swork gonna be like? So with
cognitive restructuring oressentially teaching people how
to think differently about theinsomnia while they're in the
midst of it, and then I'll addto that is I'll teach 'em about
how sleep works and as theystart getting, you know, an
understanding of how this allcomes together, they can have
what we call like an aha momentand it , and it kind of can
pull this together and you cansee that sleep anxiety drop and
(18:42):
then they start sleeping betteragain.
Speaker 2 (18:43):
So compare that if you will to medications. So
people in our society, it's nottheir fault. Our society is
kind of into medications.
That's what I do for a livingmore than I wish I did. How
does sleep medications work andthen how does that differ from
what you do? Well
Speaker 3 (18:59):
And so first I wanna to defend these people because
by the time they come to theirprovider, there is that anxiety
or panic about not sleeping. Sothey're desperate. Mm-hmm .
they're more familiar with. Butthe interesting thing is when
we compare the data and we'vehad uh, numerous times they've
done comparisons. There's anorganization called the Agency
for Healthcare Research andQuality. A federal agency back
(19:20):
about seven or eight years agoran some data and they found
the medications work about 60to 65% of the time
Speaker 2 (19:27):
Sleep medicines do .
Yeah , yeah .
Speaker 3 (19:28):
And in contrast, when we look at the data for
CBTI , we're at about 75 to80%. So one of the points that
is helpful I think to convey isthat our data is better, but
what is also helpful tounderstand is really what the
medications are doing. Andthat's usually one of two
things. They're either creatinga drop in a person's anxiety or
arousal or they're creatingmore sedation. And these are
(19:49):
two things we can do withoutmedications. I can make my
patients more sleepy by justhaving them go to bed later
temporarily. Mm-Hmm,
make them more relaxed by doingthe cognitive reframing or
sometimes we'll also integratesome relaxation techniques. So
the CBTI can actually targetthe same things though though
it does take a little morework, but overall it tends to
be more effective andhealthier.
Speaker 2 (20:10):
That's really interesting to me. You said you
can make people more, you know,you so you can address the
sleepiness issue that themedications kind of claim to
do. And the most popular sleepaid medicines that you can buy
at your local drugstore areantihistamines. You know,
they're just, we're using 'emfor some side effect and they,
they might make you more sleepyor they reduce your, they
sedate you kind of, or theymake you less anxious. You can
(20:32):
do all those things without amedication and have better
success than any of thosepills. And the data supports
that.
Speaker 3 (20:38):
Yeah . And the data supports that. And also, you
know, medications have adifferent target than cognitive
behavioral therapy forinsomnia. The target for a
sleep aid be at theantihistamine or the
prescription sleep aid is toaddress a single night of
sleep. Mm-Hmm . Okay . So ifsomeone has maybe acute
insomnia or just a singlenight, perhaps that's a good
fit. But when it's a chronicproblem, people are now using a
(20:58):
one night at a time approachfor a chronic problem. And as
such, people are taking thesesleep aids indefinitely for
years. But
Speaker 2 (21:05):
These also have lots of side effects too. Uh,
there's all kinds of sideeffects too. Uh, even the over
the counter ones, folks, youcould , there are side effects
to over the counter sleep aids.
Older adults can have troubleswith their bowels, they can
have troubles with B anddehydrated all from these sleep
aids. And the prescription onesalso have quite a few side
effects. Some of them arelegendary that you might have
(21:25):
read about. We're not gonna getinto that in much more detail,
but is there a downside to theCBTI that you're talking about?
I mean, what would the sideeffect be? Is there a downside?
Speaker 3 (21:35):
Well, there are what we call contraindications and
what a contraindication meansis this somewhat has some other
health issue that maybe someaspect of CBTI should not be
done. So sleep restriction,which is one of the tools we
don't typically recommend itfor some of the they history of
bipolar disorder , um, seizuresor we call parasomnias. Um , in
(21:55):
all those situations, if we dosomething that amplifies
sleepiness, be it through sleeprestriction or a medication,
you can increase those symptomsor those health risks. What's
Speaker 2 (22:04):
A parasomnia?
Speaker 3 (22:05):
That's a terrific question. So that's
Speaker 2 (22:07):
A whole nother episode, isn't it? That's
Speaker 3 (22:08):
A whole nother episode. But so our body is
supposed to do certain thingswhile we're awake and do
certain things while we'reasleep. And in a parasomnia
these signals get crisscrossed.
Probably the most commonexample that people are
familiar with is someone whosleepwalk, we're not supposed
to walk while we're sleeping.
We're our muscles are supposedto be flacid and we're not
supposed to be moving. Butthere's a variety of other
conditions too where our bodykind of gets the signals get
(22:29):
crisscrossed and we find whensomeone does anything that
amplifies sleepiness, likesleep restriction or the sleep
medications, you can get eitheran occurrence of it or a more
frequency if it's alreadyexisting. And, and for people
that sometimes heard of some ofthese sleep medications, some
of these stories that you'retalking about, oftentimes
that's what's happening isthey're amplifying their, how
sleepy they are and then you'retriggering these parasomnias
and so they're out walking intheir sleep or driving their
(22:51):
car or what have you. Little
Speaker 2 (22:52):
Practical things about CBTI before I ask you to
give some tips for what peoplecan do right now, but when you
do engage in CBTI , what canyou expect? You talked about
sessions. Is this an ongoingthing? Does it go forever? How
many sessions is it? How dothey access it? Things like
that.
Speaker 3 (23:07):
So even though most of the time it's administered
by a psychologist, it it , it'sgonna have a much different
feeling or structure to it incomparison to traditional
therapy, which can go on formonths, even years. CBTI is a
brief treatment. Um, it usuallytakes somewhere between three
to six sessions and when youget in with a sleep
psychologist, you're not gonnabe delving into , uh, your deep
(23:28):
history typically. Usually it'sas a behavioral treatment,
people are assignedrecommendations or homework. Uh
, oftentimes they'll tracktheir sleep using a sleep blog
and when they come back wereview it and keep modifying it
so it moves pretty quickly.
And, and like I said, usuallytakes between three to six
sessions. The , the target forCBTI and we don't always reach
the threshold is actually tocure the insomnia to resolve
(23:50):
it. And so, you know, I tellpeople what if I , when I try
to like kind of simplify it, Isimplify it as basically we're
retraining you to sleep. Sojust like it can take a little
time with a treating an infantand it's
sometimes a little frustrating.
It doesn't always happen rightaway, but it has a lot of the
same goals. We're trying toretrain someone to sleep and as
such we could , we can actuallyget to the point they don't
(24:11):
need further treatment
Speaker 2 (24:13):
And you can access that through your healthcare
system if you happen to be inMinneapolis. I encourage nobody
more than the sleeppsychologist at Hennepin
Healthcare right here indowntown Minneapolis. Okay.
Practical tips. If someone'shaving sleep problems right
now, they're not yet engaged inCBTI . What, what tips could
you give people who arelistening if they're having
(24:33):
some trouble falling asleep,what behavioral things could
they do?
Speaker 3 (24:36):
Well, I find it's helpful to, to think about this
in the same way you think abouthow you'd want your own kids to
sleep if you have kids. So forexample, with our kids, we want
them to go to bed and wake upat the same time each day. Well
, we wanna do the same thingfor ourselves because our sleep
operates a lot like our needfor food. And just like if we
ate meals at all differenttimes of the day, our appetite
would be irregular. If we sleepat all different times, it's
(24:58):
gonna create a , anirregularity of when we're
sleepy. The second thing is tolimit to what we do in bed to
sleep and intimacy. If we thinkback again how sleep training
works for an infant, wewouldn't give our infant all
these different things to do intheir bath , in our crib in an
effort to intimate sleep or weactually discourage that . So
you really wanna be only in bedfor sleep and intimacy at
(25:18):
night. And, and the third one,and this is more of I think a,
a modern manifestation isreally get off the internet in
that hour or so before bedtime.
And, and this ends up not justaffecting insomnia, but we're
seeing now people staying ontheir phones for hours and
hours, which at that pointthey're not getting enough
sleep. Not because they cansleep, but they're just not
using their opportunity tosleep.
Speaker 2 (25:39):
Those are great tips and I, I don't think I do any
of 'em. Mark , I think I havesomething to work to do on
there. You know, regularschedule , um, uh, the bed for
sleep and intimacy only andless screen time right before
bed. Those are fantastic tips.
What about alcohol and exerciseright before bed? Those are two
things I get asked a lot. Youshouldn't drink right before
bed, you shouldn't exerciseright before bed. True. Or is
(26:00):
that a myth? So
Speaker 3 (26:01):
Let me get into the weeds a little if I may. You
may. Um ,
drink alcohol close to bedtime,which ironically at one point,
and this is maybe 15 years agoor so, it was one of the most
common ways people on their owntry to rectify their insomnia.
And while at times it can helpfall asleep a little bit with a
small amount, alcohol is adepressant. So what happens is
(26:22):
it messes with our respiratorysystems of sleep and we tend to
have a lower quality of sleep,more awakenings and feel less
rested in the morning. Sousually the benchmark we say is
we encourage no alcohol withintwo hours of bedtime. Exercise
is interesting because back inthe day, old sleep hygiene
discouraged any exercise in theevening. And this was largely
based on the idea that when weexercise our body's physiology
(26:45):
changes in a way that makes itless likely to sleep. But where
we've evolved in that over timeis a little bit, first of all,
it doesn't take our body a fullevening to cool down . For most
people it takes a couple hours.
Second exercise, especiallycardio is in a very effective
tool to deal with stress. Sowe're now actually encouraging
some of our patients, if theyhave a lot of day-to-day stress
(27:05):
is to do some modern intensecardio two to three hours for
bedtime. That's a great bit of, uh, advice to give. Thank you
for all of that. Before I letyou go, mark , what final
thoughts would you leave withour listeners? Well , what I'd
really suggest for people is tothink of their sleep health in
the same light that they thinkof weight loss and smoking. In
that if you take care of yoursleep health proactively ahead
(27:27):
of time, that will help youacross the board in so many
areas of your health. So whatI'd really encourage people is
not wait to the point that youneed to see a sleep specialist,
but see what you can do now toreally make sure that you get
the quality and quantity ofsleep you need to maintain good
sleep health. I feel sofortunate to get to work with
colleagues across medicalspecialties. Mark , thank you
(27:47):
so much. This has been anincredibly helpful show. Thanks
for being with us and thank youfor having me. Well, that's a
wrap on season three of thepodcast and I can't stress
enough how thankful I am forall of you who are listening
and supporters of the podcast,three seasons in the books.
Thank you for downloading.
Thank you for listening. Thankyou for telling your friends
(28:08):
about the Healthy Matterspodcast and don't lose any
sleep. We'll be back for seasonfour in the next two weeks with
a new episode. So please joinus for that. Thank you for
listening and in the meantime,be healthy and be well.
Speaker 1 (28:23):
Thanks for listening to the Healthy Matters podcast
with Dr. David Hilden. To findout more about the Healthy
Matters podcast or browse thearchive, visit healthy
matters.org. Got a question ora comment for the show , email
us at Healthy matters@hcme.orgor call 6 1 2 8 7 3 talk.
There's also a link in the shownotes. The Healthy Matters
(28:45):
Podcast is made possible byHennepin Healthcare in
Minneapolis, Minnesota, andengineered and produced by John
Lucas At Highball Executiveproducers are Jonathan , CTO
and Christine Hill . Pleaseremember, we can only give
general medical advice duringthis program and every case is
unique. We urge you to consultwith your physician if you have
a more serious or pressinghealth concern. Until next
(29:06):
time, be healthy and be well.
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