Improve your Sleep!

Improve Your Sleep

Presenter:  Eric Zhao, MD, Instructor, Harvard Medical School; Attending Psychologist, Psychosocial Oncology & Palliative Care, Dana-Farber Cancer Institute; Attending Psychologist, Children's Hospital Boston

This is a recording of a workshop presented at the 2019 GVHD Summit. 

Presentation is 40 minutes, followed by 11 minutes of Q&A. 

Summary: Insomnia is a common problem after transplant. Although "sleep hygiene" and medication are widely promoted to resolve the problem, cognitive behavioral therapy for insomnia is actually a more powerful tool.

Highlights: 

• A Stanford study found improved sleep efficiency leads to increased survival rates in cancer patients.
• Cognitive Behavioral Therapy for insomnia (CBTI) is a tool which aims to cure insomnia through behavioral changes and positive self-talk.
• Tracking your sleep with pen and paper is more accurate than using apps and smart watches.

Key Points:

01:23 Most patients have never been asked about their sleep by their doctor.

06:04 A clinical diagnosis of insomnia means it takes you at least 30 minutes to fall asleep and or wake up 30 minutes or more in the night for at least three nights a week.

08:40 GVHD patients are at a higher risk of developing an insomnia disorder.

16:20 Taking certain prescription medications for sleep such as Ambien, increase the risk of death and should not be used long term.

17:17 Over-the-counter melatonin is not regulated, and studies show that the content of a pill is regularly higher or lower than what the label states.

19:30 Prescription and over-the-counter medications only treat the symptoms and do not provide a cure 29:48 3 Sleep restriction involves eliminating sleep during the day so that your body goes to bed and stays asleep during a specific window of time.

30:51 Stimulus control is a method to train the body to connect the bedroom with sleep by restricting all other activities in that space.

34:37 Removing clocks in the bedroom reduces anxiety and can lead to less insomnia.

37:46 Sleep is not one size fits all. Each person is unique and needs a different bedtime, wake time and number of hours of sleep.

00:00   [Moderator] Good morning. Thank you all for joining us today. I hope you're well rested for this session on sleep. My name is Jackie Foster. I'm from Be The Match and I will be the moderator for this session today, and I'm looking forward to hearing from our speaker on this really important topic. This session is designed to be interactive, so while Dr. Zhao will be speaking for a good period of time, there will be lots of time for question and answer at the end. And we are recording this, so I will want to make sure that everybody uses a microphone to ask their questions because BMT InfoNet will be making these sessions available to people online afterwards, so everybody who can be here today can still learn from this information.

Speaker Introduction:  So, I now like to introduce our speaker Dr. Eric Zhao. Dr. Zhao is on faculty at the Division of Sleep and Medicine at Harvard Medical School and is an attending psychologist at Dana Farber Cancer Institute and the Boston Children's Hospital. Dr. Zhao's research focuses on how we can better understand and treat physical and psychological disorders commonly experienced following cancer treatment. He has presented his work on sleep disorders and sexual health at international conferences and has published peer review articles extensively in the field of health psychology and behavioral medicine. Please join me in welcoming Dr. Zhao.

01:23   [Zhao] Good morning, guys. Absolute pleasure to be here chatting with you. And as was just said, if I have to talk for 45 straight minutes, you will be bored. So please put up your hand, feel free to ask questions about some of what, all of what we talked about. The more questions you ask, which I suspect other people will have, the funner this will be for everybody and the sooner you get to lunch, which I always tell students it drives me crazy and usually put in a time like this where I'm the last thing between you guys and lunch. And boy, it's a tough spot to be in.

So we get to talk about sleep, and sleep is something that I'm willing to bet that the vast majority of you have not had a conversation with your transplant doc, with your primary care doc, with any other provider that you see in your life. And I'm making that bet simply because that's been the experience with almost every post-transplant patient that I've had the privilege of working with.

And that is certainly not an indictment on you and not appreciating this issue, but about how little as a field we talk about sleep in general. So hopefully this conversation is the starting point for you rather than the end.

02:48 How Much Sleep Do You Need? Now, I like to ask this question because I'm curious about some of the beliefs and the biases that we all have about sleep. But on average, so forgetting about having to travel to Chicago, having to come here and wake up early, just that home in your regular day to day life, how many hours of sleep do you think you get on average?

03:13   [Audience] Five.

03:14   [Zhao] Five.

03:15   [Audience] Four.

03:15   [Zhao] Four.

03:17   [Audience] Six and seven.

03:20   [Zhao] Six and seven. Others.

03:21   [Audience] Eight to 10.

03:22   [Zhao] Eight to 10. You seemed very sheepish that you said that.

03:25   [Audience] I feel embarrassed.

03:27   [Zhao] Why would you be embarrassed that you get eight to 10 hours?

03:30   [Audience] Because most people that I know don't get sleep that long.

03:34   [Zhao] It sounds to be. It's funny that you feel embarrassed that you're actually sleeping more than the rest of us.

03:39   [Audience] Are you including naps?

03:41   [Zhao] I'm including everything. Absolutely.

03:45   [Audience] Maybe naps. I take naps every day. I have.

03:52   [Zhao] People should be sleeping 6 ½-9 hours daily:  Absolutely. We're going to talk about potentially. Sometimes that's fantastic and sometimes it's something that interferes with what we want to do with feeling good when we wake up.

So there's a good range here. And the reason I asked is that we're actually going to talk a little bit later. But we know that in this country just not you, but in general for adults less than seven hours is not recommended. That's not to say that there aren't people out there who sleep five and feel phenomenal. There are short sleepers out there. But generally we look at folks who should be sleeping somewhere on the order of six and a half, seven, seven and a half, eight, eight and a half, nine. Somewhere above seven.

And we've actually seen over the past several decades that the percentage of Americans sleeping fewer than seven hours is getting higher and higher.

04:41   Short sleep duration tends to be a symptom of a larger problem: This is an epidemic of just how our society functions not necessarily who we are as patients. But moving on from that, we're going to come back to duration. Duration is one element of sleep, but it often tends to be the symptom of a larger disorder. And there are a lot of sleep disorders because when we think about sleep for the majority of us, we just think about the quantity, are we getting enough? Are we getting a large enough number? But we don't think about all of the different reasons why people may not get enough sleep or why their sleep may actually not be as fulfilling as they want it to be.

05:25   Criteria for diagnosing insomnia:  So there's this terribly boring book that you should not read. But of all of these disorders, I would suspect that in this room beyond the one that we're going to talk about the most which is the most common in folks with GVHD, which is insomnia, all of the others are things that potentially can exist together with insomnia, make it worse or if you don't have insomnia, in and of itself make you feel crummy when you wake up in the morning. And these are other ones that we can definitely talk more about particularly afterwards.

06:04   Like I said, I'm going to focus on insomnia just because it's the most common one. It doesn't mean it's the only, just the most common. Now, to be diagnosed, it's a really low threshold and that's the message that I want you to take home from this. Please don't memorize this. It's simply a guide to say, to actually meet the diagnostic criteria, you have to, and again don't look at this, look at me. I'm going to tell you what you need to think about. You have to take at least 30 minutes or more to fall asleep or be awake for 30 minutes or more in the middle of the night for three nights a week or more, for three months or more.

07:01   All the other stuff that's out here is essentially what doctors do to make sure that it's not other disorders, like this can't be explained by another physical health issue. Like for example if you broke your leg you're in the hospital for surgery, and you didn't fall asleep for 30 minutes, you don't have insomnia, you broke your leg. Or other things that are irrelevant to what we need to think about. But think about that threshold for us. 30 minutes per night of falling asleep or staying awake in the middle of the night, three nights a week for three months. You don't have to raise your hands here, but I suspect the stats are right, at least a quarter of people here in general would meet that criteria and hopefully more of you guys which is why you're here talking about sleep.

07:52   But to meet that bar hopefully you're thinking, "Well, what does that mean? I have this disorder." Well, it's actually incredibly impactful on not just how we feel, but our health. So, in terms of how common this is generally, this is not in GVHD populations, but in general. We tend to look at this from a clinical perspective.

08:05 Do you have some symptoms or you have the disorder. Symptoms mean you have some of these struggles, disorder means you meet all those criteria and what we see in Canada, in studies in Norway and studies in Great Britain, and studies in France, studies here in the States, across the board this is a massive issue for folks who've never had to endure any of the fun medical stuff that you folks have.

08:40   And those struggles that you've had medically are things that make you more likely to actually develop insomnia disorder. Now, that means realistic we're talking about one in three people in this country which actually have symptoms and what does that mean though? Well, you read things like in Reader's Digest. Look at this. What I consider a clickbait article title. You've all seen these, right? Things like America sleep crisis is making us sick, fat, and stupid. Your job is, well, to click the article so they get the ad views and they get paid, right?

You think well, this can't be true. This is just some terrible writer, sorry Beth Weinhouse, who wrote this silly thing just to get you to click it. It cannot possibly be true, but let's stop and think about this for a moment.

09:26 Sleep and Mortality: So these are the 10 leading causes of death for adults in the United States, everything from heart disease down to suicide at number 10. Let's take a look. You probably can't see it if you're sitting at the back, but if you do have the printout there, we look at things from sleep and motor vehicle accidents, sleep as an issue for hypertension, sleep as an issue for diabetes, sleep as an issue before suicide, sleep as an issue for you actually developing the common cold, and sleep for cognitive decline and dementia.

These are only six. There are many, many more that we can look at. Essentially what we do is we do a phenomenally good job of checking out eight of the top 10 leading causes of death in the country are things that insufficient sleep or poor sleep quality either contributes to making it worse or can cause in of itself. And then if you're thinking for the population, I get to see which is looking at folks at the Dana Farber Cancer Institute, talk about cancer.

10:38  Sleep Study of Cancer Patients:  A couple of years ago a colleague out at Stanford did a really, really cool study and what she did was she looked at women who had advanced stage breast cancer. She gave them an ActiGraph which is a professional-grade Fitbit, if you will, that can actually capture sleep-wake, and she measured how these women slept.

She broke them into two categories. One was a category for women who slept well, which was defined. I'm going to use a word that you will hopefully become familiar with called sleep efficiency. It's a ratio. It's the amount of time that you spend sleeping divided by the time you spend in bed. 100% means your head hits the pillow, you fall asleep and you wake up with an alarm and you don't wake up for a second in the middle of the night. No one does that, but a hundred is perfect. What she cut everyone off at was 85%, which clinically is what we think of as a threshold, which means folks who sleep efficiency was below 85%, that means they spend 15% or more of their evening not following asleep tossing and turning and feeling frustrated, okay?

11:52   Sleep Improves Survival Rates: Just based on that alone while controlling for all of the other things that may make people sicker like stage of disease, treatments that they've had, et cetera. What she looked at was how long did these women live? The blue is where you presume you would imagine wanting to be. These are the woman who were good sleepers. The red were the women who were poor sleepers without sleep efficiency below 85%. Their takeaway was that if you improve your sleep efficiency, if you are poor sleeper by 10%, this could lead to a 32% increase in survival, which is astronomical because the way I think about it is, could you imagine if Pfizer found a drug that could increase survival in woman by 32%? They did. They would be, wow, help performing expectations this quarter for their stock.

13:04   Sleep Evaluation as Part of Primary Care: The FDA would be crazy over something like that, and yet this is just simply going to bed and sleeping better. Something that fundamental that we do every day has such an impact on our health.

13:19    Doctors rarely talk to patients about their quantity and quality of sleep:  However, despite how important this is, it's not something that you guys talk about. It really isn't. So, this was a study that they did out in Germany and what they did was they went to a primary care physician's office, figured out if these patients had insomnia and figured out whether or not their doctor talked to them about their insomnia. And for 61% of the patients who have severe insomnia, doctor no idea. None whatsoever.

13:57   Now, I'm going to turn that on everybody here. At your last annual physical with the man or a woman who's responsible for maintaining your overall health, your primary care, did they ask you a single question about your sleep? One person nodded. Are you saying he's your primary care physician?

14:21   [Audience] No. I go in through his appointments.

14:22   [Zhao] Yeah?

14:22   [Audience] Yeah.

14:25   [Zhao] How many questions did he ask you about your sleep?

14:28   [Audience] Probably four or five.

14:29   [Zhao] Good for you. Where do you live?

14:31   [Audience] Batavia.

14:33   [Zhao] Batavia. Everyone should move to Batavia, take his primary-care. That's phenomenal because... You couldn't see behind you. Did anyone else nod? I saw a lot of shaking heads. Nobody else nodded. So, call your doctor and say thank you.

But for everyone else here, ask yourself that question why. How could it be that somebody whose job is it is to make sure that your overall health is good didn't ask you about an activity that you presumably do every single night. They probably asked you about your diet, they asked you if you drank alcohol. They asked you if you did drugs. They asked you if you felt good. They asked you to check your blood pressure, your temperature, your weight. Why would they not ask you about sleep? To me it's incredible that that happens.

15:28   There are risks associated with taking medication to help with sleep:  So let's just say that you are now in Batavia meeting with this man's primary care. They figure, okay, there's a sleep problem now. What do you do? You end up in a situation where likely you're asking do we think about medication as an option or do we think about therapy as an option for our sleep issues. Now, in terms of medication we know that this is the go-to for most American doctors if you present with a sleep issue. My colleague at Brigham looked at in national survey of American adults and found that one in five Americans within the past 30 days had taken either a prescription medication or something over-the-counter to help them with sleep.

16:20   You don't have to raise your hands here yourself, but have you, in the past month, done anything specifically to help you fall asleep or stay asleep. Odds are probably yeah. And the challenge with this is twofold. First, we know that there are consistent risks of taking medications. We don't have phenomenal idea of why, but we do know that whether you take anxiolytic medications repeatedly, so these are things like Ativan or hypnotic medications. These are things like Ambien to assist with sleep, this increases your risk of mortality one and a half to two and a half times which is not a good thing that we should be signing up for in the long term.

17:17   Melatonin is unregulated and its content is highly variable between samples: And this is trial after trial, after trial. Then you might say, "You know what, Eric. I take melatonin or something over-the-counter because it's safe." And what I will say is especially melatonin, which is, essentially, it seems like now marketed as almost like a vitamin that you take. It's like vitamin and you take it for a good sleep health that's actually the advertisement I hear now. You don't take it because you have a problem with sleep, you take it just like you take your multivitamins every day because you want to promote sleep health.

Well, the challenge there is it's actually, as you may know, not regulated by the government which for some things may be a good thing for what you ingest not necessarily. So, this group, what they did was they went to a CVS, a Walgreens, a pharmacy, they grabbed a whole bunch of the melatonin that you and I could buy over-the-counter and what they said was, "Let's see what in the heck is in this melatonin. Now, if you can't read it at the back, I'll read it out for you. Melatonin content was found to be highly variable between samples and lots with no pattern observed between brand, forma supplement or labeled value.

18:44   And at the high end, the actual content was almost 500% more than what the label said and at the low end was 75% less than what the label said. And at the bottom, the line reads, serotonin was found in eight of the 30 samples which is about 20 some-odd percent, which makes sense seeing as how serotonin is a precursor chemically to melatonin, but for those of you that may be on, say an SSRI for depression, you're just ingesting all the serotonin for fun and I hope that your doctor knows about it but presumably not because of course it's not on the drug label.

19:30   So this isn't to say that melatonin is bad nor is it to say that prescription medications for sleep are bad. Please don't take that away from this talk. It's to say that there is a time and a place, and a role for each of these as long as they are delivered thoughtfully.

19:49   Prescription and over-the-counter drugs for sleep treat symptoms of a sleep disorder, not the disorder:  Now, two slides ago I said to you that there were two issues related to the use of prescription or over-the-counter medications for sleep. This is the first. For some, particularly prescribed there's safety data that is concerning. Second, for over-the-counter stuff there's quality data which is concerning. But the second issue that I have is that both of these masks the symptom.

20:16   They don't cure the disorder, meaning if you take melatonin and it works beautifully, and you go to bed, and you fall asleep every night, if you're prescribed an ambien, you take it. 26 minutes later you're knocked out and you love that feeling. That's fantastic, but what happens if you have to stop?

Well, if you're like many Americans, if you terminate that medication, that over-the-counter, your sleep is back where you began. That to me is the bigger issue actually, which is why not surprisingly the American College of Physicians two years ago published their statement, their clinical guideline on how do we manage insomnia in adults?

21:02   Cognitive Behavioral Therapy for Insomnia (CBTI) recommended as first line treatment for insomnia by American College of Physicians: And their first recommendation is that they recommend that all adult patients receive what is called cognitive behavioral therapy for insomnia, if you have insomnia. This is not with medication, this is not if medication fails, this is if you come into my office, this is what we should be talking about, not the other stuff which we can get to later. Now, do folks here know what CBTI or cognitive behavioral therapy for insomnia is? Okay, good. If you did, I would say, "Well, you didn't have to waste the past 30 minutes listening to me."

21:42   Now, for many of the patients that I get to see, when they hear therapy, they think an old man, a couch, and we chat about things like your mother, maybe whether your wife loves you. But you know what, the way that I want you to reshape what you think about CBTI, is it is a very specific tool. It borrows the same first three letters CBT as you might hear for depression, anxiety, PTSD, alcohol dependence. The first three letters are the same, but the last one makes all the difference. In this case, the CBTI means that what we do is very different than somebody who's depressed which means when you are out there trying to find somebody to help you with this, if they just say, "Yes, I do CBT," and I don't know what to do with the I, that's not the right person for you.

22:45   Five principles of CBTI:  Now, if you just go online and Google what in the heck is this CBTI business, there's a number of ingredients and whether you read the Mayo Clinic's website, whether you go to the American Academy of Sleep Medicine website or whether you're just on Wikipedia reading about this, which the Wikipedia article is actually surprisingly good. There are different pieces that they mention but the five core ones that regardless of where you look and who you talk to that comprise treatment are stimulus control sleep restrictions, sleep hygiene, cognitive therapy and relaxation.

23:25   We're going to talk briefly about each of them so you understand what it looks like. The fundamental underlying premise that if you hear nothing about all of these individual ingredients that I talked about, the fundamental overarching principle of all of this work is not to worry about how you sleep tonight or how you feel tomorrow. It's about changing the goal to being you sleeping well in a month or two months, not how did I do yesterday, and you'll understand why shortly.

24:06   Collect data about your sleep:  So first, what you want to do is collect data and I say it to everybody who comes and sees me, we do an evaluation and then I send them home to do diaries which you'll see. They say, "Well, why can't we get started today?" and I'd say, "Well, it's about as silly as you're going to see an oncologist and not getting a scan because, then, what are they doing?"

In this case, we want to understand what your sleep looks like. And if you're like a normal human being who didn't tell themselves I have to remember how I slept three days ago, you forget. And our memory plays tricks on us.

So, folks often ask, "Can I use my Apple watch? Can I use my Fitbit?" And the answer is presently we don't know. There are so many of these devices that are being produced every year that researchers, which are often years behind the curve, that they try to compare it to see if it actually measures sleep. Some do a good job, some don't. And sometimes they discontinue a model which did a good job so it's a real crapshoot.

25:17   So what I'd say to patients is, often, this is entertainment. It's not good enough for us to trust it just yet, maybe in a few years, but not yet. And instead of spending $300 on an Apple watch, well, I'll print out for free, a whole bunch of paper, and this is how you end up tracking your sleep.

It's a simple sleep diary whether it's a visual one where you shade in when you sleep or it's a written one where you document when you go to bed, how long it took you to fall asleep, et cetera. They are both remarkably effective at actually capturing the data I need to then intervene upon your sleep. And I ask patients, typically to give me about 10 or 14 days worth of information, so we can see what the waxing and waning pattern of your sleep looks like before we start to fix it.

26:13   Sleep Restriction:  Now, the first dose of what treatment looks like, the biggest heaviest hitter is sleep restriction. Now, question for the group. We've got Ambien, Klonopin and Ativan here. What do you think I believe is the best aid to put you to sleep? So, what do I think that the best aid to put you to sleep is?

26:35   [Audience] A good pillow.

26:37   [Zhao] A good pillow. You sound like that guy who makes the magic pillow. A good pillow is a good thing, but the reality is, we all know you can spend hundreds of dollars on a good pillow and if you have insomnia, it doesn't matter. Sorry for that guy who sells you a $79.99 pillow.

This is what I envision is the best sleep aid in the world. For folks here who've ever had to fly on a 6:00 am flight and had to get up at 3:00 a.m., what do you think happens at 6:05 when the plane is in the air and you look around the plane with you? People are sleeping, which is insane to me because if you think about it, you are on a plane sitting like this with a complete stranger next to you, but you're actually upright and somehow you managed to sleep. How is that possible?

Imagine that tonight, I put a perfectly good stranger next to you in bed, but I make you both sit upright and I say, "Good luck sleeping." Are you going to be able to do that?

27:48   [Audience] No.

27:49   [Zhao] Why not? Well, you shake your head and go, "This guy's an idiot. How can I sleep?" I mean, good looking man. What if I put you in bed next to you here. You're not going to sleep.

But imagine, now you guys are on a plane tomorrow at 6:00 am. One of you'll probably fall asleep. It's mind boggling, but the secret, truly, is the fact that you are sleep-deprived. That's what sleep restriction does. It’s the goal is to actually deprive somebody of sleep in the short term so that they learn to sleep during a period that is functional for their life. The way I think about this, as an analogy is this: which brave person here can tell me what their most hated food in the world is.

28:43   [Audience] Liver.

28:46   [Zhao] Liver. Did some say lobster? Wow. It's delicious. You got butter. Oh, allergic. Well, that doesn't count. Are you allergic to liver?

28:58   [Audience] No.

28:58   [Zhao] Okay. So you just hate the taste of liver? The texture, okay. Imagine this. For the sake of this thought, everyone here leaves this room and we lock the doors from the outside. As you can see you have water, but no food. And I'll leave you locked in here for a week. I'll also take your phone so you can't call the police on me. After a week, I open the door and I throw down a plate of uncooked liver. You go ooh. Do you know what you're going to do a week from now having not eaten for a week? You're going to eat that liver and you're going to love every bite of it. It's true. We know this is how we feel. If we're starved for something, it doesn't matter. We have no standards at that point. But when it comes to sleep, that's what sleep restriction is.

29:48   In the short-term, it's about restricting sleep so that essentially your body goes to bed and falls asleep and stays asleep in a specific window. That again is matched to your life. So essentially if you think about a person during the weekday, this was their problem. They go to bed at 9:00, they want to fall asleep, but they wake up in the middle of the night. They wake up at 6:00 or something, they go to work, they come home on Friday night, they take a nap because they didn't sleep the night before. They still go to bed because they want to go to bed early and fall asleep early, but of course they don't fall asleep until it's almost midnight because they're watching Netflix, and then they stay in bed late because they get to sleep and it's a Saturday or Sunday, but of course Sunday night into Monday they're back to the grind. So, the goal for sleep restriction is to create that window where, essentially, we're filling in that gap in the middle of the night to get consolidated sleep first as a goal. Not sufficient sleep, consolidated sleep.

30:51 Stimulus Control: The second goal is stimulus control, which is using your bed for nothing other than sleep or sex. Now, for most of us we think about things like getting off of our iPhones in bed. Yes, that is bad for you. Not reading in bed, also not great for you. And the reason is because think about... Anyone here have a dog? Does your dog pee on your bed? I hope not. How did you train that dog which has no idea that the bed is a place which you spent thousands of dollars on a fancy mattress that it shouldn't go pee on it?

31:35   Your dog is a genius. For most of us, there would have been an event where you trained the dog to go use the bathroom outside or wherever. That's just conditioning. What do you think you condition your body to do in bed, if you go to bed and you lay there for an hour and don't sleep?

If you wake up in the middle of the night and you spend an hour watching a movie, you teach your body through repeated conditioning, this is a place for not sleep. And here's the thing, we think about this stuff, which again I agree with fully, but the worst thing that you can do is try to sleep in bed. Anybody here ever tried to sleep in bed?

32:21   If you have insomnia, you have tried for hours to sleep in bed. You lay there at 3:30, and you're like if I just turn over this way and I plug my ears, and I pulled the cup, it'll be the perfect position. And it never happens. Trying to sleep at 3:00 a.m. is actually no different than trying to sleep now, and I'm going to prove that to you, guys. So, I will give anybody here who can fall asleep in the next five minutes a hundred bucks.

33:08   Staying in bed awake in the middle of the night, trying to fall asleep, is not a good strategy:  Well, you're laughing but nobody even laid down. Now, either nobody here believes I have $100 or you recognize how ludicrous of an idea it is to try to sleep when you're not sleepy. But that's, actually, as I mentioned, precisely the same phenomenon you try to do at 3:00 a.m. You lay there willing yourself to sleep and the reality it's just like now, you're not sleepy. You would only be sleepy if you waited long enough since the last sleep period that you had, and it was at about the right time of day. So, there's a circadian preference in there and, also, am I really that hungry for sleep?

It's kind of hunger actually. If you just had lunch, could I give you a steak and eat it? No, you would say, "This is stupid. I just ate lunch. I'm full." But you don't worry that you're not going to be hungry again because you just wait six hours and you'll be hungry again.

Sleep is the same way. So, at 3:00 a.m., don't try to sleep, get out of bed. Enjoy your day.

34:17   Sleep hygiene by itself will not improve sleep. This is something that likely comprised many of the Google, "I can't sleep. What can I do?" lists. And they're all things that matter. But I mentioned it third because it's at the bottom end for most of us about what we can do to improve our sleep because we've often tried many of these things.

34:37   What I tell folks is do them reliably and consistently, and they're going to be like the cherry or the icing on the cake. They're going to make it better but this in and of itself is unlikely to be the reason for many of you why you can't sleep.

So, things like getting rid of a bedroom clock, so it doesn't cause anxiety. Having some exercise late in the afternoon. Not to tire you out actually. It's actually meant to increase your core body temperature because as you go into sleep you notice that your body temperature dips. And that occurs if we exercise, like a pendulum. Our body temperature goes up and about six to eight hours later, it cools beyond our normal temperature. So that's why we want to do it in the late afternoon, early evening, avoiding things like stimulants like caffeine late in the day, having a light bedtime snack if you struggle with staying asleep, reducing liquid consumption before bed so you don't get up to urinate and reducing electronic use. These are all good things for you, but like I said, in and of itself, likely insufficient.

35:42   Changing Your Self Talk with CBTI: The fourth piece is cognitive therapy. So many of us, if we struggle with sleep say things to ourselves like, "If I don't sleep well tonight, how in the world am I going to be able to function tomorrow to go to work, do this with the kids, whatever the case might be?" And the reality is, you know, what that just did is it just put a whole lot of pressure on you having to fall asleep. You come back to the idea of waking up to catch an early morning flight. You set your alarm for 3:30 a.m. It's 9:30, you're staring at a clock going, "Oh my god, I have to wake up in six hours. I have to get to sleep now."

36:16   And of course what happens, if you're like me, if it's 12:30, you're still staring at the clock going, "Oh my god, I have to wake up in three hours now. I'm never going to get any sleep." That pressure, nothing else changed, but that pressure to sleep started your brain, increased arousal, now you can't sleep.

Also, this has to stop my cold, my blah, blah, blah, whatever illness you have, it's going to come back if I don't sleep. Or just there's so much going on in my mind. I've got all these racing thoughts. I will never ever be able to fall asleep. But these are all things with cognitive therapy we work on.

36:55   The amount of sleep people actually needs varies:  Also, we talk about setting expectations. So I mentioned earlier that sleep duration is one element of this work and if we look at this, the dark blue is probably like 70% of us, the amount of sleep that we should be getting, but the turquoise is for like another 20% of us. So if you're the adult or older adult range, somewhere between 5 in 10 hours, that's a huge range and yet, well, the media, often your care, they tell you, you need eight, tends to be the number I hear a lot which is total hogwash. One of us might need eight, but the person sitting next to you doesn't need eight. So it's very American to think that more is better.

37:46   Quality of sleep is better than quantity of sleep:  And in this case with sleep, more is not better. It's like food, you don't want more food, you just want better quality food. And in this case, it's the same with sleep. Getting the right amount of sleep is right for you not more sleep. More does not equate to better.

And finally, it's about working with folks to remind them that sleep is a very complicated issue. It occurs in the context of things like a medical illness whether you got into an argument with your spouse, whether the Bears won last night or lost. These are truly all things that impact and impair sleep that we tend to start to attribute. It's just sleep when in reality it's all this other stuff that might also affect it at the same time.

38:35   How to find a sleep specialist:  Now, in terms of finding somebody to do a more thorough job of actually doing this work with you, this is a heat map of providers who do CBTI in the States. If you happen to live in the Chicago area, there's a large number of people I can refer you to, but of course if you happen to live in South Dakota not such a great hotbed for this unfortunately.

Now, you can go to the Behavioral Sleep Medicine website where there's a listing of providers, depending on the state that you live in, if you aren't local.

39:06  Books and apps to help get better sleep:  Alternatively, if you're one of those people that your doctor says, "Hey, you know what, Jane, you need to lose 10 pounds to lower your, say, diabetes risk and you come back six months later if you lost 20 pounds then these books are perfect for you." They will talk you through everything that we've talked about today and walk you through it with specific instructions, and also places where you fill out your diary and you put in that information, they're wonderful.  

These two are computer based programs that are currently not available but I have them because I want you to be aware that at least one of them is going through FDA regulations so that you can actually bill your insurance to pay you to actually access it. They're not going to call it SHUT-i anymore, but I believe if you go on the SHUT-i website, you should be able to subscribe to getting updates about it. So right now you have to be a part of a research trial, but it's in the pipelines for you to be able to do this work by yourself. Thank you, guys for your time. What questions can I answer for you.

40:10   [Moderator] Great. Thank you. Give him all an applause. And, so, we are recording this session, so I'll bring mics to people who have questions. Do you have a question?

40:27   [Audience] Waking up and staying awake in the middle of the night:  In general, I'll sleep about seven hours and I have sleep apnea so I have a machine and all that stuff.

40:34 [Zhao] Good.

40:34 [Audience] But I sometimes feel like I wake up and I'm in sort of still a deep rest, but my mind is going and I'm thinking these thoughts and I know I'm awake, and it can go on for sometimes just minutes and sometimes like an hour then I'll fall back asleep.

40:53   [Zhao] Is this in the middle of the night?

40:54 [Audience] Yes. It can be in the middle of the night.

40:56 [Zhao] And do you know that it can go on for hours, as in you've looked at the clock or do you just feel that is the case?

41:01 [Audience] Well, I try to avoid looking at the clock. Yes, I think I'm fairly aware that it can be a longer time. It doesn't happen a lot. I mean, it happens a lot, but not for the long time. Usually, it's just maybe for five, 10 minutes or something.

41:21 [Zhao] Okay. So, you look like you're about 35 years old. So, for a 35-year-old man. we actually know that as we age, the number of times that good sleepers wake up and experience these temporary transitions in and out of wakefulness where your brain might be active and then you shut down again increases. So, for somebody in their 30s, it may be the case that they wake up, good sleepers mind you, one or two times a night. By their 40s, that might be like two times a night, maybe three. By their 50s, that might be two or three times a night. By their 60s, 70s and 80s it might be three or four times a night.

And you can still be a good sleeper even though you experience these brief transitions in and out of sleep. It's absolutely not the case when we have this myth that you have to go to bed and never wake up for a split second otherwise you're a bad sleeper and that's not true. However, if your waking hours are extended like truly you've measured like you looked at a clock and 30, 40, 50 minutes and they occur frequently like multiple times per week, that's where I would be concerned. But if it happens once a month, I would say life is great.

42:33 [Audience] Thank you.

42:33 [Audience] I have a question. What is REM sleep? You hear a lot about REM sleep or whatever it is. What is it?

42:44 [Zhao] So REM sleep is not deep sleep, it's actually the opposite of deep sleep and REM sleep stands for rapid eye movement sleep. It's what happens when you're sleeping and because brain activity is firing all over the place, if you look at somebody's eyes during that sleep stage, their eyes almost look like they're fluttering. And so what ends up happening is when we fall asleep, one of the reasons why sleep continuity is so important is we go through a very natural progression where we get into deeper sleep and then we come back into REM sleep and then we go into deeper sleep, and then we keep doing these cycles over the course of the evening.

And REM sleep, actually that period gets longer as the evening progresses. Now, that's important because if your sleep is constantly fragmented, it means that folks actually may not be able to get into REM sleep because it's the last stage, and so it may be disruptive to how they feel the next day. So that's why we see people who are consistently sleep-deprived or folks whose sleep is constantly interrupted like if they have apnea that they're not treating that they actually dive into REM, they fall into REM sleep much quicker. And because REM sleep is longer towards the end of the evening that's actually why you tend to have more dreams closer to when you wake up than when you fall asleep.

But the good or the bad news is you can't really do too much to control how your body does sleep staging. Things like alcohol use which impacts this, drug use, et cetera of course can affect this but if you are going to bed sleeping well, waking up feeling rested, then the amount of REM sleep that you get is just it.

44:24 [Audience] Good to know. Thank you.

44:25 [Zhao] You're welcome.

44:29 [Audience] Transitioning from a Hospital Sleep Cycle: I'm a social worker in an outpatient bone marrow transplant clinic and one of the things that I was very surprised to hear, I've been there for about four months, so I was in the inpatient side for several years, patients coming and saying that they're waking up the same time that they were woken up overnight while they were in the hospital. And when I discussed it with their nurse practitioners, I hear, "Yeah, that goes on for a few months. It's kind of to be expected." But we've got this patient population that's suffering from significant fatigue in addition to all these other disturbances. Is there any recommendation in terms of how to-

45:00 [Zhao] So if you're talking about months after the fact, at that point it's not because of medication, because of the fact that the nurse came in to do a vitals check, it's not the etiology of something medical. At that point it's actually a learned circadian event. It would be the equivalent, and I'll share a personal story. So I did an externship at the VA. This was when I was in graduate school and I used to sleep at 2:00 a.m. I don't know why. Going to the VA for any of those of you who have to have appointments at the VA, they start their day really early.

So with my commute I was waking up at 5:00. I'll tell you what. That 2:00 a.m. going to bed stopped really quickly. It's learned. In this case, I adjusted where my sleep landed because of what I had to do.

In your patients' case, because they may have been woken at the same time in the hospital during treatment, their bodies actually learned this is a time to be awake and alert and to do stuff. They often tend to actually tack on activities during that time, if it's extended. I've had a number of patients who started eating at that time or going on their phone at that time because well, they're up and they might as well do something.

So, they've actually created all these associations along with that event. So, what you can do with that is actually to start to really log how this is. Maybe they really are in bed for too long and that's why they have this opportunity to be up for a half an hour, hour in the middle of the night, but they're simply compensating for that by staying in bed an extra half hour in the morning.

46:39   [Moderator] Questions?

46:41   [Audience] Okay. Insomnia and Bed Times:  So I'm the caregiver for my husband and he suffers with this insomnia so he tends to stay up very, very late, and I encouraged him no matter what time he goes to bed to get up early so that the following nights he'll be tired enough to go to bed at a more reasonable time. Am I just torturing him or is there some sense to that?

47:05 [Zhao] Well, first of all, where is he today?

47:07 [Audience] He's at another conference.

47:09 [Zhao] Ah. All right. Well, you sound like a wonderful partner and what I would say for him is for folks, one of the sleep disorders that I talked about was delayed sleep phase. That is a disorder but people also have internal chrono types which is our internal preference, are we a lark, which means for me 2:00 a.m. is an early morning, or am I an owl which means 2:00 a.m. is a late night. So, larks like to be up early, owls like to be up late.

This is just who we are. Perhaps your husband is an owl and his natural circadian preference is to go to bed at midnight and wake up at 7:00 or whatever the case might be. If that's the case, then you might be punishing him by not letting him land where his natural circadian tendency is.

We actually see this issue for high school kids. There's a push to delay school start times for high school kids because naturally for teens, their circadian phase runs later. The high schools start earlier. In your husband's case, it would be figuring out well, if we kept the same window of time, but we let you go to bed at 2:00 a.m. and not 11:00 p.m. and you woke up five, six, seven, eight, whatever number of hours later consistently, does that feel better?

And if it does, that may be a bigger issue than the duration of his sleep for example. If you are able to wake him up and that's to say, that's not the issue, if you wake him up at the same time every day, I would say importantly at the other end, don't let him go to bed and not sleep because what often happens is they go to bed, they catch a catnap here or there, bless you, and they end up getting sufficient sleep so that they've spoiled their appetite for the main course, which is when they really want to sleep.

So, it's about tracking it actually again and trying to see what ends up happening. And when I say reliable, keeping in that wake time, at least 10 days to see what it looks like. Most people don't get there. Most people up to three days tell their wife, "Screw it. I'm going to my friend's house and I'm going to sleep. I can't do this anymore." But it's about seeing that. Like I said, it usually takes four to six days for their sleep to get worse before it gets better, and by about 10 days you'll see it start to equilibrate.

49:30 [Moderator] Any other questions?

49:36   [Audience] Best Time to Nap: So speaking about napping, I had a doctor tell me that if you've napped, make sure you do it between... I forget exactly but 11:00 am and 2:00 p.m. and no later because otherwise it'll mess up your rhythm or your sleep. Is that somewhat true or not?

49:56 [Zhao] It is somewhat true in the sense that there is... Remember, I just mentioned that people have different circadian preferences. Creating that bound rule is completely unfair to somebody who is a late person for example. It is to say though, and I think you mentioned this earlier about napping. It's about figuring out what works for you. It's about having the sufficient dose, nap, so that you can sleep and feel rested and good without it impacting your sleep at night.  Whether that occurs at 11:00, at 2:00, or at 4:00 varies from person to person, and it's about experimentation.

What I tend to tell folks is you do not want to be napping in the six to eight hours before your actual desired bedtime and you want to limit it. Three-hour naps don't feel good. 30 minute naps, 45 minute naps tend to be the ones that are restorative, meaning it recharges your batteries sufficiently and it doesn't impair that night.

So it's this careful balance. Now, when I say 30 or 45, again, it's not a rule, it's to say maybe for you it's 15, maybe for you it's 60. But I would try different dosages at different times and you figure out what creates the least impact on that night and the next day that makes you feel the best that day.

51:17   [Moderator] Thank you. Any other questions? Okay. Well, thank you so much for this presentation.

51:22 [Zhao] Thank you for your time everybody.