Dr. Frank Cahill, clinical psychologist and insomnia specialist, is joined by FX Medicine ambassador and psychologist, Dr. Adrian Lopresti, to delve into understanding and treatment of insomnia. Nearly half of all Australian adults report some form of sleep issue with a rise observed through increased patient visits at Dr. Cahill’s practice during the pandemic.
Dr. Cahill’s extended experience in treating insomnia comes to life in this podcast as he explains the concept of homeostatic sleep drive or sleep pressure and explains how identifying sleep habits and manipulating them, can help to realign sleep patterns from insomnia to a healthy, restful sleep. Dr. Cahill and Dr. Lopresti identify common factors that cause both acute and chronic insomnia, and step through aspects of treatment required for various categories of insomniacs. An on-the-spot assessment is done on Dr. Lopresti’s sleep patterns as Dr. Frank Cahill explains the sleep drive requirements and effects this may have on his sleep. Understand how cognitive behaviour therapy (CBT) tools of sleep hygiene, relaxation therapy, stimulus control, restriction therapy can be useful for various situations and tools such as sleep diaries, distractions and medication may be useful.
Don’t miss the discussion on testing melatonin and administering as a treatment. You will understand its usefulness for circadian rhythm disorders and Dr. Cahill shares his specific timing and dosing for effective treatment.
Covered in this episode
[00:33] Welcoming Dr. Frank Cahill
[01:24] The prevalence of insomnia in Australia
[03:27] Stress as a major contributor
[05:13] Long-term vs acute insomnia
[10:18] Three types of insomnia
[12:08] The different effects of anxiety versus frustration have on sleep
[14:38] Treating early morning waking
[18:13] Calming the busy mind
[20:02] Sleep hygiene is not effective for insomnia
[21:33] Sleep restriction therapy and increasing sleep drive
[25:38] Reduce sleep effort buy focusing on rest
[28:08] Utilising sleep diaries and the DAAS questionnaire
[32:58] Is there value in functional testing for melatonin and cortisol?
[37:41] Recommendations around food, caffeine and sleep
[40:12] Exercise and sleep
[40:57] Can natural health practitioners treat sleep
[43:09] Melatonin: less is more
[45:10] Herbal remedies and supplements
[46:54] Thanking Frank and final remarks
- What is Homeostatic Sleep Drive? Pressure for sleep (homeostatic sleep drive) that builds up in our body as our time awake increases. The pressure gets stronger the longer we stay awake and decreases during sleep, reaching a low after a full night of good-quality sleep.
- What is Sleep Effort? The concept of heading to bed and trying to get to sleep (which includes sleep hygiene practices) is counterintuitive to building good sleep for those already suffering sleep onset insomnia.
- Common precipitating factors to sudden onset of sleep issues are stress/anxiety related – financial, relationship, work and in terms of the pandemic, environmental and health stress. Chronic sleep issues are commonly linked with family history or neurological disorders.
- Equal success can be had for treating acute and chronic insomnia patients – the key is to understand the perpetuating factors that influence their homeostatic sleep drive. People can be categorised into chronic or acute insomniacs.
- Common perpetuating factors for chronic insomniacs
- Not ready to sleep
- Lying in bed worrying about falling asleep
- Waking in the middle of the night, laying awake and worrying about returning to sleep
- Worried about catching up on sleep
- Consistent napping
- Common perpetuating factors for acute insomniacs
- Anxieties around sleep onset and maintenance leading to:
- Clock watching
- Worrying about functioning the following day
- Focusing on rest and not sleep for those with middle and early morning waking issues. A concept called sleep state misperception can kick in where the person, in a restful state, can have periods of sleep without realising it. Often reported by the person resting their eyes and suddenly it’s 7AM.
- A busy mind or thinking can be alleviated by ”feeding” or “starving” it. “Starving” means to break the pattern of thinking by getting out of bed and doing something else. Then return to bed, thinking about another thought, like a memory to drift off with.
- Those with ADHD (and undiagnosed ADHD) can find the busy mind state difficult to “starve”. In their case a distraction may be useful – podcasts, radio or audiobooks can be good distractions while their sleep drive builds.
- Insomnia treatment through CBT is the gold standard and involves five components
- Sleep hygiene – least effective for insomniacs
- Relaxation therapy
- Stimulus control – most ideal for insomniacs
- Restriction therapy – most ideal for insomniacs
- Cognitive therapy – most ideal for insomniacs
Tools for managing sleep
- Sleep diaries are valuable in helping to see a patient’s sleep patterns and for the clinician to plan their treatment. This can be used in conjunction with a Depression and Anxiety and Stress Scale (DASS).
- Holistic management includes considering conditions such as sleep apnoea, restless legs syndrome, narcolepsy and other factors not already covered. Consider eating patterns and digestive symptoms – reflux, timing of meals, types of foods eaten at meals.
- Working collaboratively with patients can assist with compliance as a clinicians main goal is to have them in bed for a set amount of time i.e. 6 hours total – the actual times they’re in bed doesn’t matter i.e. 9 – 3am or 12 - 6am.
- Sleep restriction therapy is designed to build up one’s sleep drive. This helps correct the mismatch of their time in bed compare to time asleep. This method is useful for the sleep maintenance and early waking insomniacs.
- Sleep stimulus control therapy can be effective for the sleep onset insomniacs. This method involves removing the person from bed if they’re having issues falling asleep and after a short period of time they can return to bed which helps to shift thinking from “I can’t fall asleep” to “I can fall asleep eventually” – reducing their anxieties around sleep.
- Watch out for caffeine and alcohol. Alcohol is commonly used as a sleep aid to assist with sleep prior to bed and in the middle of the night. Coffee habits differ from person to person so severe restriction for one person may not work for the next.
- Early morning exercise helps to get exposure to bright light that can maintain the regular sleep-wake cycle with late evening exercise not recommended due to being overly stimulating.
- Melatonin testing via saliva may be valuable in understanding one’s circadian rhythm especially in complex cases. Single data point analysis isn’t recommended and the costs are significant to test multiple times. This is where sleep diaries become the most cost effective tool.
- Melatonin use can be useful but increased dosing doesn’t mean more effective. Less is more with melatonin with research suggesting the 3mg dose being the ceiling for effectiveness. Timing is also important where Dr. Cahill recommends 0.5mg of fast release melatonin five hours before bed and another .5-1mg dose an hour before bedtime for those suffering from sleep onset insomnia.
Resources discussed and additional reading
|Website: Dr. Frank Cahill
|Australian Institute of Health & Welfare: Australian Sleep Statistics and risk for chronic conditions
|Website: Sleep Health Foundation
|Article & Report: Rise and try to shine: the social and economic costs of sleep disorders (Sleep Health Foundation, 2021)
|Website: Australian Sleep Association
|Resource: Sleep diary
|Resource: Depression Anxiety and Stress Scale DASS (-42)
|Article: Cognitive Behavioural Therapy for Insomnia (CBT-I), (Sleep Health Foundation, 2023)
Cognitive Behavioural Therapy for Insomnia Courses*
|Cognitive Behavioural Therapy for Insomnia Masterclass, University of Oxford, Sleep and Circadian Neuroscience Institute
|The Conquering Insomnia CBT-I Program, Dr. Gregg D. Jacobs
*Please note, FX Medicine is not affiliated with nor do we endorse these courses in any way but are including as a reference for potential further training for practitioners interested in furthering their skills in this area.
FX Medicine acknowledges the traditional custodians of country throughout Australia, where we live and work, and their connections to land, sea, and community. We pay our respect to the elders, past and present, and extend that respect to all Aboriginal and Torres Strait Islander people today.
With us today is Dr. Frank Cahill, a registered clinical psychologist with over 20 years of experience in helping people overcome a range of psychological disorders. Frank has a particular interest in treating complex sleep-related disorders, including insomnia, parasomnias, and circadian rhythm disorders. In his practice, he also works with people to help them get off their sleeping medications.
Welcome to FX Medicine, Frank, thanks for being with us today.
Frank: Oh, thanks, Adrian. Thanks for having me.
I know that sleep disorders are extremely prevalent in the community, and their prevalence is higher in people experiencing a range of medical and physical disorders. I had a brief read of the literature, and I know that there's inconsistency in the research, but I've seen statistics that show that approximately 50% of people regularly report feeling sleepy during the day, and a third of people are asleep less than seven hours a night.
Frank: Yeah, I think that's pretty true. I actually picked up some research with the Sleep Health Foundation recently. They did a study, about 2019. They took a sample of about 2000 people, and they broke it down in terms of how many in that population were struggling with their sleep. And they broke it down in terms of gender, and they found that about 13% to 14% of males struggle with sleep, or meet the DSM classification of insomnia. Around about 10% or 11% of females met the criteria, the DSM criteria for insomnia. So you're looking around about - this is for chronic insomnia - you’re looking around about, well, say if you average that out, it's probably about 11% or 12%...
Frank: ...of the population really struggling with their sleep. But you're right. I think when you broaden it out and move away from the DSM criteria of insomnia, which is typically sleeping for at least three nights a week for at least a couple of months, most of us, and well over 50% of us really struggle from time to time. We go for periods where we struggle with sleep. We see this a lot particularly during the warmer months when we struggle to sleep at night.
But I think also what we are seeing, or I'm seeing in the practice is a lot more stress-related insomnia, which is coming out of the current period that we're going through, coming out of the pandemic that really messed with a lot of people's sleeping patterns. And also financial stress, which is one of the major stressors in Australia at the moment, is also messing with people's sleep as well. So, we're seeing a whole bunch of factors impacting upon the way in which people are sleeping at the moment.
Adrian: So, you mentioned their financial stress. So stress is a trigger, or associated with the sleep disturbances. Are you seeing that generally insomnia or sleep-related problems are increasing over your time as a clinician?
Frank: Absolutely. I just remember prior to the pandemic, it was quite interesting. Because of the nature of the work I do, it's pretty short-term, so the average would be about two or three sessions if a person came in for treatment for insomnia. So, it's not long-term therapy. But what I found prior to the pandemic, I would probably have my appointments booked out for about two weeks.
When the pandemic came, particularly I think it was 2020 where it really started to hit, there was a tsunami of insomnia cases coming up and I was booked out for a month or two months trying to get people in. It was a phenomenal increase in the rate of people seeking help for treatment around insomnia. So, the pandemic really did make a significant impact on people's sleep patterns. And of course, the anxiety associated with that also precipitated sleeping difficulties.
Adrian: Well, also I know that a lot of clinicians were obviously inundated with referrals for depression and anxiety, but you're also seeing problems with sleep increasing.
Frank: Yeah, we did. We absolutely, we did. When you think about sleep, usually there's a precipitating event that usually kicks it off. And it could be a whole bunch of things. It's usually things like financial stress, relationship issues, work-related issues. A lot of people were laid off during that period of time. They lost their job.
Frank: And that was a major precipitating factor that really started to affect people's ability to actually fall asleep or waking too early, and then lying in bed worrying about how they're going to pay the bills.
Adrian: And so the people who were coming in to see you for sleep problems, would they have had a history of sleep problems in childhood or adolescence, or do you think it was just a new condition that they experienced as a result of the stresses that they were experiencing?
Frank: Yeah, that's a really good question. I guess it could be broken into two categories. You have people who I guess, had difficulties long-term in relation to their sleep, starting from childhood. And we see this a lot with neurological disorders like ADHD, Autism Spectrum Disorder, where they've always had difficulties and they take that into teenage years and adulthood. There's also a genetic component there as well. If the parents had difficulty sleeping or struggled with insomnia or circadian rhythm, we often see that coming out in the children, and they often present as part of their long history associated with sleep. If I was to put a percentage on that, I would say, probably about 40% of the people I see fall into that particular category where they've struggled with their sleep for many, many years, and they've just decided to come at a particular point, decided to get help.
But quite often what we see is we have good sleepers, great sleepers who could really sleep throughout their life into childhood, teenage years. They'd go to bed, they'd put their head on the pillow and they go out like a light. And they would have a precipitating event, as I said, it could have been a stress-related event. It could be a loss of a job, it could have been marital conflict. We often see it with mothers, young mothers who are great sleepers until the baby comes along. And after the birth of their child, they then start struggling with their sleep. So, we have a lot of people who are great sleepers, and then suddenly their sleep goes off and they get very, very anxious. And there's a lot of anxiety that's then tied in with that, that perpetuates the insomnia. They get really worried, and then they start reading all the press about the impact that poor sleep could have on their mental health...
Frank: ...physical health, and their longevity. And of course, that feeds into their anxiety, which continues to perpetuate their inability to fall asleep in a reasonable time or maintain sleep throughout the night.
Adrian: So, with the people who are experiencing more recent problem for them, as opposed to the people who have had a history of poor sleep, how successful are you in treating the more chronic sleepers as opposed to the ones who have it more as an acute condition?
Frank: Equally successful.
Adrian: Really? Wow.
Frank: Yeah, equally successful. It's really interesting. The approach is a little bit different. When you've got the long-term sleep, people suffering from insomnia, a lot of them present in their 30s, 40s, 50s, and 60s, and a lot of them had had a long history of sleeping medication. So, we see people that they have been on Stilnocts for, let's say, 10-20 years, Temazepam, 10-20 years, and their sleep is up and down, up and down. Their GP wants to get them off it. So, when we sit down and start talking to them, what we found is that they have been making the same mistakes for the last 20-30 years in relation to their sleep.
So, these mistakes fall into the category of what we call “perpetuating factors.” So, what are the mistakes that people make? Going to bed too early when they're not ready to go to sleep. So, they're lying in bed for long periods of time getting anxious about their ability to fall asleep, or waking in the middle of the night and lying in bed for long periods of time getting fretful and frustrated, or catching up on sleep, napping during the day consistently. So, then when we target those perpetuating factors and tighten up their sleep, particularly around increasing their homeostatic sleep drive, what we often see is a miraculous turnaround within about a week or two. It's quite phenomenal.
Then you get those that have had a brief onset of insomnia. And they're a little bit trickier because often what they present with is just significant anxiety about their sleep. They were great sleepers, sleep has gone off, and they have difficulty either initiating sleep or they wake in the middle of the night and they can't go back to sleep. So, sleep-onset and sleep-maintenance insomnia. And with that, they bring, as I said, an enormous amount of anxiety. They go to bed every night with a degree of uncertainty and, of course, uncertainty loves anxiety or vice versa. So, they often get into bed, they have what we call a “conditional arousal response,” where the brain no longer associates going to bed with the degree of certainty that they used to rely on. And they lie there thinking, “Will I get to sleep tonight?”
And of course, their cortisol levels start to spark up, and they start to get anxious. They start clock-watching and worrying about their capacity to function the next day. And of course, that feeds into it. And then they start developing a pattern of either difficulty falling asleep each night or waking for long periods during the night. So, with that class or that group, I'm often dealing with the anxiety associated with it. So, we have to address their anxiety about not falling asleep. But they're two different angles that we approach when treating insomnia.
Adrian: In terms of… you've mentioned sleep onset, so the difficulty falling asleep, and then sleep maintenance, the difficulty staying asleep. Is it a 50/50 split? Do you think that in your experience, are you having more people with one as opposed to the other? Or how's your practice looking?
Frank: They generally fall into three categories. Those people that have difficulty falling asleep or initiating sleep, but once they're asleep, they generally stay asleep. So, that's what I would call sleep onset insomnia. The other one is sleep maintenance insomnia or middle insomnia. This is where people can fall asleep okay, but they tend to wake about the same time every night. And they could be up for about an hour or two hours, even three hours, and then they fall asleep before the alarm goes off. And the last group is what we call early morning waking. So, early morning waking is where they can fall asleep throughout the night, but they wake about 3:00 or 4:00 in the morning and they can't go back to sleep. So, you've got three types of insomnia which require slightly different approaches, but we address it in the same sort of theme.
Now, sometimes you can get people with the trifecta, they have sleep onset, middle insomnia, early morning waking, and it varies across the week, but generally, we see it in those three formats. I tend to see a lot of sleep-onset insomnia with younger population, probably in their 20s and 30s, we see a lot of that. Sleep maintenance, I see a lot in the older populations. And early morning waking, I see a lot with people who are often working and are in stressful jobs, and they wake and their brain switches on and they just can't switch off. They think about the next day. So, they get in a bad habit of sort of lying there thinking about work and thinking about issues. And then they start looking at the clock and start calculating how much time they've got left to get up. And that, of course, starts feeding into their anxiety and makes it more difficult to get to sleep.
Adrian: And so you mentioned that for some people who have difficulty falling asleep, there's a worry about falling asleep and the anxiety around falling asleep and when you talk about sleep onset, are there any other causes that you think are going on or typically going on with sleep onset insomnia?
Frank: No, 99% of the time, as long as there's no pain involved, pain can be a big issue, but 99% of the time it's anxiety. Absolutely anxiety. It's the question, “Will I get to sleep tonight?” And they start thinking about that during the day. They start thinking about that in the evening.
The best example I often give to clients that I'm working with is it's a little bit like being bitten by the backyard dog. You used to be friends with the backyard dog who'd greet you every day when you came home from work and very friendly, but all of a sudden turns on you and one day bites you, and you think, "That's strange." And then the next day you go through the backyard and it bites you again. After a while, you start getting a little bit anxious about going through the backyard to see the dog. And in the same way, people get very, very anxious after a while if they find that they have night after night where they struggle to fall asleep, and this is where they start to turn to sleeping medications, which is a bit of a slippery slope.
Frank: But it does create enormous amount of anxiety for people who struggle to fall asleep, particularly if they were great sleepers prior to the insomnia developing.
Adrian: What about, then, for people with sleep maintenance? Do you think it's anxiety there too?
Frank: No, it's frustration. It's really interesting.
Frank: Frustration. Absolute frustration.
Frank: It's really interesting. You ask them, "Are you anxious when you go to bed?" And they go, "No." And I go, "How do you feel when you wake at 2:00 on the dot?" And they go, "Frustrated." "What do you do?" "Oh, I lie in bed. I toss and turn. I play on my phone. I look at the clock."
Frank: "I just get frustrated."
Frank: They do get a little bit anxious if they're lying there for a long period of time, and then they start perceiving lying there as a significant threat to their capacity to function the next day. But I would say it's frustration first followed by a smidgen of anxiety, but more frustration. And same with early-morning waking, it's usually frustration. Because if you think about it this way, they've already had...those with middle insomnia, they've already had probably two deep sleep cycles, so they've gotten the bulk of their sleep.
Frank: So, they've gotten to sleep, but they just lie there getting frustrated by the fact that they can't go back to sleep. And that, of course, in itself is a perpetuating factor that keeps the insomnia going for days, weeks, months, years.
Adrian: So I noticed sometimes if I'm struggling to fall asleep, and I might wake up at the same time, and it's like I wake up at almost identically the same time for a few nights. What's going on there? How come it's so... Is there something going on? Is it the REM cycles and the different stages of sleep that are going on that it's waking me?
Frank: What time are you getting up, Adrian? What time are you waking at night?
Adrian: Actually, at the moment, it's 4:00 AM.
Frank: And what time do you get to bed?
Adrian: Probably about...
Frank: Or get to sleep, I should say?
Adrian: Oh, I fall asleep, well, yeah, straight away. So, I probably go to bed 10:30 and 10:35 I'm out.
Frank: Okay. So what's that? If you're waking at 4:00, that's five and a half hours. So you're waking five and a half hours after sleep onset. So if you think about it this way, most of your sleep drive has been burnt off during that time. You've gone through your deep sleep cycles and you're coming into the lighter end of the night. And typically when we see the back end of the night after about 4:00, we see a lot more REM going on and lighter sleep. So a lot of people are likely to wake around that time around about 4:00. So that's what we call early morning waking. The other thing too, what time does it get light there? You're in WA, aren't you?
Adrian: It is getting a little bit later, but yeah 4:30 it was getting light, so.
Frank: Oh, yeah, yeah, yeah. If you're a bit of an early bird, you're going to be stimulated by the light and more likely to wake at that point in time.
Frank: But this is the other thing. If you wake at, let's say 4:00 on the dot every morning, and you wake and you look across and look at the clock every morning, what that actually does, it actually trains you to wake at 4:00. It's like a queuing process. So, the general rule is you get rid of the clock. Your room should be like a casino. So that'd be the first thing.
The second thing is that a lot of people do wake at that time and, of course, they get frustrated, and think, "Why can't I sleep right through? What's wrong?" And a lot of people have a belief that you should not wake during the night, that you should sleep straight through. In actual fact, it's quite normal to wake.
So, with early morning wakers, what I generally get them to do is, first of all, normalise the wake. It's okay to wake at that time because you've burnt off the majority of your sleep drive. Secondly, I often get people to get out of bed at that time just for a short break, 10 or 15 minutes. And we find that that's very, very useful because it helps do a bit of a reset and it actually drops the body temperature as well. Because often when we wake, there's a bit of a rise in the body temperature that wakes us. So getting out of bed helps us reset our body temperature, and then back into bed. And this is the thing here. I get people to go back to bed and I get them to focus on resting, not trying to go back to sleep. And this is the biggest mistake people make, is that they try to go back to sleep. As soon as you engage in a thing called sleep effort, you might as well get up and start the day.
But if you can go back to bed and just focus on resting your eyes closed without any effort of trying to go back to sleep, it's a phenomenon called “sleep state misperception,” where you can often be asleep or have pockets of sleep without even realising. And the one thing that will tell you that is that if you got up 4:00, 10 minutes, came back, and the alarm went off at 6:00. If you felt that that time went relatively quickly, chances are you're asleep without even realising. So that's generally how we would approach that. Also, I would probably just tune in to see what was going on with the individual. Do they have a busy mind at that time? And also we could do some work around managing their active thoughts in bed.
Frank: Well, interesting. Let me put it this way. You either feed it or starve it. Most people get that. So what they're doing, if something comes into their head, they think they should process it, think about it. People lie in bed planning about the work ahead and this is... So, I basically say, "Look, you either feed it or starve it." And they say, "What do you mean?" Well, I say, "Get out of bed, have a break, that will shut that down. Come back to bed.” Notice the difference between active thinking and passive thinking. So if you start thinking about work, just gently say, “Let it go.” Turn your attention to something else. Typically, a memory can be quite useful and to just drift off onto that.
But it's useful to make note that there is a group of individuals where this is quite a difficult process. And here I'm talking about the ADHD population. And I've been seeing a lot of that presented in my practice. People presenting with undiagnosed ADHD. And one of the major presentations they have is that they have massive difficulties either switching off their active brain when they go to bed at night, so they have these long sleep latencies, or they wake about 3:00 or 4:00 in the morning and their mind just runs like a freight train, and they have difficulty turning that off.
In that particular case, what we often do is we either introduce medication that can actually help or the other one is just using distraction strategies. So here, I often encourage people who've got very active minds or people that are living with ADHD, often encourage them to put on a podcast, put on a radio, listening to an audiobook just to distract them from their thoughts and help them sort of drift off to sleep. So distraction strategies can be very useful with that population.
Adrian: Okay. All right, so you've got people with sleep onset insomnia, and then you mentioned that anxiety is a driver there and you'll start modifying some of the beliefs around that and working a CBT-based approach. Is that what you're basically doing, your CBT for insomnia?
Frank: Yep. CBT for insomnia is the gold standard. And how we approach it, we tweak it little bit. It's made up of five components. You've got sleep hygiene, we've got relaxation therapy, we've got stimulus control therapy, sleep restriction therapy, and cognitive therapy. Just a quick heads up on sleep hygiene. Sleep hygiene is the first thing that people go to if they're having difficulty falling asleep. And in actual fact, it's not an effective treatment for insomnia.
The best way to think about sleep hygiene is very similar to oral hygiene. It's a preventative process. So, it's designed to prevent the onset of insomnia in the same way brushing your teeth and flossing is designed to prevent cavities. But when a person gets a toothache and they go to the dentist, the dentist doesn't recommend more flossing and brushing your teeth, it requires more consistent work or more in-depth work. And this is where probably the top three areas that we focus or work on when we're dealing with insomnia would be sleep restriction therapy, stimulus control, and cognitive therapy. They're the top three. And they work extremely well.
Frank: Absolutely. Sleep restriction therapy is basically designed to build up the sleep drive of the individual. Often what we see when a person presents their sleep diary in the first session and you have a look at the sleep diary, there's often a mismatch between the time in bed and the amount of sleep that they're getting. So, for example, a person might be going to bed at 9:00 at night and getting up at 6:00. That's nine hours in bed and they're probably getting about four, five, let's say five to six hours of sleep. So, there's a little over a 50% sleep efficiency. So what we do is that if we can get a person to go to bed much, much later and get up much earlier, in fact, try to match their time in bed with the average amount of sleep that they're currently getting, what we often find is that it increases their overall sleep drive.
So, sleep drive is built throughout the day. The longer you're up, the stronger the drive. And it's that sleep drive that actually helps us address a lot of the insomnia issues, manipulating sleep drive. So, sleep restrictions are very, very useful. It's extremely effective when you're dealing with what we call sleep maintenance insomnia, where people are waking in the middle of the night, and they're struggling to go back to sleep. When we increase their sleep pressure by getting them to go to bed much later and getting up much earlier, after about three or four days, it's a little bit tough, but after about three or four days, we start seeing the sleep drive picking up and kicking in.
Frank: And the individual starts waking less and for shorter periods of time during the night. But it's probably the most successful approach to dealing with particularly sleep maintenance, and even early morning waking.
Sleep restriction can also be very useful for sleep onset insomnia, but I get a little bit careful about that because there's massive levels of anxiety there. So getting the person to go much later, they often struggle with that. And that can actually increase their anxiety. So what we generally do, unless they're going to bed at ridiculously early times, what we generally get them to do is go to bed at a reasonable time, get up at a reasonable time. But if they're having difficulty falling asleep, we then introduce stimulus control therapy, which is getting them, if they haven't fallen asleep within a reasonable period of time, and I'm not putting a timing on this, like 20 minutes, it's when they get into what I call a negative state. We get them out of bed for a period of time.
There's two schools of thought here, the first one says you get them out of bed until they're actually dead tired, falling off the chair, and then you get them back into bed. I've often had a lot of success with getting people out of bed for a short period of time for about 10 or 15 minutes just to reset, drop their body temperature, back into bed, and then rinse and repeat as required. And I find that's quite useful in breaking that pattern of, "I go to bed, I don't sleep," to, "I go to bed, I eventually fall asleep." So stimulus control is often used in conjunction with moderate levels of restriction therapy for sleep onset insomnia, but definitely sleep maintenance insomnia and early morning waking definitely respond very well to sleep restriction therapy.
Adrian: Okay. I've got a couple of questions. The first one is, so you said sleep restrictions, so you get them to go to bed later. Is it always with sleep restriction, always go to bed later? Can you do the reverse where they get up earlier so they go to bed, say, 10:00 PM and wake up at 3:00 AM?
Frank: It's often been up for negotiation.
Frank: For example, if we came to the conclusion with a client that their average sleep ran about five and a half hours, and we agree, I want you in bed for say, six hours, they can negotiate that. They can do say, 12:00 to 6:00, they can go to what, 11:00 to 5:00, or what, 10:00 to 4:00. So yeah, absolutely, it's to do with the time in bed. It's what we are looking at here. So it just doesn't matter what time you do that.
Frank: No. My standard line is “Get up and go down to the kitchen and stare at the dog," assuming that they've got a dog. And they go, "Oh, I don't have a dog." I say, "Well, you have to get a dog to do this exercise." No, I basically just say…
Adrian: So you get them to buy a dog. So, you do some pet therapy too, then, do you?
Frank: That's the one. That's the one.
Adrian: Yeah. Terrific.
Frank: No, actually, I just get them to just go downstairs, go down to the kitchen...
Adrian: Well, now you're going to get them to buy another house too, if they don't have a two-story house.
Adrian: Oh, wow. Okay.
Frank: So many conditions to get your sleep, like, my God. Yeah, no I get them to go down and just sit quietly, that's all. Just sit quietly. I get them maybe to put the range foot on, keep the lights down low. That's important. I usually don't get them to read or play on their phone, just sit quietly, maybe a glass of water, shuffle around for a bit, and when they're ready, usually about 10 or 15 minutes, head back to bed. Often that works. If they're really struggling, sometimes I say, stay out of bed until you're ready to go back to bed, but I often find a short break often helps. But the main thing here is when I get them back to bed, I get them to focus on resting and drifting rather than trying to get to sleep.
Adrian: Yeah, good point.
Frank: And this is where we get into this whole area of sleep effort, where people will go to bed and they'll try to get to sleep, and as soon as you start trying to get to sleep, you can't for all morning. So our major focus is focus on resting and drifting. You could be asleep without even realising, but as long as you're lying there and you're relaxed, stay there. But as soon as you get into that negative state and you get frustrated and you're tossing and turning, that's when you get out of bed.
And I just might add also it's critical you get rid of the clock. Particularly people are struggling with their sleep, the clock and clock-watching is a major perpetuating factor that feeds into their anxiety and their frustrations.
Adrian: Well, yeah. Good, good. I know certainly with my clients, I often say to them certainly in most things in life, if you try hard, you do better. But when it comes to falling asleep, trying hard is certainly not the way to go. You generally don't do that much better if you're trying too hard falling asleep.
Frank: You're dead right. You're dead right. That's the major area. In fact, I summarise the work that I do in two basic principles, and that is stop trying to get to sleep and stop worrying about not sleeping. Once they get their head around that, usually it resolves itself.
Frank: Yeah, I do. I do. Sleep diaries are very, very helpful. I use a...I was going to say a graphical one where they just sort of draw a line, if you will, put a marker in terms of an arrow when they go to bed, and then a line when they thought they were asleep, a gap on the form where they thought they were awake, and so on and so forth. And then an arrow when they got up. And when you look at a sleep diary for two weeks and it presents on a page, you see the pattern really quickly and you get an understanding that sleep really does fall into a pattern. You're either sleeping well or you're not, but the pattern is really clear.
You can either see that they have difficulty falling asleep and it's not every night. You'll have two nights where they have difficulty falling asleep and usually, by the third night they have a good night's sleep, and then the next couple of nights are poor, and then the next third night is usually a good night's sleep. And that's because of the nature of sleep restriction. So you get to see whether they're waking up during the night, for how long, whether it's early morning waking, or whether it's sleep onset insomnia. So very quickly, you get a visual, I get a visual and I go, "Okay, I know where to go with this one." And how to treat it. So they're very good.
The other thing too is that people, in doing the sleep diary, they find it very interesting because they then see the pattern that they've been engaged in for many, many years. And that in itself can be very helpful in part of their education to get them starting to change their pattern or starting to address some of the perpetuating factors that are feeding this pattern and has been for many, many years for some clients.
Adrian: So with the sleep diary, you've got obviously the timing of sleep and waking. Is there anything else that you get them to record in that sleep diary?
Frank: No, the only other thing too is, I get them to do a DASS, Adrian.
Adrian: Okay. Yes.
Frank: A DASS can be quite useful, a depression and anxiety and stress scale. If there's high levels of stress coming out of the DASS or depression, we know depression and sleep have a bidirectional relationship. Depression can cause sleep and sleep can cause depression. That can give me an idea if there's any sort of comorbidities there that I need to address. When I get somebody who has difficulty sleeping, often I see this with early morning waking, and I have a look at their DASS and their stress levels are very, very high. It then leads to a conversation about what's happening in their work. And that often leads to conversations about managing the stress in their work life or home life. And when we reduce the stress there, that can have an impact on resolving some of the insomnia as well.
Adrian: So it's not only just, obviously, what you do when you fall asleep and how to deal with the thoughts about sleep but it's also how you manage your day and how you manage stresses and things like that.
Frank: Correct. So, sleep is an event that occurs within a 24-hour sort of cycle. And within that you've got relationships, you've got work, you've got your general health issues as well. So, it's useful to have a look at those areas as well to see how much of those are impacting upon sleep. But quite often when we're dealing with sleep, it's quite discreet. Quite often I have people coming in who believe that their sleep is associated with a general anxiety disorder. But when you ask about their general life, are they anxious about other things? They say no. And then I say, “Are you anxious about your sleep?” And they say, “Yeah.” And I've seen people that have never had a history of any mental health issues that have presented with significant anxiety and it's all about their sleep, and it's the one thing in their life they can't control.
And again, I see this a lot with people who are very good on the control scale. They're very good at controlling things in their life. They're very successful in their life because they've been very good at controlling their environment. But when their sleep goes off they really fall like a pack of cards because their first response is to try and control sleep. And the way they tend to control sleep is they go onto the internet and they look at every sleep hygiene strategy in the book, and they start applying it. So they start doing things they never did before. Like warm baths, lavender on the pillow, turning the TV off at 8:00, changing the wattage around the house, all the lights.
Frank: The whole process. And what they do, they do all these things and then they get into bed and they're wide awake and they just feel like a failure and they think, "Nothing can fix this." Because they've taken on every advice that anyone's ever given them about how to get to sleep. And of course, any tips that you get or are given to get to sleep actually going to fail because it gets you to engage in sleep effort. So what I generally do is if I have a person coming to me, the first thing I look at is what's the sleep hygiene strategies that they've adopted. And basically, I get them to scrap it, but usually, it's over the top, and I get them to go back to what they used to do before the sleep problem started. And they find that often a great relief.
Frank: Yeah, the other thing I'm looking for, when a person presents with sleep problems you need to have a very open view about what might be going on. Because often sleep issues can be associated with other conditions like sleep apnea, restless leg syndrome or periodic limb movement. And then you've got other conditions such as daytime conditions like a narcolepsy, idiopathic hypersomnolence, which is the daytime sleepiness. So when a person comes with problems sleeping and they talk about their difficulties during the day, their difficulties remaining awake during the day, it's important to open up and get a sense of is there anything else going on. Often the referral base that I get is coming from a sleep physician. Now, it's gone through a GP, the person's gone to the GP having sleep problems. They're referred to a sleep physician. The sleep physician will then often do a sleep study to rule out sleep apnea, restless legs, periodic limb movement, narcolepsy, hypersomnolence.
And if all those things are sort of clear, then it's considered as insomnia, then it's often referred to me and then I usually address the insomnia. But often they don't go via the sleep physician and have those sort of assessments or tests. So I've got to be very careful if I'm dealing with somebody who's, let's say for example, is waking a lot during the night or waking unrefreshed in the morning. I'll often ask questions about, do they snore. Often I'll do an Epworth sleepiness test to identify their daytime sleepiness, and high scores in that may indicate a range of other conditions. So there are some tests that I do and further assessments that I do do. And if I sense that there's something else going on, I'll refer them off to the GP.
Adrian: I know certainly listening to this podcast, there's a lot of complementary medicine practitioners who listen to this podcast. And some of them would be doing testing, say, for cortisol, might be doing salivary cortisol testing, or they might do some melatonin. Do you ever do any of that? Do you see what are the pros and cons? You think any benefit in that?
Frank: Oh, absolutely. That can be quite useful. It can help the person understand what's going on. We often do melatonin testing or saliva testing to work out a person's current circadian rhythm. That can be quite useful to see where the circadian rhythm is actually sitting if they have an irregular sleep-wake cycle. So, it certainly does play a role, particularly when you're dealing with more complex cases.
Adrian: Yeah. And would that be a single point you'll do with the melatonin, or when would that be collected?
Frank: Well, we were doing that a while ago when I was working down at the Monash Healthy Sleep Clinic.
Frank: We were doing a lot of work around circadian rhythm disorders. If we had a person who had a free-running circadian rhythm, this is where the sleep onset continued to delay around a 24-hour clock. We would often try to work out where their melatonin onset was, how that was tracking to see how we can grab it and where we'd get them in to do saliva testing or urine testing. Sometimes we would just get them in as part of our sleep study. So we would get them in and start doing saliva testing in the evening to see where their melatonin onset was occurring. And that could be quite useful as well to work out their circadian rhythm. So that information can be quite useful.
Do I do it on a routine basis? No, I don't. Generally, if I'm dealing with a circadian rhythm disorder that is particularly a delayed circadian rhythm disorder, I'll often rely on sleep charts and sleep diaries to get an idea of where the person's sleep onset is sort of sitting around, whether it be 2:00 or 3:00 in the morning, and when they generally would like to generally wake up when they don't have to get up for work or any other activities or responsibilities. So, I would generally rely on that sort of data. Doing melatonin testing can be quite expensive.
Frank: So it's something I haven't done for a long time.
Adrian: Yeah. I think people need to be a bit careful too. I do a lot of the testing. I have the luxury of doing a lot of testing for a lot of the research studies that I do. And we've done a lot of cortisol testing, and done some melatonin testing, and there is significant variability across the days. And so you do have to be careful about reading too much into a single point or a single-day testing. And ideally, you'd like to do it over several days, but then it becomes incredibly expensive. So I agree with you. There's all your assessments that you do, your sleep diaries and I think they're far more viable than some of the hormonal testing that people do. So, yeah.
Okay, so you've mentioned obviously the CBT-I, are there any other...I mean, in terms of foods, do you look at the foods that they eat? Do you see a relationship between their eating patterns and their sleep?
Frank: I'm guilty of that one, Adrian. I do not. I do not. The only thing I'd look out for is caffeine and too much alcohol at night. Because a lot of people do rely on alcohol. Surprisingly, a lot of people rely on alcohol to actually get to sleep as a sleep aid. One or two glasses just as they go to bed, or if they wake in the middle of the night, a shot of vodka to get back to sleep. So that often goes on. But in terms of foods, generally not. You've had a lot of experience in this area. What's your take on that?
Adrian: Yeah, I mean, I think, yeah, obviously timing of eating is really important. And that can be an issue. And then obviously there's certain foods that people are eating that they're intolerant to and it's causing reflux or some digestive disturbances. I'll ask about whether that's happening. So, I'll ask about when they last eat, what they're eating, are they experiencing any digestive discomfort, and then making modifications there. And obviously ideally trying to eat as healthy as possible and then limit some of the unhealthy foods that they eat at night. So, I think that can be helpful.
With the caffeine, do you become a Nazi? Do you take them off the caffeine completely and they go….
Frank: No. No, no, no.
Adrian: Oh, great.
Frank: So, this is the thing. No, no, a lot of people, you know how I mentioned before they go overboard with their sleep hygiene, they give up their morning coffee because they think that's gonna make a difference. It usually doesn't. But if they're having about what four, five, six, seven cups of coffee a day, well that's a red flag clearly. I think caffeine stays in the system for about six hours. So early morning caffeine, totally fine. Later in the afternoon, not a great idea, But yeah, different people have different tolerance to caffeine.
Frank: There are some people that can have a cup of coffee when they go to bed and they sleep like a log.
Frank: And other people, they're wide awake. So, generally what I do is I get people to experiment. If a person's having three or four cups of coffee, I say, let's bring it down to one coffee in the morning and just see how you go. If it makes no difference, then go back to what you did before. But I very much like to experiment with people and just say, "Well, what kind of works?" So, taking things out, seeing if it makes a difference, and then maybe putting a portion of that back in. But no, I'm not a Nazi when it comes to caffeine. My God, if I gave up caffeine, I would not be a happy chap at all.
Adrian: Yeah, exactly. That's great. I'm glad you're saying that.
Frank: Yeah, exercise is great. Early morning exercise is great. Getting a lot of bright light therapy, bright light exposure that can help maintain the regular sleep-wake cycles. Exercise late in the evening, it's often difficult, particularly if it's competitive stuff. And we often see the AFL players who have late-night matches, they really struggle to unwind and to get back to sleep. But generally, try to keep exercise in the early evening as a general rule, too close to bedtime can often be a bit overstimulating and that can cause sleep onset issues. But other than that, exercise is great as is just keeping healthy. Just keeping a healthy mind and body can actually be very useful to maintaining a healthy sleep pattern.
Adrian: Now, I mean, obviously, your specialty is working with people with sleep problems. So a complimentary health medicine practitioner, can they treat sleep problems? I mean, what's your thoughts about other practitioners treating sleep?
Frank: Absolutely. Absolutely. The only thing I would say is that, and I get this a lot in my practice, is that when a person's struggling with sleep, and GPs are guilty of this as much as anyone else, is the first line is to go for sleep hygiene. And sleep hygiene is great, as I said, as a preventative strategy. But when a person's struggling with chronic insomnia, more sleep hygiene usually doesn't help. Unless they're doing ridiculous things like drinking stacks of coffee throughout the day. Napping a lot during the day can also be a major factor that they can address. And too much alcohol and so forth.
But generally, the CBT-I training is not just for psychologists, anyone, any health professional can actually do it and should probably look at it. It's pretty straightforward work. And to answer your question, no, anyone who's interested in sleep and is seeing patients who have difficulty with sleep, getting their head around the key components of stimulus controls, sleep restriction therapy can be very, very useful.
And when we talk about sleep restriction therapy, sometimes just getting them to go to bed a little bit later and getting up a little bit earlier, may be all they actually need to actually address a lot of the problems, and just keeping a healthy lifestyle. But there's lots of programs that they can do in terms of CBT-I. And I think if there are any health professionals out there that are interested in sleep, I would encourage you to do some training around CBT-I because you can do that and provide enormous benefit and service to your patients who're struggling with their sleep.
Adrian: Yeah, I’d certainly agree with you there. I think because sleep is such a major problem in our practice that anybody working with clients should have some good understanding of sleep and the treatment and yeah, doing a brief workshop or course in CBT-I is invaluable. So yeah, definitely agree with you there.
Frank: Yes. Melatonin, I think, is overprescribed in terms of quantity. A lot of people think more is better, in actual fact less is more when it comes to melatonin. Melatonin, you've got a couple of products on the market. You've got slow-release melatonin often coming in the form of Circadin. And it's quite useful for sleep maintenance insomnia. When we are looking at sleep onset insomnia, lower doses are a lot more effective. In actual fact, the way I tend to prescribe melatonin, particularly young people who have difficulty initiating sleep, they may be a little bit phase-delayed, not a lot, struggling to get to sleep before 12:00. What I often do is I actually introduce half a milligram, it's 0.5 milligrams of fast-release melatonin about five hours, four to five hours before their bedtime, and then half to one milligram about an hour before their bedtime. And we often see that it produces amazing results in terms of building their sleepiness coming up to bedtime.
Adrian: That's for people with sleep onset insomnia.
Frank: Yeah, very much so.
Frank: Sleep maintenance, slow-release is quite useful. But less is more. I've seen people on 5, 10, 20 milligrams of melatonin and they all repeat, it makes no difference. So we often see it has less effect. I think the research suggests that after three milligrams it's less effective, lower doses are more effective.
But yeah, it's widely used. Is it useful? I think it's when you compare it to a range of other medications or sleep medications that people can engage in like Risdin that's often used a lot, but that bums people out the next day. But then they if they're really struggling after melatonin's not working, they go and see the GP and they're often onto harder or stronger sleeping meds that are often hard to get them off.
Frank: Short answer, no. Not because I don't think they're useful. Most of the people I see have already been using them like magnesium. What are some of the other ones that they'd use?
Adrian: Yeah, you got your Valerian that often is quite common too.
Frank: Yeah. I'm not saying they're not helpful. In fact, if anything, they're probably more beneficial. If somebody's gonna take something, probably better off doing that than taking sort of harder medications like Stilnoct, Quetiapine, and so on and so forth. So, yep. I'm not knocking it. Just the short answer is I don't recommend it only because most of the people I see have already covered that ground, if you will.
Adrian: Yeah, yeah, definitely. In terms of any recommendations that I give, I think they can be useful. And ultimately, it's about, are you targeting it for sleep or are you targeting it for anxiety? If it's a generalised anxiety that's going on, then you might look at your different adaptogens and Ashwagandhas and Rhodiola and things like that.
But it's interesting how you've mentioned how you used the melatonin five hours before a lower dose and then a higher dose just before sleep. So, I think practitioners need to think about dosing too. If they're gonna use magnesium, for example, do you just take it an hour before bed or do you actually look at introducing it a little bit earlier to help that slowing down and then something just immediately before? So that's an interesting thing and certainly, unfortunately, in research studies, it's never done that way, but you made a really good point that gets me thinking.
Adrian: Great. All right, well thank you very much, Frank, for having a discussion today. We could go for hours. I think that there's so much valuable information that you've given people. And sleep is such a profound problem that many people with both medical conditions and psychological conditions experience, so I encourage people to certainly learn more about sleep and re-listen to this podcast because you've just given some great information. Well, thank you very much.
Frank: Thanks, Adrian. Thanks for having me.
Adrian: All right. So, thank you everyone for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the FX Medicine website. I'm Dr. Adrian Lopresti, and thanks for joining us. We'll see you next time.