Guest Interview Script From Americas Web Radio Podcast: Sleep and Insomnia
I was lucky enough to be invited to be a guest on America’s Web Radio to discuss sleep and insomnia treatment with host Dr. Ann Schiebert. https://americaswebradio.com/podcasts/DrAnnJun19.2019.mp3
Check out the script below:
Dr. Bergstrom, welcome. Before we get into the area of insomnia, I know you have other specialties. Tell us about them.
Thank you so much for having me on the show. I’m always happy to spread the knowledge about sleep. Yes, so aside from insomnia my other specialties include the treatment of PTSD which is Posttraumatic Stress Disorder, the treatment of psychosis, depression and chronic pain. PTSD aside from insomnia is very near and dear to my heart and in fact my dissertation topic was looking at marital functioning among veterans with trauma. The treatment of psychosis has also been a as I was able to have the opportunity to co-write a Cognitive Behavioral Therapy based curriculum with a former supervisor of mine Dr. Michelle Sallee. This curriculum has now been recognized by a major HMO based medical center in Northern California (of which I work for) to be used as standard of practice by all mental health clinics within that HMO’s region.
Why did you become interested in sleep issues?
With the various areas of work I was involved with working with my patients, there was a very common theme that showed itself across all the areas, and that was an issue around sleep. Whether it was the folks Ive been treating for PTSD, psychosis, depression, anxiety, chronic pain, memory issues, sleep in one way or another was almost always related. So I became really interested in learning more about that relationship and decided to pursue the area of insomnia and how to trot it. I wanted to know the whys and hows behind sleep impacting so many things not just for mental health patients but for all of us.
Sleep is vital to our health. Why is that?
Sleep plays a major role in major domains of our lives. It impacts things like our emotion regulation and mental health, our immune system, our reproduction system, our ability to resist impulsive behaviors (like eating the wrong foods), our physical and mental healing, our processing speed, ability to pay attention, our ability to learn new information, to process and remember that information and then to apply it to already existing pieces of information we have. As such, there are vulnerabilities and risk factors associations to chronic untreated insomnia including cancer, Alzheimer’s Disease, depression, anxiety, psychosis, weight gain, obesity, diabetes, high blood pressure (lack of sleep actually increases your contracting rate of your heart, increasing the systolic blood pressure). heart disease, and chronic pain flair ups. A lot is going on during sleep.
What is considered the right amount of sleep to have each night?
This is tough one. There is conflicting research about how much sleep we actually need. It does of course depend on your age, lifestyle, stress level, and health. But some studies have indicated about 6 hours being the necessary time, where others show it’s more like 8 or 9. Ultimately, I believe everybody is different in terms of what they personally need, we know our bodies enough to ultimately be the ones to determine what makes the most sense. Something to keep in mind is that a lot happens within our sleep cycles. In a minute we’ll go into more detail about this, but a typical sleep cycle is 90 minutes long and during that 90 minute time frame, a lot is happening in our physical and mental restoration. Regardless, I do see that people tend to overestimate the amount of sleep they need. We work ourselves up in catastrophizing that the next days is going to be ruined, that we’re going to blow that presentation at work, feel crummy all day, have zero energy, but the truth is, we don’t actually need as much sleep as we think. Yes, you will have bouts during the day of feeling tired, not being 100%, but our bodies can handle it. You may find yourself having those bursts of energy intermittently throughout the day. You may even surprise yourself at the end up the day as you reflect back and say “huh, I actually wasn’t that tired today and accomplished more than I thought”. This corrective experience can then help ease that sleep performance anxiety. The example I use in the class I teach ….interview the next day…you can keep your stuff together for 60 minutes? Yes, you probably can.”
We hear about REM sleep and that it is the most important type of sleep to have. Please explain REM sleep to us and why its so necessary:
Actually, all stages of sleep are equally valuable bc each stages does something unique. As I mentioned before, a sleep cycle is approximately 90 minutes long. In that 90 minute sleep cycle, we go into Stage 1, 2, 3, 4, and REM sleep. Another way folks refer to these stages is to separate them into Non REM sleep and REM sleep. Stage 1 to 4 increase the depth quality of sleep, meaning stages 3 and 4 are the deepest stages of sleep. Stage 1 is the lightest amount of sleep, the way I describe this is that instance when you’re siting on the couch at night with your spouse watching a movie, all of a sudden you get an elbow nudge being told to wake up and you say to them “what are you talking about, I was awake this whole time!”. Actually you were likely in stage 1 sleep and didn’t even know it. Another notable experience that occurs during stage 1 is that hypnic jerk. The sensation that you’re falling. It’s actually quite normal and occurs as a result of your mind trying to relax your body enough to fall into deeper stages of sleep. You make notice that during especially stressful times, you may have more of these jerks because you are more physically tense than normal.
The deeper stage of sleep are in Stages 3 and 4 and that is where most of the physical restoration of the body is occurring. Tissue and muscle repair, immune system repair, etc. is occurring here.
So after NonREM stages, REM sleep proceeds. This is also described as “paradoxical sleep” because if we were to look at your brain waves during REM sleep, it would look very similar to the activity of an awake brain. The function of REM sleep is to help integrate the emotions and learnings earlier that day into more complex systems.
In terms of memory in general, sleep helps prepare by making room to make new memories, to internalize and maintain the memories and information you learned that day, to retrieve memories that you couldn’t necessarily remember before, and also to apply and store new memories with already existing knowledge from the past. We call it memory consolidation. So to basically - the wake state receives memories, NREM stores and strengthens those memories and REM integrates and connects those memories with already learned memories. So it makes sense then that during REM sleep we dream. And yes, we all dream, in fact most of it occurring during REM, it’s just a matter of whether you’re actually remembering the dream. If you are remembering the dream, it is likely because you have woken up out REM sleep.
Tell us about insomnia. How would you describe it for our listeners?
Insomnia is a specific type of sleep disorder that is defined as trouble with sleep quantity or quality due to difficulties with falling asleep, staying asleep, as well as early awakenings, that are causing significant distress or impairment in functioning, which occurs at least 3 times per week and last for 3 months.
There are a couple types of insomnia: primary insomnia, which means essentially no other medical or mental health condition is causing this sleep disturbance, versus whats called Secondary Insomnia, which means there is something medical or mental going on that is causing the insomnia to occur. Examples of this could be Sleep Apnea, PTSD, asthma, postpartum depression (estrogen and progesterone are sleep promoting hormones that decrease, and hot flashes).If this is the case, these need to be addressed first.
Why do people have difficulty falling asleep?
There can be a lot of reasons in causing difficulties with falling asleep. Some of the biggest culprits are trying to go to bed too early than what our body actually needs. We have this false idea that we need to have a set bedtime when really what’s important is that we go to bed when we are actually tired, not because it’s just 10:00 and need my 8 hours (more to come on that later).
Another common reason is people do not give themselves enough time between their busy day and bed time. I call this the buffer zone. Folks are so busy coming home from work or the gym, going into dinner and cleaning mode, getting the kiddos off to bed and really have no time left to decompress and allow your brain and body to unwind and prepare for sleep.
Other common reasons are too much caffeine in the body, too long of naps earlier in the day, medical conditions, too much anxiety and worry that hasn’t been properly coped with, and what’s being talked about a lot lately is exposure to L.E.D. lights on our screens at home.
Why do people have problems staying asleep?
A lot of the same reasons why people cannot fall asleep initially. However, what I see most contributing the mid evening awakenings is people will find themselves with worry and anxiety. Something to keep in mind is going back to that 90 minute sleep cycle concept. What happens at the end of each of those 90 minutes cycles, is the tendency to ever so slightly, and quickly, we wake up before going into another 90 minute cycle. So waking up in the middle of the night is actually normal. Its around this time that people may find themselves awakening and because they have a lot on their mind, their brains start to go into overdrive and ruminate about those worries instead of going back to sleep immediately. The other common reason for the mid evening awakenings is people will have the tendency to look at their phones or clocks to see what time it is. That alone can make a huge impact on our ability to fall back asleep because of what that light exposure does to our brain.
When light enters are eyes, specifically blue or white shades of light, our brain actually falsely assumes that it’s time to wake up and stops producing melatonin. Some people have such a sensitivity to light, that it can take them 2 hours to be able to fall back asleep again.
What are sleep disorders?
Sleep disorders are a set of dysfunctions related to sleep or wakefulness that vary in presentation and severity and causes. Some of the main ones are restless leg syndrome, obstructive sleep apnea, jet lag, narcolepsy, night terrors, sleep walking, and of course, insomnia.
What causes a sleep disorder?
Because there are actually quite a few different sleep disorders, there are quite a few causes for them that can differ for each. Obstructive Sleep Apnea for example is largely caused by a physical process going on with one’s breathing, while restless leg syndrome’s etiology is a completely different medical condition. I would say one of the most prevalent sleep disorders is insomnia. The biggest causes for insomnia are both the behavioral and cognitive processes we engage in Some common behaviors that serve to cause and maintain insomnia are: too long of naps, not having a consistent sleep schedule, too much caffeine, too much LED light exposure at night, making the error of getting into bed too early in order to watch tv, read, or do some work on our laptop. Some of the cognitive factors that cause and maintain insomnia include distorted or false beliefs about sleep. Examples are the belief that we absolutely need 8 hours of sleep, or the belief that the day will be ruined without adequate sleep, having too much anxiety about our sleep in general, telling yourself that you have no control over anxiety, that if you wake up in the middle of the night something must be wrong with you. There is a type of treatment that addresses these causes for insomnia called CBTi, where it intervenes on both the behavioral and cognitive components which we will talk more about in a bit.
I recently came across something called, “sleep anxiety”, Will you explain this to us?
Yes, so sleep anxiety, or another term I like to call “sleep performance anxiety” is the result of finding yourself in a pattern of not being able to sleep each night and developing worry or anxiety about it. They worry they will continue to not perform sleep well enough and so bedtime can be quite anxiety provoking. Some common sleep anxiety thoughts are “Im never going to fall asleep tonight”, “here goes another sleepless night”, “I just know I wont get enough sleep tonight”, “I have no control over my insomnia”. What this does is a few things – anxiety amps people up physiologically, meaning your body is wide awake due to anxiety, which ironically serves as a self-fulfilling prophecy for the person in really not being able to fall asleep soundly that night, and the other thing is that bedtime is now paired with the association of anxiety. Sometimes it becomes even as extreme as to associating your own bed with anxiety because you’re telling yourself you’re not performing sleep well!
The key thing here is to eliminate the worry over not sleeping. It CBTi a lot of the work involves cognitive therapy around changing your thoughts, changing your relationship with sleep, so that anxiety and worry is not playing such a strong factor in it, thus calming your anxst and promoting better sleep.
So many challenges can affect our sleep. Talk to us about how stress can affect sleep.
Stress plays a huge roll in our ability to sleep. The way our human bodies function is to be attuned to the threat in our environment. Whether it was a tiger back in primal days or that stressful work meeting, or the argument with your spouse, or the aging parent you are caregiving for, our brain and body do not know the difference between what immediately needs to be addressed in the middle of the night or something we can put aside for the next day. Anxiety trumps sleep and can take over in trying to tune into that threat. Further, with stress comes the Fight or Flight response and also a surge of Cortisol and adrenaline release in to the body, all physiological processes that arouse the body to be very awake and unable to relax enough to fall asleep.
I think most of us realize that caffeine, alcohol, and nicotine can negatively affect our sleep. Will you comment on this?
Alcohol is a sedative. It may seem quite easy to fall right asleep after consuming a few, but being sedated is not the same thing as sleeping. It also interferes with REM sleep, and there’s a process called the Alcohol Rebound Effect. This process is when after having a few drinks it feels quite easy to fall asleep. A few hours however, typically around 3 or 4 hours later after your body metabolizes the alcohol out of your system, you wake up, your alert state actually rebounds higher than it was before, thus making it difficult to fall back asleep.
Nicotine actually acts as a stimulant. So although it may seem like you are able to relax after the first few inhales, for most, that relaxation is more associated with the physiological craving of needing that cigarette diminishing.
Caffeine is a stimulant and stays in the system a long longer than folks realizes. The “half-life”, meaning, the amount of time HALF of the substance takes to metabolize out of your body is 5 to 7 hours. So that means, after 5 to 7 hours after you’ve consumed caffeine, half of it is still very much in your system and suppressing your brain from being able to sleep.
Many of my patients love their midnight snack. Any thoughts about how eating large meals within two hours of bedtime affects sleep?
There’s a few things here – by all means, don’t go to bed too full and don’t go to bed too hungry, as both interfere with the body’s ability to sleep soundly. In a minute I’ll talk about specific foods that can actually be good for those midnight snacks or to eat before sleep. My caution though, is that folks can get themselves into a pattern where they actually wake up in the middle of the night because their body has associated that time of night with the need to go to the fridge. By having a midnight snack consistently, you could be teaching your body a bad habit of feeling the need to eat every night regardless if hunger is even the reason. That’s where people can find themselves gaining weight or perpetuating the insomnia cycle.
I’ve heard that having carbs at dinner and protein at lunch is more conducive to good sleep. What are your thoughts about this?
Foods can play an important role in our sleep ability. Not only the types of food, but the timing and quantity. There is a lot of conflicting research about what kind of eating style is best for not only weight management but also for sleep - You’ve probably heard the research promoting multiple small meals a day, intermittent fasting, or the phrase, “eat breakfast like a king, lunch like a prince, and dinner like a pauper”. But in one study Eating high carbs and low fat was show to decrease your deep NREM but increased the amount of REM, compared to a low carb high fat diet.
That said, a lot is also out there about certain foods that are said to promote sleep. To preface this, some things to keep in mind. The amino acid Tryptophan, the neurotransmitter serotonin and melatonin. Low levels of Serotonin are shown to interfere with sleep. Tryptophan increases Serotonin thus promoting sleep. Melatonin also promotes sleep. So, eating complex carbs like whole grains, popcorn, oatmeal before bed can help bc on the contrary, refined carbs like break, pasta, cookies have been shown to decrease your serotonin (which remember low levels impairs your sleep). Healthy fats like almonds and walnuts, as well as certain fruits like raspberries, bananas, and kiwis contain melatonin (that hormone that helps regulate our sleep cycle), lean proteins like cottage cheese, milk, tuna and turkey have tryptophan which helps promote sleep because of the rise in Serotonin.
As always, consult with your medical doctor to determine the right plan for you because everybody is unique with their own personal health needs. Rule of thumb though is pretty basic – avoid being too full or too hungry and be mindful of not having too much of a high carb diet.
Any opinions about exercising before bedtime?
Exercise is great for all the well known reasons for our physical, mental, and cognitive health. Studies have shown that being active improves our immune system, decrease inflammation, decreases depression and anxiety, and has even show to improve cognitive functioning, specifically helping slow down the process of dementia. It also helps with promoting a better night’s sleep. Specifically, exercise has been found to increase the amount of sleep time, particularly the deep stages of NREM sleep. No surprise, it works the other way too. With less sleep the night before, exercise intensity was less as well.
So the caveat – don’t exercise at least 2 to 3 hours before bedtime. Two reasons – it takes a while for the body to physiologically calm down and also because the body’s core temperature rising from that exercise needs to time drop down again in order to promote falling asleep. It’s amazing how much a difference it makes with just a few degrees in core body temperature.
I don’t know if you have patients that do this, but many of mine tell me that when they can’t sleep at night, they take a nap during the day. What are your views about napping during the day?
Naps for some people can temporarily give a boost of energy when needed during the day, for other people it may seem that they are even more tired upon wakening. The general rule of thumb I give to my patients though is if you have to nap, don’t nap for more than 25 minutes. The reason being is that anything past 25 minutes, you are going into deeper stages of sleep which then takes away from your sleep need at night, which thus affects your ability to sleep later that evening. It’s more about the larger landscape of keeping a consistent sleep schedule which can be impacted by taking too long of naps or even a nap too late in the day because it takes away sleep need. Think of naps as the equivalent of snacking. Having too big of a snack or too late in the day takes away our hunger for dinner.
Ive heard that sleep can be affected by anxiety and depression. What is your experience with this?
This is an interesting thing being studied. We know that anxiety can cause difficulties with being able to fall and stay asleep because of the excessive worry, rumination, and heightened physiological state. With depression, it can go either way - you sleep too much because it’s your emotional escape from emotional pain, or you can’t sleep enough because theres that ruminative process going on as well. The majority of my patients coming in to treatment for depression or anxiety will have sleep issues. In this way, this would be called secondary insomnia. A person is having trouble sleeping because of the depression and anxiety causing it. However, what is also being acknowledged is that sleep issues can exacerbate or even cause anxiety and depressive symptoms. Sleep is an important force and when we lose grip of it, night after night, it affects a person’s emotional well being, thus causing mood symptoms. And it also has to do with the brain’s inability to receive enough emotional restorative sleep at night which can leave a person feeling more emotionally unrestored.
Tell us about good sleep hygiene is.
Good sleep hygiene involves utilizing proper patterns of behavior that are conducive for good sleep. For sleep hygiene to be effective, there needs to be consistency with it. And if these are new patterns of behavior you’re trying to stick with, like any new behavior, it takes time and patience to make a habit out of it. You may not have to engage in all sleep hygiene practices, there’s a lot of them, but consistently sticking with a handful of things can really make or break the quality of your sleep in the long run.
These techniques can include: having a regular sleep schedule of going to bed and waking up at the same time every day, if you can’t sleep for more than 20 minutes, get out of bed and do something boring until you’re feeling ready to fall asleep. Don’t take naps more than 25 minutes during the day, create a To Do or Worry List prior to bed time in order to clear your mind of worries, limit caffeine consumption (I recommend no more caffeine after 1:00), have a “buffer zone” at night that allows space to calm the mind and body down from a busy day, making your bedroom as dark and as quiet as possible, having a comfortable temperature inside your home (too hot or too cold makes it more difficult to sleep, limiting alcohol and nicotine, eating well, exercising (but not too late in the evening, 2-3 hours), and I would say one of the most difficult things for people to change is to only use their bed for sleep and sex. That means no more reading, watching tv, being on your phone, doing your taxes, eating or any other “wakeful activities” while physically in bed. Otherwise, your brain begins to associate wakeful activities with bed and not necessary sleep. This goes for laying in bed for more than 20 minutes not being able to sleep. Guess what. THAT is a wakeful activity too. Again, get out of bed and do something incredibly boring.
Having said that, my disclaimer to insomnia patients is - Sleep hygiene ALONE does not effectively cure chronic insomnia. In Cognitive Behavioral therapy for Insomnia, sleep hygiene is referred to as “stimulus control”, that is, controlling the stimuli and patterns of behavior around you to help improve your sleep. There also needs to be the component of sleep restriction and cognitive restructuring for chronic insomnia to be effectively treated.
What are the top 5 insomnia remedies?
Out of all the different tips and techniques to help with insomnia, my top 5 would be:
1. Have a consistent sleep schedule. Same bed and wake time every day. It’s amazing how your body’s circadian rhythm becomes on point.
2. Limit your light exposure at night. Light exposure at night really plays a huge roll in our ability to sleep because the light entering into the eye into the brain disrupting the brain’s sleep process. It’s particularly the blue light and white lights that are most detrimental, which, happen to be the same shade of lights in our electronic devices. There are glasses you can purchase who’s lenses actually block those lights from entering the eye and studies have shown very promising benefits.
3. Try to stay away from naps. If you have to, limit them to 25 minutes. Also consider eating a healthy snack or get some light physical activity instead of the nap. This may just be all you need.
4. Only get into bed when you’re ready to fall asleep. This may seem contradictory to the tip of having a consistent bedtime each night, but, if you’re patient, you will see that you will just naturally become tired at the same time every night.
5. Create space in the day to process any worries or agenda items. Consider journaling, create a To Do list or even a Worry List. Being able to remove these thoughts out of your mind and to put them on paper can really help clear your head for bed time. We so often don't give ourselves the space to reflect until we are laying in bed and ALL our thoughts and worry flood us.
What do you think about sleep Apps?
I think sleep apps can be great. I have no personal, financial or professional obligation to these, but a few I like to mention are CBTi coach (essentially its delivering a very similar protocol in cognitive behavioral therapy for insomnia that would gain from going to a clinic, but, obviously bc its an app, there would be some limitations and requiring more self discipline to comply). Other apps that serve more of a purpose to help calm the mind and body are apps called Calm, Headspace, Breathe, and Insight Timer.
So many of the folks that I counsel settle down with a sleep App every night. They swear their sleep app is a “miracle”. Why do sleep Apps seem to work?
I think there is some validity in the ability for sleep apps to be effective because of what it supports regarding relaxation and mindfulness techniques. But I also think a large component of it has to do with the association the sleep app begins to have with sleep. For a person using the app regularly, it has become a regular bedtime habit for bedtime use thus creating a healthy association with sleep. The things we can pair with bedtime can help create a stronger association in telling the bed it’s time to sleep. Apps are a nice thing to pair it with.
In your experience, how does lack of sleep affect relationships?
There can be a number of things that come into play here with sleep and it’s effect on relationships. One being that lack of sleep can be quite taxing in one’s day to day. A partner may just be too physically exhausted to participate or fully be present for activities the couple would want to enjoy together. Another factor is, lets face it, we aren't exactly rays of sunshine to be around when we’re sleep deprived, and unfortunately it’s those around us, name our partners that are the front end of this. So lack of sleep can really disrupt the quality and positive space usually inherent within the relationship’s functioning. Another issue being the mismatch of sleep related behaviors within the relationship. These can include mismatched sleep schedules or sleep habits - one may be more of a night owl while the other is more prone to falling asleep early. One partner might prefer to sleep with the tv on, while the other needs complete silence. One partner may find that getting into bed together at the same time is a very important part of their intimacy as a couple, regardless of whether the other partner is ready to fall asleep. Another can be that one partner is unintentionally keeping the other from sound sleep due to snoring or tossing and turning. The problem with these differences is that they can create tension, frustration, and further sleep problems if not addressed as a couple. There needs to be some conversation about making some behavioral shifts, perhaps meeting half way with some of these factors.
Where can people go to get help with sleep problems?
I would start with your primary care doctor. Have a conversation about the sleep problems you’re experiencing, rule out any medical factors that could be the primary cause such as sleep apnea. Once medical issues are cleared, talk about finding support through obtaining thorough sleep hygiene education or consider the first line of treatment for insomnia which is CBTi. Your doctor can more than likely help steer you in the right direction of where you can obtain this. Usually this would be in a local mental health clinic or any therapist that specializes in it.
What are the five best pieces of advice you could share with our listeners who are having challenges getting a good restful sleep?
Have an open mind and stay consistent with at least a handful of the tools discussed here today. If sleep issues have been around for a while, it will also take some time to break the insomnia cycle, so be patient with the process.
Waking up in the middle of the night multiple times is actually a very normal and healthy thing bc it usually indicates you just completed a 90-minute cycle of sleep. So instead of becoming anxious about being up, roll yourself over and tell yourself you’re about to start another sleep cycle.
Don’t let the 8 hour myth fool you. Our bodies can handle a few poor nights of sleep, remember a lot happens restoratively in 90 minute sleep cycles.
Keep in mind other factors that may be at play here. Consult with your doctor to rule out any medical conditions such as sleep apnea or depression or anxiety. These things can play a huge role in sleep issues and may need to be addressed first.
Insomnia does not have to control you. By making some consistent adjustments in your environment and behavior patterns, you can take that control back and have a normal sleep pattern and get your life back.