I Can't Sleep, Now What?

Transcript

Sydney Fitzgibbons:
Your sleep deprivation takes more than that night from you. It takes the next day from you. It takes sometimes a week from you. It sometimes takes years from you when it turns into a cycle of not getting enough sleep.

Ellie Pike:
When paramedic, Sidney Fitz Givens' occasional sleepless nights grew more and more frequent, she wasn't too concerned. But before she could get the situation under control, her lack of rest cascaded into tenacious insomnia, eroding her daily life and sense of self.

Sydney Fitzgibbons:
It takes away my cognitive ability to make good decisions. And for me, working as a paramedic, that's something that's critical to the job. You have to be able to think clearly and make quick decisions.

Ellie Pike:
Trapped in exhaustion. Her mind felt ensnared by a feedback loop of an insomnia and anxiety.

Sydney Fitzgibbons:
They just feed off of each other and one makes the other more difficult. Anxiety makes it harder to sleep and lack of sleep causes more anxiety.

Ellie Pike:
With stability slipping further away each night. She had no idea how to change, that is until she asked one really important question.

Sydney Fitzgibbons:
What was I willing to do about it?

Ellie Pike:
From Eating Recovery Center and Pathlight Mood & Anxiety Center, you are listening to Mental Note podcast. I'm Ellie Pike. I don't know about you, but I can really empathize with what Sidney described. Though insomnia has never been a struggle of mine, I am no stranger to sleepless nights. That's the sound of my baby crying in the night. For the most part, becoming a mom has been a beautiful experience, but extended sleep deprivation can leave me feeling like a shell of my true self. Sometimes it's difficult to fully show up at work with friends, and worst of all, as a parent. So yeah, I'm not only aware that sleep is really, really important, I feel it. Yet, as crucial as sleep is, there are an awful lot of us who just don't get the rest that we need.

According to the Center for Disease Control and Prevention, one in three American adults don't get enough sleep on a regular basis. One in three? Given how much sleep can affect our health and abilities, it's alarming that so many of us are missing out. And that's why I wanted to create today's episode. We'll look at this most important of daily rituals and figure out what you need to know to get better sleep. We'll cover what makes sleep important. What causes us to get poor sleep. Eight areas of your life that you can adjust to improve your nightly slumber. And how to know when you may need therapy or medical recommendations to help get back on track. And luckily, we have an amazing guide to help us with all of these topics. Meet Dr. Karima Clayton.

Dr. Clayton:
My name's Dr. Karima Clayton. I am a clinical licensed psychologist working out of New York City.

Ellie Pike:
In addition to working at the VA and seeing private practice patients, Dr. Clayton is also a clinical instructor at the NYU Grossman School of Medicine, and especially trained in CBTI, cognitive behavioral therapy for insomnia.

Dr. Clayton:
I guess, when I think about why I do what I do, I think that over the years working in mental health I've really realized the importance of sleep hygiene. And I think a lot of people struggle with sleep related difficulties for multiple reasons. And you can really see how it impacts functioning.

Ellie Pike:
You know It's funny in some circles I feel like people talk about sleep and it's really important. And then in other circles it's like, "Oh, you can do without it. You just got to push through. You'll be fine." So, if you could speak to what the importance of sleep is, I think that would be a great starting.

Dr. Clayton:
Yeah. I agree with what you're saying. I do think that there's a range of responses when it comes to sleep and people's opinions on sleep. But generally, I think when we think about someone's overall health and wellbeing, sleep is really a part of it. Right? I think that sleep is a part of not only our mental health but also our physical health. So, when our bodies are sleeping or when we're resting, this is the time that our bodies rejuvenate. Right? This is the time that the healing and repairing happens of our heart, our blood vessels, things like that. And I think when there's ongoing sleep deficiency, it can really contribute to health related problems. And like I mentioned, mental health related difficulty. So, I think when I think of the importance, it's really about overall health and wellbeing. Yes, some people may be able to function on a low level of sleep, but when we really think about the overall functioning and you're wanting to be at your optimal level of functioning, then sleep becomes a really important component of that.

Ellie Pike:
So you're telling me it's not just a time for your mind to repair and reset itself for the next day, but your body's actually physically repairing itself?

Dr. Clayton:
Exactly. Exactly. For some people recognizing the impact on your physical health can be something that highlights the importance. So, exactly, it's really a time for repair, rejuvenation for the body as well.

Ellie Pike:
So what exactly happens when we don't sleep?

Dr. Clayton:
A lot of things can happen when we don't sleep and there's a lot of negative effects to poor sleep. So I think some of the more obvious that I'm assuming people can likely relate to or connect to in some way, some of the things that you notice maybe initially are decline in your attention, concentration, your memory, attention to detail. Things like that don't quite click off the same as they do when we're functioning at our optimal level. Some people talk about irritability, anger, so they may respond in a more irritable way than they typically would when they're missing sleep. Some mood related disturbances, impaired judgment, or like slower reaction time on things. So that's where it becomes difficult or dangerous, let's say, for even driving things like that, when you're operating on a lower level of sleep. Your reaction time is not the same as it typically would be.

So that also kind of connects to coordination, physical coordination, things like that are impaired with poor sleep. Also more generally when we think about physical related issues. So they talk about a weakened immune system when you're not sleeping in the way that you do. Right? If we think about sleep as being something rejuvenating for your body, then it can really weaken your immune system, which a lot of research talks about it, making you more susceptible to certain diseases. So they talk about high blood pressure, heart disease, diabetes, stroke, things like that. And then of course there's the effect on mental health. So we see it in the context of depression, generalized anxiety disorder, some of the trauma related diagnoses like PTSD. So I think that there's a lot that poor sleep can affect.

Ellie Pike:
You bring up such a good point. Like when I asked the question, I said, what happens when you don't sleep? But that's not really the right question. It's like poor sleep or less sleep or inconsistent sleep. It seems like any disturbance with our sleep can start to affect our attention, our mood, our judgment. And I can speak from a personal experience, as soon as I had my first kid, people tell you, you don't remember those early days and I didn't believe them, but I actually don't truly remember those first few months when I wasn't sleeping because I really wasn't sleeping.

And so, I think I've personally experienced that lack of memory and not being able to function fully like myself and had to write everything down much less like the mood that I could feel was affected. Right? Like I felt more irritable, less calm. So I know I'm not the only one. And lots of people are affected by poor sleep. Can you speak to some of the factors that contribute to poor sleep. Because there's transitions or change in life status, but there's a lot of other things that can contribute as well.

Dr. Clayton:
Definitely. So like you said, you mentioned like adjustment or life transitions. That's a big one that I think can contribute to stress in its own way, which then can definitely impair sleep. And there's a range of things that can be considered life transitions or related to adjustment. Right? Starting a new job, moving, having a child. I think that these more significant life events. But even smaller transitions that I think can really impact our sleep because there's a change in our routine in some way. And in some way that requires an adjustment to our daily routine or our sleep routine. So I think definitely life transitions, adjustment, just increased stress, which can be related to all sorts of things. Right? If we think about stress in the context of interpersonal relationships or things happening in our day to day life, those can impact our sleep. Right?

So for a lot of people when you lay down to go to bed, that's like the first quiet moment you've maybe had during the day. And oftentimes this is like, it almost feels like an invitation to all of the worry thoughts that you have kept at bay because you've been distracted with other things. So I think at times those stressors rear their head when you're trying to relax. I think, of course, medical issues can contribute to sleep related difficulties. So something that people bring up often is if people have physical pain or chronic pain, that's something that can really make it difficult to get comfortable and to fall asleep. Mental health related issues like I mentioned a little bit prior. So people who experience depression or anxiety disorder or PTSD, or even other mental health related diagnoses might also suffer from sleep related difficulties.

Certain substances. This can be some prescribed medications, but it can also be some of the recreational drugs that people use including alcohol. So people oftentimes say, "Oh, but alcohol helps me fall asleep." And the quality of sleep that you get in using substances is an not the same. So it really can be problematic and really contribute to your not getting really good sleep. Poor sleeping environments, which unfortunately is often beyond people's control. If you reside in a community or area that may not be the most conducive to your getting restful sleep. Right? Whether it's the noise or not feeling safe, things like that can really impact your ability to sleep.

Ellie Pike:
It is eyeopening when I see it in that list of mental health issues, transitions, work schedules, stress, medical issues, poor sleep environments, loss or grief. I mean, some of these things are in our control but some of them are not. Right? And so I imagine that's the challenge that you come up against working with people, is what's in people's control, what's not. And where do you start when you want to better sleep quality and sleep hygiene? Which we'll jump into in a minute. But it's absolutely complex. It's not so easy just to remedy overnight, as we all know. Can you speak a little bit to the types of sleep disorders there are, and more specifically, insomnia? Because I know a lot of people say, "I deal with insomnia or I struggle with not sleeping." At what point does it actually become a diagnosis? And what does that diagnosis even mean?

Dr. Clayton:
Yeah. I think that's a great question. And I agree with you. I think that the term insomnia in some way has become like a blanket term for sleep related difficulties. So I think generally when we think about insomnia, it can include a few different things. So there can be the component of difficulty falling asleep, waking during the middle of the night, waking up too early, maybe popping something wakes you up and then not being able to fall back asleep. And this is actually pretty common, some version of this. Right? I think that the last statistics I recall seeing are over 60%, almost 70% of adults between, I think the ages of 18 and 29 report experiencing some type of insomnia, so some version of what I just mentioned.

And then around 50% to 60% of adults who are in the older range, right? So 30 to 64. And then you also see almost 50% for people over 65. So it's pretty common. Right? When despite the age, over half of our population has experienced insomnia in some way in the way that we describe it. And so, when we think about it diagnostically, we really look at, and this goes for a lot of other diagnoses as well, we really incorporate the period of time this exist also. Right? If someone has a couple nights of sleep related difficulties, they may not get the formal diagnosis, but when it becomes a significant pattern over time, then it's something that we think about in a more clinical way or recognizing that it's maybe more of an issue in that regard.

So, it's pretty common. And I want to be mindful not to just label everyone with insomnia, but really to have a sense of, one, the period of time the symptoms have been present. Two, also how it's impairing functioning. We also think about that when we're thinking about diagnoses. Right? Is it impairing your day to day life? Are you having more trouble at work? Are you having trouble in your interpersonal relationships? So, I think things like that also come into play when we're thinking about a formal diagnosis of insomnia.

Ellie Pike:
Going back to the general concept of sleep and sleep quality, I think a lot of people have opinions about sleep, but I'm curious what the research says. And so, how much sleep should we be getting? Do we have real numbers on that?

Dr. Clayton:
This is a great question. Because I think most people, and I say that and I'll add to that later, but most people need about six to eight hours of sleep. And the disclaimer on that is that it really varies though. I think there's a lot of individual variation. So I think some people can function optimally with less sleep and some people need more. So you may find people who, after three to four hours of sleep per night, they are like good to go. And then for other people, they need 10 to 12 hours of sleep per night before they're feeling like really good to go. So I think while on average we hear that six to eight hours of sleep per night is ideal, it really depends on person to person. And so I think when people are having sleep related difficulties, a lot of the treatment is individualized because of that. Because we really need to get a sense of what's optimal for that individual person and then respond or act accordingly.

Ellie Pike:
So is that just gauged off of how well that person functions in life with different levels of sleep? Or how do we know what the right level is for ourselves?

Dr. Clayton:
Mm, good question. So, there's a type of treatment for sleep I've engaged in which is called CBT or cognitive behavioral therapy for insomnia. And essentially at the beginning of treatment, we do sleep diaries with people. So we start to test out what's an optimal amount of sleep. And literally there's like a, it's called a sleep diary. So it's like a sleep journal that you're essentially recording when you go to sleep and when you wake up. And we keep track of what works and what's not working. And in doing that, we are able to identify an optimal amount of sleep. And then there's some ways that you can even calculate some of this and look at certain numbers in terms of your time in bed versus the time you're actually sleeping. Right? Because some people may lay in bed for 10 hours, but they're actually sleeping six. So we have to also take that into consideration when we're thinking about what the optimal amount of time you actually need for sleep is.

Ellie Pike:
I really like your emphasis on the individual variation, that we're all different. And this takes a lot of like self-monitoring, if we want to notice first and just assess where we are before we can jump into bettering our sleep.

Dr. Clayton:
Exactly.

Ellie Pike:
So, in terms of talking about sleep hygiene, what are some good routines that the general public should know about? So, sleep routines or daily routines that might just help us have better quality of sleep.

Dr. Clayton:
So, sleep hygiene really refers to good sleep habits. And so there's been a lot of research around some of these tips or things that I'll suggest. And I think the research has shown that incorporating some of these into your life can really make a difference in providing long term solutions for sleep related difficulties. So the first thing I like to highlight for people is avoiding caffeine, which I'm not saying you can't drink coffee at all. I know that's a staple in many people's day, but really being mindful of the time of day you might consume caffeine. So for some people you really shouldn't consume caffeine in the four to six hours before bedtime. Because what happens is, anytime you're introducing something into your body, your body has to process it. I mean, we know the effects of caffeine generally, and then there's the processing that happens. Right?

So those organs of our body can't sleep when it's trying to process something that's been introduced into the system. So the same goes for eating meals. Right? So some people are late night snackers and you really should be mindful of how much time before bed you're eating. Right? So you don't want to eat in the 30 minutes before bed, but maybe be mindful of having a gap maybe two or three hours before bedtime where you have your last real meal. Let's see. Another thing I'd like to highlight is, and this can be hard depending on your setup, but like the bed should really be for sleeping. Right? It's almost about conditioning your body. So when your body gets to laying in bed, in some ways it should be thinking, "All right, this is my sleep space." I know in New York City, some people live in studios and the bed is like everything. Right?

You sit there, you lay there, you do work there. But in the ideal, the bed should just be for sleeping. So really being mindful that you shouldn't, like I said, watch TV there, eat there. You shouldn't be reading, you shouldn't be working on your laptop, because you want your body to connect the bed to sleeping. I like to also highlight having a sleep routine. There's certain things that you can do to start signaling your body that it's time to relax and prepare for bed. Having a sleep routine might include for some people like, you take a hot shower or you do relaxing stretches or breathing before bedtime. Another thing I like to highlight for people, not just having a sleep routine but being mindful of your daily routine.

And that can include having a bedtime and awake time. I know this can be difficult for people because they think about weekends where you have more time. But I think generally, again, it's about training your body. So like putting yourself on a clock in some way. So that at 10 o'clock every night, my body starts knowing it's time to wind down. Because at 10 o'clock every night I engage that routine. And then also the same, it helps to have the same wake up time every day as well. Again, it's about conditioning your body in some way.

Ellie Pike:
Can I pause you on that one?

Dr. Clayton:
Yeah. Sorry. I know I'm just running through it.

Ellie Pike:
No. Are you kidding? This is wonderful and such great feedback. I'm curious about the concept of conditioning your body. We're almost like teaching our body to notice signals because our body's like still a cave man body, even though our brain is more developed. And so, I find that really interesting. So our body, it seems like it wants routine. Is that correct? Where it wants to be able to predict what's next and it catches on to patterns really well. So what does it look like then if someone tries to catch up on sleep? People talk about that all the time. "I need to catch up on my sleep. I'm going to sleep until noon." Does that actually work or is that actually negative for our sleep hygiene?

Dr. Clayton:
So, good question. Don't get me wrong. I think yes. There are the times you have a Saturday where you can just get a little more sleep, and I think that's okay. And we have to recognize the effect that that can have. Right? So, if I sleep till 1:00 PM on Saturday, when usually I'm up at 7:00 AM and start my day, I have to recognize that getting the extra sleep, almost like taking a nap, why that can be problematic. It then throws off the rest of my day. So when I maybe try to go to sleep at 10:00 PM at night, my body's likely not going to be tired because of the extra sleep that I had. So in some ways I'm probably not going to go to sleep on time, let's say that night, which then might throw off the next day and the next day.

I like to tell people if you're going to do that, you have to also set some restriction on it. Right? So go ahead and sleep till 1:00, if you can't go to bed at 10:00 PM. Okay. But the next morning you really have to still engage your routine. Right? So it might require you waking up at the 7:00 AM time again so that your body's ready for bed at 10:00 PM the next day or that evening I mean. So I think you can make modification, but do it within reason because once you throw the pattern off your body reacts to that, right? And then you have to really readjust it in some ways.

Ellie Pike:
Sounds like there is room for flexibility, but then awareness to bring your body back to some routine so that your body can be conditioned in a positive way.

Dr. Clayton:
Exactly. Exactly.

Ellie Pike:
And then I'll let you hop back in. I know you were talking about sleep hygiene and some of those pieces and I interrupted you when we talked about sleep routine.

Dr. Clayton:
Yeah. No problem. No problem. So I guess just a couple of the other things I'd like to highlight are, really setting the conditions for your sleep. And I think you mentioned this earlier, in terms of like what you can control. And I think that this becomes so important when we think about sleep related conditions right? So, for some people, if you can regulate the temperature in your space to a temperature that's ideal for you to sleep comfortably, then things like that are important. For some people, if you can regulate the sounds. Right. And again, if you're living in a city, it might be harder because there's noises beyond your control.

I've heard people like the white noise machines, things like that that can help make the space more comfortable. Some people sleep more comfortably if it's completely dark, others sleep more comfortably if there's a little bit of light. So, again, figuring out what works for you in that regard. Even things like your mattress and your pillow become really important. Right? Because it's really about the comfort level that you're creating in that space as well. So let's see, regular exercise can be a really good idea. But you really shouldn't do anything too strenuous in the four hours before bed.

So, while exercise generally can be helpful, you want to be mindful of the timing. And some people tell me they like to do something physical before bed, and I let them know there's certain things that are more ideal. Right? So, I always talk about stretching or even yoga. Something that's not going to excite the body or wake it up in ways, but something that's going to be more relaxing and grounding in that way can be something that you can definitely engage before bedtime. And then, let's see, the last couple things. I think I had started to mention this, no naps. I know. I get it. I want a nap almost everyday.

Ellie Pike:
That sounds so hard.

Dr. Clayton:
It's really hard. So, I'll say a couple things about that. It's best to avoid taking naps, but if you're going to, then you have to be mindful of the period of time that you sleep. So it should be definitely less than an hour and you should do it on the front end of the day in some ways. Right? So before 3:00 PM in the ideal. And again, this is about the routine or the clock that your body's running on. Right? Because you've done the work for your body to know when it's bedtime. But getting that sleep in the middle of the day can really throw off the clock. Something else to just highlight. I was just being mindful about maybe some of the more recreational substances, especially alcohol. So, again, I'm not saying you can't drink at all.

I get it, people want a glass of wine to wind down the day. But again, being mindful of the timing that you're doing it. So I think if you're doing it in the two hours before bed, it can really make it difficult to have a good quality of sleep. And this goes back to what I talked about in terms of your body, having to engage the thing that's been introduced to it. Right? It has to process it and almost reawakens parts of your body so that you're not getting that quality sleep that you're actually wanting. And I lied, one more thing I want to highlight is, if you can't fall asleep, you should get out of bed. I know. After about the 20, 30 minutes mark, if you realize you're just tossing and turning, you should really get out of bed.

Because we want to associate your bed with sleep and it can be associated with something not so restful if you're always tossing and turning. I tell people if you do get up out of bed to try to do something quiet. Right? You don't want to start getting on your phone because that's stimulating. Right? We've heard about some of the lights in phones and technology that restimulates rather than prepares you for bed. So if you get up, you want to do something boring. I know that sounds weird. But you want to do something that's not going to alert you as much as something that's going to facilitate relaxation or decompress. So I tell people, if there's something you find boring, to read, or something that's, again, just not stimulating, that will be the most important.

Ellie Pike:
This is so wonderful and super informative. And it makes me understand why in your modality of using CBT for insomnia, you do sleep diaries and journals. Because it is a lot of self-monitoring, not just when you go to bed but also when you had caffeine, when you exercised or didn't exercise. So, for some people, this is going to work where they can finally align and it works for them to create a new routine that really improves their quality of sleep. What about the people who have... I'm sure you work with a lot of veterans with PTSD and insomnia, at what point does someone need to seek medical guidance and medical care or even medication along the way?

Dr. Clayton:
Yeah. I mean, I think that's a great question also. I think that medication is always an option for people. And for some people they feel like that's the route they would like to go initially, especially if they feel like it's not feeling realistic for me to make some of these changes. I think that when a person gets to a particular level of sleep deprivation, it's almost hard to take in anything that's going to be helpful or feel like you have energy to apply it. Trauma related history can even add another component. Right? Because there's maybe the related insomnia, but there's also the nightmares. And so there are medications that tend to that more specifically. And so, I mean, there's a whole separate line of sleep related treatments that really incorporate the experience of nightmares also. And so, I think for some people the medications can also be helpful in that way.

Ellie Pike:
Right. Absolutely. And if someone is seeking medical care or therapy for sleep, where is the best place to start?

Dr. Clayton:
There's a lot of providers out there who provide these types of treatment. Right? So if you're thinking about medication, this is something you can even start the dialogue with with your primary care providers. It doesn't necessarily have to be a psychiatrist, it can be, but a lot of primary care providers will also engage some of the dialogue around insomnia and be able to provide treatment. When it comes to therapy, I think of course you can ask your primary care providers for referrals for psychologists or licensed mental health counselors or licensed social workers who can guide through some of these sleep related treatment.

Of course there's websites, if you aren't connected to primary care providers, I think there's a slew of websites out there now that really connect people to some of these provider resources. So like, Psychology Today, things like that, where you can do a search based on what you're needing and find providers who provide that type of care. And then also, I also recognize that therapy while helpful is not always accessible for people. Right? It's a resource that unfortunately without insurance can be a cost that people may not feel like they can take on. So I also like to remind people and let people know that there are so many, actually I feel like I'm realizing more and more even in the context of the pandemic, there's so many apps that have been developed that we can download on our phones that can be really useful for sleep as well. Right.

And a lot of these apps are free. And some of these can be used to guide you in certain relaxation strategies that are helpful. There's some that have sleep diary type spaces that you can fill out independently. So, while of course I think having the guidance of a mental health provider would be ideal just to cater to your needs, I also recognize it's not a resource that's always available. So, really just wanting people to be aware that there's also certain technology and apps that can be helpful when you can't access some of these other resources.

Ellie Pike:
This is so incredibly helpful and a topic that I've been wanting to interview someone on for a long time. So, thank you so much Dr. Clayton for bringing your expertise on sleep hygiene and just all that goes into it and understanding the individual variances. I very much appreciate that. It's definitely not a one size fits all cure to fix this sleep. So thank you so much for your time. And I know know that our listeners are going to find a lot of these tools extremely helpful. So, thank you again.

Dr. Clayton:
No problem. You're welcome. Thank you for having me.

Ellie Pike:
We covered a lot with Dr. Clayton, but I think the most important takeaways will be those eight sleep hygiene suggestions. They'll be listed in our show notes along with time stamps so that you can go back and review, but let's list them one more time just to get them in your memory. One, mind the caffeine consumption. Two, designate the bed as a sleep only zone. Three, find a sleep routine that winds you down. Four, similarly, find a consistent time to both fall asleep and wake up. Five, don't forget about the ambiance of your sleep space. Six, mindfully move your body but keep it relaxing if you like to be active before bed. Seven, avoid napping if possible. Eight, get out of bed if you can't sleep. And if I could add a number nine, just try, you're not going to get it perfect. And that's okay. Just try one of these at a time. Do you remember Sidney the paramedic from way back at the beginning of the show, while I really enjoyed how she explained the positive effects of finally getting the sleep she desperately needed.

Sydney Fitzgibbons:
I'd say it makes me a more active member of the planet, which I like to be when I can. Anybody that's struggling with sleep, don't give up. There are so many options and so many tools that you can use to help yourself. And when in doubt, contact your doctor and talk to them about out what you're struggling with because you're likely not their first patient to say they've struggled with sleep.

Ellie Pike:
Mental Note podcast is brought to you by Eating Recovery Center and Pathlight Mood & Anxiety Center. If you'd like to talk to a trained therapist to see if treatment is right for you, please call them at (877) 850-7199. If you like our show, sign up for our eNewsletter and learn more about the people we interview at mentalnotepodcast.com. We'd also love it if you left us a review on iTunes, it helps others find our podcast. Mental Note is produced and hosted by me, Ellie Pike, and directed and edited by Sam Pike. Till next time.