Sleep and Mental Health Disorders An Overlooked Treatment Issue

We are going to learn about sleep, its functions, the different sleep cycles, how much is really enough, how lack of sleep contributes to feelings of depression, anxiety, and irritability. We'll understand the connection between sleep and circadian rhythms, and finally, we'll review some techniques for improving your sleep hygiene.

The Connection Between Circadian Rhythms and Sleep

People whose **circadian rhythms** are off often have difficulty getting restful sleep. Now, remember, circadian rhythms are far bigger than just sleep, but when circadian rhythms are off, people often have difficulty getting restful sleep. When your circadian rhythms are off, you usually have higher **cortisol** levels, that stress hormone, and remember when stress hormone levels are high, **serotonin and melatonin** levels are going to be low. People whose circadian rhythms are off often report being tired at all the wrong times. Your circadian rhythm tells your body to secrete cortisol at its highest amount in the morning, that's that Awakening response, and then it's supposed to decrease throughout the day. If it's not doing that, then you're not going to know when it's time to be awake and when it's time to be sleeping. They also have difficulty concentrating and often confuse sleep and hunger cues.

Now, it's important to recognize that if your sleep is poor quality or inadequate, that's one of many things that will throw your circadian rhythms off. Likewise, as I already mentioned, if your circadian rhythms are off, it will impair your sleep. So it's a sort of a downward negative cycle.

Prevalence of Sleep Disturbances

What are the prevalence of sleep disturbances though, why do we care? In **4 to 22% of adults**, we see symptoms that meet the criteria for **Insomnia Disorder**, so those of you who have difficulty sleeping, you're not alone. **40 to 50% of people with comorbid mental illness** report symptoms of insomnia. Now, that's a big number and we're starting to recognize that **adenosine**, one of the substances that's cleared out during good sleep, is connected to or may be connected to mood disturbances. That's an interesting new avenue of research that's happening here in 2023. But do recognize that these things work, you know, sort of that chicken or egg, which came first, the insomnia or the depression, but it doesn't really matter, we need to treat both of them and as one gets better, likely the other one is probably going to improve.

**Hypersomnolence** or sleeping too much impacts **5 to 33% of Americans**, so that's a big number and one of the things that we see with hypersomnolence is that people who sleep too much are usually getting poor quality sleep when they are sleeping and then they're sleeping throughout the day, so their circadian rhythms are a complete mess. **Circadian rhythm sleep disorder** accounts for about **3% of people**. **Obstructive sleep apnea** impacts **15 to 30% of males and 10 to 15% of females**. Now, normally I try to give you an idea in terms of numbers instead of percentages because those percentages don't sound huge but when you think of it in terms of one in ten or two out of every 20 people have obstructive sleep apnea, wow, look around you and it's really easy to see how quickly that adds up. **4 to 14% of people** struggle with **restless legs**. Now, these sleep disorders may be ongoing or they may be episodic. So when somebody's having a um episode of major depressive disorder, their insomnia may get worse. It's we're not saying here that everybody experiences this or 33% of Americans experience hypersomnolence all the time, but they have gone through periods where they had hypersomnolence.

Assessing Sleep for Intervention

There are four things that we really want to look at when we as clinicians, counselors, social workers do an assessment, do a mental health assessment or a behavioral health assessment that include sleep, because sleep is so incredibly important in the recovery process.

The first one is **sleep latency**. How long does it take the person to get to sleep? And we want to look at sleep latency for the first time they go to sleep, you know, the first time they lay down at night, how long does it take to get them to get to sleep but then also how long does it take for them to get back to sleep if they wake up during the night. So there are multiple little sleep latency snapshots that we want to get because if they can fall asleep really quickly at first but then they wake up three hours later and they're awake for two hours, that's something to be aware of.

The next thing is we want to look at the **wake after sleep onset duration**. So how long is it between the time they lay down and the time they wake up? And for some people it's seven, eight, nine hours or more, for other people it's two hours. So if they typically fall asleep and sleep for two or three hours and then wake up, that's important for us to know and then we want to find out how long does it take you to get back to sleep?

How many **Awakenings** do you have during the night? And there's a lot of reasons that we're going to talk about that people wake up during the night. Some of them are very preventable through good sleep hygiene, others may have to do with medical conditions that can be addressed by a physician.

And what is your **sleep efficiency**? And basically, you take the number of hours the person's in the bed and you add up how many hours during that period of time they were actually asleep. So if they were in bed for eight hours and they were awake for a grand total of 20 minutes then their sleep efficiency would be 7 hours and 40 minutes but if they were in bed for eight hours and they were awake for three hours in the middle of the night then there's sleep efficiency would only be five hours and that's really important. It's not just about how much time you're into bed and we'll find it's not necessarily just about how much time that you are asleep if you're not getting good quality sleep. So we want to look at all of these things.

I will note here two things. One, it is normal for people to kind of wake up when they cycle through their sleep phases when they're in Phase One non-rem sleep, that's not unusual, but most people either don't even realize it or they very quickly go back to sleep. It's not disruptive. It's also important that we don't have our clients get too hung up on managing their sleep and getting better quality sleep and I know I sound like I'm contradicting myself, don't I? A lot of fitness trackers, for example, have sleep monitoring capabilities but they are not very accurate. So unless the person is working with a sleep physician and has actual medical grade sleep monitoring equipment then trying to monitor their sleep quality, how much deep sleep they're getting versus light sleep is probably in most cases going to add more stress and contribute to more sleep dysfunction than if they didn't look at it at all. So when we are monitoring sleep, what we really want to look at we don't want to get too far down in the weeds, how long is it taking you to get to sleep, how many number how many times do you wake up and um what is your sleep efficiency. So we want to have people kind of look at that so we can get a picture and if it looks like they're having regular difficulty getting adequate amounts of sleep or if we recognize that they're getting adequate sleep but that's they're waking up and they're not feeling rested then we want to make a referral.

The Importance of Sleep

I've talked about the importance of sleep but I really haven't articulated why. Sleep is when your body rests and restores. Adequate sleep **improves memory and learning**, **increases attention and creativity**, and **aids in concentration and decision making**. Think about the children that we work with who have behavioral disorders, who have difficulty learning, who have difficulty focusing and concentrating. Now granted, there are other things that can contribute to that, however, we also want to rule out the obvious: poor sleep, poor nutrition.

Sleep is a time when the body rests and restores. If there's not good quality sleep, the person is going to have **brain fog** in the morning. If there's not good quality sleep, the person is actually going to be a lot more likely to get sick. **Toxins that accumulate in the brain** are thought to be cleared out during sleep. **Adenosine** is one of those that I was mentioning earlier. **Healing and repair of cells** takes place during sleep and sleep helps the body maintain the balance of hormones in the body and this is important to recognize. It's not just your hunger and satiation hormones but it's also your insulin, it's also your gonadal hormones. So sleep by virtue of helping the body stay healthy and functioning efficiently and by virtue of helping maintain that circadian rhythm will help manage some of these things and the hunger and satiation hormones for example may impact a person who is having difficulty managing their food intake. We look at the criteria for depression for example and it's a significant change in eating habits. Well, part of that could be because they're not getting good quality sleep and their circadian rhythms are off.

Sleep also allows the brain to focus on rebuilding and repairing itself. They found that animals deprived entirely of sleep lose all immune function and die in just a matter of weeks. Now obviously it's a cruel experiment in my opinion, but this is zero sleep. Prisoners deprived of sleep entirely often develop **psychosis**. New parents deprived of sleep often have difficulty with memory and concentration. How many of us have referred to and in my day we called it mommy mind but when you have new children at home or even a new puppy that has to go out every three, four hours, you're not getting good sleep. How many of us have difficulty thinking clearly and being on our A-game? Well, that's because we're not getting good sleep.

Muscle growth, tissue repair, protein synthesis, and growth hormone release** occur mostly or in some cases only during sleep. Poor sleep contributes to the buildup of toxins, **oxidative stress**, and you're not going to have the same level of release of growth hormone so you are actually contributing to expediting the aging process.

Other rejuvenating aspects of sleep are specific to the brain and cognitive function. While we're awake, here's that thing I keep talking about, adenosine. While we're awake, neurons in the brain produce adenosine, that's kind of the byproduct of thinking if you will. The buildup of adenosine in the brain may lead to our perception of feeling tired. They call it **sleep pressure**. As adenosine goes up, sleep pressure goes up and as adenosine goes down, we start to feel more awake and alert.

Sleep deficiency is also linked to a higher risk of **cardiovascular disease, stroke, diabetes, kidney disease and just plain old systemic inflammation**. When you are sleep deprived your body registers that as a stressor and in its infinite wisdom tries to help you stay awake and alert which means triggering that **HPA axis**, triggering that stress response and when that goes on for an indefinite period of time the cortisol loses its anti-inflammatory abilities. You become resistant to the cortisol and you start to see systemic inflammation and we know that systemic inflammation is correlated with increases in pain, increases in sleep disturbances, increases in mood disturbances, you know, it just kind of spirals from there. So this is all connected. Sleep deprivation is also correlated to **difficulty concentrating, irritability, and fatigue**. Now, why do I have those three set out in particular? Because those three in particular and also I should add um changes in eating but those are symptoms of a variety of mental health issues. So if we're just saying okay you've got depression and we're treating their cognitions, well, that's great, you know, there's probably some work to be done there but if they don't start getting good quality sleep if they don't start regulating that circadian rhythm, some of those symptoms may not improve at least nearly as much as they could.

Sleep Disorders are often accompanied by **DSM-5 TR diagnoses** so these are official psychiatric diagnoses including depression and anxiety, cognitive disorders, substance use and non-substance use disorders, so for example gambling disorder, and other medical conditions. We want to recognize this. There's an entire chapter in the dsm-5tr on sleep disorders. They also may represent early warning signs of an episode of mental illness providing opportunities for early intervention to stop or reduce the intensity of a full-blown episode. So for some people prior to becoming a hundred percent symptomatic, you know, one of the early warning signs of an impending depressive episode or anxiety episode or manic episode may be sleep changes. Likewise, sleep changes especially sleep deprivation can trigger some of those episodes. So again we're back to that whole chicken egg, either way you can't remove one or the other, you've got to address it.

The Body Factory Analogy

We'll go back to that analogy I usually make of the **body factory** just to kind of bring this all together. During the day in your body factory the workers and the machines, all of your bodily systems do their thing. When the factory shuts down for the day, when you go to sleep, the maintenance crew clears out the trash, tunes up the machines, restocks the shelves to ensure effectiveness and efficiency. So hormones are rebuilt, adenosine and other toxins are cleared out, the machines, all of your different systems are repaired and restored so everything's ready when you wake up in the morning to jump out of bed and hit hit the floor running.

If the factory never shuts down, think about these poor workers, supplies run low, the machines become less efficient and break down, trash builds up and maintenance is trying to work at the same time and I think most of us have experienced this like before an audit when you're burning the midnight oil making sure all your ducks are in a row and everything and you're almost tripping over each other because everybody needs, well this is back in the days of paper files but everybody needs the file, the nurse needs the file, you need the file, and we are in the way of the maintenance crew that's trying to get everything cleaned up and cleared out and ready to welcome not only the Auditors but also the clients the next day.

Understanding Sleep Cycles

I mentioned we were going to talk a little bit about sleep cycles and again this is just for your understanding. This is something that they can pick up in a sleep study but during **Stage One non-REM sleep** this is when you **drift in and out of light sleep** and can easily be awakened. So think of it going back to that analogy of the factory, non-rem sleep is like packing up for the day, you haven't left the office yet so you can easily be called back into work but you're ready to go. You've pretty much mentally shut down.

**Stage Two non-REM** brain waves slow with intermittent bursts of rapid brain waves. The eyes start, stop moving, the body temperature drops and the heart rate begins to slow down. This is sort of what I say akin to clocking out, the machines cool down and it's your decompression time as you drive home. So you've left the office, it's going to be a lot harder to call you back in now. Can it be done? Yes but it's going to be harder. This stage usually lasts for approximately 20 minutes. Now we've got to recognize that your sleep cycles the duration of each stage changes a little bit throughout the night especially your deep sleep. In the beginning of the night, stage three non-rem sleep is a lot longer and because this is when a bunch of stuff is done but after that stuff's done then the maintenance crew is just going back and double checking so it doesn't take them as long to go through each floor of the factory.

So **Stage Three non-REM sleep**, also known as **deep sleep** or **Delta Sleep** is marked by **very slow Delta brain waves**. There's no voluntary movement, you're very difficult to awaken. So at this point this is like the factory having only maintenance staff doing their job and they're doing it very well thank you very much. But if all of a sudden you need to reopen the factory for an emergency, it's going to take a minute because you've got to call everybody back into work. So during Stage Three non-REM sleep, during this deep sleep you're out as my mother would say, you're out like a light and it's really difficult to wake you and when you do wake up sometimes you're disoriented and groggy and it takes you a minute to figure out who what where when why. This stage usually lasts for about approximately 30 minutes early in the night and the largest percentage of deep sleep comes in the early part of the total night's sleep pattern. So on a official medical grade sleep study you're probably going to see this duration of stage three shrink throughout the night because again most of the work all of the hard stuff is done on the first round of the building then successive round to the building is just double checking.

**REM sleep** or rapid eye movement is characterized by **temporary paralysis of the voluntary muscles** and fast irregular breathing, inability to regulate body temperature, faster brain waves resembling the activity of a person that's awake. Most dreams but not all of them, **most dreams occur during REM sleep**. During REM sleep the **amygdala** which is the fear part of your brain but it's also the part of your brain that processes emotions, activates and processes those emotions. Interestingly and I'm not going to go into a deep dive on sleep paralysis or REM sleep deprivation except for to say most antidepressants suppress rapid eye movement sleep and they found in repeated studies that restriction of rapid eye movement sleep, restriction of dreaming, restriction of the person's ability to turn on that amygdala and process those emotions actually improve depressive symptoms. Now do not try this at home, do not try to time this and not sleep but it is important to recognize that this may happen and people who begin taking antidepressants or who've been on antidepressants for a long time and weren't aware of this it may help them understand why they don't dream as much or why they may not seem like they dream at all.

How Much Sleep is Enough?

How much is enough? Part of it depends on the person, part of it depends on the quality of sleep and I as I said we don't want clients getting too wrapped up in how much deep sleep they're getting versus light versus REM, we just want to know how much sleep they're getting because if they get too far down in the weeds especially with inaccurate equipment they may actually cause themselves extra stress.

* Newborns need **14 to 17 hours** of sleep.
* Three months to one year old **12 to 15 hours**.
* One to three years old **11 to 14 hours**.
* Three to five **10 to 13 hours**.
* 6 to 13 years old this is elementary school and middle school **9 to 11 hours of sleep**. So think about what time that child gets up to get ready for school in the morning if they get up at six, you know, count backwards and figure out what time they need to go to bed so the median would be you know eight o'clock and if children are staying up until 10 11 12 o'clock at night then obviously they're not getting enough sleep.
* 14 to 17 year olds need approximately **8 to 10 hours** of sleep.
* And true adults over 18 need approximately **7 to 9 hours**.

Now, if you're sick, if you're pregnant, if you're undergoing something you very well may need more sleep than this and there are times where you may not feel like you need as much but in general for your body to do what it needs to do and function most efficiently and effectively these are the guidelines. Now, the deep sleep needed is approximately **15% or more** of your actual sleeping time.

Sleep, Hormones, and Nutrition

Sleep in hormones, I know I keep going back to some of this physiological stuff but it's important for us to recognize because if as we age our hormones uh production decreases which can contribute to sleep disorders. When we're pregnant, when we're taking birth control, if people who are taking hormone therapy for other conditions it may and likely will impact their sleep at some level so we need to recognize that because poor sleep may end up leading them to our office with mood disorders.

**Estrogen** at normative levels for that person usually improves the quality of sleep, reduces time to fall asleep and increases the amount of REM sleep. Now why do I say normative levels? If somebody's estrogen levels are within normal range for them and they take estrogen it's not going to improve their sleep, it's actually likely to worsen their sleep because too much estrogen or estrogen dominance is often associated with anxiety.

Too little or too much **testosterone** may also affect overall sleep quality and too much testosterone is associated with sleep apnea and reduced sleep efficiency. We want to look again, remember people regardless of their biological gender have estrogen and testosterone, the balance is just different but it's important to recognize that the way we're wired biologically at birth um affects how we respond to particular uh to particular hormones so that may be a treatment issue we need to consider. Sleep issues may be a treatment issue we need to consider with people undergoing hormone-related therapies. Sleep quality may result in alterations in testosterone levels.

**Thyroid hormones** which are too high can cause insomnia and too low can cause fatigue and lethargy. Back to that physiological aspect again, no amount of sleep hygiene effort is going to radically improve if somebody is hypo or hyperthyroid, that is a medical issue that needs to be addressed for the person to get maximal gains and thyroid dysfunction often co-occurs with insomnia, restless leg syndrome and obstructive sleep apnea so we want to also screen for these things.

The stress hormone **cortisol** prevents restful sleep. Higher levels of cortisol can create agitation, insomnia and sugar cravings. Think about when you're stressed, you tend to be a little bit more irritable, you may have more difficulty sleeping and you may crave sugar. Why is that? When the HPA axis is activated, the stress response, you're in fight or flea, what is sugar? Sugar is a very fast release source of energy so it makes sense that that may happen. Low levels of cortisol can be associated with inability to handle stress, extreme fatigue, low libido and mood instability.

**Estrogen** increases norepinephrine and serotonin and decreases dopamine so we want to recognize that um normative estrogen levels can help decrease dopamine. Why is that important? Well dopamine gives us energy so that can be helpful to have a slight emphasis on slight decrease in dopamine. What do antipsychotics do? Decrease dopamine and what is one of the side effects of antipsychotics? Extreme lethargy. **Progesterone** helps balance estrogen, promotes sleep and has a natural calming effect but abnormal levels of progesterone can cause insomnia and contribute to irritability. So many times I've referred to that Goldilocks principle, too little a problem, too much a problem, we need it to be just right for that person and each person's levels are going to be a little bit different. That's why why doctors have ranges but some people may be within the normative range but at the very low end and experiencing symptoms so we need to encourage them to advocate with themselves for themselves with their doctor if they feel like yeah it's in the normal range but it's barely there and I'm feeling like crap.

In terms of **nutrition**, poor nutrition can also impair sleep because we need to have the building blocks for serotonin to make melatonin to help us drift off to sleep. So **tryptophan** is important and that's a protein that's really really abundant in just about all the foods we eat, you don't need to take supplements but it's important that you eat a high quality diet with enough protein.

**Caffeine** is a stimulant with approximately a **six-hour half-life**. So half-life is how long it takes the body to eliminate half of the substance. **Nicotine** is a stimulant with a **two-hour half-life**. So how long does it take to get nicotine out of your system so you can sleep? Interestingly and and this has been updated, **decongestants** are stimulants with a half-life of between two and six hours and that's for your rapid acting if you will, decongestants, not your extended release, extended releases way longer than that but it's important to recognize if you're sick and you're taking decongestants, it may impact your sleep latency, it may impact your sleep quality, there's a lot of things that may impact, however you got to weigh the good with the bad, how much worse is your sleep going to be if you can't breathe?

**Antihistamines** are common over-the-counter sleep aids and also used by people who have allergies. They tend to make you drowsy when you take them which can help some people fall asleep but they tend to have rebound drowsiness the next day and often contribute to poor quality sleep.

**Alcohol**, a lot of people drink in order to get relaxed so they can go to sleep. Well yeah, it does help people get to sleep faster, it reduces their sleep latency. It also tend to like SSRIs tends to block REM sleep. It can also because it's a system depressant can worsen sleep apnea and it causes poor quality sleep in the second half of the night. Think about if you've worked in a detox unit, you're familiar with this. As people's alcohol gets out of people's system, it leaves their system faster than the body can compensate with its own endogenous depressant substances so people's blood pressure and their anxiety tend to spike at a certain point during the detoxification process. So if you're drinking especially if you drink enough to get drunk and you go to sleep, well, you may sleep hard, maybe not well, but you may sleep hard the first part of the night but then you may wake up or you may toss and turn a lot the second half of the night because your HPA axis is activated.

Eat a high protein dinner to ensure you have enough tryptophan in the body and make sure you're getting enough **selenium, vitamin D, calcium, vitamin A, magnesium and zinc**. Again, most people do not need to take supplements if they're eating a relatively healthy diet, however, if you're not getting enough and you can track your meals in a variety of different apps, if you're not getting enough of particular nutrients, talk with your doctor about whether a multivitamin is hopeful. Some doctors are very pro multivitamin, some are very anti-multivitamins so you really need to talk with your physician.

Circadian Rhythms and Sleep Hygiene

I've mentioned circadian rhythms and I'm just going to touch on them one more time to um re-emphasize the fact that it's approximately a **24-hour internal body clock** that involves patterns of brain wave activity, hormone production, cell regeneration and other biological activities. It's not just sleep. The circadian clock is set by the **light-dark cycle** as well as **temperature**—you need to cool down in order to go to sleep—and **socialization**—are your activities over a 24-hour period. So when little kids come home from school and they play and then they eat dinner, then they go to bed or then they take a bath, then they read a story, then they go to bed and if you change it up on them then a lot of times they're going to have difficulty getting to sleep because their brain hasn't been cued in. Circadian rhythms allow organisms to anticipate and prepare for regular environmental changes and best capitalize on the environmental resources available.

**Circadian rhythm disorders** can be caused by many factors including **shift work** so you don't have a choice, one day you're working eight to four, the next what day you're working four to twelve, **pregnancy or menopause** where there's a change in hormone levels that can impact temperature regulation, serotonin levels and just general comfort, **time zone changes**, certain **medications** will impact your circadian rhythms like the antipsychotics that I mentioned because they tend to make people feel very sleepy, **changes in routine**, **medical problems** including Alzheimer's or Parkinson's disease, so your neurodegenerative disorders, and a variety of **mental health issues**.

So what do we do? As I've mentioned multiple times, we are not dietitians, we are not doctors, we are not sleep professionals. Okay? So if a person is having a lot of difficulty with sleep, we're going to need to make a referral. However, there is a large subset of people who simply have difficulty with sleep because they have really crappy **sleep hygiene** and I think most of us have at least a few things in here that we don't do very well. So create that **wind-down ritual**. It doesn't need to be multiple hour involved but something that you do like read a book or um do a crossword puzzle or something before you go to sleep that cues your body in when I do this.

Conquering The Insomnia Cycle: Triggers, Anxiety, and The Power of CBT-I

Can CBT-I Cure Insomnia Caused by Nighttime Urination?

So let's start with the first question which is **can cbti cure insomnia caused by the need to urinate during the night** so **cbti is the gold standard treatment form insomnia** cognitive behavioral therapy for insomnia I've done other videos recent videos where I go and describe what cbti is so I won't do that here but this question is if you have to get up and urinate in the night and that's interfering with your sleep can cbti cure the insomnia.

To answer this question you have to kind of break apart a couple things here number one you need to **separate the trigger from the cause** so what's a trigger? A trigger is anything that is disturbing your sleep so that could be the need to urinate in the night it could be loud noises outside it could be a stressor going on in your life like a job that's very stressful or you're having a relationship issue or even something positive like you're going to be traveling the next day and you're excited and and it's hard for you to sleep so those are triggers that can lead to a poor night of sleep or even a couple of poor nights asleep but **that is not insomnia yet** insomnia is a pattern of trouble falling asleep staying asleep over a certain period of time that's consistent it is not just a poor night of sleep so you first need to separate these apart.

The trigger can lead to poor sleep but **what creates insomnia is the way we react to the trigger** we get really anxious we start worrying about our sleep and then we start doing things we start changing our behaviors around our sleep that then actually mess up our sleep even more these are called **poor sleep behaviors** and that increases our anxiety more which makes us want to try to fix the problem more which makes the problem worse and this creates what I call the **insomnia cycle** that is what creates insomnia **not the trigger** everybody has poor sleep sometimes and that's a normal part of being a human being but that does not necessarily lead to insomnia it's how you respond to that trigger so that's the first thing.

So one trigger of poor sleep or one cause of poor sleep can be the need to urinate now this is more common with people who are getting older let's say 50s and older and particularly with men and this is just a normal thing because of the prostate as men get older their prostate changes and they might have more of a need to urinate in the middle of the night and this is actually very common if you're doing that maybe two or three times a night there's nothing wrong with that and as long as you're able to get back to sleep so you get up you go to the bathroom and as long as you're able to get back to sleep within a reasonable amount of time which is generally **20 minutes even up to 30 minutes or less** then you don't have insomnia and it's not a problem because that's a normal part of just aging.

The problem is if that has led to you developing **insomnia** because when you get up in the night to urinate you get really anxious and you get into that cycle that I just described that actually ends up creating the insomnia so you want to separate these two because it's **not the urination that's causing the insomnia it's the way you're responding** to the fact that you have to get up in the night to go to the bathroom and it's that response that's causing the insomnia and that response can change so to answer this question **can cbti cure insomnia caused by the need to urinate during the night the answer is absolutely yes cbti can get rid of insomnia no matter what the trigger is** because it's not the trigger that's actually causing the insomnia it's your response it's the **negative sleep thoughts** and it's the behaviors the poor sleep behaviors that get adopted in response to the poor sleep that then actually make the insomnia worse unknowingly to you because you think you're helping your sleep but you're actually making it worse.

Then what you want to do is address the problem now if you're getting up in the night two or three times and you're you know let's say an older person 50s 60s 70s older than that that's normal that's not a problem as long as you're able to get back to sleep however if you're getting up you know five times a night eight times a night to do that that means there's something more serious wrong with a prostate if you're a man or if it's a woman it could be some other issue and that would be more of a separate medical issue separate from insomnia that you would want to address because that could disturb your sleep so a lot of things can like interrupt our sleep there could be loud noises outside the neighbors could be having a loud party your partner if they move around a lot in the bed that can disturb your sleep but **those things are not insomnia** those are things those are just like conditions that make it difficult to sleep but that is not insomnia **insomnia is internal** it's a pattern of poor sleep where your sleep system actually shifts based on those things I said earlier the shift in the way you're thinking about your sleep now you're really anxious about your sleep and you've changed your behaviors so you want to separate these two issues whatever the trigger is whether it's urination or something else and address that as best you can so if it's a real problem then go to your doctor and try to you know treat the prostate or whatever the problem is so you can be getting up less in the night sometimes it's a matter of drinking less a few hours before you're going to sleep sometimes people drink a lot of liquids in night at the night time tea things like that so you want to reduce that so you're not having to have the need to go to the bathroom as much but then if the insomnia is already there even once you remove the trigger **insomnia remains** once it becomes a pattern you have to address it as a separate issue and in that case the **gold standard is cbti** and again I've done videos on that I'll put a link to the video that I recently did or the playlist that I that I'm creating that kind of goes into cbti in more depth.

Dealing with Severe Anxiety and Insomnia at Night

Let's get to question number two **how does it work if you have severe anxiety when you are awake at night and feel so bad you have no energy to go do something out of the bed** so part of cbti part of the treatment for insomnia is **getting out of the bed** at a certain point when you're not sleeping now I'm not going to get into that skill that's called stimulus control or in my insomnia program that have I call it 3030 because I don't like stimulus control and it involves getting out of the bed but it involves doing it at a certain time in a certain way there's a whole mindset around it it's probably the most challenging skill in the process because it's both behavioral changing behavior but it's also a **shift in your mindset** that's really key to overcoming insomnia and you actually don't even start doing that until the third week of the process and you're doing that in addition in conjunction with a few key skill so it's not just one skill that gets rid of insomnia It's a combination of things done in a certain sequence to answer the question here this person is asking is they're lying in bed at night they're awake they have insomnia and they're really anxious what you want to pay attention to here is the wording used in this question okay because that's one of the keys to to solving this problem first of all um this person is saying they have **severe anxiety** okay well you want to first distinguish what kind of anxiety when someone has insomnia they have anxiety they have **anxiety about their sleep** it's called **Sleep anxiety** those are caused by **negative sleep thoughts** that's things like oh my God I'm never going to get over this what's the matter with me I've lost my ability to sleep how am I going to function tomorrow if if I don't get a good night of sleep okay that creates a lot of anxiety around your sleep or your health or your ability to function and that is normal with insomnia everybody that develops insomnia has the sleep anxiety some people if they've had insomnia for a really long time won't have the anxiety anymore because they've just gotten so used to it but most people who are dealing with insomnia have this this is not unusual.

So to answer this question it depends on the type of anxiety if you have other type of anxiety if you have **panic attacks** if you have let's say **PTSD** post-traumatic stress disorder okay that's an anxiety disorder so there's other types of anxiety have nothing to do with insomnia that people can have in addition to the insomnia so if you have severe panic attacks you know during the night yes that is definitely going to make it difficult to sleep because you're getting extremely anxious you're releasing adrenaline and that's the opposite state you want to be in when you're trying to sleep or if you have severe PTSD and you're having flashbacks or some kind of traumatic reaction when you're going to sleep yes that's going to really disturb sleep but again like I said in the previous question **that is not insomnia** that's a separate issue that is interfering with the sleep and then as a result you might have also developed the insomnia in addition to these this other anxiety problem what that means is if you have a severe anxiety problem that's not insomnia related meaning it's not sleep anxiety it's PTSD or panic attacks you need to go and address that separately with a qualified psychologist who knows how to treat anxiety disorders and the best treatment for that is cognitive behavioral therapy this is just the **general CBT not cbti** which is specifically for insomnia but CBT and that's the best there's a certain type of CBT that I recommend for this and I'll put a link to that in the description but if it's so severe that you're paralyzed in the night or it's it's it's that you can't sleep then yes you sometimes you need to address that as a separate issue in addition to the insomnia most likely even if you address the separate anxiety issue you're still going to have the if it's been in place for a while because that has become a separate problem of its own and then in that case you still want to do the cbti but if it's so severe that you're paralyzed and you can't do anything you might have to address that first.

But what if the anxiety you're having is anxiety from the insomnia it's the **Sleep anxiety** you're you're having all those negative sleep thoughts then in that case one way to get rid of that anxiety and to start reducing it is to **get out of the bed and to to do something else** so the other part of this question the other language that I want to focus on here is this person says **I feel so bad I have no energy to do something out of the bed** what you say to yourself has a huge impact on how you feel emotionally and the things that you think you're able to do if you say I feel so bad I can't get out of the bed or I can't do anything you're kind of screwed because you're trapping yourself you're telling yourself I can't do anything and the fact is when someone is anxious and even severely anxious they can still do things you know if you think about people they might be terrified to give a speech and yet they're up in front of the audience giving a speech they might be terrified when they're in combat if if they're a soldier and yet they have to learn to be able to you know be in combat even when they're very very anxious and afraid which is normal for someone in combat because they're in they're actually in a dangerous situation if you think about it when you're anxious you have a **ton of energy** because the anxiety is fear anxiety is fear that means you're in the **fight or flight response** and when you're in the fight or flight response you are generating a lot of adrenaline and epinephrine and that's putting a lot of energy through you in addition with insomnia you have what's called **hyperarousal** where you're super like awake and alert so yes you might be exhausted right and you don't feel like getting out of the bed it's not fun to get out of the bed at a certain point but that doesn't mean you can't do it and it doesn't mean that you don't have the energy to do it you're just telling yourself that and that is sort of keeping you stuck in that place okay this is assuming it's sleep anxiety and not you know severe PTSD something like that.

First of all what you want to do is switch around the language and say something like or think something like yes this is really uncomfortable being anxious I'm really scared about my sleep and it does not sound fun getting out of the bed or it does not sound fun getting up and do something but **that's what I need to do to solve this problem** that's a key thing I need to do to solve the problem and when you actually do that with the powerful thing about this skill is that **when you get out of the bed the anxiety goes down** because you break that state you get out of the bed and the the context in the environment you're in that's actually feeding the anxiety and when you're in that mode of anxiety and arousal it's hard to break out of it when you just stay where you are so if you get out and you go to a different environment and you put your focus on something else like a book or something like that then your body starts to calm down on its own because you're not focused on sleep or trying to relax you're forgetting about it for a while now again I wouldn't recommend trying to practice this skill out of context of the full cbti treatment in process because it's a challenging skill it's very counterintuitive there's a whole mindset thing around it and when you get out of the bed and how long you stay out of the bed and that there's all these different pieces to that and so I wouldn't recommend doing that what I wanted to focus on in my answer with this question is really focusing on how you're thinking about this and that you really want to start shifting that and that **even though you're anxious you can still do things you can still function you can still take actions** and that is actually the number one way people get over any kind of anxiety and fear is facing the fear otherwise you stay paralyzed but if you face the fear even if you're petrified that's when the fear starts to go down because you're telling yourself I'm not afraid of it and that's how you learn you're going to be okay the thing you're afraid of isn't going to happen in other words **action combats anxiety and fear** okay.

My Background, Qualifications, and Measuring Success

So let's go on to the next question someone had a few questions about my background and how I got into this first one is **what is your background in sleep study** I'm a **clinical psychologist** and clinical psychologists do not get any training in sleep in graduate school unless they end up specializing in sleep they get no training now this is true also of medical doctors medical doctors go through 8 to 12 years of training and maybe in that 8 to 12 years they get 30 minutes to 1 hour of training in sleep total okay I've talked about this before it's totally nuts sleep is fundamental to our health and our life we spend a third of our life literally asleep because it's so important to our functioning and our health and all the different systems in our body and yet psychologists social workers therapists counselors medical doctors that includes psychiatrists receive very little training in sleep and that includes insomnia there's actually a hundred different sleep disorders **insomnia is the number one** like more people suffer from insomnia than any other sleep disorder and yet people get very little training in sleep so how did I get into this?

I **developed insomnia myself** after I was already a psychologist and I was a specialist with anxiety and stress and I developed insomnia and I didn't know what to do you know I had really severe insomnia for 6 months difficult falling asleep staying asleep so I had to learn and I went out and I researched and I read books and I found what was considered the **gold standard treatment for insomnia which is called cbti** and I read on it and to get an understanding of it the success rate is very high and I was convinced this was the thing for me I went through that and I was able to cure my insomnia I got completely got rid of the insomnia this was back in **2014** so this is 10 years ago and I have not had a relapse since because the last part of cbti is **relapse prevention** you learn how to prevent insomnia from coming back originally how I learned it was I had insomnia myself that I wanted to overcome and I learned the treatment and I went through it and it worked and it was amazing because to get rid of something like that it feels amazing if you're dealing with insomnia it's it's a horrible feeling and so then I started working with my clients I was already working with a lot of clients that had insomnia because I was specializing and anxiety and stress so I started implementing cbti with my clients and eventually developed an **online program for insomnia** so basically anybody in the world could could do this because it's really hard to find qualified cbti providers so that's how I got into it now I would consider myself an **insomnia specialist** there's a zillion different sleep disorders like sleep apnea and those things are separate issues they can definitely contribute or be a trigger for insomnia but basically my specialty is insomnia because it's the number one one it's like **10% of the world population suffers with insomnia** we're talking hundreds of millions of people and that's chronic insomnia and then if you expand to just the number of people that get insomnia every year is something like 30% or 40% it's crazy and that's why I I **solely focus on that as a specialty**.

Next question was **are you a qualified doctor with clinical records in the success for your courses** so I already mentioned sort of the qualified doctor like I said I'm a **licensed clinical psychologist** I've been a psychologist now for **18 years** years and 10 plus years just specializing in insomnia but I also have specialties in anxiety and stress and and a few other areas as well so I've done this with hundreds and hundreds of clients the cbti and insomnia so that's my qualifications really wouldn't matters with qualifications is not certifications and all that stuff I have the certification and the degree but **it's the experience and the skill that the clinician has in implementing the treatment** there's very few people who know this treatment well and even the ones that say they know it a lot of them don't know it well because they have they don't have the experience or they're missing certain pieces so when you're looking for a qualified clinician you just want to make sure not only do they know the treatment well and they're doing all the different parts of the cbti the way it was supposed to be done and the way it's been developed over the years but also they have experience implementing it with a lot of different clients in doing that successfully.

The second part of the question was do I have clinical records in the success so **how do I measure success** okay I said in another video I have a very high success rate in my course cbti alone has been studied on on hundreds of thousands of patients and clients with insomnia and has a very high success rate for a behavioral treatment but I find that with my programs I've had a higher success rate mainly for one reason that the people that come in who are really **committed** you have to be really committed to go through the process because it takes some time and there's some effort it's like you know losing weight or getting in good shape that kind of thing it's extremely effective but it takes effort um and if you put in that effort it pays off and you get over the insomnia and it's great and you know how to keep it from coming back for life.

The way that I measure success is a couple different ways number one in terms of data part of cbti is keeping a **sleep log** so in my program I provide a sleep log actually in a Google sheet it's pretty simple each morning you wake up you open up your Google sheet which is your sleep log it asks you a few questions you answer about your sleep the previous night and then there's calculations built in kind of like an Excel spreadsheet that will calculate some key numbers like your **average sleep time** your **sleep efficiency** which is the amount of time you're actually sleeping versus being awake when you're in the bed and the actual amount of time that you're spending in bed and then it creates averages over the week these numbers are the key for personalizing and applying the skills with cbti but **they're also the measure over time of how your sleep is progressing** so because we're tracking your sleep week by week night by night over the entire course this is over several weeks normally when you're going through cbti we have an enormous amount of data every week on how long it's taking you to fall asleep how long it's taking you if you wake up in the night to get back to sleep what time are you getting up what time you're going to bed how long are you up during the night in total and then what is your average sleep time each night and over the week and with your sleep efficiency which is a percent so we have all this data that tells us how you're progressing this is how we know you're progressing where you're progressing it also like when I work with clients and I I review the sleep logs I've looked at thousands of these things over the years and I can immediately see what the problem is when I look at a sleep log I can see if you have onset which is difficulty falling asleep **onset insomnia** **maintenance insomnia** which is difficulty staying asleep or **early morning awake** and you're waking up super early in the morning and you're not falling back asleep these are different kinds of insomnia the sleep log shows that and then it shows the data over time so is your sleep efficiency improving is that number going up is your average sleep time going up so those are the two key numbers in addition to the **instances of insomnia** how many nights a week are you having difficulty falling or staying asleep that should reduce over time and eventually get to zero and it's this data that tells us the success right if that's not changing or it's getting worse we're not getting success if that's getting better each week over time it's improving then then we know that we're getting success because that is what insomnia is insomnia is **removal of the instances of insomnia** so you're not having difficulty falling or staying asleep anymore and your average sleep time has gotten back to a normal state which for most people is **7 to 8 hours** it could be you know anywhere in that range and your sleep efficiency is **85% or better** okay that's a normal sleep deficiency so once we get to that and that's consistent and that's smooth we have a we have success we've overcome the insomnia so that's how I've measured it because I have sleep logs and and and in my program people share their sleep log with me so I have all that data in front of me for the whole program and so I know with each person how they've progressed and how successful they've been and this includes medication so if you're taking medication which a lot of people do for insomnia and you want to come off it and we two of cbti you start to taper off your medication and we track that in the sleep log as well so we have the type of medication you're taking and we have the dosage and then we see the continual reduction of that over time because you're slowly tapering off the medication while you're implementing the skills and then we see how that affects the data as you're coming off the medication how is that affecting the insomnia and your average sleep time and your sleep efficiency and the powerful thing is you see that these are not very correlated at all and that helps you get over the worry about giving up the medication and see that you have the ability within yourself to sleep so that's the main way in terms of data and tracking the success of my programs is the **sleep log and the data that comes from that**.

The second one is just **self-report from clients** if a client is going through I have a couple different options for programs one is self-guided so those clients I don't actually interact with directly much but have a program an online program that includes support from me and those people I interact with every week and they share their sleep logs with me so I see their data and I know how they're progressing and they tell me how they're doing so again with self-report people will say you know it's great I'm getting better I'm very encouraged or I've gotten off my medication they'll post um I have a community within the platform that I use where people can post successes and wins so I see it there but ultimately they'll tell me if it's it's working if they're improving how it's going and I'll see the data and that's how I measure the success in my program.

And the last question I pretty much answered it's **can you give a brief description of what motivated you to tackle the niche category of insomnia** and mainly it was because of **my personal experience of having insomnia** I had no awareness or very much awareness of insomnia or sleep issues until that point I slept totally fine until I was 44 years old and then I developed the insomnia and then now it became it became a major focus and I realized how many millions of people suffer from this I also learned as I said that the **gold standard treatment for this which has been around for decades is just not highly recommended by medical doctors and therapists** they simply don't know about the treatment because they're not trained in sleep so it's not even in their awareness and instead what they'll do is just prescribe a medication or they'll tell you to do sleep hygiene or they'll tell you to meditate or these kind of things or or supplements and **none of these things work** and so people end up staying frustrated and stuck for years with insomnia because they're not given the right path they're not given the right treatment for it which is cbti so part of my motivation was I had a personal connection to it and I saw that I could help my clients who were already dealing with insomnia I liked that it was a very specific area like for me as a therapist I like to be amazing at what I do like some therapists and doctors are just generalists they like work with everything but I don't think you can become really really excellent and expert if you work with everything because it's too it takes too much time and experience to be able to become an expert at something you can't become an expert at everything this is why doctors specialize and I think therapist should do the same so I specialized very early on in anxiety and stress and then when I developed insomnia I added that as a specialty and now essentially that's probably **90% of what I work with is in insomnia** and what that does is first of all I like it I know the treatment extremely well and I like being able to help people with this problem because I know that there's a real shortage of qualified providers there's also a shortage of access so even if there is a provider in your area many times there's a huge weight list like there could be five six month weight list sometimes to be able to do this which is just ridiculous or in some parts of the world and even in the United States there is just no providers at all and that's why I created an **online program** so people can access that from anywhere in the world as long as they have an internet connection and some kind of device to consume the material and I have actually found doing it online is better than doing it even one-on-one because basically you can go through the trainings on your time and also you still get the support and it's more flexible you don't have to drive to an office and there's a lot of other things but that's what I have found so that is why I turn it into a specialty because I really wanted to focus deeply on this issue and just be the best I can be at this and be able to help as many people as I can um with this problem who are finding it difficult to to to get treatment elsewhere okay so I hope you found these answers and these questions helpful .

5 More Weird Things That Happen When You Have Insomnia

Last week I talked about five weird things that happen with insomnia that are very common and totally normal. Today I'm going to talk about **five more weird things that happen with insomnia**. according to  Dr. Steve Orma, a clinical psychologist and a specialist in insomnia and anxiety. So let's dive right in.

1. Jerking Awake Just as You Fall Asleep

The first weird thing that can happen when you have insomnia is that just about when you're going to fall asleep, **you suddenly jerk awake**. I don't see this a lot, I don't think this is very common with insomnia, but I've seen this with a decent number of clients that I've seen which is that they get into bed and they're relaxed and they start actually going to sleep but just before they fall asleep they jerk awake and sometimes they might even sort of sit up and get startled and this could be very strange for some people. This might even happen several times in a row when they're going to sleep and it can be strange 'cuz why is this happening and it can also be very frustrating because you're just about asleep and then you suddenly jerk awake again.

This could be happening from a couple of different things, but generally I think what's going on here is when someone has insomnia they have **anxiety around their sleep** and they have what's called **hyperarousal** which is this, you know, your body kicking into kind of this hyper gear to keep you awake because you're not getting enough sleep. That is keeping you awake at the wrong time when you want to be going to sleep and so you have this hyperarousal. So when you're in that state or when you're anxious it's difficult to let go and to be able to fall asleep. You have to be able to let go and you have to be able to **let go not just physically but you have to be able to let go mentally**, meaning you have to let your conscious mind go, your reasoning mind, and just let your subconscious and your sleep system which is just built into you naturally take over. And what happens between that transition of letting go of your conscious mind and drifting into sleep is your conscious mind at some level is still observing your sleep and this is very common what happens with insomnia and why it can make it difficult to fall asleep sometimes is people have a hard time letting go. Like even when you're focused on just let go, just relax, part of your mind is observing whether you're falling asleep or not because you're so worried and concerned and you want to fall asleep so badly that you're watching it and because you're watching it, you know, even if you start drifting into sleep you'll suddenly jerk awake because your **conscious mind is still awake, it's still watching, and you have to let that go**. That's usually the main thing that's causing these **hypnic jerks** is just you're not fully relaxed and then as you're going into sleep you're jerking awake.

Now, sometimes I've seen this happen with people if they're **drinking a lot of alcohol** in the evening which can definitely affect your sleep and your sleep system and that could be one thing that as you start to relax your body sort of jerks almost like you're falling, like there's a sense of falling sometimes when you're going to sleep particularly when you're really tired or possibly when you're drinking alcohol and so it's sort of like a defensive mechanism to sort of jerk awake to make sure that you're safe. So it's normal as far as I know, there's nothing like this can't hurt you, it's just, you know, annoying and irritating and obviously interferes with your ability to fall asleep.

2. Not Being Able to Tell if You're Sleeping or Awake

Weird thing number two that happens with insomnia is **you can't tell if you're sleeping or awake**. Now this is a very common thing that my clients report to me that they experience and I also experienced this one I had insomnia is that as they go through the night sometimes it's difficult for them to know whether they're awake or whether they're asleep. Sometimes it seems like they're dreaming and then it seems like they're awake and and you know they're not quite sure which is going on here. So like when you're going through cbti which is the gold standard treatment for insomnia and it's what my insomnia program is built on, you're actually tracking your sleep each night or in the next morning after night you're recording what happened and sometimes people find it challenging to know well how long did it take me to sleep, fall asleep, or or when I woke up or because they're not quite sure when they're sleeping and when they're not sleeping.

Okay, this is a normal thing that happens and what's going on there is just because you're not fully relaxed your sleep is **restless, it's more shallow, it's more choppy**. This is particularly true also if you are taking medication or other things that could interfere with sleep like alcohol as well but just even if you're not taking medication and you're not drinking alcohol this is a normal thing that happens with insomnia because you're just not fully relaxing into your sleep so you're literally going into sleep you're coming out of sleep, you're going in, you're coming out and it can be confusing because sometimes you're not sure whether you're awake or whether you're asleep and that's normal. And really again it's just part of insomnia and the way to get over that and to smooth out the sleep is to overcome kind of get rid of that hyperarousal which you do through the process of **cbti or cognitive behavioral therapy for insomnia** which is the the main treatment for insomnia, the gold standard that you want to do.

3. Medications or Supplements Work Some Nights But Not Others

Weird thing number three that happens with insomnia is **medications or supplements seem to work on some nights but not on others**. So this is very very common with medication or even if you're just taking supplements or sometimes people are taking a combination of these things where it seems like, you know, you take your medication whatever that is and you sleep great and you think the medication really helped me sleep last night and then you take it the next night and it doesn't seem to work. You're baffled because sometimes it seems to work and sometimes it doesn't seem to work. You might be taking a supplement like magnesium or melatonin or something like that, sometimes it seems to work, sometimes it doesn't.

So what's going on here is a couple of things. Number one, just on the physical level, on the physiological level, medication if it works, and when I say works it sedates you, it knocks you out. **It doesn't actually address the underlying problem of insomnia**. I've talked about this a lot, it doesn't get to the root cause of the insomnia, it's just sedating you. It has a, you know, makes you sleepy and knocks you out. So when it's working to do that then it works then it knocks you out, you sleep, and sometimes you sleep through the night and you feel like well I got sleep, you know, it's not always the best quality sleep but you sleep. But what happens is with medications, on medications you build up **tolerance**. Tolerance means that over time the same amount of that medication doesn't have the same effect, it starts not working as well because your body builds up sort of a tolerance or get used to it so it's not like this new thing that's been introduced to your body where it has a really strong effect on your system. Our bodies are built to adapt so it adapts essentially to the medication over time and in order to get the same effect that you had before you have to either increase the dose which is what happens many times when people are taking medications for sleep, their doctor will to say well let's increase the dose or they'll switch you to another medication and you'll just keep playing this game of, you know, changing dosages and switching to different medications to sort of outsmart the tolerance your body is building up tolerance to a certain medication. So that's one thing that happens on the physical level with medications.

On another level, the psychological level, there's this thing called the **placebo effect**. You're probably familiar with this but what the placebo effect is it's a mental effect on our physical bodies and this is a very well researched, documented phenomenon that happens with treatments, with medications is if you believe something is going to work then it actually helps it work or sometimes it works just because you believe it will work right. So they've done a lot of studies where someone's given, you know, one group is given the actual medication, another group is given usually it's a sugar pill, there's no medication but they tell them this is a sleep medication and both groups sleep just as well because the group that took the sugar pill actually believed it was the medication and it was just that belief that actually caused them to sleep. This is actually the power of the mind and the mind plays a huge part of when someone has insomnia.

So when you're taking medication what happens is sometimes the medication is actually helping you sleep but sometimes medication isn't and it's just the **placebo effect**, your belief that it will help you and therefore you're more calm, you're you're expecting you to sleep better and because you're more calm and less anxious and confident you're going to sleep better, you actually end up sleeping better. And then these two things can get mixed up, sometimes it's the placebo, sometimes it's the medication, sometimes it's a combination and it's impossible to tell when you're taking the medication. You can't tell because you don't know which one is which because you're taking the medication. This is another thing that happens both with the supplements and the medication is this placebo effect and the placebo effect is inconsistent, medication is inconsistent and placebo doesn't last forever right. If that belief worked forever then someone taking a medication would just continue getting a good result because they were they believed at one point the medication was working. When the medication stops working on a physical level it starts to create doubt and it starts to undermine that placebo effect and that's why you get these sort of different results with medication.

4. You Were a Great Sleeper Before Insomnia

The fourth weird thing that happens with insomnia is that **before insomnia you had no trouble sleeping**. Now this is not true for everybody, some people come to me and they've had trouble sleeping their whole life, they've you know been difficult sleepers their whole life, but many people have no problem sleeping and then they develop insomnia and this was the case for me. I slept perfectly fine until my mid-40s and then I suddenly got really bad insomnia right. So you could have really good sleep, have no trouble sleeping, no anxiety, you get in the bed, you go to sleep and have that for decades and then all of a sudden it get insomnia.

The reason for that is this is **not a medical or a genetic issue**, it's not something that you're born with, it's something that comes from a **change in your behaviors** in response to usually some kind of trigger that interferes with your sleep. I've talked about this many times but this is what's called the **insomnia cycle** or I call this the insomnia cycle where there's some trigger in your life that interferes with your sleep. It could be travel, it could be a stressor, you're changing jobs, you're going through a relationship stress, a medical issue that interferes with your sleep and it causes some poor sleep which is not insomnia at that point, that's normal that happens with everybody and usually the way you responded to that was oh okay, you know, I'm having some difficult sleeping because this thing's going on and you don't really make any significant changes to your sleep you just expect you're going to get past it and then you do.

But what happens with insomnia is you have the poor sleep and you're got and **you react with oh my God this is not good I'm having trouble sleeping maybe there's something wrong** and you start doing things, you start changing your behavior and those behaviors which you're doing to help you sleep make the sleep worse and that turns into insomnia over time. So it's totally normal to be a really good sleeper and then suddenly get insomnia, there's not something wrong with you, you didn't suddenly develop some, you know, weird medical issue that you never had. It's just coming from the insomnia okay, assuming, you know, there isn't a medical issue, sometimes people do have medical issues and you do always want to rule that out or maybe it's sleep apnea, you want to rule that out. But if it's not coming from those things and you've ruled them out it's insomnia and it's coming from those shifts in behavior the in the way you're thinking about your sleep rather than some internal thing like a like a medical or physiological issue that's going on.

YOU CAN READ ALSO : Can CBT-I Cure Insomnia Caused by Nighttime Urination?

5. Sleeping on the Couch, But Not in Bed

And the fifth weird thing that happens with insomnia is **you can sleep on the couch but not in the bed** okay. This is extremely common where you have insomnia and you're in bed and you're trying to sleep and you're struggling and you're tossing and you're turning and you're there and it's like two hours later and you're just sick of being in the bed so you get up, you go to another room and you sit or you lie down on your couch or in a chair and you might be doing something. You might turn on the TV, you might be reading a book, and then before you know it you're asleep and you end up sleeping on the couch and because you're able to sleep there you stay there and you might sleep the rest of the night there or a couple hours there but you're able to sleep on the couch.

Okay, now what's going on here? Well, when this happens with my clients number one, I celebrate because first of all, yes we don't want you sleeping on the couch unless that's where you want to sleep, ultimately is to sleep on the couch and not in your bed, but if you ultimately want to sleep in your bed then you don't want to be sleeping on the couch when you have insomnia because it starts to **confuse your brain and you start to train yourself to sleep there instead of the bed**.

But why I have clients celebrate this is it shows them they have **not lost the ability to sleep**. If you're falling asleep on the couch, if you're having a difficult time keeping your eyes open, like before you go to bed at night, if you're really sleepy and drowsy during the day that tells you you have not lost the ability to sleep. The problem with insomnia is that the **timing is off and there's an association with your bed now with wakefulness**. So you could be falling asleep on the sofa, you get into bed you go to sleep at night and then suddenly you become alert. Okay, this was one of those weird things I talked about last week with the other five weird things is that you could be exhausted, you could be falling asleep on the couch, you get into bed and you become alert. So this is normal and this also doesn't happen with everybody. Some people with insomnia don't ever get sleepy on the couch, they don't get drowsy during the day so if that's happening with you, if you always are feeling alert during the day and you never get sleepy, you know, half of the people that have insomnia experienced that and half experience the other thing.

But what generally happens is once you start going through the process of overcoming insomnia, you're going through that process and your sleep starts to improve, **you will start to feel that drowsiness during the day** because now you become more relaxed and your body is more in tune with how tired you actually are and you start to feel more of that drowsiness and that's a good thing because again it reminds you I have not lost my ability to sleep. So you don't want to stay on the couch and you don't want to sleep on the couch. If you get up in the middle of the night and you fall asleep there you want to **get back into bed as soon as you catch that** because otherwise you'll train yourself to sleep on the couch.

All right so I hope it's helpful for me to kind of list these weird things that happen because I think sometimes when these people experiencing these things they get really anxious, they get worried, is there something wrong with me, is it's abnormal, you know, you might feel like you're the only person in the world that's experiencing these things but **all these things are very common**. I experienced many of them when I had insomnia. Yes, they're not pleasant, they're not good, you you want to address the insomnia. Like if you want to not have to experience this stuff then go through the process of overcoming insomnia. I've talked about it many times on this channel which is **cbti, cognitive behavioral therapy for insomnia**. It's the only treatment that addresses the root causes of insomnia, helps you come off medication if you want to if you're taking it and has a very high success rate.

The Unconventional Power of Sleep Restriction: Retraining Your Brain for Deep, Restorative Sleep

  The Unconventional Power of Sleep Restriction: Retraining Your Brain for Deep, Restorative Sleep

I would love to talk about, and this is something that I haven't discussed with you at any length, the art of minimizing sleep time. This may tie into CBT-I, which I really don't know that much about, but I, like a lot of people, I think have made the error—although it doesn't feel like an error—of getting into bed and even if my sleep onset takes an hour, an hour and a half, because maybe I have that "tired and wired" feeling which a lot of people do. A lot of veterans, people with PTSD, you know, suffer from this overly activated sympathetic nervous system, which I do a lot. And I'll just stay in bed, right? Even if it takes me three hours to get to sleep, I will often just kind of sit there and try to meditate my way into Oblivion, which doesn't always work very well. So, what's the counter approach?

You know, one of the conventional tips for sleep you can find all over the Internet. You can hear idiots like me speaking about the five tips of better sleep hygiene, and there's very good evidence for why those are sensible things to put in place. But what about the unconventional? And one of the unconventional components is to limit your sleep time, as you said. The principal Insomnia Treatment should not be the first line defense of sleeping pills that we discussed in the last episode.

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CBT-I: The Gold Standard for Insomnia Treatment

The current recommendation is something called Cognitive Behavioral Therapy for Insomnia (CBT-I). As you can tell by the term, it works on two things: cognitive things—in other words, your thoughts and your beliefs about sleep—and then your behaviors: what are you not doing that you should do to help your sleep, and what are you doing that you shouldn't be doing and you should stop doing to help your sleep? That's the CBT-I component.

If you look across the studies, and CBT-I has a number of different features in this treatment/therapy approach, one of the most potent tools in the box of the CBT-I therapist is what we call Sleep Restriction Therapy, which sounds paradoxical.

Let's say you come to me, and I'm your sleep clinician. You say, "I am not sleeping well. I'm in bed for about eight hours, but I think I only maybe sleep four, four and a half hours. I'm just not getting enough sleep. Can you help me?"

And my response to you is: "Excellent, I've got a great treatment for you. It's called Sleep Restriction Therapy."

You hear the kind of the record scratch, and you say, "Hang on a second! I just told you I'm not getting enough sleep, and you're telling me we're gonna restrict my sleep?"

It's actually a poorly termed phrase. It should really be called Bedtime Restriction Therapy.

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The Science of Sleep Restriction and Sleep Pressure

The therapy works in the following way: if you take that example, you're in bed for eight hours and you're sleeping for four hours. You have a miserable sleep efficiency—a sleep efficiency of 50%. Half of the amount of time that you're in bed, you're awake; half the time you're asleep. We want to see that around about 85% or greater in terms of your sleep efficiency. That's what we think is healthy.

So, rather than actually having you stay in bed for any longer, we do the opposite. We use the biology of your brain and something called sleep pressure.

The Adenosine Accumulation

From the moment that both you and I woke up, we've been building up a chemical that we've sort of discussed with regarding caffeine, which is adenosine. Adenosine builds up the sleepier and sleepier you feel. The longer that you're awake, the heavier that weight of sleepiness will be weighing you down.

Just take the extreme: let's say you pull an all-nighter or you're awake for 36 hours. Imagine how tired you are at that point. When you get into bed that following night, it's almost as though nothing's going to stop you—earthquakes, wildfires—you're just going to get into bed and you're going to be knocked out. Why? Because you've just got so much sleepiness built up, so much adenosine that hasn't been removed.

We do a diluted version of that in CBT-I with Sleep Restriction Therapy.

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Implementing Bedtime Restriction Therapy

Let's use a clear, practical example of how to implement Bedtime Restriction Therapy:

1. Establish Current Schedule: You're going to bed just for argument's sake at midnight and you're waking up at 8 AM.

2. Compress the Window: "Now what I want you to do is actually compress that window of time. I want you to go to bed not at midnight, but now push it. Go to 2 AM or 2:30 AM or let's say 3 AM, but you still wake up at the same time."

3. The Focus on Bedtime: Where we restrict your sleep is not by having you wake up any earlier, which is kind of miserable. Most people feel it's easier to go to bed later than wake up any earlier. So we start there. We limit the amount of time that you're in bed and we restrict it down to maybe six hours or five hours.

The next day you're going to feel miserable. You've only been in bed for five hours. But what happens is that as long as you commit to it—and it has to be committed, and you have to work with someone who's going to motivate you—it is hard, but it works.

After the second night of being in bed for five hours, you've been awake for longer. Now you've been awake for 19 hours during the day, and you're only in bed for five hours. That increase in your adenosine because you're awake now for 19 hours straight, for one day, for a second day, for a third day, it all starts to accumulate.

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The Breakthrough and Confidence Reset

Then, at one point—and it depends on the patient, let's say about four or five days after that—they get into bed at 2:30 AM or 3 AM, and then the next thing that they remember is their alarm going off at 8 AM. For the first time ever, they have slept all the way through, from front to back.

In that example, I've restricted the Bedtime by three hours, and they're now sleeping a solid five hours. But remember, that's better than where they were. They were in bed for eight hours, and they were only sleeping for four hours. So, I've added an extra hour, and they're in bed for less time.

The Gradual Expansion

Then gradually, what we do is we start to back that up. Once you're stable and your sleep efficiency is 85-90%, then we'll say, "Okay, now go to bed at 2 AM," and then, "Now let's go to bed at 1:30 AM," and, "Now let's try 1 AM." Gradually, we back it off.

Essentially, it's like hitting the reset button on your Wi-Fi router. You are retraining the Sleep System.

Eliminating Sleep-Related Anxiety

 

In doing so, you can start to get people's confidence renewed, because that's a big problem with insomnia. It seems like principle among the reasons that would work is that you are resetting sleep-related anxiety.

100%. Because when you are suffering from insomnia—and I've had my bouts too, and I know that you've spoken publicly about struggles before—you go into the bedroom, and the bed just looks like the enemy. You have lost all confidence in your ability to sleep, and at that point, your sleep controls you.

But by way of CBT-I and Sleep Restriction Therapy, you turn the tables. Now you control your sleep, not your sleep controlling you, and you regain confidence. That is a huge win. I can't tell you how big that is for people with insomnia. It's a terrible fear when they go into the bedroom; they just convince themselves it's not going to be their night.

The commitment to Bedtime Restriction Therapy replaces that fear with biological certainty and restored self-efficacy, making it a powerful and effective long-term Insomnia Treatment option for those seeking a non-pharmacological solution.

you can read also : Tired and Wired: Why You Wake Up at 3 AM and How to Fix It

 

 

The Dangers of Snoring: Why It’s Not Normal & What You Can Do About It

Snoring is not normal — I want to make sure that’s clear. So in this article, I’m going to walk through what snoring is, why you should be concerned about it, and what you can do to stop it.

What Is Snoring and What Causes It?

Snoring is the result of the muscles in the airway — your mouth, your nose, as well as your throat — relaxing, resulting in a narrowing or obstruction of the airway. This obstruction causes the soft tissue in the airway to vibrate, which causes the cadence, which causes the familiar sound of snoring.

The way I like to think of it is kind of like a garden hose. So if you’ve ever been out in the garden and you stick your thumb on the end of the hose and the water sprays out much faster — exact same principle. However, your nose is that hose. And so anything that blocks the opening, or things like congestion that narrows it down, makes the air move faster. So when the air moves faster, it causes that vibration, causes the cadence, causes the snore.

What Percentage of People Actually Snore?

Around 57% of men and 40% of women snore. Believe it or not, even 10 to 12% of some children will snore habitually.

While snoring itself can be a harmless and temporary occurrence, believe it or not, it can also indicate potential greater health problems for the person that’s snoring. While snoring becomes a common problem with age, certain risk factors will increase the possibility of snoring, including:

- Being overweight  
- Alcohol consumption  
- Nasal conditions such as a deviated septum or chronic rhinitis  
- Smoking  
- Pregnancy  
- Even something as innocuous as sleeping on your back can contribute to snoring

And to make matters worse, these risk factors are often indicators for even greater health problems — like obstructive sleep apnea.

**What Can You Do to Reduce Snoring? First, Understand What Type of Snorer You Are**

Let’s take a look at the different types of snoring and snorers. I’m not going to say that one very well — and where these sounds originate. Turns out, there’s types of snores. So not all snores are the same. There’s several different types of snores, and then the type often depends on where the obstruction exists.

So there’s some in the nasopharynx, some in the oropharynx, and some in the hypopharynx. For example, snoring can result from allergens irritating a person’s nasal passages — making them a nasal snorer. Inflammation from the back of the mouth or deep in the throat can cause snoring as well.

However, snoring rarely originates in just one spot, but rather from a combination of places. I’ve got people who are nose and throat snores. I’ve got people who are mouth and throat. I mean, there’s a lot of different combinations in there — but you kind of get the idea.

I’ve developed a snoring quiz that can actually help you figure out what type of snoring that you might have. I’ve made it available on my website. These questions could help you understand what type of snoring you may have, which allows you to match your snoring to a specific treatment.

A Quick Favor — Share This With Someone Who Needs It

Got to be honest with you — normally this is the part of the article where the host says “stop everything, do me a favor and like and subscribe.” I’m not going to do that. Because instead, what I care about more is that you share this article.

Do me a favor — think of one person you know who is struggling with snoring themselves, or has a bed partner who snores. I want you to send them this article right now. I promise you, they will benefit from something like that. Because whoever it is, I just want to make sure that I’m getting the word out there and helping as many people as I possibly can get a good night’s sleep.

Do me that favor — give it a share.
All right — back to the article.

How Do We Stop Snoring? Positive Lifestyle Changes That Work

So with all this in mind, what positive lifestyle changes can you make to help you stop snoring?

1. Losing Weight

 I know that’s not a simple one — but let’s start with that one anyway. To start, losing weight is often the most significant step that you can take to reduce or — sometimes even eliminate — snoring.

While people with a normal weight range can still snore, extra fat tissue around the neck and throat can narrow a person’s airway — especially guys. A lot of people don’t realize this, but we have a tendency to pack on the weight in our necks — and that’s usually where we see the snoring.

Losing some extra weight can help to open up the airway passages — sometimes eliminating the issue entirely. Once the weight goal is achieved, believe it or not, just losing around 5% of your body weight can show a reduction of about 50 dB — which, by the way, might save your marriage.

So I’m not talking about a tremendous amount of weight. A 200-pound person — 5% is 10 pounds. Right? Can you lose 10 pounds to maybe save your marriage? Probably a good idea.

However, if weight loss doesn’t eliminate the problem of snoring, there are also some other ways to proceed.

2. Stop Smoking

Okay — on top of all the other health problems that smoking presents, it can also make you or your partner more likely to snore by irritating the airways. Even secondhand smoke can increase the risk of snoring.

Quitting is far easier said than done — but doing so can help treat and prevent a variety of health problems outside of snoring.

To be fair — if you can’t stop smoking, try not smoking just before bed and not irritating those tissues — and see if you can get that decibel level to start to reduce.


3. Avoid Alcohol Before Bed

Here’s another biggie — and it’s not too fun: avoid alcohol.

It’s important to also avoid alcohol just before bed. Drinking alcoholic beverages a few hours before going to sleep can relax the tissue in your throat — causing that vibration which causes the snore.

In addition, alcohol usage is associated with sleep disorders like insomnia, circadian rhythm abnormalities, and short sleep duration. Let’s be fair — most people wake up in the middle of the night to pee after they’ve been drinking alcohol — which is a big sleep disruption.

So there’s a whole host of reasons not to be having alcohol anywhere near bedtime.

4. Avoid Medications That Promote Muscle Relaxation

Another one that a lot of people really don’t understand or haven’t heard about is to avoid medications that promote muscle relaxation.

Aside from just avoiding alcohol before bed, taking medications that promote muscle relaxation in the evening can actually increase snoring. These are called benzodiazepines — such as Xanax, Ativan, even Valium. These cause relaxation in the muscles and the throat — which can then cause snoring.

However — before changing any medications, you need to speak with your doctor first. Maybe you can talk with your doctor about moving the administration of those medications to earlier in the day — so that it doesn’t necessarily have that effect at night.

But I want to be clear: do not stop taking your medications without talking to your doctor.

5. Change Your Sleep Position

The old “bang them in the ribs so that they roll over to their side” kind of tends to work.

If you’ve tried all the things that I’ve said and are still struggling, the sleep position change might be another one that you can use.

Sleeping on your back will cause your tongue and all that anatomy to fall to the back of your throat or against the top of your airway. So if you want to remedy this, you can actually raise your head up slightly — or sleep on your side.

Now, there are wedge pillows that you can do — where it actually brings your whole torso up. That’s certainly a remedy to do that. Or again — flipping to the side — that can often help quite a bit.

For my people who like to sleep on their side and they’re trying to get used to it — sometimes a body pillow can help prop you up and put you in the right position.

You can also train yourself to sleep on your side using a tennis ball or a rolled-up pair of socks attached to the back of your pajamas.

My personal favorite is what I do: I take an old backpack, I take a football, I put a football in the backpack, and I click it on. And I can guarantee you — you aren’t going to fall asleep on your back. And within about five days, the whole thing is done and over. So it should make your life much, much easier.

6. Reduce Nasal Congestion

Also — it’s reducing nasal congestion. And by the way, this one is probably — if I had to put them on the list — this is going to be definitely right under weight loss.

Really, we want to decongest for better rest.

So if you’re congested, or if your nasal passages are irritated — rinse and clean the nasal passages with a saline solution or a neti pot. Doing so can reduce inflammation and kind of help clear away some of the debris that could be clogging up those passages.

At the very least, it’s worth getting an air purifier. This will help for any sleeper — but will remove a lot of the particulates which can actually cause congestion overnight.

Yep — you heard that right. You might not have congestion anywhere else in your house — but because you don’t have an air purifier in your bedroom and there’s some particulates in there that you happen to be allergic to — you get congested every night. And lo and behold — you start snoring.

Another good thing: a humidifier can also help reduce swelling or irritation in the airways by adding more moisture to the air that you’re breathing — again, which can also help.

7. Anti-Snoring Mouth Guards & Oral Appliances

There are a few other things out there that I think we should talk about.

Anti-snoring mouth guards can be very effective. So your doctor might suggest you get an anti-snoring mouthpiece. These are worn at night and are designed to keep your airway open by slowly moving your jaw forward.

In fact, there’s two different types:

- There’s a **mandibular advancement device**, which pushes the lower jaw and tongue forward — keeping them propped so that way, if you look here, it opens up my airway space.
- There’s just the **tongue retaining devices** — these are kind of a suction cup that attaches to the front of your tongue and pulls your tongue forward.

I’ve got to be honest with you — I’ve tried a few of them myself. They’re not for me. But I do have patients that love them.

There’s a third version that’s kind of a hybrid of the two — that brings the jaw forward and keeps the tongue from falling backwards. So there’s a lot of types out there. Personally, I like a lot of the hybrid ones — I think those work pretty well.


8. Nasal Dilators — External & Internal

Now, there are also these things called nasal dilators. Right — so what do I mean?

They’re external and internal. It’s just those — you know — those strips that go across your nose.

But I’m going to be honest with you — most people use them incorrectly. Most people put them too high. I see this all the time — they’ve got this strip up here. This cartilage doesn’t open up and move. However, if you put it just across the horizon of the nose, it will help open up the nostrils. And that’s the name of the game here — is getting more air in, getting the pipe bigger.

So these external — if worn appropriately — can be very effective.

Personally, I like the internal ones. They go — yep — I’m talking about something that goes up into your nose. But guess what? It’s in here — and it opens everything up. And it works well.

I’ll be honest with you — on the nights if my wife and I are out and I might have a bourbon or a beer — she’ll turn to me and she’ll say, “Go put that nose thingy in so you don’t snore, Michael.” And I’ve got to be honest with you — it works pretty well.

9. Over-the-Counter Snoring Aids

There are over-the-counter snoring aids. Some of the over-the-counter options that are offered by the American Academy of Otolaryngology Head and Neck Surgery include:

- Nasal — we talked a little bit about those — such as Breathe Right.
- There’s also something called nasal resistance valves. Uh — there’s only one company that I know of that has created these — it’s called TheraVent. You have to look them up. It’s an interesting product because it puts a valve on your nose and it kind of pushes air in and pushes air out — almost like having a CPAP. I found them to be highly effective.
- And then these oral appliances that we’ve been talking about — such as mouth guards — which can be self-fitted or fitted by a specialist.

Personally, I’ve used one called ZQuiet — and I found it to be incredibly effective.

10. Mouth Tape — Use With Caution

Mouth tape — this is another biggie.
Should you use mouth tape for snoring? I would have to say that the data would say yes — but only if you’re cleared from having sleep apnea.

There’s a lot of issues with mouth tape.

Number one — a lot of people are using mouth tape completely horizontally. I think this is pretty much a terrible idea. You need to have one strip that goes straight down — that’s probably the best way of doing it.

And you really do need to be cleared for sleep apnea.

Also, you need to use specialized tape — so that when it pulls off in the morning, it doesn’t pull your skin off of your lips or any of the skin around your lip area. That can be a problem as well.

But I have had people use it.

Here’s the problem — if you’ve not been tested for sleep apnea, guess what? You taped your mouth — and now you’ve masked the symptoms of sleep apnea. Sleep apnea will get worse and worse. A year from now, you could end up with rip-roaring sleep apnea — just because you didn’t check before you started using mouth tape.

So my recommendation is: do a quick screen. Figure out if you’ve got sleep apnea.

Is It Sleep Apnea? Don’t Ignore the Signs

There are now home sleep tests available — and we’ll talk about those in a second.
Snoring and sleep apnea are a big deal. Like I said in the beginning — snoring isn’t normal. Snoring can be a sign of obstructive sleep apnea — a common but serious sleep disorder that increases the risk of other serious conditions such as cardiovascular disease — even cognitive issues.
Snoring does not always mean that one has OSA. But the link between the two makes it vital to get tested and treated — to ensure that your snoring isn’t a part of a more serious disorder.
So if you’re reading this article and you’re a snorer — or your bed partner is a snorer — I want you to seriously consider getting checked for sleep apnea.
The good news is — you can now do tests from home, from the comfort of your own bed.
Home sleep tests for sleep apnea have come a long way in the last few years — since COVID. So again, there is really no downside to getting tested.
I’ve even included a link to what I think is the best HST on the market in the description below.