Shelby Harris - A Women’s Guide To Getting A Good Night Rest

Dr. Shelby Harris is a Clinical Psychologist, Board Certified in Behavioural Sleep Disorders and the former Director of the Behavior Sleep Medicine Program at Montefiore Medical Center. Her new book is called The Women’s Guide to Overcoming Insomnia — Get a Good Night Sleep Without Relying on Medication. Shelby covers the nuts and bolts of a good night's sleep, how our hormones affect our sleep and how we can change certain habits, thoughts and behaviours so we can stomp out insomnia for good.

Transcript

Welcome to Untangle.

I'm your host,

Patricia Karpis.

Today's guest is Dr.

Shelby Harris.

Shelby's the former director of the Behavior Sleep Medicine Program at Montefiore Medical Center.

She's board certified in behavior sleep disorders and focuses on a wide variety of sleep challenges in her private practice.

In this interview,

Shelby goes over the nuts and bolts of a good night's sleep,

How our hormones affect our sleep,

How we can change certain habits,

Thoughts,

And behaviors all in the service of a better night's sleep.

Lots of gems in this interview,

And we all know how important sleep is to our overall health and wellbeing.

Now,

Here's Shelby.

Shelby,

It is such a pleasure to have you back on Untangle.

Thank you so much for being here.

Thank you for having me,

Patricia.

I love talking with you.

Yeah,

You were one of our first meditation teachers,

A sleep expert,

And you did our sleep basics course on Meditation Studio.

And now you've just come out with your first book called The Women's Guide to Overcoming Insomnia.

First of all,

I'm so proud of you.

Thank you so much for writing this book.

We need it.

That's for sure.

And let's start with this question.

Why did you decide to write this book?

There are books out there for just general insomnia treatment overall,

But I work with so many women of all ages,

From teenagers to older adults.

And it's like women oftentimes either suffer in silence or they don't appreciate what is treatable and what isn't treatable.

A lot of times women think,

Oh,

This is all just hormones and there's nothing I can do about it.

And sometimes there are things that can't be done.

But a lot of times there are things that can be done.

And I wanted a book that really addressed that for women in particular.

And how has it been received so far?

Is that a silly question because we meet this book so desperately?

It's been fantastic.

I am so excited with the reception overall.

It's funny.

I have colleagues and patients who will be reading the book in like a coffee shop or something.

And then they'll tell me that other women will come over to them and say,

Where did you get that book?

I need that book.

So it's really,

It's just people coming over.

And the thing that's the most surprising to me honestly about the whole thing is that men have come up to me and said things like,

Is this book only for women?

Can it help me too?

So I never anticipated men thinking that there were secrets in there that were being kept from them.

But yes,

There's a lot other than the hormonal chapters and all these women,

There's a lot in there that's applicable to men.

Yeah,

I think so too.

Why are we such a sleepless bunch of people?

I think there's a few things.

So the biggest thing I think is that we're just a stressed society.

We just don't know how to put an end to the day anymore.

And there are some days that we're going,

Going,

Going.

We have our phones on us nonstop.

We think that we can just put things down and crash.

And sometimes we can crash and go right to sleep.

But oftentimes we wake up a few hours later or wake up early with whatever was on our brain right when we crashed right there.

Other times we just can't turn our brains off because we're going,

Going,

Going right until bedtime.

And I think that's honestly the biggest factor.

The other big factor for women especially are just hormones.

That's a big thing that happens throughout the lifespan.

So whether it's just before menstruation,

Women tend to have really poor sleep right beforehand or when they're pregnant or just after having a baby,

There's a lot of anxiety and depression that can happen.

And that's for men too.

But perimenopause,

I think distress,

Anxiety,

Depression,

Hormonal shifts.

There's a big firestorm of reasons why we're having a lot of insomnia.

One of the first things you were talking about just now was just about how busy we are and how our nervous systems are on high gear all the time.

Do you think that it is really hard to sort of shut down our bodies before going to sleep so that we're,

It's almost like we're in shock.

Like our bodies are moving so fast,

So fast,

So fast.

It's like,

If you look at a puppy that's moving,

It takes them a while to calm down.

I always describe it to patients when they always,

Patients fight me all the time about just allowing for,

I would love an hour of winding down before bed.

I think that's even not enough,

But patients will fight me for a half hour,

An hour.

But I always will describe it as sleep is not an on off switch.

If you think that you can just turn the light switch off and just go right to sleep,

You likely are a sleep deprived person.

If it really should be a process of a dimmer switch where you're slowly dimming your body,

Dimming your brain to wind itself down,

To land the plane gently so that you can then glide into sleep.

That makes so much sense.

And a lot of people use television as a way to wind down,

But you're saying that that's not really a great way to wind down.

There's two reasons.

So one thing,

The reason we don't love screens,

Like staring at screens,

Like it's one thing if you're an hour before bed,

You want to do a meditation.

I totally am all for using a meditation an hour before listening to something,

Putting your phone down,

Not staring at it.

The problem with staring at a TV or a screen right before bed for a prolonged amount of time is that it's two problems.

So one is that the screen,

Your brain reads the screen,

The light from the screen,

Just like it's the sun.

And our brains do not like the sun to be able to go to sleep.

So we have this thing called melatonin in our brains and melatonin,

We call it the hormone of darkness and it makes us sleepy.

People take pills of melatonin,

But we have in our brains naturally.

And melatonin comes out when the light goes out or the sun goes down.

If you're staring at a screen,

Your brain thinks the sun is still out and that's the problem.

So you're making your sleepiness hormone melatonin suppressed.

And we've seen in data that it can actually take an hour longer for some people to fall asleep and the quality of sleep can be worsened if you have prolonged exposure to blue light from screens.

And then the other thing can be for some people,

It can be what you're watching.

So for some people it can be that they're looking at social media that can stress them out or make them too excited or they're watching some thriller.

It doesn't matter what it is.

It's so fascinating to me.

I've seen all these teenagers all of a sudden who want to watch The Office or Friends.

I don't get it,

But they all want to watch it and they fight me about it.

So I actually have them wear blue blocker glasses to help mitigate that exposure to the blue light so they can watch something that's relaxing that they enjoy and they're not getting that almost sunlight from the screen to help relaxing a bit to be able to go to sleep.

So often when people can't sleep,

There's a lot going on in your mind.

Like in the meditation world we talk about it as calming the ruminations or the monkey mind or the negative thoughts that you have.

So on the one hand,

You could be getting into bed with busy thoughts from work.

You could be getting into bed with negative thoughts from a difficult conversation with a partner or spouse or child.

You could be getting into bed with ideas that have been stirred up from watching Law and Order Special Victim Unit.

So what happens in our brain and in our ability to fall asleep or in each of these different scenarios this is happening?

Well,

It's just keeping awake.

A lot of times there's a stressful things that are happening.

So it's keeping your cortisol levels elevated,

Which is a stress hormone,

Right?

So these are all things that are impairing your ability to have sleepiness come.

So your body is getting more stressed.

It's getting a stressed signal from the brain and then you can't relax.

When you're getting tied up in that sequela of thoughts that are happening,

It gets harder and harder to let go of it.

And that's why I'm a huge fan of using meditation for sleep.

And even since our last talk a number of years ago,

I'm using meditation more and more with patients.

So it helps them to notice the thoughts that they're having when they get in bed and they can notice them better,

But they can let them go.

So it's not necessarily that they're doing a meditation in that moment.

They've strengthened the muscle in their brain essentially to be able to notice the thoughts,

But not then go down the path of thinking about anything and everything,

Making their stress hormones rise even more.

That impacts their ability to go to sleep so they can see it.

They can almost draw like a bubble cloud around it and let it float away.

It makes them much more aware.

That's where the visualizations really help because it can help distract and also breathing exercises.

What I like to do sometimes is on the app,

We have all these ambient sounds and I'll put on a rain ambient sound or ocean waves sound.

And it's almost like it's time to the breath.

So it's very soothing.

And I don't know if you see this with children and adults,

But this idea of using sounds or soundscapes as a way of soothing your nervous system.

Oh,

For sure.

Sound is a very powerful,

Powerful soother overall.

And we use it all the time during the day.

Even just things like white noise.

I find if you are someone who just doesn't like the silence or a little noise,

White noise alone can be just soothing for some people.

It's weird.

But just using that can signal that sleep is about to come.

Right,

Right.

Oh,

That's so good to know.

You talk in the book about this idea that you may have some mood disorders.

And I think you couple them with other types of sleep disorders that might look like insomnia.

Will you talk a little bit about some of the distinctions between depression,

Anxiety,

Insomnia,

How these are different and how they can impact each other?

So I think let's start with the sleep disorder side.

So a lot of people will come to me initially saying,

Oh,

I wake up a lot at night,

Or I just,

I don't think I sleep at all in the middle of the night.

I wake up and I'm just so tired and I feel unrefreshed.

And then I just ask them a simple question.

Do you snore?

Do you pause in your breathing at all?

Has anyone ever noticed any gasps at night for you?

And it often is sleep apnea.

A lot of people think that sleep apnea is this disorder that happens a lot of times with overweight older men,

But that's not always the case.

We see it more often with men,

But we see it happen,

It was women hit menopause,

The rates for men and women actually are equal.

And I see it in thin younger adults too.

Sometimes it's just the luck of the draw of how your airway is built.

So sleep apnea can cause you to have pauses in your breathing that can cause you to awaken.

You kind of choke or gasp,

You wake up and then sometimes you have trouble going back to sleep.

So that's one thing that I really want people to get assessed,

Especially if you're in perimenopause,

Because you could be at higher risk for it.

If you are overweight or if you work out a lot and you have a bigger neck,

Those are all things that you should definitely look at because there might be something else going on.

Sometimes people kick a lot in their sleep,

They have restless legs,

A lot of pregnant women have restless legs and they might have trouble going to sleep.

Those are all things that have medical treatments for them that really need to get addressed.

When it comes to depression,

A lot of people,

Depression and anxiety actually,

One of the symptoms of depression and some types of anxiety is poor sleep and insomnia.

But a lot of people,

What they do is they go straight to treating the depression or the anxiety with the idea that it's always going to help the sleep.

And a lot of times it doesn't help the sleep.

So people will start to work on their depression,

But they still suffer with their sleep.

And what we see a lot of times is if they go for depression treatment,

But they see a sleep specialist for a few sessions like myself,

A few sessions on the side,

It actually helps them much better because it's the sleep,

The insomnia and the depression almost become separate problems,

Even though they might've just started at the same time.

So you really want to assess that and not necessarily just wait and wait and wait for your sleep to get better,

Even if you're having depression treatment.

You just mentioned restless legs.

What do you recommend for people about like restless leg syndrome or?

It varies.

So I had it myself when I was pregnant both times.

Oh,

It was horrible.

So it's just this feeling,

Everyone describes it differently,

But it felt like I just couldn't keep still.

I had like,

Felt like I just had to keep moving around at night.

For me,

And what's the most common is when people are pregnant,

It's often an iron deficiency.

So go to your primary care doctor and just tell them that you're having restless legs and they'll test you for an iron deficiency.

And if you're deficient in iron,

They'll tell you what iron supplement to take.

For me,

That fixed it.

For other people,

That's not enough,

Or they don't have an iron deficiency.

And there's other things that are actually very effective medications out for restless legs.

Sometimes there are supplements,

But really it's iron.

And then they're like,

I said,

There's the medications for some people,

They find that stretching massage can help,

But it's limited as to how often.

Some people who are really struggling in the middle of the night,

Getting up and getting out of bed and sitting on a cold floor actually helps.

But it's only for a little while.

Yeah,

Keep moving around.

But cold massage,

But really the medication or iron is usually the underlying treatment.

In the book,

You talk about cognitive behavior therapy for insomnia.

Will you tell us a bit about cognitive behavior therapy for insomnia and maybe some of the pros and cons of it?

Yeah,

For sure.

So CBT for insomnia.

So it's been around for about,

I would say 20ish even more years now,

But over the past five to 10 years,

It's really been used now as the gold standard for treatment for insomnia above medication in the field of primary care and the field of sleep medicine.

It is in the guidelines,

Their primary care and sleep medicine guidelines.

It is the first line treatment for insomnia.

So physicians should be giving prescriptions for CBT for insomnia,

People like myself before starting medication in most cases.

The problem is there aren't many people who do what I do or are specialists in it.

And that's it.

That's the issue.

The cognitive part that it's working on,

And I outline all the modules in my book,

But it's really working on the thoughts that a lot of people have about sleep.

So you can either work on it from a cognitive therapy standpoint.

So it's,

If I don't sleep tonight,

I won't be able to function tomorrow.

I won't be able to do X,

Y,

Z tomorrow.

And it's teaching you that the rational part of your brain is usually not there too in the morning and how to challenge those thoughts,

Not always in a positive way,

But in a realistic manner.

So realistic challenges to help bring down your anxiety and to bring down the pressure you're putting on your sleep.

And then the part that I use a lot more of the cognitive aspect is meditation.

Sometimes we can challenge the thoughts over and over again,

And it doesn't really do anything.

So I teach patients how to meditate during the day to help them,

Or even an hour before bed,

To help them become more aware of their anxious thoughts and their worry thoughts about sleep or anything else,

To be aware of them,

Let them pass.

But when they get in bed,

They don't get stuck on the anxious thoughts as much.

They can let them pass to let sleep then happen.

So that's the cognitive aspect.

The meditative part is a newer part that we really added in,

But I really do find it very effective for many patients.

Then there's the behavioral part.

And this is honestly,

I think this is the harder part for many patients to do.

The behavioral part is a lot of people think about sleep hygiene.

So limit caffeine from say around 2 p.

M.

On,

Limit alcohol within three hours of bed,

Limit heavy meals,

Exercise four to six hours before bed.

It's very rigid,

But I do encourage people to try and do as much as you can as often as possible.

I don't expect perfection from everyone.

I'm not perfect myself,

But really try to do as much as you can.

And then the other modules are something called stimulus control.

And this is a hard one for a lot of people,

But it really does work.

If you're not sleeping,

Don't lay in bed.

Get up,

Go sit somewhere else.

The bed is only for sleep and sex.

That is it.

Lay there for a little while,

About 20 minutes.

Don't look at a clock,

Just kind of guesstimate.

If you don't fall asleep,

Get up,

Go sit somewhere else,

Read,

Meditate,

Do something.

When you're sleeping again,

Go back to bed.

And you keep teaching your body that bed is only a place for sleep,

Not to lay awake,

Tossing and turning in the morning.

And then the final part of the behavior part of CBT is really limiting the time in bed.

A lot of people with insomnia spend too much time in bed.

I always call it a disorder of common sense.

And I fall prey to it myself.

If you're not sleeping,

A lot of people go to bed early one night or sleep in on the weekend or take a nap,

Hoping that that's the night that they're going to get that elucidated hours,

They'll catch that sleep that they've been hoping for.

The reality is that most nights you're not getting that.

And when you're not timing the amount of sleep that you get on average to how much time you're actually in bed,

You're just creating more and more problems in the long run.

So we actually create a prescribed bedtime,

Wake time for people to follow every day.

And then we open the window as you improve and we slowly trick your body into giving you more sleep.

That's a really hard one for people to do a lot of times.

So where I start,

When people find that it's very rigid,

I encourage them to say,

You know what,

You have to think about it like ripping off a bandaid.

If you really want to get to where you want to go immediately or as fast as possible,

We got to do it all.

And you got to just deal with the behavior change and it's not easy,

But that's the way you're going to make the progress.

But if it's not,

If you're okay with doing it slower and rip the bandaid a little slower,

Then okay.

What are you willing to commit to first?

And I have some patients that commit to maybe just starting a meditation practice every day.

So we start there.

And if we just start there,

Then we can build on,

Okay,

Now let's limit maybe the caffeine.

And I just find that with each behavior that you change,

You don't have to do it all at once,

But you can't expect your sleep to just magically improve.

You have to just change your expectations.

What about for people who change a few things,

But not everything,

Maybe they still have a glass of wine at night or have a cup of coffee at one or two in the afternoon and they're still having problems.

I mean,

When you talk about hormones,

Can the hormone issue override everything else?

So even if you do all of the other sleep hygiene things that you're recommending,

If you're having hormonal problems,

I know you talked a little bit about the hormones in the beginning,

But what are some things that almost at any age women can do to regulate or somehow have an impact on their hormones that their sleep will be better?

Well,

Sometimes it's a risk benefit kind of discussion that you need to have.

So when we're talking with younger women,

A lot of times who really have significant insomnia related to menstruation.

So it's that drop in estrogen that happens right at the beginning of menstruation that can set off the insomnia cycle.

That for some people is so significant that they're willing to go on,

Say a birth control pill and they're willing to go on one that's more continuous that won't have the same sort of drops that happen all the time to really regulate the hormonal.

But there's pros and cons to all that.

So it's a discussion that you need to have with your doctor regarding the pros and cons,

Like I said.

The other things that you can think about as you get older,

When you're going through perimenopause,

It's the same sort of hormonal treatments that you can talk about.

But then there are other non-hormonal treatments that we talk about.

So there's things like Black Coho,

Evening Primrose Oil,

Those are all more integrated medicine methods that we use.

And you should really still have a discussion with your gynecologist regarding it,

But they are very effective for some people.

But then there are other times when insomnia,

You can do everything you can,

And sometimes there's just only so much you can do.

So one example I always use is when a woman has a baby and you have a two month old at home,

Who's on its own schedule,

It doesn't care what time you want to sleep and you're just heightened,

Your hormones are all over the place,

You're not sleeping.

Sometimes you can do as much as you can to try and sleep when the baby sleeps,

But it's really hard and you just have to ride it out.

So do what you can,

But sometimes there's just a natural course to sleeplessness that happens.

I mean,

What about things like taking cortisol or taking magnesium or some of these other vitamin remedies?

Yeah,

No,

No,

We talk about that in the book too.

Yeah,

Magnesium is definitely one that's used a lot.

It's more calming.

The data behind it isn't as strong,

But it's definitely something that I've had some patients have with good benefit.

Things like CBD oil,

I mean,

A lot of it just hasn't been studied as much when it comes to insomnia.

That's the problem.

So like every day I have one or two patients come in now saying,

What do you think about CBD?

What do you think?

And it's just,

I mean,

If it's like some patients that swear by it and some patients that are saying it hasn't done anything for me,

It's just,

We just don't have the data on it yet.

So things like melatonin,

Melatonin has been studied a lot.

It's kind of hit or miss for some people.

Valerian is still a little hit or miss and Valerian has a lot of negative interactions with some medications.

So my one caveat is some of the stuff has some data that helps,

But it's not strong enough overall.

But for women who have hormonal issues,

The two biggest things that we see that are helpful tend to be black coalition primrose,

But to definitely talk with your gynecologist and for any of these things that you take,

Definitely talk with your doctor regardless because they still can have interactions with whatever other medications you're taking.

Yeah,

That's a great thing to mention.

So there's nothing that's a hundred percent cure for insomnia.

So let's just say that.

And in your book,

You talk about all of these different tools that can be helpful and you have to explore for yourself what's going to work and you're going to make choices.

Again,

Like maybe you know that having a glass of red wine keeps you awake,

But you prefer to have the glass of red wine.

You're making choices all the time.

How much sleep do we even need?

What's your opinion on that?

I think the average for most people is about between six and nine hours a night.

Oh my gosh.

That's where they get a lot.

That's a lot to you.

Yeah.

Well,

Nine hours for an adult.

I know.

I've worked with some patients who need 11 hours to be able to get out of bed in the morning.

I have the whole spectrum.

So it really varies.

So we see some people that are better with six and that's all they need to feel well,

Restroom or fresh.

Some people need money.

That's kind of where they get this seven and a half to eight from.

It's just sort of in the middle.

That's it.

Yeah.

But that being said,

It's really,

That's about 70% of the population that needs in that range.

There are still some outliers that need less than six and more than nine.

And what does need mean?

Right?

So need means how do you feel in the morning?

Not even just,

I don't ever use right when you get up in the morning as the judge,

I use like an hour later.

Cause some people,

I mean,

It's just,

So about an hour later where you feel like you're well rested and fresh enough to go about your day and knowing that you might have a dip here and there because it's normal to have a circadian dip in the afternoon after lunch and at various times.

But if you feel like you don't need to take a nap routinely and you can go through your day,

Then you're good.

And you don't feel like it's causing you any frustration or problem,

Then it's fine.

If you're not passing out or falling asleep all the time in multiple situations,

If you don't like fall asleep on the train,

The minute you sit down or have your head hit the pillow and you're,

Those are signs that you might need more sleep and you're excessively sleepy.

But that's really sleep need.

But the thing that I always focus on,

Because I deal a lot with insomnia patients is let's get you quality sleep over the quantity first.

So insomnia patients often come to me saying,

I have to get eight hours.

I have to get hours.

Everyone says I have to get eight hours.

All you're doing now is worrying about having to get this like eight that's painted in gold and put on a pedestal.

Right.

That makes it worse.

Now just focus on,

Let me get five hours,

But maybe five hours that aren't broken.

Let's get five hours that feel better.

And then we can slowly work to get more because sometimes five hours without all this medication feels better.

That's quality.

Then eight hours of medicated.

So it's quality over quantity.

That makes sense.

But I want to understand what you mean by broken sleep and also what is the deepest stage of sleep?

Like we hear people talk about REM sleep and we hear people talk about Theta and Delta levels of brain activity.

And can you give us a little tutorial on that?

Sure.

So broken sleep just means that it's,

You have a lot of awakenings throughout the night.

That's all it just,

It's not solid.

Now that being said,

When a good,

Let's just take a normal healthy,

Good sleeper,

Adult young adult sleeper,

When you fall asleep at the beginning of the night,

You cycle through various stages.

But what you do is we have a few different stages of sleep.

So we have awake,

Which is not sleep,

But then we have something called REM sleep,

Which is this different sort of stage of sleep where we see in REM sleep,

Rapid eye movement.

Your eyes are actually moving.

We see actually in some stages of REM sleep,

Your eyes actually move together and apart,

Together and apart.

And we can see that on a sleep study.

So your brain is actually very active during REM sleep.

That's when you tend to dream the most.

You tend to have memory.

I think of it as like memory storage,

Memory consolidation,

Mood regulation,

All happens during REM sleep.

It's very active.

That's why you have most dreams during that stage because it's all,

It's like your filing cabinets work in overdrive during that time in your brain.

Now that's REM sleep.

Then you have stages one,

Which is this kind of like in between very light sleep.

And then stage two is where you spend about 60 ish percent of your night of kind of like this middle level sleep.

And then stage three slash four used to be two different stages and then a number of years ago,

They combined them.

So stage three slash four is that deep sleep.

And everyone talks about,

I want deep sleep all night long.

I want to be passed out and have deep sleep.

That's actually not normal either.

You shouldn't have deep sleep all night long because then you're not having REM sleep.

You're not having the other stuff.

So when you first go to sleep,

You can spend more percentage of the night in that deep sleep.

That's why when,

I don't know if you've ever noticed this,

But for a lot of people,

If you fall asleep like a half hour,

Hour later,

You hear an alarm go off or you get a text or something.

It's so,

At least for me,

It can be super startling because you're usually in the deepest stages of sleep at that time that your brain is completely shut off,

That it's so startling.

So that's deep sleep.

Then you wake up and then you cycle into REM quickly and then you have an awakening and then you fall back asleep and you sleep again,

Go to the deeper stages of sleep.

Then you go to lighter sleep again.

Then you have some REM,

Then you cycle again,

Deeper,

Light,

REM,

Wake.

Each time you cycle,

You have a quick awakening.

Now it's quick.

It's usually like a few seconds.

You don't usually remember the awakenings,

But we cycle about four or five to seven times a night,

Depending on how long our cycles are and how long you sleep throughout the night.

Now the beginning of the night,

You have more of that deep sleep,

More percentage of the time in those deep sleep stages.

And as the night goes on,

You have more percentage of time in REM sleep.

So that's why people often have more dreams.

So they remember their dreams closer to waking up in the morning because you're having more REM sleep at that time.

So we have REM,

Light,

And then that deep sleep throughout the night.

And that's how it all cycles.

What drives how we're cycling through those different stages?

Is it hormonal,

Nutritional?

No,

That's actually what a normal healthy sleep stage should look like.

That's totally normal healthy sleep stage.

We can see that on sleep studies.

If you were to come in for a polysomnography,

Which is just a fancy word for sleep study,

We put all the EG leads on you and then we look at breathing and all this other stuff.

But we can see based on you're asking about like delta waves,

Alpha waves,

All those waves like delta waves,

The slow waves,

We can see based on those waves,

What stages of sleep you're in.

And ideally we want to see on a diagram,

We call it a hypnogram,

We want to see that kind of sleep architecture that I was just talking about,

That kind of deep sleep,

Light sleep REM,

Deep sleep,

Light sleep REM,

And then more REM as the night goes on.

But for some people,

They have less REM or they go into REM too fast or they don't have enough deep sleep and all that stuff can be indicative of a million different things.

It could be that sometimes hormonal things can impact it.

A lot of times we see anxiety,

Depression can cause people to go and REM sleep faster than what would be normal.

Sometimes people have more broken sleep or they won't get into REM as much or they'll have too much REM or they'll wake up and have a lot of apneas during REM.

So we can see a lot of stuff that will disturb the sleep.

And then some people don't have deep sleep or they don't have REM sleep because of medications.

Antidepressants can mess up your sleep staging left and right.

So some people don't dream at all because of antidepressants because they don't have REM sleep as much because of those medications.

Does that happen with sleep medications too like Ambien or Ativan?

It can not as much as with the SSRIs.

Well,

We see more with those things or we see sleep walking and sleep talking happen more often.

So we'll see that sort of stuff happen.

People will have more of that deep sleep,

But it's very disruptive and they'll just keep doing like the automatic behaviors and sleep.

And that's when it's more dangerous.

Since we just touched on medications,

When if ever do you think medication is called for?

Oh,

I think there's definitely a role for medication.

It's just we got to a point 10 years ago where it was just too easy to prescribe it.

And we didn't think about the longer term consequences of it.

And now we're starting to see more and more data come out that for some people,

Especially older adults,

We see it cause a lot of cognitive issues and falls in people.

And I work with a lot of older adults and it just when we know that four to eight sessions of CBT,

It's not as fast as taking a pill,

But it works.

We would much rather do that nowadays than medication.

So what I would prefer and what I think is the standard of the field is if someone can try CBT first and if that doesn't work,

Then we added medication.

That's the idea.

But CBT doesn't work for everyone either.

It works for about 60 to 70% of people.

And a lot of times I have patients that we just have to combine the two treatments,

But we don't have to use the full dosage of medication anymore.

We combine CBT,

But we can use a much lower doses of medication as we used to use in the past.

It's such an interesting field of study because I remember when we first released our sleep meditations on meditation studio,

We would get notes from our customers saying,

Thank you so much.

I've slept for the first time in five years.

And I'm thinking to myself,

I love meditation and I feel so good about that.

But wow,

Like how lucky are they to have a good night's sleep because they've changed one thing.

So I feel like you're constantly maybe trying to discover what is the best set of tools for you.

Yeah,

For sure.

So for example,

I had this patient,

He's in his mid thirties.

He works in a stressful career and we did basic cognitive behavior therapy.

I was limiting him.

We were doing sleep restriction,

All the other stuff for about two sessions.

And then I decided to start just changing my approach to doing a little bit more meditation with him because it became very clear to me that he had a lot of stress overall,

Even though he wasn't verbalizing necessarily.

And so when I had him start doing it daily,

And we were doing it actually in the morning,

He was doing a morning meditation practice for just five minutes every day.

We started building that in and now he's actually increased the time every day.

He really loves it.

He's doing so much better.

And it's really the meditation component more so than anything else that has helped him drastically.

So we've really backed off on all the other traditional insomnia treatment methods.

And I've really just focused mostly on the meditation component.

And after six sessions,

He's now done with treatment and he's gone about his merry way and doing great.

Don't you love that when you see you have that impact so quickly?

It's probably,

It's so different with so many different conditions,

Right?

But to be able to have,

Yeah,

That's what I love about being a psychologist,

But treating sleep disorders because when you treat insomnia,

Especially and nightmares too,

Actually the impact for many people is very fast.

So the majority of people I see,

I don't see them weekly.

I see them every other week.

Usually if they follow what I suggest and they start impacting it or implementing it on a regular basis,

A lot of people get better in six to eight sessions.

So it's pretty rare for a psychologist to see that on a routine basis and so rewarding and to see how when someone sleeps better,

To see how much it improves other aspects of their life.

Absolutely.

That's what I love the most.

Yeah.

It's so great to hear that.

One of your chapters you focus on,

And we've talked a little bit about this,

But I feel like it's so important is this idea of challenging your worries and identifying your negative thoughts.

And that's the real therapeutic part of how to have a better night's sleep.

Will you share a couple of other ways that we can challenge our thoughts or release our negative thinking?

So the most common one that I talked a little bit about before is just doing a thought log.

So yeah,

That's right.

Standard,

Standard thing.

So you can look it up online.

You can get it in my book.

It's just a dysfunctional thought log.

It sounds kind of bad to say dysfunctional.

When you have a negative thought about sleep or pressure,

Like I have to sleep tonight or else x,

Y,

Z is going to happen tomorrow,

Whatever it is,

You write down the thought and then there's a bunch of questions on the bottom that help you to challenge and evaluate the thought.

So if I don't sleep tonight,

I'll lose my job tomorrow.

A lot of people I work with have that worry.

I'll bomb my presentation or whatever it might be.

So what's the worst thing that's going to happen?

What's the best thing that could happen?

What's the most realistic outcome?

What would I tell a friend in the same situation?

What's the effect of believing this thinking?

Usually it's that you're not going to sleep more because you're more anxious.

So it's talking yourself through it in a realistic and rational way to help bring your anxiety down.

It's not positive thinking.

If you actually bomb every presentation and people come up to you and say that was terrible.

You have one more try after bad nights of sleep or you've gotten a car accident,

God forbid,

If that stuff happens to say,

Oh,

It'll all be fine.

That's just as bad for you.

Right.

That's just as bad.

So then we have to start being a problem solver.

Okay.

How can we deal if I don't sleep well tonight?

How can I actually get through this talk tomorrow despite being sleep deprived and usually bombing it?

So it's not positive thinking.

It's realistic thinking because normally the thoughts are a little bit less catastrophic than we think they are in the middle of the night.

The other ways that you can challenge thoughts and negative worries,

A lot of times when we aren't sleeping,

It's often the same kind of worries that are happening over and over.

Maybe the flavor is a little different,

But they're often very similar.

So we can do things like worry time.

I love worry time.

So worry time is just setting aside a time earlier in the day or early in the evening.

Will you just say to yourself,

I'm going to worry the heck out of everything for the next 20 minutes.

And you set a timer for 20 minutes.

This is a very standard cognitive technique.

It's been around for years.

Yeah.

You sit down,

You set a timer and you just sit and you worry the heck out of everything.

Sometimes I have patients write on one side,

They write out all their worries,

And then I have them write the next solution or the next best solution to come to,

Or the next step that they can do to get to a solution.

Sometimes I just have them write everything or sometimes I just don't have them write anything.

I just have them worry the heck out of the same thing over and over again for 20 minutes.

When the 20 minutes is done,

That's it.

Yeah,

It's hard.

And then when you start to worry about that same stuff again,

You say not now,

But during worry time,

The whole point of it is that a lot of people who worry,

They say to themselves,

Don't worry about this.

Stop thinking about it.

And they try to like suppress it in a way.

And all that does is I like to think of it as like this pink elephant.

It's like me saying to you,

Patricia,

Don't think about it,

But there's a pink elephant in the corner.

Don't think about it.

Don't think about it.

Don't think about it.

Now you have a perfect image in your head.

Same thing.

The more you say,

Don't think about it,

The more you think about it.

So worry time allows you to say not now,

But I will think about you tomorrow during my set 20 minutes.

So you're allowing it just not 24 seven.

Yeah,

It helps to rein in a bit.

And if you do think about it later,

You just say not now during worry time.

And that's a really effective one too.

And then the other big thing I like people to do is honestly an hour before bed,

A half hour before bed,

Just ready,

No fashion to do list.

It's amazing to me how many people don't use to do lists.

And so many women I work with,

So many moms,

Especially,

They just have it all swirling in their head and they expect that they're never going to forget it.

And when you expect that you're never going to forget it,

You're always keeping it on the top of your head so you don't forget it.

So I encourage people to just keep a to do list and then just write it all down.

Even if you don't think you need to write it down.

And then if you think about it right before bed,

Just jot it down on the paper.

And if you still think about it saying not now,

I've got on my to do list.

It's not worth thinking about because you're not coming up to solution for it anyways.

And just let it go.

Yeah,

I think it's great and gives you an opportunity to put things in a proper place.

So they're not trailing around all the time.

It's an awesome suggestion.

Yeah,

We take everything with us.

I know this floating worries all the time.

And that's why I love meditation though,

As a compliment to all those things,

Because meditation can help you like I keep saying,

Strengthen that muscle in your brain,

Just a little meditation practice,

Even if you start small,

Right?

For a lot of people I work with getting them to start a meditation practice is like pulling teeth.

But if you just start with just a few minutes a day,

Just build on it,

You're strengthening that muscle so that when you find that you're having a lot of those floating thoughts or floating worries or whatever it is,

You can be more aware of them.

You can be more aware of noticing them and just letting them go and not getting stuck on it and then kind of worrying and letting it keep going.

Yeah,

That really is the beauty of a meditation practice is having those tools so that you can bring them off the cushion out into your life just when you need them.

Okay,

I think this might be a really hard question because there are so many different topics here.

But if you had to say the top five things you recommend for getting a better night's sleep,

What would be on this list?

Top five things.

First and foremost,

I always say is consistency.

So so many people fight me on this,

But if we are meant to go to bed at the same time and wake up at the same time seven days a week,

We do not have a different alarm for the weekends versus weekdays.

If you were having trouble sleeping,

Consistency every day as much as you can.

I know it's not perfect for most people.

Same bedtime,

Same wake time.

The next thing is your room environment.

So really try to keep your room first of all,

Make it a place that you want to be right to clutter is not your friend.

If you look at your room and you just have dread,

That's not going to help you sleep.

So make your room inviting,

Make it a place where you want to be.

Also make it quiet,

Dark,

Comfortable and cool.

So quiet using like a white noise machine if you have to dark,

Meaning dark shades,

No light and cool meaning temperature should be cool.

It should not be warm in your room.

If you're waking up sweaty,

Then it's too warm in your room.

I would also say limit caffeine.

A lot of people will say,

Oh,

I have no problem falling asleep with caffeine.

That's fine.

The issue is caffeine can also disrupt the quality of your sleep.

So make sure you try and cut off caffeine by about 2pm.

If you're someone who tends to go to bed by 10 or 11 at night every night,

You can push a little later if you go to bed later.

Exercise,

I'm a big proponent of exercise or at least just moving.

Just get yourself out there.

If you can move a little bit and exercise,

You're using your battery and if you use your battery,

You'll help recharge it more at night.

But exercise right before bed is not ideal.

It actually can interfere with sleep even more.

So try to exercise.

The ideal is four to six hours before your bedtime.

That's not ideal for many people to build in.

So anytime during the day,

Just not within three hours of bed.

And then my final one that I always love is meditation.

So if you can do whatever you can to just unwind,

To quiet your brain,

To help bring a sense of calm,

Meditation is the best thing because it will help to quiet your brain and help you be aware of the anxious thoughts you have before you go to bed to let go of them to be able to get a better night's sleep.

The biggest thing I just want to say to people is that don't suffer.

There are so many really effective treatments for insomnia and they don't always,

It's not just always basic sleep hygiene.

There are specialists out there who treat insomnia in just a few sessions and don't always have to use medication.

It's a very treatable disorder and you really shouldn't just be suffering.

Thank you so much,

Shelby.

You've been amazing.

Thank you for having me,

Patricia.

Yeah,

Great to have you.

Thanks to Shelby for being with us today.

We'll see you next week.