#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.

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My guest this week is Ashley Mason. Ashley is an associate professor at UCSF, where she leads the Sleep, Eating, and Affect Laboratory.
Her research focuses on non-pharmacologic interventions for mental health, particularly exploring how treatments like whole body, hyperthermia, mindfulness-based approaches can improve mood disorders, sleep, and eating behaviors. She's also the director of UCSF's Center for Obesity Assessment, Study, and Treatment, known as COAST.
Her work integrates clinical psychology with integrative medicine, aiming to develop accessible treatments that address the biological and behavioral aspects of health. In this episode, we focus almost entirely around one area of her expertise,

which is cognitive behavioral therapy for insomnia or CBTI. Ashley gives us a masterclass

exploration of CBTI, including various methods, including time in bed restriction, stimulus

control, and cognitive restructuring to combat insomnia. We speak about how to manage racing

thoughts and anxiety, and Ashley shares techniques like scheduled worry time to address stress during the day and prevent sleep disruption at night. We talk about the impact of temperature regulation and the role of warming extremities and optimizing sleep environments for effective sleep onset.
We discuss behavioral and cognitive interventions and the impact of leveraging small, actionable changes in thoughts, feelings, and behaviors to overcome patterns of insomnia and other mental health challenges.

Ashley shares some sleep hygiene fundamentals addressing blue light exposure, food and alcohol intake, and creating bedtime routines for better sleep. She provides practical tools for tracking

progress like using sleep diaries and A-B testing to identify and refine effective interventions,

and we explore... for better sleep.
She provides practical tools for tracking progress, like using sleep diaries

and A-B testing to identify and refine effective interventions. And we explore the potential for AI and digital tools to democratize access to CBTI and address the growing demand for sleep therapy.
So without further delay, please enjoy my conversation with Dr. Ashley Mason.
Hey, Ashley, thank you so much for coming to Austin to talk about a lot of interesting things. Let's start with the one that I think everybody listening can probably relate to at least once, which is insomnia.
Where did your interest in insomnia arise? Well, I've been interested in sleep for a long time. I was fortunate to go to the University of Arizona for my doctoral work.
When I was there, the late Dick Butson was also there, and he's one of the co-inventors of cognitive behavioral therapy for insomnia. And I think I found it particularly interesting because it works so well.
We have so many different psychological treatments, and they all have varying degrees of efficacy and effectiveness. And the thing about cognitive behavioral therapy for insomnia is that it's kind of like a recipe.
If you do it, it works. And this was always just so interesting to me because it was so different than so many other psychotherapies out there that had just so much more unpredictable outcomes.
I would say that I became much more interested in it after my postdoctoral work when I'd gotten to UCSF. I was a postdoc at UCSF, but I started my assistant professorship at UCSF.
And there was this gaping hole in treatment availabilities for people with insomnia. And I thought, oh, this might be a good way for me to get back into some clinical work.
I was doing just research at the time. I fell back in love with it because there's almost nothing as rewarding as being able to see a patient seven times.
And that seventh time, have them say something to you along the lines of, I have my life back. I'm going to go get my driver's license back.
I'm not afraid to drive with my kids in the car anymore. I'm going to go back to work.
I have my life back. Not much better than that.
And so I grew the clinic that I do CBTI in, and now I just love it so much that I do it on top of my job. I do it at night with patients, after hours, because it's the most rewarding thing and you can have such a big impact and people need it.
Before we dive into what CBTI is and how it works and how profound it can be, let's maybe help folks understand a little bit about insomnia and maybe go through some of the definitions around the different types of insomnia and maybe some of the different causes for it and maybe even what some of the other treatments are pharmacologic and otherwise. Broadly speaking, most people at some point in their lives are going to have an issue with insomnia.
I think some 90% of adults at some point are going to struggle with insomnia. And point estimates, I think at any given moment might be between 5% and 10%.
The interesting thing about insomnia is that it's a very clinical diagnosis. There's no blood test for insomnia.
We can't put you in a sleep lab overnight and do a test to see if you have insomnia. And we don't diagnose insomnia based on one night of bad sleep.
If someone says, oh, I didn't sleep at all last night, or I haven't slept even for just the last week, that's not going to get you a diagnosis of insomnia. And there's a whole suite of different insomnias that we could talk about.
But I think the point that is the most salient is just that when you have a problem sleeping, and when it's been going on for a long time, at least like three-ish months, when you really feel it's a problem, that's when it's time to get help. Because there's plenty of people who don't sleep a whole lot, but it's not distressing to them.
It's not causing any problems in their life. They're not going to meet a definition of insomnia per se.
It's the folks who will tell you that I can't sleep. I haven't been sleeping for months.
It's interfering with my life, it's really upsetting, and they've probably already started trying a whole bunch of things to try and help themselves to fix it. And this is where things get interesting.
And just to be clear, Ashley, when you say that a point estimate of five to 10% of the population would have insomnia at any point in time, you mean according to that definition where it's been going on for months, it's causing distress and it's impacting life. Yeah, broadly speaking.
So it's low end one in 20, high end one in 10 people, adults? Adults. Yes.
By the way, I do not do pediatrics. So please assume everything we're talking about today is adults.
So that's a higher estimate than I would have guessed, given your definition. If the definition was three nights of bad sleep, I would say, yeah, that makes sense.
Yeah, that's at any given point in time. Insomnia is, for most people, probably quite episodic.
It's not necessarily a permanent state. People go in and out of it.
And the question is, how quickly do people go out of it when they go in it? And that's what CBTI is so beautiful for. It's helping people get out of it quickly.
There's going to be things in your life that are going to just happen and they're going to put you over the threshold for insomnia. So maybe we can talk for a minute about how insomnia begins and then how it's perpetuated because these things are actually quite different.
So you and I and everybody have a certain level of predisposing factors that are going to put us at risk for having sleeping problems, in particular insomnia, then we may experience what's called a precipitating factor. That could be a major life event like losing your job, getting a divorce, getting in a car accident, some major unexpected, unhappy life event that might throw you into a bout of insomnia.
That event will end though. That event ends.
The car accident ends, it resolves. The job loss ends, you get a new job or you don't.
The divorce ends, you move on. But in the meantime, when you're dealing with that event, you develop behaviors to cope with it.
And so you might, for example, pop a Benadryl to help you sleep or an Ambien, something stronger. You might start taking naps the next day after a bad night of sleep to try and cope with it.
You might start reading in bed a lot or flipping through your smartphone in bed. Doing all these different types of behaviors to try and help yourself calm down and actually get to sleep, which in the short term make a lot of sense.
You're trying to help yourself in the acute moment. But in the long term, these kinds of behaviors aren't actually doing you any favors.
And over time, that precipitating factor is going to go away. But all of these behaviors that you've started doing to respond to the precipitating event, they're what stick around.
And those are what are going to perpetuate insomnia symptoms and problems. Can you say more about the predisposing factors? Are those genetic? So there's, of course, genetic predisposing factors.
I've had patients come and say, I'm a really light sleeper. Can you fix that? That's going to be pretty tough to fix.
I'm going to recommend something like earplugs, an eye mask, a white noise machine, what have you. But yes, there are going to be predisposing factors.
So if you are higher on the general psychological reactivity, you're going to probably get pushed over the threshold more easily than someone else. Some people might get in a car accident, a fender bender, and they're over it by the next day.
The car is in the shop, whatever. Other people might feel antsy about driving for a while after that.
They might feel more anxious as a result of that event. And that's going to differ from person to person.
You can argue that that's genetic. You can argue that that's based on early childhood or other experiences.
But nature and nurture probably both contribute to that predisposition. And there's not a whole lot that we can do about that.
But this is the beauty of cognitive behavioral therapy for insomnia. When people come in for treatment, they're often pretty focused on what caused their insomnia.
And I actually don't ask people what caused their insomnia until the end of my first session with them. I'm asking them all these other kinds of questions about their behaviors now.
And at the end, I ask, okay, so when did this start? What do you think might have caused this? And get their attribution for what's going on. Because at the end of the day, the intervention is the same.
And that's what's beautiful about this and might differ a lot from the practice of medicine. I'm not an MD.
I'm a PhD. I think in a lot of disease states, we often look at what caused what's going on.
I'm not really concerned. I'm more concerned about what you're doing now that's perpetuating the problem.
And that's where I intervene. And that's why this particular treatment is so effective for so many different presentations of insomnia and causes of insomnia, whether people have difficulty falling asleep in the beginning of the night, waking up in the middle of the night, waking up too early in the morning.
You might think on their face, these people all need wildly different treatment, but that's not actually the case. Yeah, that makes a lot of sense.
So the focus is much more on the coping strategy and the behavior that came out of the predisposing factor or the precipitating event actually is really used to respond to the precipitating effect.

Exactly.

Okay.

Can we talk a little bit about is there a difference, for example, between the individual who can't fall asleep, this initiation of sleep insomnia versus the person that I hear much more about? Frankly, I experience more, which is, it's not that hard for me to fall asleep, but boy, I will jolt up at one in the morning with some thought or anxiety that I can't get out of my mind and my mind starts running and I can't go back to sleep. Or I get up because I got to pee, but when I come back, I erroneously just do something with my mind where I get thinking about the day's problem or whatever, whatever.
Do you think of those as difference or the different side, same coin, I guess? Those people need the same stuff. And the people who can't fall asleep at the beginning of the night, their mind's just racing earlier than yours.
Yours is just waking you up. And there's a whole suite of interventions that are part of cognitive behavioral therapy for insomnia.
There are a lot of ways that I could approach an answer to this question. So I think starting by addressing the racing mind issue, I always tell patients, if you don't deal with what's causing you stress or anxiety during the day, it's going to demand to be dealt with in the middle of the night.
It's going to say, oh, Peter, I notice you're laying there peacefully, not doing any work or tasks, and you don't have anything you need to do right now. So you're going to pay attention to me.
And it's going to demand your attention at that time. Other people, that happens right when their head hits the pill at the beginning of the night.
Oh, you're relaxing now. Okay, here's your 10 things to worry about.
So one of my favorite interventions that's actually born of anxiety treatment, but that I've co-opted and I've moved into cognitive behavioral therapy for insomnia because it fits with the theoretical framework, is something called scheduled worry time. This sounds a little bit pedantic and silly, but hear me out.
If a patient came to me and said, Ashley, I worry all day. I'm worried about all of these things.
My life is just a constant ball of worry. And I said, okay, I've got a solution for you.
And it's two words. Ready? Stop it.
That wouldn't work. It doesn't work.
I take the opposite approach. Okay, this is really important to you.
This is something you're doing all the time, all day. Guess what? What do we do with things that are really important to us? Make time for them.
We schedule them. Exactly.
Back in the day of paper calendars, this felt like a different exercise. Now people get out their phones, but I have them get out their phone or whatever and say, all right, we're going to schedule worry time and it's going to be an hour a day for the next seven days.
It is non-negotiable. I may or may not schedule an email to go out to you at the end of that time and you have to go and reply to it and tell me what you did.
And what we find is that when people work with this during the day, it does two things. The first is, let's say it's 9am and you are trying to do something in your life and instead a worry pops up.
You can actually think, oh, okay, I don't have to deal with this now. I'm going to write this down because at four o'clock I've got scheduled time to deal with this.
So that way you're uncluttering the rest of your day by moving all of the worry into that scheduled time. So this could be a valuable technique, even absent insomnia.
Totally. I'd say that probably between a third and half of my patients who come in with insomnia, they've got some bad sleep stuff for sure.
But for some of those people, it's a primary anxiety disorder and sleep is suffering also. Whereas other folks, it's primary insomnia and that's driving them anxious.
But to rewind back to your earlier question about the middle of the night versus the beginning of the night. So the other thing that scheduling worry time does, besides uncluttering your whole day, is it helps you get it done during the day so that when your head hits the pillow, it's not there.
Oh, I already worked on this. And also the knowledge, oh, I have time set aside tomorrow to work on this or to think about this.
So I don't have to do that now. Cognitively, this all makes sense.
And you would maybe think you can think your way out of this, but you can't. You actually have to try it.
And I've done this with a lot of people. I've done this with doctors, police people, people from all walks of life can really find this valuable.
The other thing when it comes to falling asleep at the beginning of the night versus the middle of the night is that there's sometimes low-hanging fruit that we can think about. You mentioned getting up to go to the bathroom.
I've found that for a lot of men who are 45 and up who still have a prostate, just not drinking very much fluid with dinner and after dinner is huge. And also throwing an electrolyte tab in there can really help.
Granted, it's got to be the right osmolarity and everything else, but there are ways to find this. Don't slam Gatorade at night.
That's not what I'm suggesting, but just throw a noon tab or whatever electrolyte replacement. I've had some male patients go from waking up three times in the night to pee to one time.
And the fewer times you wake up in the night, the fewer times you risk not falling back asleep. So little things like that can actually make a difference for waking up in the middle of the night.
The other one I have about the middle of the night is a little more out there, but hear me out. If I had five cents for every time I took away a down comforter from someone and their sleep got better, I'd have like $8.
I mean, this is huge. And this is because everybody's heard of circadian rhythm, but it's missing a word.
Circadian temperature rhythm. Your body is supposed to be its coolest at night and its warmest during the day.
And my favorite people to talk with about this are actually anesthesiologists.

They know more about body temperature than anyone. It's remarkable.
But what I've had the great good fortune of learning is that your body temperature, it's supposed to be the warmest during the day and

coolest during the night. When we do things like trap heat with down comforters, quilted nonsense,

even cotton replacement, if the word duvet is in it, comforter is in it, it's a no for me. And I give people a handout.
I'm like, here's the definition of a cotton blanket. Here are links to examples of what cotton blankets are.
If you are cold, buy two, buy three, use these. And I'm telling you, it's made a huge difference for a lot of women in particular with night sweats.

And people wake up less sometimes because they're not giving their body this message that it's time to wake up because they're not as warm.

People complain about their feet and their hands.

And I say, that's fine.

You can put your down comforter over the foot of your bed.

You can wear some socks.

But I take body temperature regulation very seriously.

And sometimes it's a quick fix.

And we don't need a whole lot of muss and fuss.

This is a very long way to answer your question, but I'll finish after this. The people at the start of the night, it's worth asking people at the start of the night if they're cold, if their hands and their feet are cold.
Have you ever tried to fall asleep when your hands and your feet are cold? Yeah. I try to be uncomfortably cold when I get into bed.
Right. But your hands and your feet? No, generally not.
I mean, it's just my body.

But again, I'm using a device to cool me as well. Slightly different.
But spoiler alert,

it's pretty hard to fall asleep when you have cold hands and feet. And what we have data on from some interesting research in a totally different realm is that people with extremity

circulation disorders who have really cold hands and feet. Right now's or something like that.

Yeah. They will have what we call early insomnia, which is difficulty falling asleep.

Thank you. different realm is that people with extremity circulation disorders who have really cold hands or something like that.
Yeah. They will have what we call early insomnia, which is difficulty falling asleep at the beginning of the night.
And when they get successful treatment or when you warm their hands and their feet, much easier to fall asleep. The whole warm foot bath before bed thing, that's an actual thing.
Your extremities help you dump heat. So when you actually warm your hands and your feet, you can actually help dump heat from your core because you're vasodilating.
And when you fall asleep, you want to be dumping heat from your core. Hard to do that when you're vasoconstricted in your hands and your feet.
So for folks who have trouble falling asleep at the start of the night, we want to make sure their hands or feet are warm enough and that they've dealt with the thoughts and the worries during the day. And that they're not trying to go to sleep at 9 o'clock when their body doesn't want to go to sleep until 11.
A lot of people just think, I need to have this much time in bed each night. And they get into bed and they struggle for two hours before their body actually wants to go to sleep.
So a major part of CBTI is aligning when your body can produce sleep with when you're in your bed. I want to kind of go into many more of these because I know this is the exciting stuff that people are interested to hear about.
I do want to take one step back and just make sure we understand what constitutes cognitive behavioral therapy before we even get into cognitive behavioral therapy for insomnia. So we've had a podcast where we talked about dialectical behavioral therapy, DBT, but we haven't covered CBT.
Can you give us a little bit of the tapestry of what defines it and why it, of course, then has this additional subset of treatment for insomnia? I should have done that first. Cognitive behavioral therapy, my favorite way to think about this is in a triangle.
We have thoughts, we have feelings, and we have behaviors. You can think about this triangle as having these three pieces that are all connected.

And cognitive and behavioral therapies, or cognitive behavioral therapies, generally will focus on one intervening on this process between thoughts, feelings, and behavior.

Thoughts, feelings, and behavior on one of these sides of the triangle.

So let me just spell out a quick example process.

So let's say we have a patient with type 2 diabetes who has the thought, I'm never going to be able to get my blood sugar under control. I'm never going to be able to manage this.
I'm not going to be able to do this. When a person has those thoughts, how do they feel? Crummy, feel bad about themselves.
When people feel bad about themselves, what do they do? Eat some chocolate cake. Eat some chocolate cake.
What does that do? That reinforces the thought, I'm never going to be able to do this. So we've got this pattern of thoughts, feelings, behavior on repeat.
Cognitive behavioral therapies will choose where to intervene on a process in that triangle. Cognitive behavioral therapy for insomnia, for example, is really focused on the area between thoughts and feelings in many ways, because people will have a lot of thoughts.
I can't sleep. I'm never going to be a good sleeper.
If I don't sleep eight hours tonight, I'm going to lose my job, whatever. And then the big emotions that follow from that.
We work on questioning a lot of those thoughts to then recalibrate the feelings that follow. Like, oh, if I don't sleep eight hours tonight, I won't feel great tomorrow, but I'll probably be okay at work.
The feeling is much smaller than if I don't sleep eight hours tonight, I'm going to lose my job tomorrow. They're noticeably different.
In terms of depression, an example that I like might be someone saying, oh, I'm really depressed now, but when I feel better, I'm going to take my grandkids to the movies. That's what I'm going to do.
I'm going to take my grandkids to the movies. I'm going to take them to the zoo.
I'm going to do all these things. So as a therapist, what I might do is I'd have the patient write all of this huge long list of stuff they're going to do when they feel better.
And then you know what I'm going to do. I'm going to get out their calendar with them and I'm going to say, all right, I don't care how you feel.
We're scheduling all of these things. So we're intervening on that behavior to thoughts line.
So we're going to make them take the kids to the zoo. We're going to make them take the kids to the movies.
And then the kids are going to have a great time and the patient's going to come back and say, oh, you know what? Pretty kick-ass grandma. Kids had a great time.
This was pretty great. So we're intervening on the behavior to change the thoughts about the self.
Like, oh, I'm going to do these things when I'm better. A major feature of cognitive behavioral therapies is intervening on behavior to change thoughts, but also intervening on thoughts to change feelings.
And there's just many, many applications for this. Cognitive behavioral therapy has been adapted for a whole host of disorders, for eating disorders, for insomnia, specifically for anxiety.
That's going to be more in the thoughts and feelings realm too. Is that kind of running the triangle in the other direction? So you change behavior to change thought, you change thought to change feeling? Yeah.
So you can change thought to change feeling. You can work on behavior to change thought.
You can operate on any way of those with different techniques that have been just repackaged into different therapies. And tell me a little bit about the history of CBTI specifically.
When did the idea come to existence in a way that's been packaged more or less the way it is today? Cognitive behavioral therapy for insomnia is actually old news. I mean, we can go back to the 1970s.
I remember when I was learning cognitive behavioral therapy for insomnia, one of the most fun studies to read about was this study of, I believe it was college-aged men who were not doing well academically. And the intervention that they did with them was one of the two pillars of cognitive behavioral therapy for insomnia, which is called stimulus control.
And what they did with these young men is they told them, all right, you're going to be assigned a carol in the library. And in this carol is the only place you can study.
You can't study in your dorm. You can't study outside.
Can't study anywhere else. Just this carol.
And only this amount of time can you study each day. If you're on a roll, we don't care.
You have to stop. If you're miserable, we don't care.
You just have to keep on doing whatever portion of the studying over and over again that you're stuck on. So they trained these young men to just study in that one place.
And it succeeded in helping these men. These men were struggling with anxiety or actual insomnia? Academically.
This is just stimulus control, where we learn to associate a place with a behavior. And fast forward a little bit, it was called the Bootsen method at one point for Dick Bootsen.
But one of the hallmarks of cognitive behavioral therapy for insomnia is your bed is only for sleep. There are two things you're allowed to do in bed.
I always tell my patients, your two things that you can do in bed are sex and sleep. If you're not sure if something counts, message me and I'll clarify it for you real quick, whether it counts in one of those two buckets.
But we really want to just associate the bed with sleep. And to be clear, just going back to this study, was there a belief or were some of these guys studying in bed? They were studying in their dorms, in their beds and everywhere else.
I mean, everywhere. So this wasn't specifically a study focused on sleep per se.
It was just focused on this associative pattern that became the bedrock of this treatment. And we can go back even further and we can look at Pavlovian conditioning, the dog and the bell and the food.
And we don't need to go over what that whole thing was again right now. But the point just is that the dog came to associate the bell with getting food.
And a lot of times when people are struggling with sleep, you know what they're doing in their bed? They're reading, they're scrolling, they're watching TV, they're listening to podcasts. They're doing like everything.
A lot of people, by the time they get to me, they're camping out in their bed just in case they're able to sleep. Oh, I'm gonna go have a snack in bed because if I'm sleepy enough, I'll roll over and take a nap and I'll get some extra Zs.
So people have moved so much of their lives into their beds that it's completely dissociated from sleep. That's one of the bedrocks.
And then another bedrock is what we now call time in bed restriction. This used to be called sleep restriction, but I don't know where along the way in the last number of years it went from being called sleep restriction to time in bed restriction.
But whoever made the change, I'm still not sure who made that change. I am thankful to them for it.
Because the other key component of CBTI is that we restrict the amount of time that a patient is in bed to match how much time their body can actually produce of sleeping. A lot of times people with insomnia will say, okay, I need to be in bed for at least 12 hours if I want to get seven hours of sleep.
I know it's hard to believe, but it's true. And we just obliterate that notion.
And this is another core and very old part of CBT that dates back, what, 1970s, 80s? But when you take those two parts, then you start to add in some of the cognitive components that have been around also for decades. The cognitive therapies part, the Aaron Beck stuff with cognitive restructuring, which is where we take a thought.
Have you ever heard that phrase, don't believe everything you think? So you take a thought and on the classic thought record tool, you'll have patients write down the thought, write down how they feel, rate their feelings from say zero to 90%. And then we have them write down, what's the evidence for this thought? If you had to go to court right now, and there was a judge and a jury and what have you, and you had to present evidence for your thought, what would you be able to present? Evidence for a thought is not another thought.
It's not a belief. It's evidence.
Last time I slept six hours, I got a worst grade on a test or something. That would be evidence.
You got a worse grade on test. But then we look at all the evidence for a thought.
We look at all the evidence against a thought. Like, oh, last time you didn't sleep so well, you didn't get fired.
Still did fine in school, whatever the thing. And then we create a balanced thought, which is even though I'm not going to be as well rested, I'll still get through this day.

Then we have people re-rate their emotions, re-rate how much they believe this new thought, this whole song and dance. This is the cognitive component.
And that's kind of the bedrock of so much of cognitive therapy. Of course, people have so many negative thoughts about sleep and dysfunctional thoughts about sleep that aren't true or that are catastrophizing and whatnot.
that is also blended in to the treatment. And then we have relaxation techniques, which are things like progressive muscle relaxation that came along as well.
And those are part of the treatment. Progressive muscle relaxation will be like where you squeeze your hands and let it go and squeeze your hands and let it go and then squeeze your arms and let them go and move through your whole body to get out of your head and into your body.
And I don't know what order those actually were packaged into CBTI, but I can tell you the first two, the stimulus control and the time in bed restriction, those were among the earliest parts of CBTI. And what we know from dismantling studies is when you take either of those out of the treatment, no dice.
Yeah. I want to talk about both of those a little bit more.
I want to bracket sleep hygiene and come back to it because I think, again, the temperature and all that light stuff, we shouldn't gloss over that even though it's easy to take for granted. And I know that many people listening to this podcast will have heard other content where we talk about it, but I'd love to have it all in one place.
I think the time in bed restriction is pretty interesting. And in talking with sleep physicians who also implement this, it seems quite draconian at the outset.
It can be remarkably difficult. They're giving people five hours in bed max, and they're really trying to force sleep pressure.
How do you navigate that and how do you decide how hard to squeeze the tube of toothpaste? Let me draw a line in the sand between what CBTI says broadly as a treatment and then how I've actually implemented it in my clinic. So what CBTI will have you do is they will have you, and I say you as the royal you, your patient, they will have you feel something called a sleep diary.
And this is a paper diary that covers seven days. Because if I asked you how well you slept four nights ago, you'd be like...
It's like a food frequency questionnaire in epidemiology. Totally.
Total waste of time. Total.
So you have to do it every morning. Okay.
And of course, I'm not obsessed with it being exact because I'm much more interested in the picture pattern of it. If you asked someone to fill it out for just one day and then worked with that, you'd have a totally distorted picture.

You wouldn't know what you're working with.

But what classic CBTI does is they'll take that seven day sleep diary and then they will

actually use the time you got in bed, time you fell asleep, how many times you woke up,

how long you were awake, what time you woke up.

It has all of these different questions in it.

And you can use that to calculate how much time a person was sleeping on average over the course of the week. And what CBTI does is it says, you patient, why don't you pick what time you want to get up every day? And then you would ostensibly pick a time.
The CBTI clinician, let's say your sleep log said you were naturally sleeping six hours a night. The clinician would add 30 minutes to that and make it six and a half hours and then work backwards from your chosen wake time.
So let's say you chose a wake time of 7 a.m. I would work back six and a half hours to get to a bedtime for you of 1230 a.m.
And of course, that's the bedtime of your childhood dreams. Imagine going to a sleepover and your friend's mom saying, all right, kids, you can't go to bed until after 1230 a.m.
Kids love it. Adults think this is torture because it is.
That's what classic CBTI would do. Six hours being the number? Six and a half.
You get that half hour of grace. As far as I know in CBTI, almost nobody's restricting less than five and a half hours.

Five and a half seems to be the floor.

I've not seen people restricting to five.

There are a subset of people, and I don't know the data on this because I don't even

know if the data exists on this, who are what we call genetically short sleepers.

And these people know who they are.

They have always been like this.

And it's not upsetting and distressing and causing them grief.

We're not talking about those people.

Okay, so that's what CBTI will do. And just to be clear, let's say five and a half is the floor.
Six is typically what you would do. So six and a half in bed.
Well, no, if your body is producing six hours of sleep, I add 30 and I get six and a half. If your body is producing only five and a half, I add 30 and you get six.
So I do this computationally for each person. I see.
So when I bring my sleep log to you, you've seen that for the past week, I've been spending 12 hours in bed. But by my recollection, because I'm looking at the clock when I'm not sleeping, I'm only getting six and a half hours of sleep in the 10 or 12 hours I'm laying there.
You're going to say, oh, okay, that's your sleep time. Take that, add 30.
That's your time in bed. I got it.
Yes. And here's where what I do is slightly different, but also the whole theoretical underpinning is not disturbed at all by the way that I do this.
So how many times have you had a patient come to you and say, oh, I really want to be that person who wakes up at 5 a.m., gets a go on my day. I want to get my exercise in.
I want to get my meal prep in, do all this stuff. And you're like, oh, OK, cool, cool.
So you want to be a 5-in person. What time do you get up now? Oh, like 11.
And I'm like, oh, OK. All right.
So this whole part in CBTI where people choose their wake time, that's not a thing for me. In my clinic, we play a game called democracy within a dictatorship.
What that just means is that instead of just letting patients carte blanche choose their wake time, I actually look at their sleep diary and I let them think they're choosing their wake time. And if I agree with it, they will have chosen.
If I don't, the dictator comes in and I look at their diary. And if they are getting up at 7 a.m., 6 a.m., 7 a.m., 7 a.m., 6 a.m., 6 a.m., 6 a.m.
And they say to me, oh, I want to wake up at 8.30. I will say, well, we have no evidence that you can sleep until 8.30.
That's not realistic. But we have evidence that you can sleep until 6 because four of the last seven days, you made it until 6.
So 6 o'clock is your wake time. And this is not anywhere in CBTI.
I've spoken with a lot of my colleagues who do CBTI and asked them, how do you choose a wake time? And there is no standardized method. But by using this method, I'm definitely making sure that I'm at least gating the patient's sleep at a reasonable time.
Because if I let that patient just choose 8.30 a.m. as their wake time and they were only producing six and a half hours of sleep.
They're going to bed at one in the morning. They're going to bed at two in the morning and they're getting up at 8.30 because they chose their wake time as 8.30.
But really, they're going to wake up at like six or seven and they're not even going to cash in on the full six and a half hours that they should be getting a bed. So I've added in this component of my own of setting their wake time to be a much more reasonable time.
And then what I do before giving them a bedtime, I give them a week at that wake time. And I see how much sleep is your body producing with this new wake time.
Now, let's say you're doing the sleep log and they're spending, you know, eight hours in bed, getting four hours of sleep. Let's say they're getting five hours of sleep, eight hours in bed, and then they're taking an hour nap a day.
So they're removing all their sleep pressure during the day by taking that nap, but they kind of need to take the nap because they're not getting enough sleep. So they're in this vicious cycle.
So do you add the hour of nap time back to sleep and say, actually, you're getting six hours of sleep. Let's do the exercise based on five plus one plus a half, 6.5.
No, no, no, no, no, no, no. We want to extinguish that sleeping during the day thing.
So there's a difference between a person without insomnia healthfully using naps. And then there's a person with insomnia who's napping to compensate for what's not happening at night.
So I think that to best explain this, I should just finish this example of the wake time thing because this directly ties in. If I'm setting their wake time and then I'm seeing how much time they're actually producing sleep, that first week when I give them the wake time, I don't give them a bedtime.
I don't even do time in bed restriction that first week. Because for some people, setting a wake time solves the issue, which is kind of nuts.
But one or two of every eight patients who I see, because I see patients in groups of eight, will have a huge improvement from just having a consistent wake time. Because their body actually recalibrates, and they start getting sleepy at a more consistent time each night.
because they're not doing that. And I do say in that first week, I take away the naps.
I say, I don't care how you slept last night. You need to just stay awake until you're ready to go to sleep.
No naps for now. Now, when I have patients, probably older patients, like 80 and up, I'll be okay with a nap, but I'll often, at this stage, I'll say, look, you have an opportunity of 25 minutes.
And a 25-minute nap opportunity means you set the alarm for 25 minutes, you get in bed, and it's going to go off 25 minutes later, and that's when you get up. I don't care how long you actually slept during that time, because I don't want you going into phase three or phase four slow wave deep sleep during the day, that's what's going to really mess you up at night.
A stage two sleep nap is not really an issue during the day as much. It's not going to be so bad.
But at this stage of the person with insomnia that we're talking about, I don't want them taking a one hour nap in the day. And they come back that second week having done the wake time that I said, and I then recompute how much time in bed they're spending.
And then I still use that wake time and I then calculate their bedtime. And then the true time in bed restriction begins week two.
Okay. But just to be clear, if you have someone who is using a nap to compensate for their insomnia, step one is just kill the nap.
Kill the nap. And then let the cards settle where they may for a week, recalculate actual sleep time, and then go through the exercises described.

I've made this point on a podcast before, I think, but just want to get your blessing.

When we're on bow hunting trips, you are going to bed insanely late and waking up insanely early. It's just the nature of when you get back to camp and eating, and then you got to be up super early.
So I've never been on one of these trips where I could actually be in bed for more than five and a half, six hours in a night. So the strategy is to get that sleep, but then I always try to get a 90 minute nap at around one in the afternoon.
And the reason I pick 90 is to get a full sleep cycle. And I tend to function incredibly well under those circumstances because remember, you're also very physically active.
Like this is demanding time. So would I be better off not doing that nap midday? Oh, that's a bow hunting trip and you don't have insomnia.
That's not a problem. Okay.
All right. Got it.
Yeah. Totally different monster.
And I tell people too, a lot of the last few years, people have had serious illnesses. They've had COVID.
They've had whatever. When you're sick, all bets are off.
What I tell people is if you need a nap when you're sick, you need a nap when you're sick, but we maintain stimulus control. You don't nap on the couch.
We're only napping in bed. And if you're awake and feeling sick, then you can be on the couch, not in bed.
While we're on that topic, what do you say to the legions of people watching who fall asleep watching TV on the couch? Oh, the worst. A lot of people fall asleep on the couch because they're just so overtired that the ship has sailed.
Their body's ready to go to bed and they're just letting it and they're not getting up and doing the thing. I tell people, look, if you want to prioritize your sleep, pay attention to your body.
When you're watching TV, do you notice that you're starting to nod off? Do you notice your eyelids feeling heavier? Your hands feeling warmer? Are you starting to sag a little bit? Okay. These are indicators that it's probably time to get off the couch and go to bed.
For people who can't figure that out, I say, okay, you want to watch TV at night? Sit in a stool. You're going to figure it out real fast.
What about just the social dynamic of it, which is when you have a couple, not that I'm saying this from experience at all, and one part of that couple, they want to be together and watch TV, but one member of that team falls asleep immediately while the other does not. And the one that does not tries to tell the one that is to go to bed, but that one wants to be with the other.
I don't know if you can ever imagine a scenario like that. I'm just making it up.
Okay, good. I'm glad you're making that one up.
I have a lot of these couple level issues that come up in sleep clinic. This is not uncommon because what's more intimate than being completely unconscious next to another person? If you think about it evolutionarily, that's probably the riskiest thing you can do.
So there is this desire for closeness in lots of couples and it becomes a challenge when one of the members of the couple has a sleep problem. And the first step is remembering this is not necessarily permanent.
We need to go about fixing this now, and then we can find a new winning solution. So in the interim, I'm assuming you've already tried maybe watching something different on TV that might be more exciting to the second partner, et cetera.
It's not about the boringness of the show per se. Doesn't appear to be.
Okay, good. So if that's the issue, then I would say, hey, if this is a priority, what are we going to do? We're going to schedule it.
We're going to schedule time to be on the couch together at a time when I can definitely be awake and be spending meaningful time with you. The problem is sometimes other members of the family who tend to be smaller also tend to be occupying all of the bandwidth during those earlier hours when the member of the family in question is able to be awake? This is a hard problem to scale.
But what I would just say is if you're actually ready to go to bed and your body is saying that you need to sleep, you should probably do that. It's more likely that then you'll be awake the next day and be a more pleasant, exciting partner to be around and be able to have more meaningful experiences with your partner that way.
Otherwise, I tell people, look, this is an issue. If it's really an issue, we're going to get a babysitter, figure it out.
There are ways to get around these things. People just often want it to work like they see in the movies.
Like, oh, this should be easy. Obviously, I'm talking about my wife here, so I'll stop double speaking.
But if my wife falls asleep every single time on the couch, but then when said Netflix is over and we go up to bed, she falls right back asleep and it doesn't seem to keep her awake. Is it pathologic? This isn't necessarily a problem.
But what I would say is we sleep more deeply at the beginning of the night. We experience more slow wave sleep in the first half of the night and more REM sleep in the second half of the night.
I think other podcast guests you've had can definitely go into the neurobiology of this much more deeply. But a way that I like explaining this has to do with evolution.
If you think about it, when we're deeply, deeply asleep, we're kind of tuned out. And on the prairie, when we figured, okay, it's safe to go to sleep right now, our bodies prioritized getting that really deep sleep when we knew it was safe.
And then as the night goes on, we sleep more and more lightly, which makes sense because, hey, there could be lions and tigers around or whatever that are going to come and eat us. So evolutionarily speaking, it was adaptive to sleep more deeply in the first half of the night.
Now, if your wife is falling asleep on the couch and getting some of that sleep at that stage of the night and maybe getting more interrupted aspects of that because there's noise from the TV or whatnot, it could be disturbing the quality of... That's the drawback.
Yeah, it makes sense. To that effect, on the prairie, it also makes sense that evolutionarily, there's diversity in people who are night owls and early morning larks.
We needed that diversity in order to keep the tribe safe from the threats on the prairie. Some people were staying up late.
Okay, no lines. Some people were up early.
Okay, no lines. And there's nothing pathologic about being a person who's going to be more likely to fall asleep earlier.
Be a person who's more of an idol. And it's very hard to change that.
A lot of patients want to change it. Broadly, two to three different archetypes of that.
I know there's a circadian rhythm test you can take online that gives you a sense of it. I almost think it's so self-evident if you pay attention to your patterns.
It is. I'm really a clinician, so I deal with what's in front of me all the time.
I'm not so concerned about these tests. I'm more concerned about what's the problem that's messing up your life right now and how can we work around that? Let's go back to sleep hygiene for a second.
We talked about temperature. Nowadays, we have these incredible devices that can cool our mattresses and things of that nature.
Obviously, we have air conditioning that can cool the room. Do you have a preference for one or the other? I mean, clearly not everybody needs to buy a mattress cooling device if they can't afford it.
That shouldn't be an impediment to sleep. Do you have a room temp set? We typically talk about the mid 60s as an ideal room temp.
Do you adhere to that? Yes. Mid 60s is terrific.
If people say, oh, this is just too cold, I say, well, what's too cold? And often they will say my feet. And we have wonderful solutions for that.
They're called socks. We can get really thick socks.
I'm also not opposed to, you know, those tiny little heating pads you can get, they're like this big foot and a half by a foot or something. Putting one of those in the foot of your bed, it's got an auto shut off.
It shuts off after like an hour or something to fall asleep with. I don't have a problem with that.
There's no issue there. But yes, a cool room is definitely key.
And insert my refrain about down comforters, duvets, et cetera. Get cotton blankets, get cotton sheets.
Let's talk about light. Do we need to have it so pitch black you can't see your hand in front of your face? Do we need to block the moonlight? How dark do we need it to be? This is a common question.
If you closed your eyes right now, you'd be able to tell that it's light in this room. We can sense light through our closed eyelids.
And many women would tell you that their eyelids seem to get thinner as they age. So I think an eye mask is a great addition.
And this is for a lot of people with early morning awakenings. Eye mask can be a game change because they don't realize that what's causing their early morning awakenings is a little bit of light getting into the wrong part of their eye, indicating it's time to be awake right now.
I don't know the details on what wavelength of light that is or what necessarily the light is coming from, whether it's a light outside from the sun or the moon or whatever it might be. But the point just is a lot of folks with early morning awakening can really benefit from having something covering their eyes, whether it's a sleep mask or there's like hats that go down here now.
I'm a big fan of making your room dark. I am one of those people who travels with a roll of black electrical tape because you go to a hotel room and there's like 50,000 lights everywhere.
You wouldn't just get relief from the eye mask in that situation? I do, but I'm one of those people who rips my eye mask off in the middle of the night and I've tried every single eye mask and it's coming off. So I like to wear it.
I start with it. I try and keep it on as much as I can.
But I also, if there's egregious lights in a room, I cover them with a lot. Meaning like you're going to cover the alarm clock and or whatever the.
Oh yeah. No, there's none of that in my room.
My trick is I unplug alarm clocks because I realized sometimes they're so complicated that they just go off in the middle of the night and I didn't realize it. And yeah.
Oh, totally. And the microwaves are the worst.
Those are the blinking time. But you mentioned the cooling mattress stuff, which I'm intrigued by, but I also am concerned about.
It seems that a lot of these mattresses have settings where you can make it cooler, but also you could make it warmer. And I worry about two things.
One is I worry about messing with our circadian temperature biology, because you remember in the 1980s for a hot minute when electric blankets were really popular, and all of a sudden they're not. They were starting to see associations between electric blanket use and some cancers.
And at the time, there was a lot of speculation that this was related to EMF. But the great thing that time does is it gives us more perspective.
And there are some indications that actually that might have been messing with circadian temperature, and that might have been part of the issue. We know that night shift work is carcinogenic.
Do we, though? Yeah. Night shift work's been declared carcinogenic.
Well, I mean, no disrespect to the WHO, I don't know what I believe that they say. I know that there's an association between night shift work and cancer, but do we really know that it's causal? I think if we go Bradford Hill on this and we look at temporality, I think that there are age-matched case control studies where they can look at people going through different control for history effects to see are people getting more and less cancers.
It is tricky because if, for example, you look at firefighters, they're way more likely to get cancer. They work way more.
They have way more chemical exposure. They have way more other things in the mix.
But I think that some of the more classic studies have also been done with hospital workers. Also confounding effects.
How do we get around the confounding effects of the obvious dietary shifts that occur in people when they're working under those conditions? I mean, if I think back to how I ate in residency or how I eat after a night of poor sleep, I mean, to me, that would be more the cause. I'd put more of that on kind of the metabolic ill health that might result, but carry on.
Yeah. I think that it's often hard for people to sleep during the day, making that change from going to sleeping at night to being a person who sleeps during the day, for some people it's not even possible.
You talk to some night shift workers, they sleep very little because they just can't sleep during the day. They're not able to flip their circadian biology.
But there's a whole history, and I know we'll probably talk about thermal stuff in a bit, but of looking at disruptions in circadian temperature as one of the most common circadian disruptions in mental health disorders. But going back to the cancer thing, what would be the believed mechanism of action? I would talk to an oncologist about that, and I would probably talk to a circadian biology person about that.
But what I can just speak to is just my understanding that electric blankets are no longer here with us and very common because there were these observed ill health effects, whether they're due to EMF or whether they're due to messing with your body temperature at night. But what concerns me about some of the exogenous interventions like mattresses that might heat up is there's supposed to be a normal circadian temperature rhythm that we do during the day and during the night.
And when we start imposing things on that, some of these mattresses can actually be set to cycle at different temperatures during the night and all of these things. Yeah.
So the one that I use, just by full disclosure, I'm an advisor to that company. The one that I use, you change how cold it is throughout the night.
So I think I run it as, I think the settings go from zero to minus 10. Minus 10 is the absolute coldest.
Zero is no temperature change. Is that like a point scale or is that degrees? No, it's a point scale.
Yeah, yeah, yeah. Yeah.
So I think I get in and I have it at minus five and then I run it down to minus 10 and then I bring it up to minus five in the morning. Something to that effect.
So I'm taking it from cold to really cold up to cold. Right.
Okay. So where my concern is just that.
You're saying people would heat themselves with these things. Yeah.
But that gets to the point which we know we don't want to be warm. We don't want the duvet.
Right. But a lot of people get in bed and they don't like feeling cold because it is easier to fall asleep when your hands and your feet and your skin is warmer.
So people will maybe mistakenly do this for more of the night than they should. And I'm just concerned that our circadian temperature rhythm is an exquisitely controlled system.
And a 10-point scale on a device, I think, pales in comparison to the complexity of what our bodies need to do in terms of temperature during the night. The good news is if you can keep your room at 65, none of this matters.
And the biggest challenge, honestly, is hotels for most people. It's where you have the hardest time.
Hotels are the worst. And there are some mattresses now, they're just hot.
There's a short list of mattresses. I just tell people like, look, that's going to be a hot mattress.
Don't get that. And you want to be really careful to make sure that you can be cool in your bed.
And I think the easiest way to do that, if you don't have the money to splurge on something that's going to be a mattress that's going to definitely be cool, would be keeping your room cool. What about blue light before bed? I've looked at these data quite a bit.
And I would say that six years ago, I was in the camp of every light had to be red. So, you know, I had to have my phone shifted into a red light phase.
My computer shifted into a red light phase. I had all of these apps that managed all of this stuff.
So as soon as the sun went down, blue light was being removed from my electronics. And I have to say, I sleep subjectively and objectively better today.
I say objectively if you can believe what a sleep tracker tells you, but we can bracket that and come back to it. We should never taking blue light out of my devices, but instead paying attention to what I'm consuming.
In other words, my new hypothesis has become, it's not the blue light that is the problem. It's the stimulus that often comes with the blue light.
In other words, not looking at social media, regardless of light color, is a far greater positive impact on my sleep than looking at those things, but just making sure that there's no blue light coming through. So let's talk about that.
What is the role of minimizing blue light when it comes to preparing for sleep? First, I want to completely agree with you. We didn't evolve for the neural experience of Instagram.
We're not ready for that. I think regardless of what color light you're getting your Instagram on, that's probably not helpful before you go to bed.
So I think that you're entirely right. I think the larger problem is not necessarily the blue light, but is the thing that we're interacting with, whether it's an iPad or a phone or a computer, because typically those things are going to involve social media, work, email, all of these other things that I think are much more potent disruptors of sleep than the blue light itself.
I must caveat this though. I have had a few patients who they were not using Instagram before bed.
They were not doing email before bed. None of this.
Not doing anything stressful or stimulating. No, but I just finished with a patient recently like this who found that using orange colored glasses, and I'm talking orange colored glasses, not those beautiful blue light blocking glasses that are clear lenses that I'm not sure what they're really doing sometimes.
I'm talking ugly motorcycle looking orange lenses. I found that a handful of patients wearing these two

hours before bed, it completely ameliorates their sleep onset insomnia such that they were able to

almost immediately quit Ambien. The beauty of these interventions is if you can isolate them

to one change at a time, you can be empirical about it. And something like wearing glasses

is benign.

I mean,

Thank you. Maybe it wasn't that.
Who cares if they return and you can fix it? Yeah, Like I try not to be terribly dogmatic about this stuff, but I also think that when people go to great lengths to remove blue light without removing stimulus, they're missing the boat a little bit. And for me, social media is not much of a stimulus actually, because I don't pay that much attention to it, but work is.
So for me, the single worst thing I can do right before bed is look at email. Whereas watching TV, it's a total beautiful way for me to be distracted by watching something mindless on Netflix for an hour.
And as long as I don't go and check my email and see what got sent to me in the last hour, it'll be great. It doesn't matter that I just finished watching a big, bright screen of Netflix.
It doesn't seem to impact me. Well, one is much more interactive and stressful, and one is very passive when you're just watching a movie that has nothing to do with you, no bearing on your life.
What I would say, back to your, what I'm going to call A-B testing, whenever you want to test one of these individual, what I call low-hanging fruit interventions, you want to collect your own data on a paper sleep diary for two weeks. Make the change.
You must do it for two weeks. And there's a few more low-hanging fruit pieces of sleep hygiene.
By the way, do you have a nice template? We have one that we give our patients. Again, it's super low-tech.
It's a piece of paper. So low-tech.
Do you have one on your UCSF website? I can make it public, yeah. Yeah, yeah.
Okay, maybe we'll link to it in the show notes. Yeah.
Easy to do. We could link ours as well, but yours is probably better.
Ours is like boxes you color in. Oh yeah.
And it's like you put C when you had caffeine, A when you had alcohol, E when you exercise. So we're documenting when did you exercise? When did you have food, alcohol, caffeine, and when were you in bed and when were you sleeping by the shading? Yours might be even more high tech than mine.
But what I will tell you is mine is just enough to get the information that I will definitely act on and nothing else. But I will tell you, can I go over a couple more pieces of low hanging fruit on sleep hygiene? Yep.
Okay. So back to the glasses.
If you are a person who has trouble with what we call early insomnia, so difficulty falling asleep at the beginning of the night.

And you're already not looking at your email, not doing Instagram.

You're just annoyed that you cannot fall asleep at the beginning of the night.

It's worth it to try these glasses for two hours a night for two weeks and see what happens.

It's so easy to do.

To be clear, is there a particular brand?

I have no affiliations with any of these things. I can tell you there's some really nice, ugly ones from lowbluelights.com, I think, if they're still in business.
But they look like motorcycle goggles. I do think that the wraparound feature is important because if we're going for it, let's go for it.
It's a worthy thing to do. Another important thing to do is to talk to your physician.
I'm not a physician, but I work with a ton of them. And I learned this from an anesthesiologist.
All medications have circadian effects. All of them.
Somehow, it's probably not known for all of them how they do, but they do. Make sure you are taking your medications at the same time every day and at the right time of day.
For example, I once had a patient coming in saying they were taking 450 milligrams of bupropion for depression before bed. No, that's going to be a pretty stimulating dose of something to take before bed.
So make sure that you go over your medications with your doctor and that you're taking them at the optimal times of day and be really consistent with your medications. And another one that is a particularly low-hanging piece of fruit is something called decaffeinated coffee.
Turns out there are speculations that decaf coffee can have as much as 15 to 30 percent of the caffeine that regular coffee has. I haven't found that reference.
I've dug. I've tried to find one that will show that.
I haven't found exactly that. But there are some data from 2006 that were published saying that 15-ish percent.

But then again, more recent data have shown that Starbucks, I think, says that their 12 ounce has 155 milligrams of caffeine, but outside laboratory testing found 310, something like that. So when you're decaffeinating coffee that's much more caffeinated than you started with, this can make an absolutely huge difference.
I tell people we're done with caffeine by 11. That's my 11 a.m.
That's my standard. Unless we've got an extreme phase delay or phase advance, I should define those terms.
A phase delay is when you go to bed really late and you wake up really late. A phase advance is when you wake up really early and you go to bed really early.
So someone who's waking up at like 3.30 in the morning and going to bed at like 8 p.m., that would be a phase advance. Phase delay would be like, I'm going to bed at 3 a.m.
and I'm waking up at 10 a.m. So in those cases, I might do something differential with the caffeine.
But for most people who are neither of those, I'll cut it off at 11. That includes your caffeinated coffee and your decaffeinated coffee.
And I never take people's caffeine away. Caffeine withdrawal is not something I want to deal with in my clinic, and I don't think it's necessary.
You can cause a lot of damage taking away someone's coffee. People really don't like that.
It really puts them in a bad mood, and it's not necessary. So I tell people, do not change how much coffee you're drinking.
Put it all before 11. Just move it all.
What fraction of people are such rapid caffeine metabolizers that they seem immune to caffeine and sleep? I think that that person doesn't actually exist. I need to be convinced what the normal caffeine half-life is four to six hours.
So even if we take someone who's four hours, that means after four hours, you still have half of a cup of coffee. And after eight hours, you still have a quarter of a cup of coffee.
And if you have that coffee at 2 p.m. and that coffee actually had 310 milligrams of caffeine in it and it was only a tall coffee from Starbucks, there's a lot of contingencies to build in here.
But I could tell you people, someone we both just know, actually stops using decaf coffee after dinner and it's a world of difference for their sleep quality. People will say, oh no, I fall asleep just fine, doesn't affect me.
Well, it is affecting you. It's affecting the electrical quality of your sleep throughout the whole night.
And I would refer you to talking to a sleep neurologist to interpret some of those sleep studies and talk with you more about that. For my purposes, all I need to know is the person who's trying to fix the insomnia is, oh, you're having two decaf coffees after dinner every night.
That could add up and that could be doing something and that could make your sleep less restful. Okay.
Low hanging fruit. Just stop it at 11.
Stop it. Like do the experiment at a minimum.
Okay. So those are three.
But don't reduce it is the key thing. Any other really obvious things to AB test for two weeks? No, I think that that's the major part.
I will tell people also, people like to fall asleep with podcasts on, don't do that. Including this one, right? Right.
Yeah. This is an easy one to fall asleep to, but I don't know.
I hope that people aren't falling asleep listening to this. Although, if this helps some sleep.
One other thing I want to talk about is on the relaxation techniques. Where does or does mindfulness-based practice come into it? So anyone who's done mindfulness-based meditation probably appreciates how difficult it is.
It's not like transcendental meditation where you're focusing on a mantra. You're instead focusing on a sensation, typically breathing.
But body awareness is a thing that you want to focus on. Is that counterproductive or is it productive as you're laying there awake? So my unsatisfying answer to so many questions is always going to be it depends because there's moderator variables.

And when it comes to CBTI,

what we know is that what's been tested

is progressive muscle relaxation,

which you could argue is a form of a body scan,

which is part of many mindfulness practices

where you scan your whole body,

you think about your hands,

you notice how they're feeling,

are they warm, are they soft, whatnot,

and you move through your whole body. With progressive muscle relaxation, you squeeze your hands and you let them go.
You squeeze them and you let them go. It's more of an active process that you're paying attention to throughout your body.
Doing this in bed right before you fall asleep for a few minutes is fine. That's the one exception to the sleep and sex rule.
I tell people that it's also fine to practice this in other parts of your house. You don't have to just be in bed.
But the body scan and mindfulness in general has been studied in combination with CBTI. And what the data have shown is somewhat fascinating.
There's no actual differential improvement on sleep duration or metrics of sleep. But people like the mindfulness stuff.
They report they're more happy with it. They like doing that.
But in terms of actual improvement on sleep outcomes, I don't think it really adds too, too much to CBTI. The effects with CBTI are pretty whopping.
When it's done well, 50 to 60% of people can get remission and 70% can get clinically meaningful improvement to their sleep.

So in the world of psychological treatments, that's really good. But to circle back to your

question, mindfulness is great. I think there's a lot of practical uses for it, for helping yourself

when you're in psychological states you don't want to be in. It's a great way to be in life.

But when it comes to sleep, do I need you to start a mindfulness practice to improve your sleep? No. So you mentioned 50 to 60% of people are going to have a remission.
Closer to 50, but yeah. 70% will have a meaningful clinical improvement.
Of the 30% that do not, why? When does the treatment fail? The treatment fails when people don't do it. So in other words, we're really saying 30% of people are not able to adhere to the treatment.
I wouldn't go that far. There are some people who are genetically short sleepers.
And at some point, this may become distressing for them. I had a story of a patient who was in her 70s, came to me saying, I have a huge problem.
My sleep is not good. And I asked her, okay, so tell me all about this.
She was like upper 70s, had a volunteer job, really active, full workout plan. I'm like, you're crushing it, lady.
What's the problem exactly? She says, well, I joined this study and I had to wear this wearable device. And I woke up in the morning and it says that things are not going well every morning, morning after morning.
And it says I'm at risk for different things. I'm not going to say which wearable company it was.
And I said, oh, okay. There's an amazing treatment for that.
Can I see the wearable device? Can I please just have that wearable device? Here's my vice grips. Boom.
Exactly. This was a while ago, but I took it away from her and the wearable devices now are not doing this.
This was, gosh, seven, eight years ago. I made a note to ask you this question.
When do you tell people, because we do this with our patients, which is take the tracker off. We're doing a six month tracker holiday done with the tracker.
Done. So is that mainstay part of your treatment is like, let's get all that anxiety out of there? For people with insomnia, I tell them, yes.
Coming to me in my clinic, the people who have bothered to wait a year and a half to get into the clinic, those people, yes, I am telling them that. And so to go back to your 30% of people, the genetically short sleepers who become distressed about their sleep are not going to be helped by CBTI.
They're not. Maybe they shouldn't be helped.
Maybe there's nothing to fix. Correct.
Correct. But they're presenting, so I'm putting them in the group.
And then, yes, we know that there's such a huge body of data on CBTI at this point. It's just wonderfully studied.
And we know that when people don't do the treatment, it doesn't work. Adherence is a major, major component.

Duration of treatment also matters.

It seems that if you do four or more sessions

with a therapist doing the CBTI,

your outcomes are gonna be way better

than if you try and cut it way short with one or two.

My treatment is five sessions.

I do an intake, you get five treatment sessions

and then I do a follow-up where we just tidy things up.

And the space between them is a week? Always one week. I am militant about this.
If you're going to miss a week, you can't be in it. You have to wait for the next cycle.
Given that people are waiting a year and a half to see you, tells me that there's a mismatch on the supply-demand curve. Yeah.
Why is that the case? First of all, there is a great directory. Can I give you for the show notes? Yes.

So there's actually a way you can look up.

We use it ourselves.

The Society of Behavioral Sleep Medicine thing? Yeah.

So that is how you would find a provider who definitely knows how to do CBTI.

One of the major problems comes down to psychologists and providers taking insurance.

A lot of the best folks there in private practice, they don't take insurance. And you could be paying hundreds of dollars a session to see them.
And they're pretty backed up as it is, and they don't take insurance. I am fortunate.
I get to work at UCSF at the Osher Center for Integrative Health, and we take Medicare and all kinds of insurance so people can pay minimal or non-existent co-pays to see me. And there are other CBTI providers at UCSF.
Their wait lists are long, long, long too. In fact, in order to see patients now with any volume, I don't see individual patients.
I see eight patients at a time in group medical visits. And I do it 90 minutes every week, all eight patients in that 90 minutes to get it done.
So what will it take for AI to replicate what you're doing to scale this much more? Because a lot of this, a lot of the work I do can be done by an AI. How much of the art and science of this is teachable to LLMs and at least as another offering.

I'm not saying it should ever displace what you're doing or what a therapist is doing.

But if we have a backlog of people for years, shouldn't we have an alternative which might say, look, there's an online course that you can do that will give you 70% of the value of what you might get sitting in the group with Ashley?

Hey, if you can find a way to replace me, I'm here for it. Or just come up with an alternative to scale.
Here's the issue. There are some CBT apps, smartphone apps, interventions out there.
And I've had patients who've tried these while they're waiting. Yes, exactly.
And they'll come in and they'll say, oh, it might have helped a little bit. And I think the major issue is that many, many people with sleep problems think that their sleep problem is unique.
It's special. This can't be treated by just a generic app.
My problem is different. And the joy of me having a group is that people can hear that everybody's problems are different and I'm going to treat you all the same way.
Y'all are going to do the same things. You might do it at different times, but you're all going to do the same things.
And I think that there is a world where AI can help with the personalization aspect. I'm actually helping a company that's making an app, it's called Rest, and they are integrating AI to use, for example, the way that I calculate someone's wake time, which is not something that's in standard CBTI.
They're incorporating that and they're able to actually do more tailoring. And I'm excited to see where it goes.
But I think that the biggest fly in the ointment with this is going to be getting patients to look at the fact that they have been assigned to wake up at the same time every day for the next seven days and think, oh gosh, I only wake up at 5 a.m. two days a week.
Normally now I have to do it every day. Getting them to really do it is going to be hard.
Before my patients enroll in my clinic, they watch a 10-minute video and it's a really scary video. In that video, I'm basically saying, look, this is gonna be hard.
You're gonna hate me. You're gonna want to make a dartboard with my face on it and play darts on it.
You are going to suffer in the beginning of this treatment. But guess what? You have been suffering for months or years.
Now you're going to suffer for five weeks. You're going to do it my way.
And if you don't like it, you can go back to your way. This is five weeks of your life.
How bad can it be? How much worse can it get? So I do one of these kind of pep talk videos. There's just something about knowing that someone else is actually really paying attention to one of the biggest problem, if not the biggest problem in your life at that moment.
Sleep is a 24 hour a day problem. This is not just a problem at night.
It is affecting you all day. It is intensely personal.
So it's a lot to trust an algorithm or an app to know, oh, okay, I really should do these things. I think it's a big ask and it's hard.
By the way, when you're giving them that bootcamp speech, is the time in bed restriction typically the thing that causes the most distress? They don't know about that at that stage. People are in the dark at that stage.
I just say, look, we're going to do this thing. It's going to be really hard.
You're going to get worse before you get better because everybody sleeps less the first couple of weeks while we're getting all these things lined up. And for some people, what ends up being the hardest is the wake time because they're used to just sleeping in whenever they can or catching up on those hours when they can.
For other people, the super late bedtime that I give them, that's what crushes them. They're like, oh my gosh, I have to stay up until then.
But the great news is that we dial it back over time. And I don't think we talked about this part with time in bed restriction, which is just that there's a benchmark for efficiency, sleep efficiency.
And we define sleep efficiency as the amount of time that you're in bed sleeping divided by the entire time that you're spending in bed. And the benchmark is 85%.
So each week I'm actually calculating sleep efficiency from people's paper sleep diaries. And once we do time in bed restriction, if they are above 85%, I move their bedtime back 15 minutes.
And then if that's the same for another week, you move back another 15 minutes. And people say, 15 minutes, what? Who cares? I'm like, oh, you'll care.
After four weeks, that's an extra hour every night. That's huge.
And are people able to, with a high enough fidelity, report a wake time in bed? For example, like if I were doing this, let's assume I've got a clock next to my bed that I can look at because you have to do that for this purpose. You have to have some device to keep track of time.
So I get in bed because my time in bed tonight is 11 and my wake up time tomorrow is 530. Okay.
So I get in bed. It's 11.
Check. Okay.
How do I know what time I fell asleep? Let's just say I didn't have an issue falling asleep. How do I know if it's 1115 versus 1130? I'm looking for the difference between five minutes and 50 minutes for that time to fall asleep thing.
Right. And in the middle of the night when you're waking up, guess what? If you're not getting laid, you're getting out of bed.
So you can look at the clock and be like, all right, I'm out of bed. And then you have to go do what I call a very fun and potentially embarrassing activity.
Embarrassing meaning if your boss caught you doing this activity during the workday, you should feel embarrassed. So for example, reading People magazine or reading some trashy magazine, you wouldn't want to be caught at your desk doing that at work.
That's exactly what you should be doing in the middle of the night. So person wakes up at two in the morning and they can't go back to sleep, get up, go and do something that is not productive, not rewarding in the way that, hey, this is, I'm building a pattern around getting up and doing something I like.
So I wouldn't be able to get up and play chess. I wouldn't be able to do the online chess thing that I love.
Maybe, maybe not. I mean, I tell people they can play solitaire.
Adult coloring books are all the rage. I couldn't check email.
No. Work-related work is a definite no.
What about scrolling social media? No, no.

We don't like that. Although that meets the criteria of you wouldn't want your boss catching

you doing it, we don't do social media or interactive. Read for pleasure? That's fine.

Okay. But we don't read about global warming, current events, politics, pandemics.
Those

things are off the menu. Stock trading? Not if it's stressful.
I wouldn't do that.

Okay, so there's a narrow subset of activities that you are going to get out of- Politics, pandemics, those things are off the menu. Stock trading? Ooh, not if it's stressful.

I wouldn't do that.

Okay, so there's a narrow subset of activities that you are gonna get out of bed to do.

Yeah.

Yep.

Stuff that's kind of boring, but entertaining enough.

Because we don't want you to get a habit

of looking forward to doing something

in the middle of the night.

This happens with parents.

Like a parent, for example,

who might be busy all the darn day

with their kids and their family's needs and everything else. Then in the middle of the night, they wake up and it's like, oh, this is me time.
This is when I'm going to do all these really fun things that I don't get to do during the day. We don't want to make a habit of you time being between 3 and 4 a.m.
That's really when you want you to be sleeping. Sometimes you have to schedule that stuff during the day.
But we want the stuff in the middle of the night to be mildly boring. And to that end, back to your blue light thing, I don't mind if people watch, for example, an episode of MASH or Gilligan's Island or Sex in the City or some other sitcom.
I like 20 minute episodes because then you can generally turn it off, check in with your body, think, am I ready to go back to sleep? And then you can go back to sleep. Do you remember in the 90s, if you played video games ever, how we had those like cartridges and we'd put them in and sometimes we have to take them out and blow them out to put them back in and reset them because they would freeze? That's what you're doing.
When you get out of bed in the middle of the night, you do a different activity. You're resetting and then you're going back to sleep instead of just having stewed in bed that whole time.
And it's much easier to fall back to sleep when you have that reset. So we don't want the activity to be too stimulating, but just mildly boring and entertaining enough.
Does that track? Yep. One obvious thing we haven't talked about, and maybe it's so obvious we don't need to, but just to close the loop on it is food and alcohol and how they pertain to this.
What's the checklist you run through with the clients? So since we're dealing with so much life, I actually don't mess with their food. All I do is say, hey, really, let's try to not eat within three hours of going to bed.
Sometimes it's rare that I'll have nighttime binge eating disorder to deal with at the same time or a blood glucose issue in diabetes that's poorly controlled at the same time. But I'm going to put those cases aside for just a moment.
So I generally will go with don't eat for three hours before bed. And when it comes to alcohol, I tell my patients, look, this is five weeks of your life.
I'm not going to drink and you're not going to drink. So when I'm running a clinic, nobody's drinking.
And the reason for this is that in order for me to actually see what's going on with your sleep, I need to see this with the least perturbation possible. Alcohol and marijuana are those things.
Now, if people are using a lot of marijuana or a lot of alcohol, I'm not here to put people into withdrawal. So they just don't enroll until they're...
No, no, no. I'll let them in.
So what I'll do is before people come to their first group, I have them do a sleep diary so I can see what's going on. And before that, I will have done their intake and I'll have them have told me their alcohol intake.
And I'll have decided, all right, here's what you're going to do. You're either going to not, or I just finished with some people.
One of them was drinking between 16 and 20 ounces of wine a night. It's huge.
And I said, okay, so you're going to drink two ounces of wine a night out of that same glass. And then, you know, you're going to keep using that glass and you're going to drink something else, some other frou-frou drink.
I don't care what it is, But I want it to be something that you don't drink during the day. So I want it to be overpriced juice or overpriced bubbly water or something like this.
Something special. Something special.
And you're going to keep drinking it out of that wine glass. And I have them do that.
And I make sure they can do it before they start treatment. And they generally can.
Because again, the other part that I have going for me is that people have been waiting so long that by the time they get to me, they'll do what I say, which is just this lovely gift that I have. But I'll make people be very consistent with that.
They'll be like, oh, I have to drink two ounces of wine a night. I'll say, yes, you do, you must.
I want this consistent, that's the thing, consistency. So if someone's saying, oh no, I drink three nights a week and I'll say, all right, cut it out.
You're going to stop. I'm going to stop.
We're all going to stop. Are there any specific cognitive techniques that people are instructed to be working on when they first wake up? No.
Nothing. There's nothing, no mind game to play.
It's all behavior, behavior, behavior. I'm all business.
Yep. At CBT, I'm a purist.
And I don't involve the cognitive techniques until week three of five with treatment. And that's when we get into things like scheduled worry time, working with the thought records.
And then also one of my favorite things to do with patients who seem to wake up in the middle of the night, maybe at 1 a.m. They jolt themselves awake worrying about something in particular.
I have a patient like that who every night in the middle of the night, maybe at 1 a.m. they jolt themselves awake, worrying about something in particular.
I have a patient like that who every night in the middle of the night wakes up at 1 a.m. and says, I'm very worried about thing A.
I'll say, okay, thing A. Here's what I'd like you to do with thing A.
I would like you to track how worried you are about thing A all day, every couple of hours. This is called tracking degree of belief in a thought.
And what you might find is that I'll build on this with an example of a patient that I had, actually. This might be an easier way to explain it.
I once had a patient with multiple sclerosis, early 30s, pretty debilitating disease to have when you're that young, working a full-time job, who used to jolt awake in the morning, every morning at 7 a.m., thinking I'm never going to make it through this day.

My whole body hurts.

This is a mess.

I'm never going to be able to do this.

And she would lay in bed for two hours until like nine o'clock thinking these thoughts

just, oh, I can't do this.

By nine o'clock, she'd get out of bed.

She'd shower.

She'd get to work by 10 o'clock because in the Bay Area, all these startups don't start

till like 10.

She'd get her coffee, work with her assistant, do her meetings.

And if I asked her, how much do you believe that thought, I'm never going to make it through

this day at noon?

She probably say, oh, like 60%, like this afternoon is going to be rough. I don't know if I'm going to make it through.
But if you ask her at 5.30 when she's done working or whatnot, oh, how much do you believe that thought, I'm never going to make it through this day? She'll be like, oh, I made it 0%. Day after day, she started realizing like, oh, I don't believe this thought at 7am because it's true that I'm never going to make it through this day.
I believe this thought because it's 7am. Once she was able to make that connection, we were able to recapture her mornings.
And at 7am, she went and sat on her couch and she started doing something she loved doing 7 and 9, which for her was learning Italian with an app, which she loved. And seven to nine used to be her most hated part of the day.
But by the end of treatment, it was her most beloved part of the day because no one was bothering her and she could learn Italian and whatnot. And so one of the cognitive tools that I've built into CBTI in that cognitive package is tracking how much you believe a thought over a given day.

And if you believe a thought in different levels throughout the day, how true can it really be? And it's really enlightening. And I would invite you to notice what you're thinking about at 1am and then just see how worried are you or how much do you believe this the next day at 3pm? Oh, not at all.
How come this deserves airtime at 1am but not. but not 3 p.m.? Let's talk about sleep supplements.
So do you do a purge of supplements when people come to you and they say, hey, I'm taking a pound of melatonin every night. I'm on an ashwagandha drip.
Just rattle them off. We could go through the list.
Can I give you two links for the show notes to studies of melatonin supplements that found that these melatonin supplements either had none of what they said they had in them? Yes, I think we wrote a newsletter on one of them. Oh, great.
Well, there's been two. And when people come in and they say they're taking melatonin, I'm like, okay, the alleged melatonin, how much of this are you taking? Let's assume that they're taking melatonin because they're getting it from one of the companies that submits to third-party testing.
And so now they know they're doing it. And again, let's further posit that they're not taking a dose that is deemed too high.
So if you look at some of the sleep literature, there seems to be, most people would agree anything north of a milligram is probably just too much. Whereas kind of in the three to 600 microgram, there might be some benefit and more importantly, not just benefit, but actually safety.
You're not downregulating melatonin receptors. You're offsetting the natural decline in melatonin levels over time.
I can tell from your face, you don't agree with any of this. It's puzzling.
So my face is also because it's hard to know where to go with this question because some countries you need a prescription for melatonin. This is something prescribed by a doctor.
It is regulated. I don't remember all the countries off the top of my head, like Australia, New Zealand, whatnot.
You want that? You're not going to find it at their Walgreens. But in the US, taking too much can't kill you.
So here you go. By the time someone gets to me, if they've got a huge list of supplements and they still have a sleep problem, I say, okay, so clearly these aren't doing what you want.
They might be undermining what we want to do. I don't know what's actually in all of those things because none of that's regulated.
The data for things like ashwagandha are weak. If you want to go Bradford Hill, we could.
The data are also pretty weak for melatonin, except in certain cases, which we can unpack a few of those with the explicit acknowledgement that I'm not a physician. I've not been trained in the biological substrates, whatnot.
But your question is, do I take people off of this stuff? Yes. Get off that stuff.
If you want to take it after treatment with me again, great. But let's get off of it for now.
Let's see what your body's actually doing, because chances are you've been adding a supplement or two or whatnot over time for years, and we don't even know what your body wants to do now. And you actually could be shooting yourself in the foot with some of these things.
Now, on the contrary, sometimes a patient will come in and will say, oh, I'm taking a beta blocker for blood pressure. Now, you and I both know that's like a fourth or fifth line treatment for blood pressure at this point.
Nevertheless, beta blockers inhibit melatonin secretion. And yet most prescribing doctors who are giving out beta blockers don't realize that there's a significant risk of insomnia when you prescribe these to patients.
And I've had some patients who don't need treatment with me at all. They need a 0.5 milligram melatonin pill every night and that's it.
And those are some of the most angry and satisfied patients ever. They have one visit with me.
It's done. They're furious that they've been suffering for 5, 10.
I had one patient who suffered for 30 years taking, oh gosh, metoprolol. He couldn't change his supplement because something having to do with the vocal cords, he was a singer.
Some of the other blood pressure medications affect that. I didn't fully understand, but he would not change his blood pressure med.
So that was all that he needed. But do I think that the average healthy adult should be taking melatonin? No, no.
Now, there's probably some excellent data that you are much more aware of than I am about how our melatonin secretion, inhibition processes, whatnot, change as we age. There may be some patients who benefit from taking melatonin, which is a hormone to induce sleep.
But remember, melatonin is like the guy at the start of the race. He's the guy with the gun.
He fires the gun. He doesn't have a car in the race.
He's not helping you stay asleep. He's telling you when to start the thing.
So for a lot of adults, taking melatonin is really messing them up because they're trying to go to sleep when their body isn't ready to go to sleep. They're forcing it to go to sleep.
Then they wake up in the middle of the night and they wonder why. And it's because, oh, you went to sleep at the wrong time and your body's all kinds of confused.
Yeah, interesting. So I really try and take people off of these things so I can see what's really going on.
And then if there's something going on that looks like it might necessitate melatonin, I tag in one of my physician friends and talk about it. So what about sleep medications? And let's talk about as many as you want, right? We can talk about benzos.
We can talk about trazodone. We can talk about Ambien.
We can talk about the erexin-based drugs. How many of the patients who come to see you are regularly taking one of these prescription-based drugs for sleep? So a lot of people take over-the-counter drugs and prescription drugs for sleep.
And there was a huge shift that I noticed when COVID started. And there was a ban on flying to different countries, Mexico and Europe.

And it turns out there are a lot of people who will fly to Mexico to get their Ambien and fly to Europe to get various sleep drugs that you can't necessarily get here. All of a sudden,

I saw a wave of patients dealing with withdrawal in the early months of the pandemic because they

couldn't go get more of their drugs. Oh my gosh, I'm screwed.
What am I doing now? How do I cope with this? Why couldn't they get them here in that situation? Ambien's prescription only. They couldn't get a prescription while they were here.
Yes, because they were taking so much that they were well beyond what they could convince someone to prescribe them. A lot of my patients are physicians and a lot of physicians are pretty reticent to go above FDA-recommended doses when it comes to Ambien.
A lot of people don't realize that I believe, I believe this is the case, Ambien is still the only drug that is differentially prescribed to men and women. According to the FDA, the starting dose for women should be 5 milligrams.
Starting dose for men is 5 to 10 for instant release. And then for extended release, I believe for women it's 6.25..
And then for men, it's 6.25 all the way to 12.5 because women metabolize it less efficiently. So the people who I've seen, I've seen people taking 30 milligrams, big doses.
And gosh, this is a very loaded question. But there's a lot of patients who come to me who will say, I've read something in the news.
It turns out this medication I'm taking for my sleep is bad for my brain. They're like, oh, you saw that, huh? And I want to quit immediately.
I need to quit by next week. Oh, okay.
And you've been taking it for how long? Oh, 20 years. Okay, right.
So that never works. That never works.
I wouldn't say that I have any sort of extreme expertise in the different classes of sleep meds. But what I can tell you is the ones that people most often are coming to me saying, I want to quit this.
I hate being dependent on this. What do I do? These are going to be the benzos, which doctors are becoming less and less hip to prescribing for sleep.
Ambien, the synodol Anesta stuff. And then over-the-counter stuff like Benadryl, maybe your occasional Doxepin.
And then people are often prescribed Remeron for sleep and they run into metabolic issues and they need to get off of it. So I think that covers the broadest swaths that I see of things people wanting to quit.
Now the QVIC, it's some of these newer ones. I don't see them as much yet.
I'm sure it's coming. And what about Trazodone? Trazodone is the one that I'm the least concerned about for a couple of reasons.
I've not seen compelling data that it negatively impacts the electrical quality of your sleep. No, in fact, I've seen data that it does the opposite, that it's slightly positive.
Great. I'm looking for what's negative.
I don't know if the study that you're speaking of was statistically powered, if the primary outcome was improvements in sleep or decrements in sleep. Now I'm trying to remember something that I wrote probably three years ago.
I believe the study looked at sleep duration as the primary outcome and a secondary outcome may have been staging. Yeah.
So I don't think it was powered for that, but I think they incidentally did find an improvement. I think you've talked about extensively, like it's important to think about what was the study power to look at and all that.
But I'm not the most worried about that also because it's an antidepressant drug. And if someone's taking it and it is helping with their depression and I take them off of it in the name of trying to help with their sleep, I have created a different problem.
Although the dose people take it, it tends to not have that effect. I mean, most people are typically taking it at 25, 50, typically no more than 100.
Maybe at 100, depending on the size of an individual, they're getting some of that benefit. I often see 100 for sleep.
And so for me, I'm thinking, ooh, I don't know if that's just for sleep. And then I'm also, if I see 50 even, and then I see another antidepressant, I think, ooh, these could be working together.
You actually also have a diagnosis of depression. We need to think about this carefully.
If folks are showing up on 20 milligrams of Valium or Xanax or pick your favorite Benzo, do you have them go and do a taper detox with their physician before they come into the CBTI program? No, I have them do it with me. So you will manage the medical withdrawal on that? Let me explain exactly what I do.
Scope of practice. So first of all, I always work with the prescribing physician.
I never start without making sure the prescribing physician is explicitly aware of what I want to do. I talk with them.
And this has to be one of your colleagues at UCSF or whoever they're prescribing. It's whoever is prescribing the medication to this person.
We now share a patient and have an obligation to. Every single time I have done this, the physician has been in support of getting their patient off of benzos, except for one time, which isn't even worth really getting into.
But the point is, it's an overwhelming amount of support. Yeah, I can imagine.
Most of the time, these physicians have already tried to get their patients to quit and to

reduce.

But in my opinion, they've tried to do it way, way, way too quickly.

And that's because there are physiological dependencies on these drugs and psychological

dependencies on these drugs.

And we have to attend to both of them while we're doing this taper process, or it's going

to be a botch and the patient's going to relapse and we're going to be back at square one or square negative one, unfortunately. So here's what I do.
Let's take a boring example. Pick your favorite benzo, favorite dose.
I don't particularly like them myself, but let's take Valium. Valium, okay.
Long acting. 10 milligram? Yeah, sure.
So let's say we've got a patient on Valium. They've tried to quit.
They've occasionally abused. They've gone up.
They've split an extra in half. They've gone up to 15 sometimes, whatnot.
The first thing that I do with a patient is I say, all right, actually for sake of better example for sleep, can we do Ambien because it's a little more fun? 10 of Ambien. Let's say 10 of Ambien every night at the beginning of the night.
And then let's say sometimes they're actually taking a fiver in the middle of the night when they wake up because they want to get back to sleep. I like the party dose.
Right. So let's say some nights it's 15, some nights it's 10.
What do we do? So the first thing I do is I take out the middle of the night dosing and I say, we're done with that. You're limited to 10 a night and you got to take it before bed.
Yes. You have to take it before bed.
You have to take it the same time every night. But if you're going 15, five nights a week and 10, two nights a week, I'm going to make it a 12.5 before bed.
Let's be generous. Start higher.
So we'll agree on a dose that the patient will take in a agreed upon time. So the prescriber and I agree on this.
Like, OK, same page. This is what the patient's going to do.
And they start doing that. Generally, the patient's like, no, no, no, I'm trying to quit.
I don't want to take more. And I say, no, no, before you quit, it must be stable.
You cannot quit from a point of instability. It will not work.
I've seen people try and people say, oh, I want to quit. I want to go from 10 to five.
No, that's not how we roll. So let's say this patient's taking 12 and a half and they're like, okay, I want to cut down.
I'm like, all right. Okay.
So how does going from 12 and a half to five sound? And they say, oh my gosh, that's going to be really scary. I don't think I can handle that.
And what I actually have them do is I rate it on a scale from one to 10, with 10 being the most anxiety provoking, upsetting thing, and one being not upsetting at all. This is called a subjective units of distress scale, suds.
I have them suds it. So I say, okay, going from 12.5 to five, that sounds really terrifying now because they've

just done a week where they're consistent with 12.5 at the beginning of the night. They've had no middle of the night crutch and they're not feeling great about that.
So then I say, okay, so how about going from 12 to 10? And they say, oh, not as bad, but that's still like a six on my scale. And I do this process all the way until I get them to a one.
And I'll say, all right, So next week, we're going from 12.5 to 12.

How are you even making that increment? I can tell you exactly how we're doing that. We're going on the internet and we are buying something called a gem scale.
Now, you and I both know that people who are wealthy enough to have gems worth measuring aren't measuring their own. So the people who are buying those scales are using them for other things.
And so what my patients end up doing is they buy these scales and they get a full-blown breaking bad setup in their bathroom. We're cutting pills.
We're weighing pills. We're doing math because the pill actually weighs more than 12 and a half because it's got binders and fillers.
What percent do we need? And we kind of make it fun. And they end up having to put the crumbly pill into a shot glass with some water.
We shoot it and the whole thing. We make a whole production out of it.
But the point just is they're going from 12.5 to 12. And we do that for like three weeks.
If they've been on it for years, we're looking at three weeks. And the first couple nights are a little rough.
There's a little stress. If they're only doing a seven-week program with you.
Oh, no, no. This taper program we make and it will last a long time.
Before they enter the program. No.
This is a separate issue. This is a separate issue.
And we do this after they finish CBTI treatment. During CBTI treatment, I stabilize them on their meds and we just get it so they're not erratically taking five different cocktails of things.
When people come in to see me for treatment, they'll say, oh yeah, so Mondays I do Ambien, Tuesdays I do Trazodone, Wednesdays is Benadryl because they have it in their head because they think they don't want to get dependent on one. So they think that by doing a rotating merry-go-round of these things that- That's actually smart.
I would have never even thought of that. Oh yeah.
Sinister. It's working great.
Yeah. So I generally work with the doctor and we decide, okay, here's the one you're going to do.
Here's the dose you're going to do. And you're going to be consistent with this.
So vodka on Monday and then tequila on Tuesday, red wine on Wednesday, and then Chardonnay Thursday. And this way I'll never become an alcoholic.
Figured it out, Peter. In short, I have people really stabilized during CBT and sometimes during week four, week three, four, they're ready to start this.
And we start them on this program. And once I have them in this way, they're able to do this on their own.
So they'll go from 12 to 12.5 for like three weeks and they'll be keeping sleep diaries. So they'll see, oh, okay.
And we'll get some confidence. And then they'll email me, you know, they'll message me and they'll say, okay, so now what? And I'll say, all right, well, how are you feeling? Like, what if we go down to 11.5? How does that sound? Sometimes that'll be too scary.
For some reason, crossing the five threshold is really scary. So we go from five to 4.75 sometimes.
And just to be clear, this is psychological. There can't possibly be a physiologic difference between four, 4.75 and five milligrams of Ambien.
In fact, the medicine isn't even homogeneously enough compounded within the capsule. So as long as everybody understands that.
Probably not. But think some for tablets and I don't know about the requirements.
Yeah, because the binder and the active ingredient. Yeah.
And generic has to be 85% similar to the real deal. So there's all kinds of mess ups here.
Remember how I said there's a psychological part and the physiological part? This is a psychological part that I think gets left out of a lot of the, oh, just cut it in half to start decreasing your dose aspect, which is dealing with, okay, what can we physiologically do? I'm talking about what can we psychologically do? And do you think that this methodology of the incredibly slow taper with incredibly high precision, do you think it works for opioids? So I don't think I've ever seen that in my clinic. It's just not something I've had to deal with.
I don't mean for sleep. I just mean in general.
Or is the problem so grave that you have to be a little more aggressive and switch them to a completely different class of drugs? That's so far outside my area. I can't speak to it.
But what I can tell you is just that doing this method with the sleep drugs slowly over time, people get more confidence and they can make larger reductions at a time. And then importantly, Peter, when someone is tapering and something crazy in their life happens, like a child gets diagnosed with cancer or something terrible happens, we stop the taper and we stay where we're at.
So your taper might look like this. Yep.
But there's not a huge rush to get off this thing. You've been on it for 20 years.
Better to stably get off it. I always joke with people like if you can lose 10 pounds in two days, how quickly do you think you can gain two pounds? So when it comes to quitting these meds, slow and steady wins the race.
Having people gain the confidence that they can do it is such a big part of it. I know that one of the critiques I've gotten from folks is like, well, wait a minute, some of these pills have coatings and da, da, da, da, da, but it's a lot of it is psychological.
So this works really well for a medication taper and people can do it themselves. There's no like magic.
I mean, I think we've covered a lot on CBTI and let's now revisit the idea of the types of things that people should be on the lookout for that need to be addressed first. So we haven't talked about sleep apnea.
We haven't talked about restless leg syndrome. What are the other things where you just want to have some sort of sign off that says, hey, we've also confirmed that these things aren't present or what gets your suspicion roused that says, hey, we got to look at something else because you're presumably not doing polysomnography on everybody on the way in.
How do you navigate that? So I have the wonderful luxury of being able to look in people's charts and see who referred them to me and why they are referred. They can't be self-referred? Everybody needs a referral of some kind.
And it can be from anybody, but any referral. A lot of my referrals come from sleep disorder centers because they've already done all that workup and they say, all right, it's not a good thing.
I see, I see. So here you go.
If a patient tells me, I always ask a patient like, oh, has your partner or anybody you've slept with ever told you that you snore or that you sound like you're gasping for air in the middle of the night? I do have a bunch of those types of screening questions and I aggressively refer to colleagues with expertise in those areas before treatment with me. A lot of times people have a CPAP and they say, oh, I don't really use it.
I'm not sure about that. And I say, well, I'm here to tell you that you should be sure about it and that you should use it every single night.
It doesn't fit. Cool.
I'm going to make a call because we're going to get it to fit. There's a different mask you can probably get.
There's all these different issues that we can tackle. It just sometimes takes making a phone call.
And unfortunately, a lot of patients don't have great follow through for their CPAP in terms of help using it and figuring it out. So sometimes I have to just make that extra connection.
The one thing I think I want to make sure that we put a bow on also is this obsession with bedtime.

I can make you wake up at any time by setting a very loud alarm.

I can anchor you wake up at any time by setting a very loud alarm. I can anchor you into your day with a wake-up time, and that can be consistent every single day.
I cannot wave a magic wand and make you fall asleep at the same time every day. So when people think, all right, I'm going to get a handle on my sleep, I'm going to go to bed at the same time every night.
No, no, no, no. Wake up at the same time every day.
That's a much more important first step. And if you're waking up at different times throughout the week, that is the first thing to fix.
Yeah. What degree of social jet lag do you tolerate? Just for folks listening, social jet lag, meaning the experience of changing your sleep time during weekends, which could be akin to jet lag if it differs by hours.
In an ideal world, there would be zero, right? In an ideal world, I wake up at seven o'clock in the morning every single day of the week. For an individual who says, oh, but God, on the weekends, it's just so nice to not have to get up at seven.
Do you say, look, give yourself a 30-minute grace and that would still be considered perfectly healthy? So during treatment, I tell people you need to wake up at the same time every day that ends in DIY. So that means Monday, Saturday, Sunday.
Yeah. That's all of them.
Yeah. That's during treatment.
I had to check. Yeah.
Good. There is no room for negotiation during treatment.
We're in the dictatorship. But what I do teach people at the end of treatment is how to cope with the fact that life is going to happen when treatment ends.
It happens during treatment, but there's a lot that pauses during treatment, to be honest. But let's say that you've got a major event on a Friday night.
You're going to a concert. Yes.
And you're going to be out way later than usual. What I tell people is, look, you need to pick which day of that weekend do you want to suffer and which day do you want to feel good? Because we can sleep in one day.

You cannot sleep in two days in a row.

That's going to take you off the wagon.

We're not doing it.

So let's say Friday night you go to a concert and you want to feel good on Saturday.

Cool.

Sleep in on Saturday.

Sleep in by an hour on Saturday.

Okay, fine.

Go to bed on Saturday night when you get tired.

Spoiler alert, you're probably going to get tired past your usual bedtime because you slept in.

But then Sunday you have to wake up at your wake time and Sunday you're going to suffer. But let's say you want to feel good Sunday.
That means on Saturday, you're going to wake up at your usual time. Saturday is going to be a struggle bus, but you'll make it to your bedtime and you'll go to bed at your bedtime.
Then you'll feel better Sunday. So you just have to choose.
When do I want to do the suffering? The immediate day after? So basically force the suffering into the narrowest place possible. But you can choose because sometimes people don't want the suffering to be the next day.

They want it to be the day after.

So you get to choose that.

But I tell people, look, don't sleep in more than one day in a row.

It's going to mess you up.

You're not really getting quality sleep when you sleep in past your wake time.

When it's been a pattern for a long time, when you sleep in past your wake time, you're

probably getting some extra stage two sleep.

You're not getting more deep sleep.

That's for sure. We're recording this on a Tuesday, Sunday, two days ago, I was flying back to Austin from LA and the flight got delayed over and over and over and over again for reasons that are so asinine, they're not even worth describing.
And then we finally got on the plane and taxied, and then the water was leaking out of the coffee machine. So we had to go back to get another plane.
I'm not making this up, but I can only tell you how ridiculous this is. The punchline of the story is we didn't get home till two in the morning, which is long past my bedtime.
So what would your strategy have been getting home at two in the morning prior to Monday, a work day where you do have some leeway? I don't have to get up at six, which would be my normal wake up time. Would you have said, just get up at six, stick with it and make it up by going to bed a lot earlier Monday night? Or would you say sleep until eight? You'll probably feel better than if you woke up at six.
How would you handle that situation? I'll say which day is more important for you to feel good on, Monday or Tuesday. Let's say I said Tuesday because I'm sitting down with you.
Well, then I would say probably try and not to sleep in too much so that you can go to bed at your regular wake time on Monday. If you sleep in horribly on Monday morning, you're going to stay up later Monday night and then you'll get up at your wake time today.
You will have had shorter sleep for today. It will have rolled all the way over.
That's actually what I did. So having not thought about this, I just slept until, I think my wife tried to get me out of bed at seven and I said, can you let me sleep till eight? So I didn't get up till eight, but last night, you're right.
I had a very hard time going to bed. It was like 11 o'clock and I was still up meandering around.
Yeah. You just have to very carefully decide which day do you want to prioritize and that's how you make that decision.
So you have more control than you think is what's beautiful about that. And I just remind people, you can never really make up for lost sleep that easily because sleep architecture really matters.
And when you're sleeping in, you're not getting more deep sleep. You're getting some more maybe light sleep.
And at worst, that's robbing you of maybe some of the deep sleep you would have gotten the following night because you're on a circadian plan here. And we didn't really talk about process S and process C.
Maybe I can just briefly tell you what those two things would be. Absolutely.
Okay. So process S is sleep homeostasis.
And that's this sleep pressure idea that we are working on. Every day we build up sleep pressure until it's bedtime.
And then we capitulate, we fall asleep. And then our sleep pressure drains throughout the night while we sleep.
And then in the morning, we build it up again the next day. And this is just adenosine building up? Yeah.
Think about it that way. And that's also why caffeine is problematic.
So caffeine blocks adenosine receptors. The caffeine crash when it wears off and then all the adenosine floods the receptors and we experience that, oh, sleepiness.
And that's why taking a nap is so difficult because what napping does is it basically kind of deflates your balloon a little bit of your sleep pressure. It robs you of some of that sleep pressure.
So by the time you get around to your normal bedtime, if you've taken a long nap, you've reduced how much sleep pressure you would ordinarily have at that time. That's why napping can be dangerous.
And then we have process C, which is the circadian process. And that just marches on.
It doesn't really care about your sleep pressure or how much you've slept. I'm sure you've pulled an all-nighter, but when people pull all-nighters, what they often will notice- How many all-nighters do you think I've pulled in my life? Oh, hundreds.
Yeah, I would need scientific notation to count them. It's so pathetic.
Yeah, it's a lot. The thing to note about that is that you're sleepy during the night when you're pulling the all-nighter, but in the morning you kind of have a burst of energy.
And that's the circadian part speaking up. And when we look at the sine curve of it, that's because your temperature is coming back up.
Your adrenal glands still make cortisol. Right.
So your circadian process doesn't really care much about the sleep pressure. It says, oh, okay.
If you line these two things up on a graph, they look like they talk to each other. They don't.
But these two processes really determine a whole lot about your sleep. And there are things that we can do to support each of them.
But CBTI really focuses on the sleep pressure aspect by regularizing people's schedules. And then it supports the circadian aspect by some of these little things that I talked about that I don't even know if you can't really call them standard CBTI, like standardizing what time people are taking their medications, for example, doing things that we know support circadian biology, not eating right before bed.
In my perfect world, all of these different Zykebers, which are timekeepers during the day, would be consistent from day to day. You eat lunch every day at the same time, breakfast every day at the same time.
All of these things would support your circadian biology and probably improve your sleep. Any rules about exercising? Do you have people that are showing up and you're going through your intake and you realize based on their schedule, based on work, based on kids or other obligations, the only time they're going to get their workout in is in the evening? And is that counterproductive? Put it this way, if it is an issue, how do you adjust? This is a really nuanced issue.
I once had a patient who a long time ago who said, oh yeah, I take the 10 o'clock spin class in the Castro. I was like, oh, okay, moving on.
I assumed it was 10 a.m. I was wrong.
And I learned that the next week when we were talking about other things. But for some people, exercise at night is fine.
For other people, it's super stimulating. And it also really depends on what kind of exercise we're talking about.
I think one moderating variable here is also going to be level of fitness. If you take a person who's extraordinarily cardiovascularly unfit and you put them in a spin class in the evening, do you know it could take their heart rate quite a while to recover? You could probably provide me a lot more information about that than I know.
And what we know in order to fall asleep is that your heart rate should be lowering. So if your heart rate is still elevated from a whole bunch of exercise you just did, that's not gonna help you.
But if you're super fit and your heart rate recovers really quickly, it might affect you less. So this matters.
I think there was for a long time this general suggestion to not exercise close to bedtime. I still think for the most part it applies, but I think that it's important to think about what kind of exercise you're doing.
If someone tells me, oh, I'm going to a yoga class, I find this really relaxing and calming. It's a form of stretching for me.
Fine. Okay.
This is the only time of day you can do it. You got a job, you got kids, whatever.
I'm not going to tell you to not go just because of the time of day that it is or weightlifting or whatnot.

But if you want to go to a HIIT class, I'm going to say, well, can we not do it at 10 o'clock at night? I think it would really be great if we could move it earlier. We try to do that.
I do tell people, I have some patients who've come in and said, oh, my body wants to wake up every day at 7 o'clock, but I really want to go to this 5 a.m. spin class every day.
I'm like, OK, well, I understand exercise is very important. I'm a believer.
Also, your circadian biology has you going to bed at 11 and getting up at seven. And even if you're getting up at 445 to get on your home spin bike to do this thing with this group, your body doesn't want to go to bed until 11.
And we're not going to be able to change that. So you're going to have to make that cost benefit analysis with, do you want to lose that much sleep to do that thing? Yeah.
My brother-in-law plays in a men's hockey league and you only get ice time late at night. So I think they literally play Sundays at 11 PM or something.
And he's always fried Monday because pretty hard to play a game of ice hockey and then fall asleep after that. So I want to understand more what the spectrum of CBTI looks like.
I mean, your process sounds super dialed in, but also it's quite bespoke. You've brought a lot of your own expertise to it and

you've created a system where you've got, we're going to do the intake. We're going to do these

five sessions, which I think are group sessions, the way you've described them. Then we do kind

of the exit. You bring so much rigor to it.
Is that the way it is always done? Or are there CBTI

therapists out there who function like psychotherapists and they say, yeah, we're just

going to engage with each other until your problem is fixed and we'll see each other once a week or maybe once every other week. Everything you're doing sounds formulaic.
And I say that not in a bad way. I think that's probably a big part of its efficacy.
Is that something people should expect when they are going to a CBTI therapist? It's something people should ask for. Before people start treatment, they fill out the Pittsburgh Sleep Quality Index and they fill out the Insomnia Severity Index.
And I tell them, look, we're going to fill this out when you're done with treatment too. And we're going to see how this worked for you.
We're going to actually take measurements. What type of scores are you getting on the PSQI? I mean, it ranges from zero to 21.
I get all the way to 21. Wow.
Okay. Yeah.
And below five is considered no clinically significant sleep

problems. I relax that to six or seven, because if you have a prostate or if you're going through menopause and have hot flashes, you're going to be elevated on that scale by no fault of your own or your sleep's fault.
And the insomnia severity index, I mean, yeah, we see all the way up to, what was it? 22, 23, something like that. So I see all the way up to the most severe levels in both of these scales commonly.
And the average point drops are huge in clinic. So I don't know if it was like 10 points in the insomnia severity index.
Like it's very high, very responsive to this treatment. But back to your original question is, I wish everybody did it by the book.
I think there's a lot of practitioners out there who want to do it this by the book. I have a luxury to do it by the book.
I think there's a lot of practitioners out there who want to do this by the book. I have a luxury to do it by the book because I'm able to enlist help from my team to help me process sleep diaries every week and do probably two hours of work outside of my clinic of prep for me.
So they feed me my stuff that's been built into the systems that I have. I'm prepping half an hour before clinic.
I see everybody for an hour and a half, and then I've got my notes, my templates and things. But I think that it is very difficult to do CBTI when you're not seeing patients weekly, because I look at weekly sleep diaries and I make changes based on that.
So when you find a CBTI therapist, I would say, ask if you can set up a time in the future with that therapist and see them weekly for a set of whatever, five to eight weeks and put it on the calendar that way with them. If they say, oh, they don't have bandwidth to do that for another month, say, okay, cool.
I'll wait and then get on every week. And a lot of practitioners also aren't going to necessarily score your sleep diaries for you.
You can score them yourself if you want to. I mean, it's not that difficult.
If you just Google online, you can find a sleep diary calculator and it's very easy to do the math yourself. There's a book that I really like called Quiet Your Mind and Get to Sleep, written by Rachel Manber and Colleen Carney and Dick Bootson wrote the foreword.
It's kind of a guided way through the treatment and you can use that workbook yourself to do it. And you could also use that workbook when you're working with a provider.
But I think there are a lot of CBTI providers out there who can see you weekly and can do this. You'll probably just have to do your backend work with your calculations because they don't have the billable time for that.
They'll be busy during the sessions trying to teach you things. I would also note that between my sessions with my patients, I make them watch very annoying videos that I've made of myself giving a lecture about all of the science because I've found that if you explain the science to patients, you'll get the adherence.
Here's why we're going to do this. People think, wait, I have problems sleeping.
Now you're going to make me not go to bed. This is not what I'm going for.
And I have to explain to them, okay, here's why we do this, because this will ultimately get you where you want to go. But the principles of what I'm doing are not at all bespoke.
I'm doing the time in bed restriction, stimulus control, the cognitive techniques, the relaxation techniques, and the sleep hygiene. Those are the five major components.
What is bespoke is the way that I set the wake time, because that's not been standardized in the literature, the way I deal with standardizing medications, the way I deal with medication tapers, some of the anxiety tools that I bring in, like scheduled worry time, tracking of belief during the day, I think that is actually pretty well incorporated into CBTI. But some of those are a little bit more tilted toward my audience, which tends to be higher in anxiety.
I build those in. But otherwise, find someone on the website that we'll put in your show notes who knows how to do CBTI, and I have a feeling you'll go far.
The treatment works when you do it, and it doesn't work when you don't do it, is what I tell all of my patients. The book, Quiet Your Mind and Get to Sleep, you mentioned that that's something that people could do in therapy, but you also mentioned that it's something people could just do on their own.
So if somebody is listening to this and they're thinking, A, I can't afford CBTI, or B, every practitioner I've called said the soonest I can get in is nine months from now. If my choice is continue to suffer or do something proactively, you would recommend that as a great strategy to start? They can get that.
They can try some of the apps. They're out there.
I think they have less traction currently. They're still in early stages, but try and help the rest app.
But the Quiet Your Mind and Get to Sleep book, people can do it by themselves. And I actually had a patient this summer who was on the wait list.
He got his intake and he was like, look, I'm fixed. I did the book.
It was awesome. But I still want to be in this group because I want to see what it's all about.
I'm not giving up my spot. And it was great having them in the group because they just cheerlead everybody else and said, this works when you do it.
Any concerns with extreme temperature changes before bed? So people using sauna, people using cold plunge, taking hot showers, hot baths. Subjectively, from my experience, a sauna before bed really seems to help.
Maybe it creates a bigger gradient in temperature drop as I go from high body temp to low when I get into that super cold bed. But what is your experience with that and how do you manage it through the process? Well, let's first take cold plunge before bed off the table.
That's not a good idea because we know that when you get in the cold plunge, it's immediately cold on your skin. But then once you get out, your body is busy warming itself back up.
And that's not what we want to be doing right before bed. Then I'm going to come to the sauna part by saying that it's another it depends.
The outline that you just gave of the temperature gradient is beautiful. It makes a lot of sense.
For people who are naive to sauna, who get in a sauna and it increases their heart rate, increasing your heart before bed. It might be the same problem as the exercise issue.
It might be the same problem as the exercise. Yeah, if they don't have the rapid recovery.
They don't have the rapid recovery. So that's something to learn about yourself.
And in fairness, I don't actually go straight from sauna to bed. It's usually sauna to 30 minutes of Netflix to bed.
That's going to be person to person. Another thing to keep in mind is that some people who will go in the sauna at night then drink a whole bunch of water afterwards.
And then that ends up causing them to wake up more in the middle of the night. So it defeats the purpose.
That's a consideration also if that's an issue for you. But I would say just don't make it too strenuous.
Some people find that it's really helpful. I do best with it a few hours before bed as opposed to right before bed.
I think it's going to be a do what works situation because we don't have enough data. But we are, I just started an NIH funded trial where we are looking at people who have difficulty with falling asleep and we are giving them whole body heating at home before bed and we're giving them cognitive behavioral therapy for insomnia through an app and we're going to have them do this whole home-based treatment that's going to combine a body-based heat treatment for before bed with the CBTI treatment.
And the idea here is what you explained, which is that by heating you up right before bed, if we're heating up your hands and your feet and we're helping you actually open the vasculature and dump some heat, it's going to create that gradient. And we think that gradient might be important for people with the early kind of insomnia, with falling asleep at the start of the night.
So we're going to see if that helps people using a sauna blanket type thing. Ashley, someone listening to us for the last two and a half hours might assume that the only thing you know about is CBTI, but it turns out that we've only scratched the surface of your area of expertise.
And there are other clinical areas that you have a lot of interest in that I think our listeners would have interest in as well. The good news is we've, when I say we, I mean you, you've delivered kind of a masterclass on a topic that I've wanted to know much more about.
You know, it's interesting. It's a bit of a black box because we send a number of our patients to CBTI therapy around the country.
And I would concur with what you said, which is based on their ability to comply, the efficacy has been unparalleled, simply stated. As far as regular old doctors, I think we're pretty good at helping people with sleep given the nature of our practice and how much attention we can pay.
And therefore, I think by ourselves, we do pretty well. But when we can't, and we refer to CBTI, I would have to think if there's been a patient who hasn't been helped.
So that's great. But truthfully, you've filled in all the gaps for me.
And I think more importantly, I think you've really helped listeners understand this. And I hope given people a lot of confidence, because what I also take away from this is there's really nobody who should be suffering from insomnia.
It's really not a necessary thing to suffer. There's things we might have to suffer with in life, but this isn't one.
I think from very large percentage of the population, that's the case. I'm afraid to say never because you just never know.
But there are so many, so many people, countless, suffering from this who definitely don't need to be. The drawback is we have kind of run out of time to talk about a few other things that are really interesting, which is not uncommon on this podcast, which means we're going to have to do a part two at some point to talk about eating behaviors, thermal regulation, the impact that that has on depression or other things like that.
So apologies that maybe we spent more time on CBTI than we intended to. But as I kind of warned you before we started, we love to just meander where the discussion goes.
So is there anything else you want to talk about on the CBTI front? I have a lot of notes on where I wanted to go, but I also realized there's probably something I've forgotten or there's an area you want to double click on. No, I think it's important for people just to remember with this one that even if you don't know what caused your insomnia, you can do this treatment.
You don't have to have figured out, oh, this is where it started or this was the root of it all. You can start this

treatment without that knowledge because this treatment is going to address what you're doing now that's actually perpetuating the problem. And don't wait.
There's never going to feel like a good time to do it. Now is the best time.
Your life is always going to be crazy. You're always going to have 50 more things on the schedule than you wish you did.
It's always going to be too busy. You're always going to have events.
Just do it now because it's so difficult to live with insomnia and all of the problems that it causes. I had this patient who was 87, who I finished treatment with last year, and she just said, my, I wish I'd done this 40 years ago.
Don't wait. Just do it.
You won't regret it. Are you under the impression that obviously people are waiting a long time to see you? That probably speaks to how good you are and the resources that UCSF provides maybe in combination.
But if a person's listening to this and they're like, yeah, I wish I could work with Ashley, but I just want to work with somebody. Do you have a sense of how large the CBTI community is and how long a person should expect to wait? And do these therapists ever work via telemedicine so that you have more opportunity to work with folks? I think that it is easier now to get than ever, largely because of telemedicine.
So I see patients all over California. I'm licensed in California.
Oh, so your eight people per bracket don't all physically come to San Francisco? Nobody does. Great.
I only see patients on Zoom now, which is actually a whole lot safer because patients used to drive in, for example, from Fresno, they'd stay overnight in a hotel in San Francisco. Yeah, they would just screw up the whole thing.
Screw up everything. Patients would have to fly in in some cases.
It was nuts. But now I just see people on Zoom, which is great.
And there's a lot of versions of me who do that. By going to that website, you'll be able to find a CBTI provider.
And chances are they do telemedicine. There are just so many benefits.
And one of the great pieces of news about that is that if you live somewhere more rural now, it is instantly more accessible to you. Although we have to hope that the providers, if you live in Iowa, we want to make sure they have license in Iowa because you wouldn't be able to see somebody.
They'll be licensed in Iowa. And there's also actually a growing and great thing called SIPACT where I think 40 different states now are members of SIPACT where if you're licensed in one state, you can be licensed in all of these states.
Of course, California does not participate because we're California, but it's getting

easier and easier.

And I do think that there's ways you can start to do this on your own.

If you get that book, if you try an app, you can actually do this.

You just have to remember that as special as each human is, you need to try and not

feel like a delicate flower with your insomnia.

Just assume that you need to do this as it says you need to do it. Well, Ashley, this was awesome.
I learned a lot and I'm pretty sure everybody listening did. So thanks for sharing and look forward to round two at some point next year.
Okay. Thanks.
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