Insomnia and CBTi Part I (A Better Night’s Sleep Podcast)

Insomnia and CBTi Part I (A Better Night’s Sleep Podcast)


[Dr. Kinn] [music] Welcome back to A Better
Night’s Sleep, a podcast about sleep, sleep disorders, and evidence-based treatment from
military health sleep experts. I’m Dr. Julie Kinn at the Defense Health Agency. [Dr. Olin] And I’m Dr. Jonathan Olin, sleep
physician and medical director of the Evans Army Community Hospital Sleep Lab. [Dr. Kinn] So glad to have you back with us,
Jon. Today we’re going to be talking about some
of the basics of sleep. Jon, last time you mentioned that sleep is
a brain state. And I was wondering if we could start there. What exactly do you mean by sleep is a brain
state? [Dr. Olin] Well, brain, obviously, a pretty
complicated organ. [Dr. Kinn] That is true. [Dr. Olin] There’s one area of the brain called
the SCN, or suprachiasmatic nucleus, that’s actually a brain clock or a clock within a
brain. That’s what jet lag is, when that brain clock
is out of sync with the sun clock. So if you take me to the other side of the
globe, my brain clock would think, “Oh, it’s midday.” But it may be, in fact, midnight. So that will gradually get reset. Obviously jet lag, a temporary condition. But that then can become relevant with some
sleep disorders. So the brain clock is close to and gives input
to sleep-inducing areas and wake-inducing areas. And obviously you want the sleep inducing
ones generally working at, say, 10 PM or 22:00. There are alerting areas of the brain and
sleep-inducing areas of the brain. They’re near this suprachiasmatic nucleus,
or SCN, the clock in the brain. And obviously you want to go to sleep, generally
at night, and wake up in the morning. So these nerve cells are very, very important. As background, I’ve heard reported that if
you take a dog’s SCN and transplant it to a cat and a cat’s SCN or clock and transplant
it into a dog, guess who starts taking cat naps? The dog. [Dr. Kinn] Wow. So I’ve heard a lot of people using melatonin
to solve that sleep clock problem. But I know that’s not something that should
be used in the long term. Is that a problem you see a lot of service
members coming in using melatonin? [Dr. Olin] A fair number. I generally say I like melatonin. But I like melatonin released by your brain,
by the person’s brain. That’s an example of an area in the brain. In this case, for melatonin, it’s called the
pineal gland. And it releases melatonin. It’s release is inhibited by light. So I like people releasing their own melatonin. [Dr. Kinn] Okay. And how do we do that? [Dr. Olin] And we do that with dark. If people aren’t sleeping and then get up
at night and play with their phone or play with their iPad, they are then inhibiting
their own melatonin. So I like melatonin. But I like stacking the odds so that we, the
person, is releasing their own melatonin at the appropriate times, not interfering with
melatonin release. [Dr. Kinn] So these days, most of our mobile
devices come with blue light filters. And I know a lot of folks will use their cell
phone or tablet at night but with a blue light filter on. My guess is that it’s still quite activating
to be using a device like that before sleep. It’s still getting you engaged and interested. And you’re still looking at light. I’m guessing the blue light filter doesn’t
completely negate the effect. Is that right? [Dr. Olin] Yes. That’s correct. If I’m then texting my spouse, or I’m writing
emails, or I’m watching funny YouTubes, I am actually stimulating my brain. Obviously this is wake daytime alert type
of behavior and I’ve been training to do it at these times of the night. [Dr. Kinn] Oh, that’s a good point. [Dr. Olin] What’s my brain going to do if
I were doing that at 2:00 AM for the last two weeks? What’s my brain going to do tonight at 2:00
AM? It’s going to be ready to look at YouTube. [Dr. Kinn] It’s a good reminder that just
like we spend years sleep training our children, sometimes we have to sleep train ourselves. [Dr. Olin] Exactly. So what I say to people is, “You didn’t raise
your hand and ask for insomnia. But here you are with a habit component of
it.” And many people will have the similar sleep
patterns each night. So they’ll say, “I’m lying in bed for two
hours trying to get to sleep. I’m very frustrated. I can’t turn my brain off. And this has been going on, and nothing has
worked.” With each successive week and month, they’re
further in training to do the same. [Dr. Kinn] So what advice would you give to
a patient who has been using melatonin to go to sleep and has been using it for weeks
or months? [Dr. Olin] I would take a history and find
out what type of insomnia they have, how long they’ve had it. I would clarify what type of melatonin they’re
using, how long they’ve used it, what dose. And then I would, in general, review some
non-medication strategies for treatment of their insomnia. I’m a fan of tapering meds. So then beginning to taper. Say if they were on nine milligrams of melatonin,
go down to six milligrams with the non-medication treatments. In general, I view medications as, at most,
supplements to the non-medication treatment and preferably short to moderate term but
not long term. There’s relatively little evidence that medications
are useful for long-term treatment of large populations with long-term insomnia. [Dr. Kinn] Okay. It’s not like an antidepressant, where we
can expect someone to stay on that medication, feasibly for the next 10 years. [Dr. Olin] Correct. So with antidepressants, there’s data that
people with multiple episodes of depression are more prone to future episodes of depression. And there’s actually evidence that staying
on an antidepressant can be useful reducing severity and frequency of future episodes. With sleep medication, there’s not that evidence. In fact, there’s evidence to the contrary
that the non-medication treatments are, overall, better and more effective. And I’ll say that in my experience and my
review of the literature, sleep medications are not stand-alone treatments for longer-term
insomnia. [Dr. Kinn] So then let’s turn to some of the
non-medication treatments we can use for insomnia. [Dr. Olin] Sure. That’s a great question. [Dr. Kinn] It’s almost like we planned this
out beforehand. [Dr. Olin] The non-medication treatments for
insomnia are generally referred to as Cognitive Behavioral Therapy for Insomnia, or CBTi. In my opinion, there are generally four components
to that. One would be relaxation technique. This is a person in an organized way attempting,
generally daily for maybe 20 minutes, to do things to calm their brain. This usually involves at least three components
or three major components: breathing in a relaxed manner, doing muscle relaxation, and
then focusing on thinking in a relaxed manner, often with five senses including imagery,
being in a relaxing place, doing something relaxing, etc. and removing, attempting to
reduce intrusive thoughts. So those three components with the breathing,
the muscles, and then the thinking without worrying about, “I was late for work today,”
or, “What am I going to do tomorrow?” or, “I’m having problems with my car,” etc. So really focusing in an organized way. [Dr. Kinn] It’s such a good point in the show
for me to make a note of some of the other free resources we’ve made in the Defense Health
Agency that can help with insomnia and general wellness. So one is another podcast, the Military Meditation
Coach, in which every week we release meditation, mindfulness or relaxation exercise. They’re made by Military Health System experts
and usually the Navy Center for Combat and Operational Stress Control. Although, of course, like everything, it’s
good for civilians too. And we also have our mobile apps, one that
primarily is important is the CBTi Coach or Cognitive Behavioral Therapy for Insomnia. Also, Virtual Hope Box and Breath2Relax held
with diaphragmatic breathing and we hear from our users, from our beneficiaries, that many
folks are using these apps to help them get to sleep. [Dr. Olin] So, yes, I’d encourage people to
take a look at that, both potential patients and clinicians. Now the relaxation technique is generally
not a standalone treatment if someone has moderate or severe insomnia and has had that
for two years, we’re not going to say, do that and everything’s good, but it can be
a useful component. If I was your sleep doctor and you came to
me and said, “I can’t turn my mind off at night, my mind is racing at night,” I’m not
going to say, “Hey, I have an idea, why don’t you lie in bed for two hours, thinking about
all the things that went wrong yesterday and today, and that you have to do tomorrow.” That’s a bad idea. That’s enhancing alertness, so we earlier
talked about alerting cells and sleep-inducing cells, and we earlier talked about the SCN,
suprachiasmatic nucleus or clock, so with that, I’m further in training, or training
myself to then be alert at that time with that activity, with lying in bed. That’s why you really think relaxation technique
can be an important component of CBTI or Cognitive Behavioral Therapy for Insomnia. Another component of CBTI is sleep hygiene,
which generally involves six, seven components. Limiting daytime naps, avoiding stimulants
such as caffeine, exercising regularly – generally in the morning, not immediately close to bed
– steering clear of foods that can be disruptive before sleep, heavy foods, foods heavy in
oil, good exposure or adequate exposure to light. Again light, frankly, resets or helps reset
the clock, the SCN, suprachiasmatic nucleus, establishing a regular bedtime routine and
making sure that your sleep environment’s pleasant, for example cool. You know, 60 to maybe 67 or 70 degrees, but
not 93 and not 200 lbs of dog on your bed, for example. [Dr. Kinn] So sleep hygiene basically means
good habits to promote sleep. [Dr. Olin] Exactly, exactly. That’s exactly right. And many people will do it, say they have
insomnia for a year or two, they’ll do it for– or they’ll do one or two components
of it for a week or five days, not get better and say, “I tried it and it didn’t work.” In my opinion, that’s not– A, they might
not have tried all of it and b) they probably, in that example, didn’t try it for long enough. [Dr. Kinn] Well, it’s like any major life
change, like if you’re changing the way you exercise and eat, that’s something that’s
going to take a while until you see the benefit and it needs to be a life-long change. It can’t just be something you do a few days
on, a few days off, if you want to see results. [Dr. Olin] Exactly. Exactly. So I view it as comparable to physical therapy,
if I had a bad shoulder, you’re going to– I think I may have said this in the first
podcast, and you’re my shoulder doctor, you’re going to give me exercises to help with strengthening
and stretching, I’m not going to do those for two days and note a significant benefit. If I’ve had one day of insomnia, yes you can
possibly give me a medication that’s likely to work, but if I’ve had it, six months of
insomnia, me reducing my caffeine in half for two days, that may not be standalone treatment,
probably not, depending on what else is going on. [Dr. Kinn] I know there’s a couple more components
of Cognitive Behavioral Therapy for Insomnia, CBTI. How about we continue the conversation next
time? [Dr. Olin] Great, looking forward to that. [Dr. Kinn] [music] Thank you so much for joining
us today. A Better Night’s Sleep is produced by the
Defense Health Agency. You can learn more about us in our free health
resources for the military community at Military Health on Facebook and Twitter. Let us know what questions you have, so we
can help you get a better night’s sleep.

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