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Dr. Jade Wu is a clinical psychologist and behavioral sleep medicine specialist at Duke University School of Medicine. Her current research focuses on treating sleep disorders in those with chronic illness. In the clinic, she uses treatments that do not involve medication to help people with insomnia, circadian rhythm disorders, and other sleep concerns.
In this episode, Jade and I discuss a number of concerns that are common among people with chronic insomnia — we talk about how much sleep we need, whether we can lose our ability to sleep, whether insomnia is caused by a chemical imbalance in the body, whether chronic insomnia causes any serious health problems, and whether we have any control over the negative impact insomnia can have on our lives.
We also talk about why cognitive behavioral therapy for insomnia (CBT-I) is such an effective treatment for people with chronic insomnia, even if it’s present alongside another health condition.
Many people have inaccurate beliefs about sleep and this is a big contributor to sleep-related worry and anxiety that can perpetuate insomnia. My aim with this episode is to help change the way you think about sleep and insomnia. I hope this will help reduce the intensity of any worry or anxiety that might be making it more difficult for you to improve your sleep and encourage you to pursue CBT-I so you can enjoy better sleep for the rest of your life.
Click here for a full transcript of this episode.
Martin Reed: Okay. So thank you so much for sparing some time and coming onto the podcast today Jade.
Jade Wu: Well thank you so much for having me. I’m very happy to be here.
Martin Reed: So let’s start right at the beginning. How did you get interested in the field of sleep and insomnia in particular?
Jade Wu: So my background is in clinical psychology and when I was getting my PhD, I actually started out doing research in mood and anxiety disorders. And while I was doing research in that area, it became really clear to me that one common threads through a lot of things I was seeing was sleep problems. Everybody who came in, whether they had generalized anxiety disorder or OCD or depression, everybody has something wrong with their sleep. So I was very intrigued by this and I ended up doing a little bit more neuro-psychology research in Parkinson’s disease and there to sleep was a big issue.
Jade Wu: So it just started to dawn on me more and more that sleep was this common trans diagnostic factor that, if we can improve sleep for people, then I bet we can sort of raise the water for all boats. And so that’s how I got interested in sleep. And insomnia specifically, I think I just got really interested in, because it’s one of the most common sleep problems. And I was working at the VA at some point, and a lot of veterans have problems with PTSD and with insomnia. So that was something so common in the clinic. I just got really interested.
Martin Reed: So I think you hit upon a really important point, just this link with anxiety and just the mental impacts the sleep has. And I think it’s kind of like it’s two way street. I was actually just talking to a client yesterday and they said to me that they’re not sure if they have an insomnia problem or an anxiety problem.
Jade Wu: Yeah. That’s so common.
Martin Reed: So it’s really kind of this… In my opinion, it’s like this chicken and egg scenario. I don’t think it’s one causes the other all the time or the other one causes one all the time. I think there’s like this two way relationship. What are your thoughts on that?
Jade Wu: I absolutely agree. I think it’s possible that a stressful event that causes you anxiety kind of kicks off that first a bout of insomnia in the first place, or it could be that for some random reason you had a bout of acute insomnia and that caused you anxiety about it and either way it doesn’t even matter, I think which one started it, but once you sort of gained momentum, I think you’re exactly right that the two feed off of each other and then you end up in this vicious cycle where the anxiety keeps the insomnia going and the insomnia keeps anxiety going.
Martin Reed: Yeah, and I think that’s why we’re seeing these research articles coming out that are finding when there’s anxiety present with insomnia, which I’m still waiting to find that person with insomnia that doesn’t have any anxiety. They’re finding that regardless of which was the precipitating factor, which is the origin of the insomnia, if you implant like these cognitive behavioral therapy for insomnia, these CBT-I techniques you help in terms of sleep and anxiety. So it’s really not, I have to prioritize one over the other. Really, like as soon as you’re taking steps to improve your sleep, you tend to improve anxiety as well.
Jade Wu: Yeah, I think that’s such a good point. And I really liked that CBT for insomnia is so… It can help with both aspects as you said. And it can be a really nice introduction for therapy too, for people who maybe haven’t had experience with psychotherapy before. So maybe the reluctant to engage in therapy for their overall anxiety disorder, but let’s try to improve your sleep and then in the meantime the anxiety improves a little bit too and they see the benefits and then it sort of builds a good positive reinforcement cycle. So I really like that about CBT-I.
Martin Reed: Yeah, I love that positive reinforcement cycle. Because it’s something I talk with clients about a lot because they easily recognize the opposite. That vicious cycle of you worry about sleep so you get worse sleep and you worry more and that leads to worse sleep. But one of the great things that you see with CBT-I is it just takes a little bit the edge off the anxiety, sleep improves a little bit, then you worry less, then your sleep improves, then you worry less, so it does really just turn that vicious cycle on its head, and so there’s positive cycles.
Jade Wu: Yeah, I love that.
Martin Reed: It gave me a kick that you said that, because sometimes I feel like I’m the only one saying stuff like this and so when someone else comes out with it, it just gives me a kick.
Jade Wu: For sure. Yeah.
Martin Reed: So all right. As I’m sure you know, people with insomnia have tried so many things to improve their sleep. Whenever I taught someone within insomnia, I ask what they’ve done to try and improve their sleep and they give me this whole long laundry list of things they’ve tried. And as I’m sure you probably recognize, most of the things that they try through no fault of their own are actually quite unlikely to help and can actually increase worry and anxiety, especially when you’re told to try something like by say a doctor, or you’ve read something in a book to try, I’m thinking along the lines of sleep hygiene here as an example.
Martin Reed: So you try these things and then they don’t work and it just lead you to worry more. And I think that also people with insomnia have a lot of inaccurate beliefs about sleep, and a lot of this again is just the messaging that’s prevalent in the media, online, when you Google sleep, go on Twitter and look up information about sleep. So I thought it would be good to talk with you about some sleep myths, common sleep concerns and see if we can address some of those if you’re up for it.
Jade Wu: Yeah, let’s go for it.
Martin Reed: All right, so let’s start with the big one. Should we all be aiming for eight hours of sleep and do we all need eight hours of sleep to feel good the next day?
Jade Wu: The short answer is no. And a longer answer is some people need eight hours of sleep, some people need more, some people need less, and I think it’s actually very problematic, this idea, this myth that we should all be aiming for eight. It’s kind of like saying to everybody in the world, everybody should drink 8 eight glasses of water per day. I mean, some of us need more, but not everybody. So like a pro athlete at the height of their training don’t you need more water than a couch potato or a five-year-old, sitting on the couch? I don’t know. Those are bad examples, but I think it’s… well, similarly with sleep, where our need for sleep differs between individuals, between us and also it changes over the course of the lifetime.
Jade Wu: So it’s really hard to say for any given person you need eight hours or you need seven hours. It really depends on a lot of factors and the only real way to know how many hours you need is to see, well how many hours can your body sleep if you give it enough opportunity, and can you consistently sleep that amount without getting insomnia? So that sweet spot is sort of where you feel pretty good, and you’re getting enough opportunity to sleep but you’re not lying there awake struggling to sleep a lot.
Martin Reed: Yeah. I think… Yeah, I completely agree with you. Is kind of akin to… Just use another analogy I think you had a good one with the water, but another one would be just like the thought that we all need to wear size eight shoes.
Jade Wu: Right.
Martin Reed: It’s completely ludicrous when you say that and think that, but it’s no different to thinking that we all need to get eight hours of sleep. And I think it is a damaging message because people can then strive and it’s like a sleep effort. And as soon as we put effort into sleep, we put pressure on ourselves to sleep, it just makes sleep more difficult.
Jade Wu: Absolutely. Yeah. I always tell people sleep is one of the very few things in life that does not reward hard work. Like just working harder and trying to improve in almost every other aspect of life usually works pretty well. So when people are having insomnia, they try to apply the same strategy by trying harder, working harder and it just backfires. And I also tell people sleep is kind of like a very nice but really shy friends that you have. She’s always going to hang out with you, she will always come back, but if you are too intense in a relationship and you’re stalking her and you’re trying to hunt her down, she’s going to run away from you because who wants that? It’s too much pressure.
Martin Reed: That is a brilliant analogy. I’m totally going to steal that from you and use that one. That’s great.
Martin Reed: Yeah. I think another issue with that message is when… I was working with a client recently and she was implementing the CBT-I techniques doing really well, she was getting consistently between six and a half, seven hours of sleep each night feeling good during the day. She goes to her doctor and her doctor says, “That’s not good enough. You need to get eight hours of sleep.” And so then she comes back to me like all this progress, it felt like we’re kind of taking this big step backwards because of this messaging. And it’s just so damaging.
Jade Wu: It really sucks when another health care professional kind of undoes the hard work that we’ve put into helping someone sort of reposition or rethink their perspective on sleep. But that’s too bad.
Martin Reed: Yeah. Just to stay with this sleep duration. When I have clients just enroll in my basically free sleep training course, I talk a little bit about sleep duration and I actually dug out this study out of Germany it was the Institute for quality and efficiency in healthcare, and to quote their actual words, they actually wrote, the average person sleeps about seven hours a night around the age of 40 about six and a half between the ages of 55 and 60 and a healthy 80 year old will usually sleep about six hours a night.
Martin Reed: But then they go on to say, but these are all only averages even though we’re already below that eight hour mark. And they said, everyone needs a different amount of sleep. And here in the States, even the National Sleep Foundation, when you read behind the big headlines that they like to come out with, they themselves, found that for adults between 26 and 64 years of age, as little as six hours of sleep may be appropriate. And for adults 65 and over as little as five hours may be appropriate. So when you dig away, you really see that this eight hour myth is just so prevalent but so inaccurate.
Jade Wu: Absolutely. That’s so true. And the recommendations that you quoted there from the National Sleep Foundation, they publish this I think pretty well known graphic that shows you the ranges, right? For each age group. And I think it’s really important to know that, within each range, for example, for adults between 26 and I believe 65 the range is somewhere between like six and nine hours or six and 10 hours or something like that. So within that range, it’s not like the more you get the better. It’s personal and it’s very individual. So if someone only needs six and a half hours, that’s all they need. Trying to get seven is not going to better. It’s only just going to mess up their overall pattern.
Martin Reed: Yeah, exactly. It’s just something that we can… I don’t know. It’s just something not worth striving for. Just trying to compare yourself to others. I mean it just popped into my head. It’s like being upset if you’re lefthanded really wanting to be right-handed or vice versa. It’s just you’re different, and that is okay. It’s okay not to be getting eight hours of sleep just like it’s okay to be left handed or right handed. So yeah, I wanted to lead with that because I just think that’s the biggest thing that I come across. And it’s a big issue in terms of the messaging that’s out there about sleep.
Jade Wu: For sure.
Martin Reed: So here’s the next question I’ve got for you. Do we need to catch up on lost sleep after we have a bad night or after we’ve had a string of bad nights?
Jade Wu: Yeah. That is such a common question. And I think so the answer is a little bit more complicated here, but I’m going to lead with no, because I think that should we try to catch up? This question really implies should we go out of our way to try and sleep more than our bodies feels like. And I don’t think that’s helpful because let’s say last night you slept poorly. Today, if you go to bed really early, you’re trying to catch up, but before your body is ready, before you’re sleeping, then you’re going to lie there and struggle and that’s going to compound the problem.
Jade Wu: And now you feel like you’ve gotten two bad nights and now you’re going to try harder, and feel more anxious. And before you know it, you’ve gotten into this pattern, where you may end up having prolonged sleep problems. All right if last night you got a bad night of sleep and tonight you start feeling really sleepy earlier than usual and go ahead and go to bed. That’s your body telling you that you’re sleepy and you need a little bit more sleep. So I’d say really the answer should be listen to your body and give it opportunity. Give yourself opportunity to feel your sleepy cues coming on, but don’t go out of your way to try and catch up on sleep, if you are not feeling sleepy.
Martin Reed: Yeah, I would agree with you there. And the one issue that I would say is let’s say you’re going through a course of CBT-I, you’re implementing these techniques and one of them is the sleep window, sleep restriction, bedtime restriction and we trying to say just try and just stay awake until the start of your sleep window. And so let’s say that someone has a string of bad nights and they’re really sleepy at like seven o’clock and their sleep window doesn’t begin till 10, they then go to bed at like seven o’clock they’re like, I can’t do this anymore I’ll go to bed. Well then they’re probably going to wake earlier in the morning then and either struggle because they’re going to be frustrated that they haven’t slept through until the end of the sleep window, which is an issue in itself. But then if you’re getting out of bed, then and starting your day earlier, again, you’re kind of off track. So when you try and compensate it kind of derails you further down the line, if that makes sense.
Jade Wu: Yeah, that’s a really good point. And I think I should amend my answer by saying it depends on whether someone has chronic insomnia or not. So if they have chronic insomnia and they’re working on a sleep position, sleep training, bedtime time restriction program, then I would say it’s going to feel really awful for a couple of weeks, but stick with it, it’s going to… It’s like a hard reset button in which case even if you feel sleepy at 7:00 PM don’t go to bed until your sleep window. But if someone doesn’t have sleep or doesn’t have chronic insomnia, and this is kind of like occasionally they’ll have a bad night and it’s like okay, then it’s not as big of a deal. You can sort of listen to your body and be more flexible with it.
Martin Reed: Yeah. Well what are your thoughts on like weekend lie-ins? So it’s something that most people that don’t really think about sleep will do just naturally. They’ll stay in bed a little bit longer on the weekends, but it’s something that when people have insomnia, we typically recommend that they don’t do so. So what are your thoughts on that in particular? Those weekend lie-ins?
Jade Wu: If someone does have chronic insomnia, then I would say very strictly, the most important recommendation I will give is to wake up at the same time and get out of bed at the same time every day. Because that will serve as the anchor in the 24 hour cycle that will that basically the better you stick with that, the faster your body is going to reset and regain its natural patterns.
Martin Reed: Yeah exactly, because if someone’s got chronic insomnia, we are implementing these quite rigid, quite structured techniques just because they’re kind of the fastest and most efficient way of helping you get your sleep back on track and get to that point where you’re not really thinking about sleep anymore.
Jade Wu: But I do tell people it’s not for the rest of their life. It’s like… I say, it’s going to be bootcamp for the next few weeks and it may be really, really hard and you’re going to feel very tempted to get out of bed or just sleep-in or lie-in on weekends, but that’s okay. This is temporary. The ultimate goal is to get you to a point where you feel confident enough about your sleep and you have a good relationship with your sleep such that the occasional lie-in is not going to really mess things up.
Martin Reed: Yeah. I like to tell people it’s just this case of bit of short term pain for that longterm gain and just to remind people doesn’t matter how long they’ve been living with insomnia up to that point, if they can just push through for the next few weeks, couple of months. Is going to be hard, but probably no harder than just having insomnia for the foreseeable future.
Jade Wu: Exactly.
Martin Reed: So I think the alternative is a little bit more appealing if when you reframe it that way.
Jade Wu: Sure.
Martin Reed: All right, so let’s move on to the next question I’ve got for you. Can we lose our ability to sleep?
Jade Wu: That one I get a lot as well. Not that I’ve seen. Like I always tell people the part of the brain that controls sleep is right next to the part that controls breathing and heartbeat and the very, very basic biological functions. So sleep is just so evolutionarily old and it’s so biologically basic in our brain that a lot of other things would have to happen first before we lose our ability to sleep. Now there are neurodegenerative disorders that will affect the brain sleep circuits and we’ll mess with sleep somewhat. But even then, for example, people with Parkinson’s disease a couple of decades into the disorder, they will have some sleep problems, but even they are able to sleep. So if someone comes in with insomnia and says, I think I’ve lost my ability to sleep, I will be very optimistic for them that probably most likely has not happened.
Martin Reed: Yeah, a hundred percent. And I think it’s important to just remind people that you never lose your ability to sleep. And it is this core biological mechanism, just like breathing. And sticking with that breathing analogy one like to use a lot is, just like if we’re really anxious, it makes sleep more difficult. It’s almost like this body’s survival mechanism. It keeps us alert to protect us from this perceived threat, this perceived danger. And in that way it’s like breathing because we can take a deep breath and hold our breath voluntarily, but eventually the body’s going to take over and make us breathe. And it’s just the same with sleep. No matter how anxious or worried we are, we can suspend sleep temporarily, but eventually we’ll get to that point where our sleep drive, which never goes away will just get so high, so strong, that we will sleep.
Jade Wu: Absolutely. The brain is very much self-adjusting when it comes to sleep. And not only that, so I really love your breathing analogy. If we hold our breath for as long as we can, not only will our bodies just involuntarily take over at some point and make ourselves breathe again, we will probably also take a really deep breath to compensate for the breath that we have been holding and just like with sleep, if we’ve been sleep deprived for an amount of time for whatever reason, the next time we sleep again the brain is going to generate more deep sleep to make up for the deep sleep that we lost. So the brain is very adaptive and very resilient when it comes to sleep.
Martin Reed: I think you made a great point there in terms of the body compensates because I think everyone listening would probably have expected you to just say something like, so you’ll get more sleep, but that isn’t always the case. Some times the body would typically just start off by prioritizing that deep sleep. So if you go through this string of bad nights, your body will put you into deep sleep quicker and you’ll spend more time there. But your overall sleep duration itself might not be longer. And I think that’s important to emphasize because some people might think, well I just don’t get those long periods of catch up sleep, so that’s evidence that there’s something wrong. But that’s not necessarily the case because it’s like you said, behind the scenes, the body is making all those adjustments. You just might not see it in terms of duration alone.
Jade Wu: Exactly. Exactly. And that’s why I think sometimes the idea of sleep debt can be misleading because it makes us sound like for every hour of sleep that you didn’t get, you need an hour to make up for it. And I think I’ve heard the analogy of for every brick you put in your backpack, you have to take a whole brick out to lessen that weight. And that sounds, I think, really scary for people. How much pressure is that? Like if I think about all my university years, that’s a lot of sleep that I would never ever catch up on. But I’m functioning fine because my body is resilient and our bodies can adjust to what we need in terms of sleep.
Martin Reed: Yeah, absolutely. Staying on this idea of sleep ability, I think one reason why some people can become concerned that maybe they’re losing the ability to sleep is they’re no longer recognizing sleepiness cues. I think that’s quite common in people with chronic insomnia. So you think back on the good old days, when you didn’t really think of sleep and you remember how sleepy you’d get and you’d go to bed and you’d fall asleep pretty quickly, whereas now you’re struggling and you just seem to have lost that feeling of sleepiness. So how do we explain that when we’ve just said that it’s impossible to lose the ability to sleep?
Jade Wu: Yeah, that is such a good question. And I think there’s two aspects to the answer. One is that there is a difference between sleepiness and tiredness. And I bet you’ve heard this a lot where people conflate the two, right? They’ll say, but I’m so tired by 10PM, but as soon as I go to bed, I’m lying there for hours and I’m not falling asleep. Why is it that I’m so tired but can’t fall asleep. And then I spend some time teasing apart the difference between tiredness and sleepiness, where sleepiness is really more of a behavior almost than a feeling. You can feel it coming on perhaps. But it’s something observable whereas tired is a little bit more subjective and you may be feeling emotionally tired, you may be feeling exhausted or cognitively drained, but you may not be sleepy yet just because you’re tired.
Jade Wu: So I think that’s one important distinction to make. And I think that often reassures people, because then they’re not thinking, wait a minute, how come I’m feeling tired but not falling asleep. And another thing I would say is that insomnia really is a 24 hour hyperarousal disorder. So it almost is not a sleep disorder per se because as we’ve been talking about, when you have insomnia you haven’t lost your ability to sleep. So it’s not really a sleep disorder is more of a hyper arousal disorder that makes you tired and antsy during the day and irritable during the day and makes you more likely to perceive weight and feel wakeful during the night. So I think a big part of what CBT-I does is to decrease that anxiety and that arousal over the 24 hour period. And that helps with feeling better during the day. And that’s helps with sleeping better at night.
Martin Reed: Yeah, it is so fascinating that you said maybe insomnia just isn’t a sleep disorder because it definitely shares… I mean, it’s not the symptoms on an inability to sleep. There’s nothing wrong with the physiological side of sleep. But yeah, we class it as a sleep disorder and I got this earlier podcast episode with Nick Wignall and he just comes out with it. He says, insomnia is an anxiety disorder as far as he’s concerned. And the more I think about it and the more I talk about it, I’m definitely more inclined to think of it that way.
Jade Wu: Yeah, for sure. I think we think of it as a sleep disorder because we are blaming the daytime symptoms on the nighttime sleep problems. So really both the daytime and the nighttime symptoms are caused by a third factor, which is hyperarousal. So often I think my patients will think, I feel tired and cranky and pain during the day because I slept so badly at night. And then that feeds into the pressure to sleep better and feeds into the sleep effort as well. And so that kind of keeps the vicious cycle going. But in fact, we don’t really have to blame those daytime symptoms on sleep problems. We’re actually, we should be blaming all of the symptoms day and night on hyperarousal. So I don’t know if that helps people to hear that, but I’ve had at least a few patients where when we just straight up said, you don’t have a sleep disorder, you have an anxiety disorder, and then I think that was a breakthrough moment for a lot of people.
Martin Reed: Yeah, I agree with you. I mean some people would probably take comfort in it, some people might not be happy to be labeled as someone that’s got an anxiety problem at the same time. So it is difficult. We’ve tried and like a thin line, we’re never going to satisfy everyone. But what I tend to find is people just have this confusion. They’re like, I’m not… Like I touched upon earlier, I’m not sure if it’s an anxiety problem or an insomnia problem. Whereas really it’s kind of all the same thing. We don’t really need to make that distinction. And I think that CBT-I techniques are so helpful because they really address both.
Martin Reed: They help reduce that hyperarousal, that high level of worry or anxiety and just alertness, and at the same time they give you these behavioral techniques to make the biological sleep mechanisms work for you. To build that sleep drive so that you are going to bed when you’re sleepy, not tired. To break that kind of any conditioned arousal, because a lot of people will say to me, “I feel really sleepy at seven o’clock but then just before my sleep window starts, or when it’s time to get into bed, I’m wide awake.” Which is a common symptom of this conditioned arousal because you’ve experienced all this wakefulness and worry and sleeplessness night after night, you’ve kind of just learned that, that’s what to expect at night. And CBT-I also helps address that too.
Jade Wu: Yep, absolutely.
Martin Reed: All right, so what was the next question I have for you that I hear sometimes. Okay. Is insomnia caused by a chemical imbalance in the body?
Jade Wu: That is also a no. So it kind of dovetails on to what we’ve been talking about how insomnia is not a physiological problem with sleep, but I do find that, that’s a common misconception. And in fact I’ve heard many different theories from my patients about why they have insomnia. I’ve heard stuff about the pituitary glands, about GABA, about serotonin, and the truth is that none of those things are the culprit.
Jade Wu: And if it were just one neurochemical or one circuit or one brain region, then it would be a much simpler fix, or it would be a pharmaceutical fix that will solve the problem. Whereas we know that sleeping medications actually don’t solve the root of the problem. And that’s why you have to take them, and take them, and take them, and take them, instead of taking them for a short amount of time to reset your brain. So if it really was a chemical imbalance, then we would expect medications to work better. But in fact is the behavioral changes and cognitive changes that really solve the problem. Which tells me that it’s not a chemical imbalance in the brain.
Martin Reed: That’s a really interesting point. Because my answer and as I’m sure you’d clearly expect, is that insomnia is not caused by a chemical imbalance in the body. But I love the way that you said, we have evidence that it’s not, because if it was, then we’d have medications for it and your problem would be solved. Whereas we know that there’s not one medication out there that exists as a long-term solution for chronic insomnia.
Jade Wu: Exactly. Yeah.
Martin Reed: All right, so you kind of touched upon this earlier, but let’s focus on it specifically. Do we need less sleep as we get older?
Jade Wu: Yeah, I would say so. I mean, even as you alluded to before, the National Sleep Foundation recommends a shorter duration sleep range for adults over 65 as low as sometimes five hours. And we also know from some recent meta-analysis and longitudinal studies that for middle age and older adults having, I believe the window was about five to seven hours of sleep was actually associated with the least risk of dementia and mortality 10 years down the line. Whereas more than seven hours and more than eight hours or shorter than five hours are both associated with higher risk. So again, it’s not the more the better, it’s that there is a sort of a sweet spot, but that range is pretty wide. Right? Five to seven hours that’s a two hour range and within that range or maybe sometimes a little bit outside of that range, it really depends on the individual person.
Martin Reed: Yeah. And I think the reason that I wanted to ask you that question is because I think it’s important to bear in mind that sleep does change as we get older. And if we’ve had chronic insomnia for a very long time lets say you’re now in your ’60s and you’ve had insomnia for decades, you might have in your mind as your goal to sleep like you did when you were 20 years old or 30 years old. And so you’re kind of giving yourself that goal that you’re never going to attain, and that can just perpetuate the problem and make it harder for your sleep to improve.
Jade Wu: And the longer you go on, the harder your goalpost is to reach, because as the older you get, probably the further you are away from the way you slept before.
Martin Reed: Right. Yeah. So you’re just moving further and further away and then that can lead to more worry. Right. So that I think it is important to just recognize that we typically do get less sleep as we get older and we also tend to get like more of that lighter sleep. So we tend to find that we wake a little bit more often as we get older. And again, that’s just like waking itself is normal, that’s something to also emphasize next. A lot of people worry about waking, but especially as we get older, it’s even more common to just wake a little bit more frequently during the night as sleep becomes lighter.
Jade Wu: Yeah. And have a smaller proportion of deep sleep too. And that’s okay because we get the most deep sleep when we are babies and kids and teenagers. And the reason is that during deep sleep, that’s when we’re releasing human growth hormones and sex hormones, which we need a lot of, when we’re going through puberty or when we’re still growing our brain, but when we’re 80 years old, we don’t really need to grow anymore. We don’t really need those sex hormones either. So it’s okay to not be getting as much deep sleep.
Martin Reed: Yep. Great point. So you kind of touched upon this just now, but I think it’s something component to talk about. So I’m going to ask you this one next. Does chronic insomnia cause any serious health problems?
Jade Wu: Yeah, that’s a great question. And again, the short answer is no. The problem is that I think we’ll find a lot of headlines out there that associate insomnia with chronic health problems. And that’s not surprising because there are lots of things that cause chronic health problems that also causes insomnia. So for example, smoking, we know that smoking causes long term health problems. We also know that smoking makes one more likely to have insomnia and sleep problems. So then if you look at that person, but without the context of the smoking, it looks like it’s the insomnia that’s maybe causing the longterm cardiovascular or other brain health, whereas really it’s this third factor smoking that’s doing the action.
Jade Wu: So I think it’s really important to make the distinction between correlation and causation. Where correlation just means two things co-occur at the same time, whereas causation means one action leads to the other. And from the latest research that we know, I think a 2019 meta-analysis that included over 30 million participants, we found that in this giant meta-analysis that insomnia does not cause shorter mortality or does not cause mortality and doesn’t increase risk for serious health problems.
Martin Reed: Yeah. This is like something that I’m sure you experience it too, that I just come across all the time is people have this real intense concern that their insomnia is going to cause this big health issue in their life. And that just is a driver of the worry and anxiety they have about sleep and about their insomnia. And it’s really hard to kind of pick away at this because you can feel like you’re making progress talking to someone and explaining the difference between association and causation, and the fact that a lot of these studies don’t even use people with chronic insomnia as well. They just deliberately sleep deprived people, which I think we will talk about in a moment.
Martin Reed: And so that you kind of feel like you’re making progress and then the next day, they’ll just send me links to these 10 new news articles that they just read that has about heart disease, obesity, Parkinson’s, Alzheimer’s, and I know before I even click on them that none of them are going to say that chronic insomnia causes X, but it’s just having to just… It just feels like everything’s working against us. All these media articles, everything in the press is… They really just kind of take the talking points and just emphasize them and it’s just so damaging.
Jade Wu: It’s so true. And that’s something I constantly struggle with because when it comes to sleep, there’s not one headline that will really adequately capture anything of importance. It’s so hard to just squeeze all of that information into one headline. Because the truth is it’s really hard for consumers to really understand what’s going on with sleep because something like sleep apnea, does cause cardiovascular problems, does cause neurological problems, but insomnia is completely different from sleep apnea. But then often the media articles will say sleep problems cause cardiovascular and it’s like, well what type of sleep problem? There are so many different ones and it’s very hard to get nuanced with those articles.
Jade Wu: And I think you’re absolutely right. It drives up the anxiety level for people with insomnia quite a bit. But one thing I’ve found helpful is falling on back on this idea of your body will tell you if you’re not getting enough sleep. So if you have chronic insomnia that almost guarantees that you’re not chronically sleep deprived because if you are chronically sleep deprived, you will be sleepy. And if you were sleepy you wouldn’t have insomnia. So if someone is sleeping like 11 or 12 hours, I will be a lot more concerned about that than someone’s sleeping seven hours for example.
Martin Reed: Yeah, that’s a good point. So another thing that we see in these studies, which I kind of just touched upon, was the fact that a lot of them don’t even look specifically at people with chronic insomnia, a lot of them will just take otherwise people that sleep fine and then either just completely sleep deprive them for a day and then find that they’re grumpy the next day, big surprise. And then just say that it causes all these anxiety issues or they’ll just take someone and just limit the amount of sleep they’re able to get. So they want to get more, but they’re like, “No, we’re going to wake you up after four hours and make you do some kind of test or do a blood test, whatever.” So why is that important? What’s the difference between sleep deprivation and chronic insomnia?
Jade Wu: Yeah. I think the easiest way is to understand the difference between the two is that sleep deprivation is when some external factor is preventing you from sleeping when your body wants to sleep. Whereas chronic insomnia or insomnia, is when you have ample opportunity to sleep, but your body doesn’t feel like it. So you’re not sleeping at the time that you wish you were sleeping, maybe, but you’re not being prevented by any outside force.
Jade Wu: So often when my patients come in and they’re really upset and they’re thinking sleep deprivation is a form of torture, it’s like prohibited by the, war time, like humanity or whatever. Am literally getting tortured right now by having insomnia, but I’m like, so is someone keeping you up? Is it like every time you’re falling asleep someone is turning on the lights and playing music really loud? They’re like, “No, I’m just lying there trying really hard to sleep and I can’t.” And they’re it lies the difference, is that is it your own body that doesn’t want to sleep or is it something else keeping you awake?
Martin Reed: Yeah, that is interesting. And I think the one thing, I think the latest a new fad that’s doing the rounds is all this talk about drowsy driving, which is a legitimate concern for people who are sleep deprived, but not necessarily something for people with chronic insomnia to be too concerned about. What are your thoughts on that?
Jade Wu: Yeah, well, I would much rather get into a car with someone who has insomnia, than someone who is sleep deprived.
Martin Reed: 100%.
Jade Wu: I would even be more willing to get into a car with someone with insomnia than someone who’s a healthy sleeper, because a person with insomnia has 24 hour hyper arousal. Remember, they’re more likely to be even more alert and actually have more adrenaline and more vigilance during the day, than just the average person. So I am not at all concerned about my patients with insomnia getting on the road. I patient with sleep apnea, that’s a different issue, but with insomnia I’m not worried.
Martin Reed: Yeah, exactly. If you’re working with someone with chronic insomnia or talking someone with a chronic insomnia and they’re telling you that they’re kind of randomly falling asleep during the day or they’re falling asleep without any warning, then that’s not really insomnia. That’s a sign of something else-
Martin Reed: … like sleep apnea perhaps. But people with chronic insomnia, the primary complaint is just that fatigue, that feeling of just being worn out, that feeling of exhaustion, but that’s not the same thing as excessive sleepiness and it’s the excessive sleepiness that we’re concerned with that hits all the headlines when we’re talking about drowsy driving and the dangers associated with that.
Jade Wu: Yeah, and I think the distinction is really important because sometimes my patients within insomnia will cancel plans and not go out and have fun and not do activities because they’re afraid that they’ll drive drowsy. But that’s just actually the problem because now they’re even more anxious and upset about their sleep and it’s keeping them away from having fun and their mood is even crankier and they’re not getting the exercise that they otherwise would. So it can hit a downhill from there if we don’t make that distinction clear.
Martin Reed: Yeah. And you led me perfectly into the next question, which was do we actually have any control over the negative impact of insomnia? Or of a bad night of sleep or a string of bad nights of sleep? Are we just destined to have a bad day and just live a miserable life?
Jade Wu: Well, I would throw that back on a person and ask them, have you ever had a good day after a night insomnia? And also, have you had a bad day after a good night of sleep?
Martin Reed: Yes.
Jade Wu: And I bet the answer is yes to both of those. And so I think it’s actually the exact wrong thing to do to limit our life because of insomnia. Because the more that we let insomnia affect our daytime functioning and we let it get in between our social activities and relationships and the things that are fulfilling to us. The more we’re putting pressure on sleep. It’s almost like we’re pausing everything else and waiting for sleep to get better before we live life. And that again is sleep effort and that’s only going to push sleep further away. So yeah, I think we totally have control over the… Not totally, but we have a lot of control and maybe more than we think over the negative consequences of insomnia. Like if we feel tired, if we feel fatigued, maybe going out and having some fun would be the best antidote to that rather than staying home, trying to nap, trying to sleep.
Martin Reed: Yeah, absolutely. It’s something that I always encourage people to do is just try to really just stick to your normal daytime routine. Just like be an actor or an actress. Just kind of pretend that you don’t have insomnia during the daytime. Try and do everything you can to just stick to your normal routine and do things normally. And there’s no doubt it can definitely be more difficult to do that. And the temptation to cancel your plans or stay at home and conserve energy, you can just be overwhelming. But the problem then is you’re guaranteeing a bad outcome and when you do these things like conserving energy, maybe you’d be tempted to nap, you start implementing these behaviors that actually perpetuate the issue. Make it hard actually harder for your sleep to recover rather. So it’s actually having the opposite outcome than what you’re actually hoping for.
Jade Wu: Exactly. Completely agree with that.
Martin Reed: And another analogy I like to use is every time we do something because of insomnia, it’s like the cookie monster. Like if you imagine insomnia as the cookie monster, so you cancel plans with friends you’re basically give in the cookie monster a cookie. And what happens then he demands more. So then you do something else. He demands more. But if you just kind of ignore the nagging, ignore that urge to modify your life, eventually he’ll move on and ask someone else for cookies, if that makes sense.
Jade Wu: Yeah. I love that. I’m going to steal that one. Yeah. That’s great.
Martin Reed: All right, so I think we did a good job of busting a lot of the sleep myths and sleep beliefs. So moving on from that. As a practicing sleep psychologist you use cognitive behavioral therapy for insomnia techniques, the CBT-I techniques, I talk a lot about on this podcast to help your clients with insomnia. Why is it that you think CBT-I is so effective for people with chronic insomnia?
Jade Wu: Yeah, I think because it has several prongs that work at the same time to address the main issues that perpetuate insomnia. So it’s got the behavioral component that is like a hard behavioral reset button that really just jacks up that sleep drive. And I think it’s really good to lead with that because sometimes… I would say often actually patients come in feeling a little skeptical. Like, I’ve tried a lot of stuff and it hasn’t worked and you’re telling me that maybe I have a lot of anxiety about it, maybe I don’t think I have anxiety about it. So I really like to lead with some behavioral change Just to give people a sense of accomplishment and hope right off of that. Like yes, the needle can be moved. And at the same time I think CBT-I is very education focused.
Jade Wu: Like I’m sure you do this too, where you provide a lot of education about how sleep works, how insomnia works and I think knowledge is power, right? I really love to make sure that the patients are understanding and they’re on board with the rational for what we’re doing. Because I think that’s more than half the battle, is understanding why we do what we do. And building on that too, on the knowledge about sleep, the cognitive aspect of the therapy, which is to help people to see their insomnia from a different perspective, to build a different relationship between them and their sleep.
Jade Wu: I think it’s also really, really helpful, and often, sometimes the cognitive therapy doesn’t work right away, but sometimes there’s like one breakthrough moment that really changes things for folks. So yeah, I think between the cognitive and the behavioral and just a sense of hope and a sense of yes, this is a brief therapy that actually allows you to see some changes on the order of days and weeks rather than on an order of months, gives people a sense of yes, this is something I can do something to help.
Martin Reed: Yeah, I think it is important to make it clear that it does often take time, but not an inordinate amount of time, but it takes weeks, maybe a couple of months. Some people I talk to, they tell me they didn’t get that breakthrough moment until like six weeks. And people like that I just admire because if that person had given up after five weeks, they’d be back to where they started. But they persevered and they carried on going. And I think the breakthrough moment was relatively minor in the grand scheme of things. I think it was… They got like six hours of unbroken sleep.
Martin Reed: And that to them was their breakthrough moment. For other people, the breakthrough moment is just feeling that sleepiness before bed and that’s like the transformational moment for them. And so it really is just about finding that kind of positive trigger moment, that breakthrough and just working towards it. And I think once you’ve got that breakthrough moment and you kind of recognize that all this effort is paying off, that kind of gives you the confidence to push on and keep moving forward and make further gains in your sleep.
Jade Wu: For sure. Yeah. And Hey, six weeks compared to other types of therapies is not bad at all. And I like to tell people it’s kind of like go into physical therapy. If you have a sprained wrist, you won’t expect an overnight change, but you expect that over the course of a few weeks you’ll at least feel some difference, and feel a sense of mastery. And I think that’s exactly how it works with CBT-I.
Martin Reed: Yeah. And to sleep within six weeks, if you’ve had insomnia for six years, let’s say, then six weeks isn’t a bad pay off in terms of trying to get better and improve your sleep.
Jade Wu: Absolutely.
Martin Reed: So I think it’s important, really to highlight these success stories when it comes to insomnia because it’s just so easy to feel like somehow your insomnia is unique, you’re the only one with this certain type of insomnia, you’ve tried everything, you’re beyond hope. So do you have any good success story or two that you can share with us? Maybe there was a client who was really struggling with the CBT-I techniques but they made that breakthrough and now they’re doing much better.
Jade Wu: Yeah, sure. Well two really comes to mind. One was a young woman who came in just so distraught about her sleep. She was in tears almost all of the first session. And she felt like she had lost her sense of self. It was more than just a sleep problem for her. It felt like she had completely lost control of her life and insomnia had begun to overshadow everything else in her life. And she was one that was canceling plans and not going out with friends and not engaging in the things that she liked and not applying to schools and jobs that she was interested in, because she didn’t think she could conform because of her insomnia.
Jade Wu: And so it was a case that really stuck with me because she came in so distraught. And when I told her that usually I see people between four and six and maybe eight times to cure their insomnia. She said, “No offense, but I think you’re crazy. There’s no way you’re going to turn me around and in six weeks.” And I just kind of asked her to go on this journey with me. We’ll see. If it doesn’t work, it doesn’t work. And then after a few weeks we sort of really hit this breakthrough point where we just said “This is not a sleep disorder. Your brain is totally capable of sleeping and this is… how would you live if you didn’t have insomnia? If I had a magic wand that like this could just wave away your insomnia, what would you go out and do?” And she said, “I would go on a trip with my friends, I would go to the gym, I would apply to this job.” And I was like, “Go for it, do all those things.”
Jade Wu: And then a couple of weeks later it really turned around for her and she went on her trip. She had fun and for a couple of nights in a row she didn’t even think about insomnia. She didn’t even think about having to plan her day around sleep. And that’s when there was a… She got this glimmer of hope and things started to get better. So that was a really good pace. That really sticks with me. And by the end I ended up seeing her five times. And at the end she said, “I really thought you were crazy when you said four to six times, but here we are. Like, I don’t need therapy anymore.” So that was lovely.
Jade Wu: And another type of case I think of when I think of success stories is when people come in with insomnia plus something else. So insomnia plus chronic pain, insomnia plus, history of breast cancer or Parkinson’s disease. And these patients, it’s so sad that they have so little hope when they come in because they think, how is it possible that my sleeps could get better when I have cancer or when I have chronological disorder. Don’t I have to cure my Parkinson’s before I can sleep better? And of course that’s not all possible. So am I doing to this poor sleep for the rest of my life?
Jade Wu: And they may not return to sleeping the way that they did before their disease or return to how they slept when they were 25 but, I’ve had a lot of really successful cases where people end up having a healthy relationship with their sleep. They’re satisfied with their sleep and their sleep is not impairing their life or keeping them from enjoying their life anymore. So I think that’s an important thing for people to know is that you don’t have to have perfect health in every other aspect of your life in order to get rid of your insomnia. We can work on that no matter what else you have going on.
Martin Reed: That’s great. I think people are going to take a lot of comfort in hearing those stories, especially that one. I think a lot of people are going to relate to, especially the first example. Well, I think with both, but the first one really stands out for me because I don’t think I’ve come across one person with insomnia who hasn’t modified their life in at least some way because of the insomnia and recognizing that. And it’s almost like just raising the middle finger to insomnia and just going about it and just doing all the things that you enjoy, like in spite of the insomnia, you can just have this kind of just change the whole way that you think about the insomnia. Just like you said, it just re-frames your relationship with sleep and with the insomnia itself.
Martin Reed: And once you recognize that maybe it’s not holding you back quite as much as you originally thought, because you’re giving yourself evidence of that by going about your day doing things you enjoy, I think that’s like a real stepping stone towards just long term improvement. All right, Jade, well I’ve taken up so much of your time, I really appreciate how generous you’ve been. I do just have one last question for you though. So don’t think you’re getting away just yet. If someone with chronic insomnia is listening and feels as though they’ve tried everything, they’re beyond help and that they can’t do anything to improve their sleep, what would you tell them?
Jade Wu: First I would say embrace yourself for trying so hard. I feel for you. It must be extremely, extremely frustrating and there is nothing more frustrating than struggling with something that happens every day and something that feels like it should be so easy. And maybe it was one so easy for you before you had this problem. So my heart goes out to you. It really sucks. And I would say that’s almost every patient I’ve ever had.
Jade Wu: Every person who comes in has tried a lot of other things and many of them have even tried to some version of CBT-I before or what they thought was CBT-I and it turned out that the person that they saw for CBT-I was not quite a sleep specialist or was not really practicing CBT-I the way that you and I do it in the evidence based way. So it may be possible that what you’ve tried before was not really the first line treatment that for example, the American College of Physicians recommends which is CBT-I for insomnia. So don’t give up quite yet. I have seen hundreds of people who were coming in as sort of a last ditch effort, not thinking that their sleep was ever going to get better and then they did. So you’re not alone and this is a solvable problem.
Martin Reed: Yeah, absolutely. And I think you’ve already made a good point there about so many people… because I get it too. So many people say, “Oh I tried CBT-I it didn’t work for me.” And then I had to kind of do a little dig in. “So tell me what kind of techniques you’re implementing.” And they tell me things like, “Oh I was told to like listen to this hypnosis tape an hour before bed. Like not drink caffeine during the day. More like the sleep hygiene stuff, which is a world away really from CBT-I and so-
Jade Wu: They’re the control condition in our studies, so we don’t expect it to work.
Martin Reed: Yeah, exactly. It’s the control group, right? We know it’s like the no intervention group. We know it doesn’t work for people with chronic insomnia, but when you try it and it doesn’t work, especially if it’s been recommended to you, that just leads to more worries. So yeah, I think that was a really important point that if you feel you’ve tried CBT-I it might just be worth looking into it again just to make sure it really actually was I CBT-I that you were implementing. And just even if it was, maybe just ask yourself if you tried it for long enough. Maybe you just tried it for a couple of weeks and… Another goal I have with these podcasts episodes is to try and motivate people to look into it and really try it and really commit to it. Because I think it really is like the magic pill. We spent so much time looking for this magic pill for insomnia and it exists, but it’s not in a physical form. It’s this collection of skills, behaviors, techniques known as CBT-I, and they are just so helpful. So it’s something I really encourage people to look into.
Jade Wu: That’s a great point.
Martin Reed: All right, Jade, thank you so much for taking the time to be on today, I’m sure everyone listening is going to find it really helpful, especially busting those sleep myths because sometimes I feel like I’m swimming alone in the ocean, trying to burst them by myself. So it’s good to have someone here to talk through them with, and those success stories at the end were a really great way to end as well. So thank you.
Jade Wu: Thank you so much for giving me the opportunity, for having me on this was really fun and thanks for the really good work you’re doing. We should really… I love it when people are getting the good word out there about CBT-I.
Martin Reed: Yeah, I appreciate that. We need more people. So if anyone’s listening to this and you’re maybe like a CBT-I provider or you work with people with insomnia get in touch because there needs to be more of us and we need to do more collaboration and we need to get the message out.
Jade Wu: Absolutely. I agree.
Martin Reed: All right. Thank you, Jade.
Jade Wu: Thank you.
Martin Reed: Thanks for listening to The Insomnia Coach Podcast. If you’re ready to implement cognitive behavioral therapy for insomnia, CBT-I techniques to improve your sleep but think you might need some additional support and guidance, I would love to help. There are two ways we can work together. First, you can get my online coaching course. This is the most popular option. My course combines sleep education with unlimited support and guidance and is guaranteed to improve your sleep. I will teach you and help you implement new CBT-I techniques over a period of eight weeks. This gives you time to build sleep confidence and notice results without feeling overwhelmed. You can get the course and start right now at insomniacoach.com/online.
Martin Reed: I also offer a phone coaching package where we start with a one hour call. This can be voice only or video, your choice. And we come up with an initial two week plan that will have you implementing CBT-I techniques that will lead to long term improvements in your sleep. You get unlimited email based support and guidance for two weeks after the call along with a half hour follow up call at the end of the two weeks. You can book the phone coaching package at insomniacoach.com/phone.
Martin Reed: I hope you enjoyed this episode of the Insomnia Coach Podcast. I’m Martin Reed, and as always, I’d like to leave you with this important reminder. You can sleep.
Mentioned in this episode:
Insomnia and mortality: A meta-analysis (A meta-analysis published in 2019 that included 36,938,981 individuals and found no difference in the odds of mortality for those individuals with symptoms of insomnia when compared to those without symptoms).
A conversation about insomnia and anxiety with clinical psychologist Nick Wignall (Podcast Episode #7)
Every time you feed your insomnia, you make your insomnia more powerful and more demanding (The Cookie Monster Effect)
If you’re ready to improve your sleep using evidence-based cognitive behavioral therapy for insomnia (CBT-I) techniques, click here to get my online insomnia coaching course. We can get started right now.
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