Dr Dave McCarty: Why You Need an Empowered Approach to Sleep and Insomnia

David E McCarty MD FAASM attended medical school at Duke University, and completed an internship and residency in Internal Medicine in Boston, at Massachusetts General Hospital. He began his career practising primary care, but after a handful of years in practice, he followed his own white rabbit into a whole new world called Sleep Medicine.

Dr McCarty learned the art from the great Dr Andrew Chesson (world-class physician, and past president of the AASM). While at LSU, Dr McCarty won some teaching awards, published a few papers, and it’s also where he developed the Five Finger Approach, which has remained the cornerstone of his teaching about patient-centred problem-solving, to this day, and is featured as the pinnacle for orienteering around the Isle.

In addition to patient care and academic endeavours, Dr McCarty has had plenty of experience as a public speaker at regional and national meetings throughout his career.

He retired from the practice of clinical medicine in 2021, to devote his energy to patient education.

Dr. Dave McCarty: Why You Need an Empowered Approach to Sleep and Insomnia Introduction

Well, today we revisit sleep, and I have the pleasure of inviting back Dr. Dave McCarty, a sleep physician whose practices in Colorado at the Colorado Sleep Institute. Dave attended medical school at Duke University. Went on to study with one of the greats in sleep medicine, Dr. Andrew Chesson, a world-class physician and past president of the American Academy of Sleep Medicine. It was while he was studying with Dr. Chesson at Louisiana State, LSU, that he developed his five-fingered patient-centered approach, which he shared with us the last episode, but goes into one particular aspect of that more so today. And it’s interesting, Dave’s soaring.

Dave’s book, how Sleep Apnoea, is really taking patients on a journey through The Bay of Narratives down through rivers and mountains. And just to give you a feel for that first five or 10 minutes, he’s even worked in some birdcalls. So it gives you the sense that you really are on a journey with him and there. So don’t try, and don’t be surprised when you hear it. I was talking to Dave, and we got so engrossed that the bird seemed like an interesting or just a little bit of added effect to it. We go into the subject of insomnia. We talk about what some drugs are that cause these problems. We talk about circadian rhythms, we talk about a whole range of things. And it’s just a wonderful conversation. And I just love Dave’s patient-centered approach and passion. I hope you do, too. I hope you enjoy this conversation I had with Dr. Dave McCarty.

Podcast Transcript

Dr. Ron Ehrlich: [00:00:00] Hello and welcome to Unstress. My name is Dr Ron Ehrlich. I’d like to acknowledge the traditional custodians of the land on which I’m recording this podcast, the radigal people of the Eora Nation, and pay my respects to their elders past, presentt and emerging. 

Dr. Ron Ehrlich: [00:00:15] Well, today we revisit sleep, and I have the pleasure of inviting back Dr. Dave McCarty, a sleep physician whose practices in Colorado at the Colorado Sleep Institute. Dave attended medical school at Duke University. Went on to study with one of the greats in sleep medicine, Dr. Andrew Chesson, a world-class physician and past president of the American Academy of Sleep Medicine. It was while he was studying with Dr. Chesson at Louisiana State, LSU, that he developed his five-fingered patient-centered approach, which he shared with us the last episode, but goes into one particular aspect of that more so today. And it’s interesting, Dave’s soaring. 

Dr. Ron Ehrlich: [00:01:07] Dave’s book, how Sleep Apnea (Empowered Sleep Apnea) is really taking patients on a journey through the Bay of narratives down through rivers and mountains. And just to give you a feel for that first five or 10 minutes, he’s even worked in some birdcalls. So it gives you the sense that you really are on a journey with him and there. So don’t try, and don’t be surprised when you hear it.

I was talking to Dave, and we got so engrossed that the bird seemed like an interesting or just a little bit of added effect to it. We go into the subject of insomnia. We talk about what some drugs are that cause these problems. We talk about circadian rhythms, we talk about a whole range of things. And it’s just a wonderful conversation. And I just love Dave’s patient-centered approach and passion. I hope you do, too. I hope you enjoy this conversation I had with Dr. Dave McCarty. 

Dr. Ron Ehrlich: [00:02:05] Welcome back, Dave.

Dr. Dave McCarty: [00:02:07] Thank you so much. It’s great to be here.

Dr. Ron Ehrlich: [00:02:09] Dave, last time we had you on, you took us on a wonderful journey. And you’ve got a map there behind you. And I know your book goes in. 

Dr. Dave McCarty: [00:02:17] Yes, yes.

Dr. Ron Ehrlich: [00:02:18] Goes into it. 

Dr. Dave McCarty: [00:02:19] I feel like a weatherman, and I’m sort of pointing out the green screen anyway.

Dr. Ron Ehrlich: [00:02:23] Yes, you do. You do. But you took us… Let me just remind listeners, you took us through The Bay of Narrative. You then dealt with the Five Reasons To Treat, took us on the River of Decision, which was how we were going to treat it. You talked about the Treated Territory, which we’re going to come back to, and then the Five-Fingered Approach Mountain. And you finished in this wonderful place called Pleasant Dreams Beach. So I wondered whether we might just start with the end there and just remind our listeners what a good night’s sleep. How do we define a good night’s sleep?

Dr. Dave McCarty: [00:02:57] It’s very subjective, isn’t it? If you ask someone if they sleep well, I’ve gotten answers like, Well, sure, yeah, I sleep fine, I don’t have any trouble. And then you clarify, and you say, Well, but does that mean you sleeping through the night and you’re waking up feeling rested, and you’re not tired during the day, and people will suddenly double back, and they say, Well, I never feel like that, but that’s normal for me. And so really getting down to something that I’ll call a Sleep-Wake Complaint can be a very individualized journey for people. They start out with no complaints, and then they realize that they actually do have a problem. 

Dr. Ron Ehrlich: [00:03:25] Yeah, yeah. It’s quite amazing how people have normalized this sleep. I mean, I guess they have no other reference. So, you know, I mean for us who are exploring and asking this question through hundreds of patients. 

Dr. Dave McCarty: [00:03:41] What does a good night’s sleep feel like? yeah

Dr. Ron Ehrlich: [00:03:43] Yeah, yeah. So how do what should a good night’s sleep look like? 

Dr. Dave McCarty: [00:03:48] You know, most people can expect to wake up one or two times per night, so just having an awakening at night is not unusual. Sleep is designed to go through stages. So we start in a late stage, and we go down into a deeper stage, and often we’ll have a REM cycle and then back up to a light stage again. So it’s almost like a dolphin sort of going through and up and down throughout the water. 

And if people aren’t aware that they’re supposed to wake up, they may identify that as a problem, even though it’s part of what normal is, you know. So drilling down to what’s actually bothering the patient is the first order of business. You know, one of the things that I learnt early on in my career and the reason I came up with The Five Finger Approach Mountain was people can come in with complaints that are completely incongruent with their diagnosis. 

And the five-fingerer approach was invented because a woman who actually carried a diagnosis of narcolepsy with cataplexy walabeleded early on with sleep apnoea and was therefore after, sort of treated for sleep apnoea. And you know, the patient complaints kind of got lost in that diagnosis. So around the year five, when I finally first met this patient, and I asked her how she was doing on her CPAP machine, she said, you know, fine, because that’s what she always said before. But it turns out that this machine wasn’t addressing her original problem, which was, believe it or not, her original problem was, I can’t sleep through the night. Okay. 

So she got put into a silo that was sort of an insomnia silo. That’s how people started thinking about her. And it turns out not sleeping through the night can be part of the narcolepsy complex. But, you know, obviously, that’s not insomnia. Right. But to the patient, that was what she was experiencing. So I think it’s very important that we understand that to the patient, to the individual. What’s important are the complaints to practitioners. We try to put a label on it. 

Dr. Ron Ehrlich: [00:05:33] Okay. To remind us, she used the term narcolepsy and just remind us what that is? 

Dr. Dave McCarty: [00:05:38] Oh, boy. Narcolepsy is a fascinating problem of the brain where the cells that are supposed to create a neurotransmitter called hypocretin. This is a special neurotransmitter that is kind of the ringmaster of all of the neurotransmitters that help us stay awake. So it helps to regulate other neurotransmitters and for reasons that are probably multilayered. The cells that produce that neurotransmitter get immunologically destroyed, kind of the same way that pancreatic islet cells get destroyed when type one diabetes happens.

 And so the outcome of the destruction of these particular cells in the hypothalamus is that people develop this very strange syndrome where they have trouble stabilizing states. So wake is difficult to stabilize. So people have dozing spells, sleep is difficult to stabilize, so they wake up a lot, and the REM sleep stage becomes discombobulated. So elements of REM sleep, like the imagery, the dream imagery, the things that you can see in your dreams, can actually intrude upon wakefulness. 

The paralysis of the body that can happen during REM sleep can intrude upon wakefulness. So it’s a very interesting and complicated disorder. But obviously, this woman didn’t knowing about all she knew was that she wasn’t sleeping through the night. And when she came to the sleep clinic and at some point answered the question, you know, sometimes to the question about snoring, that’s when the stamp came down, and she got the diagnosis. 

And then after that, it became sort of a diagnosis driven strategy, which is, of course, what The Five Finger Approach is supposed to guard against. It’s supposed to bring us back to the patient’s sleep, wake complaints, and remind us that there might be more than one possible contributing force to that.

Dr. Ron Ehrlich: [00:07:19] So her diagnosis was narcolepsy.

Dr. Dave McCarty: [00:07:21] Her diagnosis ultimately, I met her for the first time five years into her journey and starting to talk with her. I realized that the treatment we were giving her wasn’t solving her problems. And after a little bit more investigation, we found out that her actual diagnosis was narcolepsy. This is on my website. 

There’s a blog post about this, about the origin of The Five Finger Approach, because I thought it was important. You know, it’s very easy in a complex medical system. Once you get a label, that label becomes your narrative instead of what is should be, rightfully so, your narrative being your narrative.

Dr. Ron Ehrlich: [00:07:52] So ultimately, how was she diagnosed? How did you diagnose that? Narcolepsy? 

Dr. Dave McCarty: [00:07:57] Yeah, narcolepsy is a complex disorder, and it’s typically diagnosed with a daytime sleep series of study. So you sleep overnight in the sleep lab to document that the overnight sleep doesn’t have anything intrinsically wrong with it, like a bad case of sleep apnoea. And then, the next day, the patient is given five opportunities to fall asleep in the daytime. And if the patient falls asleep quickly on many of those naps, especially if there’s REM sleep in the nap, that’s indicative of narcolepsy. 

Dr. Ron Ehrlich: [00:08:27] Wow. Okay. So one of the things that we didn’t really touch on and I wanted to explore today was the badlands of insomnia. Because what’s the difference between, you know, a lot of people use that term because they’re not sleeping well. And what’s the difference between not sleeping well and insomnia? 

Dr. Dave McCarty: [00:08:49] Well, I’ll say to the patient very little because it represents a form of sleep dissatisfaction. So technically, insomnia is an inability to achieve sleep despite the need and the opportunity to do so to the degree that it causes some sort of dysfunction, that sort of insomnia disorder, the way it’s listed, and the international classification of sleep disorders. 

The problem with that, I believe we have with our with our diagnosis and classification system is simply that, you know, many people have more than one, possibly two or three elements that are contributing to their sleep complaints and simply labelling it insomnia and saying, you know, that’s the pathway we’re going to take can kind of turn off your brain to solving the actual problem at hand. So there’s lots of research about insomnia. 

Those patient groups are carefully selected so that we’re sure we’re studying a single thing, and that’s all great. But in the real world, people usually have more than one problem. That’s where the Five Finger Mountain comes in. That’s my finger approach. Mountain? Yeah.

Dr. Ron Ehrlich: [00:09:52] Yeah. And just one of the first part of that five-fingered approach is circadian misalignment. Can you talk to us a little bit more about that? Because our relationship with the sun is an interesting one and our relationship with light is an interesting one. What is circadian misalignment? 

Dr. Dave McCarty: [00:10:14] So all of us have what is called the circadian sleep phase, which is. Time frame in our 24-hour cycle that is most opportune for a prolonged sleep interval. For most of us, that circadian sleep phase occurs at night. And so what we’d like to have happen is for the circadian sleep phase to be beginning right when we’re ready to put our head down on our pillow. 

Now, the interesting thing about the circadian sleep phase is that you can move it. You can move that window of opportunity for sleep forwards or backwards. And most of us have habits in our life that tends to promote delay of that sleep phase. Okay. Now, the interesting thing about this circadian sleep phase is that the 2 hours preceding that sleep phase is a timeframe of fairly robust activity of the ascending reticular activating system, which is the part of the brain that is there to keep us awake. 

Dr. Dave McCarty: [00:11:08] For example, if you went in there and you burned up parts of that, all of the ascending reticular activating system with an electrode, we would create a person who is not able to wake up anymore and lane by term four, that is a coma. That person’s asleep forever. So we need the rest. The rest is there to help promote wakefulness, and it builds up its activity as the day goes, because the whole time we’re awake, we are busy collecting fumes in the attic. 

There’s fog; there’s chemicals that build up in our brain as a matter of being awake and in the business. We call this sleep pressure. Not that it’s actually under pressure, but the idea is more and more chemicals build up in the brain. The longer that we’re awake, they’re called sleep-regulating substances, and those chemicals make us sleepy. So the longer we’re awake to arrest. It’s those birds again. I wonder… Is that… Okay, I’ll just keep talking. 

The arrest is acting up, and in the final 2 hours of wakefulness, it’s actually on full steam ahead. And that’s there for a reason. It’s designed to get us to the finish line so that we can properly stay awake until it’s time for us to go to bed. Now, the problem is if we’re shining lights in our eyes and having sort of sunlight and daytime-type information coming into our brains, at the end of the day, the next day; it’s going to push everything a little bit later. Okay. 

So we’re giving ourselves sort of a social jetlag by using our devices, having our electric lights on. Really, the only wavelength of light that doesn’t do that to us is the wonderful orange wavelength of a campfire, you know. So if you get your illumination from a beautiful campfire, it’s not going to harm you. But if you’re, you know, trying to do your taxes at 10:00 o’clock at night with the lights on, you’re going to have a hard time getting to sleep the next night because it’s trying to push your circadian sleep pace later. 

Dr. Ron Ehrlich: [00:12:57] Hmm. But I think when we talk about that orange glow of the campfire, which inherently, instinctively we feel drawn to, it’s that end of the, you know, the spectrum red, orange, yellow, green, blue, indigo, violet. And when we were having incandescent lights in our houses, that was probably less it’s more down the red end of the spectrum. A lot of our light now is down. The blue end of the spectrum isn’t.

Dr. Dave McCarty: [00:13:27] Our full spectrum. Yeah, we’re really getting daytime-type information at a time frame when we’re supposed to be really quieting that down. I didn’t mention that right in the middle of that forbidden zone. That’s what that time frame is called in that great name. It sounds like a wonderful 1950s, you know, sci-fi show, you know, The Forbidden Zone. But it’s hard to fall asleep there. That’s why it’s called that. 

So if you’re doing plotted graphs, it’s 24 hours at a time. You can see that there’s a certain time frame on that when people just generally they’re not tending to fall asleep by natural selection. That’s the forbidden zone. That’s that robust activity of the ascending reticular activating system. Right there in the middle of that is an event. Okay? It’s a circadian event called the Dim Light Melatonin Onset. We like to call it the dilmo. Okay. 

The dim light melatonin onset means that if you are in dim light, about an hour, an hour and a half before you’re supposed to put your head on your pillow if you’re in dim light, there will be a sudden uptick, a sudden surge of melatonin levels in the bloodstream. And that can be measurable, actually. So experimentally, you can measure that in saliva. So they have people spit into a cup every few minutes, and you can find that place where it suddenly zooms up. So that’s called the dim light melatonin onset.

And I like to like liken the dilmo to an aeroplane Captain Dilmo I call him and his job is to sort of announce to everyone, we’re putting the wheels down, you know, the tray tables have to go up, the seatbacks have to come up because we’re about to make our landing and into Sleepy Town Airport. And so it helps everything sort of happen smoothly. So what’s happening everywhere is that the dim light melatonin onset, I call it melatonin a shy hormone because it doesn’t come out in the light. Okay. So you can make Captain Dilmo late for his shift. 

Just by turning the lights on. Just by having overhead lights on, you can make him light furniture. So when you get into the bed without the dim light melatonin onset happening appropriately, it’s like trying to land the plane with the wheels up, so the transition doesn’t happen very well. And people will come to the doctor’s office, and they’ll claim that they have insomnia because of that, because they’ve just destroyed their own internal signaling, you know. 

So one of the things I mention in the book is just, you know, listen, this happens. Captain Dilmo is important. We need to protect her shift. We need to get him to work on time, so he can help land the plane and get you to sleep the way you’re supposed to. And actually, my partner, my authorship partner on the book, Dr. Alan Stothard, she was involved in a really wonderful study at the University of Colorado Boulder called the camping study was a series of studies where their team actually showed that only three days of camping with nothing but campfire as illumination completely normalized the patterns of melatonin, of social jetlag. Three days going camping. So, you know, I live in Boulder. 

Dr. Ron Ehrlich: [00:16:29] yeah, yeah. And it’s so interesting to hear you say that, because, throughout my life, I have been almost obsessed with having dimmers on my house lights. You know, I just and. 

Dr. Dave McCarty: [00:16:41] Do you turn them down at the end of the day?

Dr. Ron Ehrlich: [00:16:42] Absolutely. I find it in a room that does not have a dimmer, really. I feel irritated. I don’t just try to go, how can you do this? How can you have so much bright light in your house?

Dr. Dave McCarty: [00:16:55] I do the same thing. I tend to turn everything off. And, you know, when the sun goes down, I turn the little light on and the hood over this, over the range. And I let that illuminate the kitchen and I just kind of it feels good to have things a little bit darker, you know? 

Dr. Ron Ehrlich: [00:17:09] Yeah. How you’d feel very comfortable in our house. Dave, next time you’re in Sydney, you’ll have to come over. 

Dr. Dave McCarty: [00:17:14] Oh, I totally. I made some, I made some Australian friends at the FDA PMD meeting at the collaboration’s first meeting is wonderful. 

Dr. Ron Ehrlich: [00:17:23] Yeah. Now I want to talk about that in a moment because, you know, that was that’s always an interesting meeting. But coming back to the circadian rhythm, we’ve kind of done a double or triple whammy to undermine it. One is demonizing the sun, the other is our devices, and the other is how we light our homes. What is the relationship? What should our relationship with the sun be? From a sleep perspective.

Dr. Dave McCarty: [00:17:54] I would like to see everybody getting up at the same time every day, roughly within a 30 to 60-minute window at the most on the weekends, and not a lot of variabilities. I’m on my side. The most important thing is to get up and get bright lights in your eyes first thing in the morning. 

So some people seasonally they’ll have to use a bright sort of a sun lamp type of device. But if you have sunlight, it’s a great time to sort of get your circadian rhythm kickstarted. It knows where things begin. That’s the first domino to fall. So if you get up and get bright lights in your face first thing in the morning, your circadian has a nice anchor point. It knows where it’s supposed to be, and the rest of the dominoes are more likely to fall into place. 

Dr. Ron Ehrlich: [00:18:33] Hmm, and that would be without sunglasses on?

Dr. Dave McCarty: [00:18:36] Yeah, theoretically, yeah. The sunglasses, it can seriously block that, and it can prevent whatever normalizing effects it can have. Yeah.

Dr. Ron Ehrlich: [00:18:45] And we’ve talked about house lights and, and he sees the difference between incandescent and LED, which I think most houses are now LED lights, and that’s sound down the blue end of the spectrum. But these devices, these devices which we hold in our hand, you know, at all, put in our lap and often now do late at night, they undermine they might compromise that as well. 

Dr. Dave McCarty: [00:19:11] I certainly do. Yeah. And you know, we have the added benefit. There’s a little bit more awareness, and people know about the Night-Time mode, which shifts it over to a warmer color spectrum, which is good, but you know, it’s very close to our face, so it’s lights that’s going great and straight into our face. 

And I like to emphasize that it’s not just the light, you know, there are lots of non-food tech ways to stimulate the brain, and obviously, the internet is full of those things, including social media and news. So those are things that can really kind of drive the rest into overdrive, even, you know, at a time frame when we know we’re supposed to be kind of taking the heat off about part of my brains.

Dr. Ron Ehrlich: [00:19:46] Yeah. Yeah. I often say that time of night is the time to connect with your pillow, not the world. and that makes a big difference. You also mentioned sleep pressure. And I think one of the things, one of the chemicals that pushes that is adenosine.

Dr. Dave McCarty: [00:20:04] Yeah.

Dr. Ron Ehrlich: [00:20:05] And that’s so interesting, isn’t it?

Dr. Dave McCarty: [00:20:07] Yeah, I love that story. Yeah. So you’re talking about one very well-studied of group of chemicals that are called sleep-regulating substances. Right. And essentially what these are. Is there breakdown products of metabolism, inflammation, and body stress? The more you do, the more of these substances are going to build up in the brain. 

And it makes sense. You know, for example, when I think of her as sort of an American goddess, Lindsey Vonn, the skier. I don’t know if you saw her in the Olympics when she’s training, she gets 10 to 11 hours of sleep per night. And, you know, that’s amazing. Most of us get 6 to 7, but that’s because she’s training like an animal. You know, she just uses her body and really works hard. And so she needs that amount of sleep. I think Michael Phelps was 10 to 11 hours a night. 

So these incredible athletes, they’re using their bodies to such an extent they need this extra time to recuperate. So that’s something to think about. And I used to teach that to my patients because, let’s face it, what if you have cancer? What if you have sleep apnea? You know, these are stressors on the body, and their sleep apnea has the dubious distinction of it, stresses the body, and it also keeps you from sleeping. And so you get a real double whammy there. And it’s very it can create some real problems. 

So the word insomnia, when I say the badlands of insomnia, I really mean that it can be a very lonely place because to a doctor and to a provider, insomnia is a pure choir sort of a concept. And we have algorithms for treating insomnia, you know, Oh, you shouldn’t take sleeping pills, people might say. Or really, we only recommend cognitive behavioral therapy for insomnia. Now the problem there is that the patient doesn’t come in with a perfect brand of insomnia. The patient comes in with a complaint. 

And if that patient has insomnia because they’re taking three different medications that are keeping them awake and they didn’t connect the dots, they’re not going to do well on cognitive behavioral therapy, and they’re going to think the whole system is kind of set up to make them fail. So again, insomnia is a thing that means I’m not sleeping well, and the sleep is dissatisfying to me, to the provider. It means we need to get in and clarify what that narrative feels like to the patient. And then we got to take a trip to the mountain. We got to go to The Five Finger Approach and sort of go through it and figure out what in there we can fix.

Dr. Ron Ehrlich: [00:22:29] Hmm. Well, we’ve talked about circadian misalignment and sleep pressure. And interestingly, when I heard adenosine being, as you mentioned, just one of those chemicals that presents because ATP adenosine triphosphate is the currency our body uses to produce energy. 

Dr. Dave McCarty: [00:22:52] That’s our fuel. 

Dr. Ron Ehrlich: [00:22:53] Yeah. And it’s so interesting because it said, you know, doing some exercise, getting out and moving your body will improve your sleep. Well, that’s because I guess one of the many reasons is, well, you’ll see the sun for a start, so that’ll be positive, and you’ll be producing more energy ATP adenosine triphosphate, and the by-product of that is adenosine, which will be pressure. 

So it’s a win-win all around. But pharmacological influences, I mean, that’s got to be a huge issue. I mean, when you consider how many pharmacology from how much medicine people are taking, what are some examples of medicines that adversely affect sleep quality sleep? 

Dr. Dave McCarty: [00:23:35] Yeah, there are lots, and I deliberately place the pharmacologic influences as the second finger of The Five Finger Approach. This was when I was back in academics. I was teaching fellows how to deconstruct cases. And one of the things that I notice is, depending on the fellow’s background, they may or may not have kind of comfort with going in and critically evaluating medications that were prescribed by other providers. 

For example, my psychiatry-based fellows really didn’t sort of take a look at that, the cardiology meds, it was kind of like, that’s the cardiologist, and I’m not thinking about that. But, you know, it’s important. For example, beta-blockers, have you heard of this drug class? Very commonly prescribed anti-blood pressure medication slows the heart rate. 

So beta blockers, many people don’t know this can do a terrible number on sleep. Okay, REM, actually, it turns out in order for REM to happen, adenosine. I’m sorry, not adenosine nor epinephrine in the brain, it goes through sort of ebbs and flows. Levels of that neurotransmitter and norepinephrine has to be receding. 

And on ebb part of this, in order for REM sleep to occur. Okay, melatonin is actually an adrenergic phenomenon. So if beta blockers are on board, melatonin release is blunted, and REM phenomenon can get this discombobulated. So many people who are taking beta blockers will suddenly experience difficulty getting to sleep, difficulty staying asleep, and sometimes even intrusive REM behavior such as dream enactment behavior or frank hallucinations. 

Dr. Dave McCarty: [00:25:18] Now, if those are the complaints and someone doesn’t connect the dots between, oh, I’m going to go through The Five Finger Approach and think about each of these drugs. And when did this problem start, and when were these medications start? You might miss it, and you might end up with a label of, you know, psychosis. 

You might end up with I actually saw a patient who had her chief complaint was formed visual hallucinations at the sleep-wake barrier. So she was awake but about to fall asleep, and she would see people walking in the room, animals crawling under the sheets. This was all related to her beta blockers. How’s that for a story?

Dr. Ron Ehrlich: [00:25:54] Wow. That’s incredible because that is not an uncommon medication. 

Dr. Dave McCarty: [00:25:59] Yeah, it’s a very common medication with an uncommon side effect. Yeah. And The Five Finger Approach is designed to keep us from falling into the trap of what’s called a search satisficing error. Search satisficing error. That’s a blended word. Kind of like smog is a blended word. English majors call those words portmanteau, which is a split suitcase that opens up like this. Anyway, I like that image because it makes you feel like you’re going on a trip somewhere, someplace new.

Dr. Ron Ehrlich: [00:26:25] You’re always taking us on a journey. 

Dr. Dave McCarty: [00:26:28] But a search satisficing error is a type of medical decision-making error, where as soon as you find something that’s sufficient to explain the syndrome that you have at hand, you’re done, and you start thinking about it. And this is what happened in Darwin in the case that I tell the story on my blog that created The Five Finger Approach. 

She came in with a story of I’m not sleeping through the night, and I’m sleepy, and oh yeah, maybe I snore. She got a label of sleep apnoea, and then she was given a machine. And from that moment onward, she was that label. And then the narrative disappeared. And that troubled me, you know, that troubled me deeply. And I felt like that was something that systemically we shouldn’t ever have to happen again. 

And The Five Finger Approach has gotten me out of more hot water, difficult situations. It’s my favorite Swiss Army knife. I used to teach it to my patients, and then they’d go home, and they’d come back, and they’d tell me what was wrong with them. It’s a beautiful, beautiful little magic trick. As if you teach your patients enough, they’ll solve their own problems.

Dr. Ron Ehrlich: [00:27:29] I love that I mean, that’s been a mantra of mine since I learned to over 30 years ago from, from Dr. Janet Ravel, who said if you ask your patients the right questions, and you know what questions to ask them, they’ll not only tell you what’s wrong with them, but often they’ll tell you how to fix it. 

Dr. Dave McCarty: [00:27:48] Isn’t that wonderful? It’s just isn’t. And they’ll feel good about it, and they’ll think you’re a genius when they solve their own problems.

Dr. Ron Ehrlich: [00:27:53] Yeah, yeah. But back to the medications, because the beta blockers are a pretty common one, and I must admit I had not heard that one before. I do know that there’s a difference between sedatives taking sedatives to sleep for improving sleep and actual sleep quality. There’s a bit of a contradiction there, isn’t there? Can you talk to us about another pharmacological group?

Dr. Dave McCarty: [00:28:19] That can disturb sleep or the work on the other side. So there’s many drug classes that can disturb sleep.

Dr. Ron Ehrlich: [00:28:24] Yeah.

Dr. Dave McCarty: [00:28:25] Antidepressants are a very common one. So antidepressants that alter synaptic transmission of more epinephrine and dopamine, both of those are fairly potent alerting neurotransmitters in the brain. So I’m talking about drugs like venlafaxine. Trade Name Effexor, desvenlafaxine trade name Pristiq, bupropion trade name Wellbutrin. 

All of these drugs are, you know, they’re very common. They’re effective antidepressants. They also have some off-label indications. For example, Venlafaxine has some data to treat post-menopausal hot flashes to reduce the frequency and severity of postmenopausal hot flashes. So that’s all interesting. But what’s fascinating is, you know, the sleep-related effects are really, really prominent in some people. 

And I’ll just tell a little story. A woman that I had been working with on a mild sleep apnoea case called me one day, and she says, Doc, I haven’t slept in four days, and I’m going insane. And she was literally coming unglued. And so I got on the phone with her, and I couldn’t figure out what was going on. And so finally I went back to the mountain. And so we kind of drilled down. I didn’t sound like circadian misalignment. She was going to the bed same time and waking up the same time every day. 

So I didn’t feel shifted. We got to the second finger, which is drugs, and we went through it. And it turns out that two weeks prior, her OB-GYN had started her on again, the vaccine to be post-menopausal hot flashes because she wasn’t allowed to take hormones because she had a history of cancer. And so she had been taking these pills to try to reduce the hot flashes, which, by the way, her main complaint was these hot flashes are waking me up four times a night, and I’m drenched, and I can’t sleep. 

And so she starts taking this pill to reduce the hot flashes, and her sleep gets shorter and shorter and shorter. Well, you’re still having. Well, take a higher dose and take it. Night. That’ll do it. That’ll reduce the hot flashes. So by the time she called me, she was taking 225 milligrams of venlafaxine at bedtime, and she hadn’t slept in four days. And. And it was The Five Finger Approach mountain that got us out of that jam. 

And some friendly advice to go back and speak with her OBGYN about maybe a different drug, possibly gabapentin, which actually has a sedating side effect profile and also has some data for hot flashes. So anyway, by facilitating that conversation, she did go back, got her medication switched around, and ended up with a more satisfying experience. So you know that that’s a function of listening, you know, just sort of opening your ears and helping people focus on what they need to know so that they can help track down the culprit for what’s wrong.

Dr. Ron Ehrlich: [00:31:06] Mm-hmm. Wow. What a great story. What a great story. Because another I don’t know whether we put it into pharmacological influences or the fourth finger, the psychosocial influences, but alcohol is another one, which finger?

Dr. Dave McCarty: [00:31:22] I think it depends on how you want to classify that. Right. It doesn’t sort of matter because it’s not like you’re writing a textbook and somebody’s going to check your answers. It’s a checklist.

Dr. Ron Ehrlich: [00:31:32] Yeah. 

Dr. Dave McCarty: [00:31:32] But I would consider alcohol usually in my pharmacologic ground. I consider social pharmacology as well. So nicotine gets you coming and going then that nicotine is a central nervous system stimulant. Got a half-life of about an hour. Really wonderful psychology that they put 20 cigarettes in a pack. Don’t they get one for each hour, and they get 4 hours off, you know? But if you’re a heavy smoker, the physical discomforts and the psychological discomforts of nicotine withdrawal are very real. 

And they’ll just start affecting you while you’re sleeping. And there’s a little, not a little known fact. Most people sort of intuit this. But if you introduce physical discomfort while you’re sleeping, you obviously can alter the sleep experience, you’ll alter dream content. So the experimental data shows that when you watch someone go into REM sleep, and then you waft in some rotten egg odors into the room, the content of their dream, the valence of their dream will be different, and they’ll usually report negative type of things. 

So imagine going to bed and trying to sleep each night with some painful physical sensation. What will that do to your sleep and your dreams? People who have sleep apnoea will say that they’re dreaming of drowning or suffocation at night, you know. So all of these things can affect the sleeping experience. So insomnia is not one thing to the patient when you look at the literature, and you look at recommendations. 

Insomnia can be sanitized and they can say we should retreat insomnia with these. But that patient population is going to be different than Joe Blow off the street who walks in with a complaint because that person may not have insomnia, that person may have medications, pain, painful medical situations, may have circadian misalignment, not the same thing as insomnia, but to the patient, it doesn’t make a difference. They’re still suffering from poor sleep.

Dr. Ron Ehrlich: [00:33:20] Mm hmm. I mean, alcohol is another one that people feel helps them get to sleep. 

Dr. Dave McCarty: [00:33:27] Oh, it does. It’s wonderful. It’s the most commonly used hypnotic in the world. Right. Hypnotic is a sleeping agent, and the problem is that it doesn’t work very well to get people what they want. So although it helps people fall asleep while alcohol levels are high, it induces sort of more light-stage sleep. You don’t get better REM. 

Usually, you get kind of crummy sleep, but you’re asleep. As alcohol in the bloodstream is receding, the level is going down. That response to sleep is that sleep becomes much lighter. So sleep just becomes fragile in the second half of the night with an alcohol-induced sleep experience. And as a result, it doesn’t feel as restorative. People wake up a lot and just feel kind of like it’s lousy quality.

Dr. Ron Ehrlich: [00:34:12] Hmm. I think there’s some. In some cases, it’s referred to as a hangover, isn’t it? In extreme. Extreme?

Dr. Dave McCarty: [00:34:19] Yeah, that’s part of it. It’s not just the drug, it’s what the drug has done to your rhythm. Usually, a hangover is involved with you. Stayed up way too late, and so your rhythm is all out of whack, too. So there’s a lot of elements to what? What is a hangover? Hmm.

Dr. Ron Ehrlich: [00:34:32] I meant to ask you back at circadian. Number one, the finger circadian misalignment about chronotype. You know, that’s a word we’re hearing a little bit more of. You know that, oh, I’m a person whose best night, the best window of sleep is 9:00 O’clock, no no, my best window is 12:00 O’clock and what do you think of Chrono Talks, and can you change your chronotype? 

Dr. Dave McCarty: [00:34:55] Well, you know, you can certainly change the timing of your circadian rhythm, but a chronotype is referring to whether someone tends to be a morning lark or a night owl, and most of us know which one we are. You know, morning larks tend to feel like their best time of the day is on the front end, and they are very quickly to be the ones who get into bed.

And it’s time for bed for me, and I’m out. That’s me. I’m a morning lark this happened. My wife is a night owl. And so night owls, you give them any opportunity, and it’s very easy for them to delay their circadian sleep. So they tend to be sensitive to this phase, delaying influences. At the end of the day, they tend to choose to stay up later than they will announce that their favorite time to do something is going to be kind of afternoon and evening if they have to take a test or perform or something their best in the evening.

 And that’s a trait-like characteristic. You can’t change it. You know, you’re born that way. So my, my, one of my kids is a morning lark like me. The other one of my kids is a night owl like their mom. And it’s just how you know, how you are. So I think people who are like that, they just need to sort of understand and do the self-care involved towards the end of the day to avoid those phase delaying influences in the last 2 hours of the day, things like bright light, you know. 

So there’s a concept that I call in the book, it’s called Proactive Wind-Down Time. And a proactive wind-down time is basically just trying to avoid all of those electronic conveniences that are kind of keeping us from they’re preventing the dim light melatonin onset from happening appropriately. And they’re delaying the sleep days. So a proactive wind-down time looks like kind of a semi-recumbent position, low lights. 

The activities that you choose to do are fairly nonstimulating. So you’ll be reading something generally from a page reading source or something that’s not backlit, and it’s gonna be something that is going to bring your blood pressure down, you know, poetry read, read something lovely. Do not read Stephen King. You know, this is not the time to get yourself riled up. And once you’ve identified the activities that you do, it becomes sort of a gentle ritual. 

People like their camomile tea. They’ll put on some soothing music, some soft lights, a candle, and it becomes a nice, ritualized way to signal that bedtime is coming. And once people get into that routine, it eliminates all of the activities that we know are going to keep us awake. And it introduces something truly enjoyable, and that’s sort of self-compassionate. It’s a time to be quiet and reflect on the day and get you ready for bed.

Dr. Ron Ehrlich: [00:37:35] I think one of the challenges is when you behave like a night owl and wake up like a morning lark, you know? I know. And I was that person. I was that person up until about 15 or 20 years ago when I started to explore, sleep and realize actually 6 hours a night is not so good, you know.

Dr. Dave McCarty: [00:37:56] So that’s interesting. Did you feel like the daytime, you know, a lot of people say that they only recognize their problems in retrospect. 

Dr. Ron Ehrlich: [00:38:03] Yes. Well, I never. 

Dr. Dave McCarty: [00:38:04] Had the experience and.

Dr. Ron Ehrlich: [00:38:06] I never thought I had a sleep problem. And I’ve mentioned this to my podcast before until my snoring got so bad that my wife forced me to act. And I rather begrudgingly, you know, for, you know, like, I want to stay in the room, I’ll do something about it. And when I got my appliance, that stopped me snoring. I thought, Wow, so this is a good night’s sleep. And it was literally life-altering and potentially life-altering. 

Dr. Dave McCarty: [00:38:33] Can I ask you, in retrospect, like, if you could go back to the former self and look at that person, what were the symptoms that that person was experiencing? Like, could you say it’s life-altering? I’m better now. So what got better?

Dr. Ron Ehrlich: [00:38:47] Well, energy levels, for sure. I mean, you know, like I was I have more energy now at 67 than I did at 47. I mean, were. 

Dr. Dave McCarty: [00:38:56] You actually falling asleep? 

Dr. Ron Ehrlich: [00:38:58] No no, I well, see. 

Dr. Dave McCarty: [00:38:59] I think that’s an important point. Your daytime impairment was not excessive daytime sleepiness. Your daytime impairment was more subtle.

Dr. Ron Ehrlich: [00:39:07] Huh? Oh, yes. Oh, yes. I would have it on the Epworth Sleepiness scale. I think I would have scored at three or four. And it’s interesting that on that scale and that’s a scale where just to remind our listeners where certain questions are asked about your likelihood of falling asleep, how likely are you to doze off watching TV, being a passenger in a car and cinema, talking to someone, driving, God forbid, and how likely are you to fall asleep? And interestingly, the Epworth Score says six is normal. And again, I find that I find that unacceptable. 

Dr Dave McCarty: [00:39:43] Yeah. Yeah, it’s really it’s a test that if you get high numbers, then you have to start asking questions. Yeah. You know, it doesn’t mean that you have sleep apnoea, but it means I wonder why you’re not able to effortlessly stay awake in the daytime. That’s weird, you know. And the most common reason is that people just aren’t getting enough sleep at night, you know? So if you’re our listeners today are sort of like, I took that score, and it’s high. Oh my gosh, you know, it just means that we need to go and start solving problems. And the most common reason for a high score is that you’re just not getting enough at night.

Dr Ron Ehrlich: [00:40:17] Yeah. Yeah. Now with the fourth. Spengler is a psychosocial influence, and I wonder when people aren’t sleeping. I mean, there are many psychosocial reasons, you know, life being one of them, modern life being one of them. But when you’re not asleep at night, it’s almost, and you’re not sleeping. You can really stressed out about that, too, can’t you? 

Dr Dave McCarty: [00:40:40] Boy, you sure can. You sure can. And people really get wound up about sleep. And of course, as soon as you get that emotion involved, you know, our brains are problem solvers, and we can get our brains involved in anything and try and solve that problem. The place we really don’t want to get the brain involved in problem-solving is when we’re trying to fall asleep because it will ruin it every time, you know, because usually, it says, oh my gosh, I’ve got to get up. And I’m like, What time? Oh, gosh, I’ve only got 4 hours left. 

And that narrative, you know, kind of takes on a life of its own. So, yes, the fourth finger is there to remind us that sleep, wake, and complaints are very common as part of the spectrum of mental health disorders. So depression and anxiety, of course, but it’s also, I think we need to view sleep through the lens of, you know, is this person safe at home? Does this person feel comfortable? What is their environment like? and for a clinician to start asking questions like that, I think it does two things. 

It helps you solve the problem and helps you go through another area that is often overlooked. But, I believe many patients might not have ever been asked questions like that before. And it can sometimes bring the provider and the patient a lot closer together to sort of understand each other. 

Quick example in exploring this domain with one of my patients, I was just trying to get a clearer picture for what their sleeping environment was like. So, where do you sleep, and how do you sleep? Simple question, right? Because we all sort of figure, oh, everyone goes upstairs and gets into the bed, you know?

Dr. Ron Ehrlich: [00:42:14] Mm-hmm. 

Dr. Dave McCarty: [00:42:14] This poor gentleman had very thick cracking fissured calluses on both of his knees, and he had gotten into the habit of sleeping on his knees with his arms on a couch and his head kind of on a couch pillow because he couldn’t breathe at night. And that was his sleeping position every single night.

Dr. Ron Ehrlich: [00:42:35] Wow. 

Dr. Dave McCarty: [00:42:37] Yeah. Wow. And as a provider, I just felt my hands sort of come up to my heart, and I said, Wow. Oh, my God. Yeah, I had no idea, and it brought me to a new place in this gentleman’s care. And I understood his suffering on a much different level at that point, you know.

Dr. Ron Ehrlich: [00:42:57] Wow, that is a well, and I think a timely reminder to ask people how safe they feel in there in that environment. But, you mentioned anti-depressants, anxiety, and depression, it often shocks me, It surprises me and shocks me. How often people come in with, have been on antidepressants for 20 or 30 years and no one has ever asked them about this? 

Dr. Dave McCarty: [00:43:22] Sleep or that. That breaks my heart, too, because the symptoms of anxiety and depression are, of course, you know, we try to study those disorders as if they’re clean and very straight. But, you know, it’s true that having disrupted sleep can bring people to mental health crises, and it can make people feel depressed and anxious. 

And it can be very difficult to discern, you know, what’s the sleep disorder and what’s organic and what needs to be managed independently. Because it’s true sometimes that if you can just get people sleeping well again and get them breathing normally, those symptoms might magically disappear, and maybe the label was inappropriate to begin with. It’s a fascinating development when you can watch people remove medications that were piled on for labels that maybe it was all just related to the sleep disorder after all. 

Dr. Ron Ehrlich: [00:44:16] You also mentioned Cognitive Behavioural Therapy is one approach to this, and I’ve often thought that one of the most powerful tools in that would be to remove the stress of sleep. You know, like I’m lying there in bed, asleep. What if you just said to a person, Don’t worry about it? I mean, you’re not going to fall asleep, just enjoy the rest. What do you think of rest as an alternative to sleep? 

Dr. Dave McCarty: [00:44:42] Rest is great. You know, it’s a time to rest the body, and you can kind of relax, and you can let your mind wander. And I think the self-talk that goes along with the inability to sleep can be really important. And I think that’s what you’re talking about, is how do we talk to ourselves about the experience of being awake at night? And if, you know, most people who suffer from insomnia, they have got lots of invectives that they can come up with about the experience. 

You know, they’ll awful, and they’ll say, you know, “This is terrible, and I’m going to feel terrible tomorrow, and I’m not going to be able to function.” And I’m, you know, it gets even worse. Existentially, people start to believe that they’re broken, that their brains just are somehow broken, and it’s because of my depression. And they’ll start to have narratives that go along with the reasons for it.

Dr. Dave McCarty: [00:45:26] So all of those narratives go back to the arrest, the ascending, reticular activating system, and they turn it on, and they get the arrest ready to solve problems. So the alternative narrative that we can give people is positive things like, “You know, the longer I’m here awake, the more sleep pressure I’m going to get.” Right. 

So it’s a changing situation. “The longer I’m here, the more sleepy I’m going to get. So it’s okay.” Like just like you said. Another thing you could say is, “You know, if I don’t sleep well tonight, I’ll have more sleep pressure tomorrow. I’ll sleep better tomorrow. So that’s okay.” There’s another technique that’s called Stimulus Control Therapy.

Dr. Dave McCarty: [00:46:03] Stimulus Control Therapy is based on the notion that the act of being awake in bed can functionally become a conditioned response. Kind of like Pavlov’s dogs learned to salivate when he rang a bell instead of showing them meat, he rang a bell, and that made him salivate. That’s called classical conditioning, right? 

So to the person who experiences an unpleasant situation, every time they walk into the bedroom. Going to the bedroom and seeing the bed becomes that conditioned stimulus. So these people will tell you things like, “God, I’m so tired. And then I walk into the room, and it’s like somebody flicked a light switch on in my brain. Suddenly I’m wide awake.” Have you ever heard that?

Dr. Ron Ehrlich: [00:46:45] Mm hmm. Yeah. Interesting. 

Dr. Dave McCarty: [00:46:47] It’s the fact that there is a habitual component to insomnia. So understanding that and understanding that, that we will eventually become the behavior that we rehearse most often. That will become us. Everybody’s heard, Ooh, if you’re not in, if you’re not sleeping, go do something else.” Everybody’s heard that advice, and they usually turn it into something maladaptive. 

So the maladaptive approach to that advice is, “I’m not sleeping in bed, so I’m going to go watch season four of Stranger Things, you know?” Okay. You’ve fulfilled that quest. You’re not in bed, and you’re doing something else. So the answer is if you want to practice Stimulus Control Therapy, what you’re doing is you’re saying, “Look, I’m not going to be an awake person in the bed. So if I’m not sleeping, I’m going to simply, quietly, and with a lot of easy, gentle self-talk, like, okay, I’m not sleeping. I’m going to go back to wind down time. So my proactive wind-down area for 30 minutes.” 

Okay. “I’m not going to wind down to wait for a sign from God that my I can’t keep my eyes open anymore. Now it’s time.” “I’m just going to go for another 30 minutes, fill up of my sleep pressure, and I’m going to do a wind-down approved activity.” Okay.

Dr. Dave McCarty: [00:47:59] So, again, I’m not reading Stephen King. I love him. I’m not going to read that. I’m going to maybe listen to some quiet meditation, maybe some affirming things that you can get off of, you know, your music service. There are lots of things available now, soothing music, reading things and setting your time when 30 minutes is up, turning everything off, going back to bed and lying down, and letting sleep come to you. 

And then the truth is, for people practicing this stimulus control technique the first night, they’re probably going to be walking back and forth. They’re going to be wearing a hole in the carpet back and forth between wind down and the bed. And the key to tell people is, “Don’t worry about it. That’s just the habit of insomnia, fighting back”. That’s the extinction burst of insomnia. And at some point, you will reach a critical moment where there’s enough sleep pressure to overcome whatever that tension is. And you’ll sleep.

Dr. Dave McCarty: [00:48:56] This technique is what gives people a sense of empowerment about that. They feel less victimized by their sleep. They feel like they’ve got control over it when that happens. Typically Stimulus Control Therapy is combined with another technique called Sleep Restriction Therapy, which sounds a little odd. But the basic idea is if sleep pressure if the sleep-regulating substances are kind of like internal sleeping pills or internal Ambien, you can think of it. 

What you do with people is you tell them, look, we’re only going to give you 6 hours of time to be in the bed. That’s it. You’re going to go to bed here, and you’re going to get up here no matter what you’re going. If you sleep poorly, you’re going to get up at the same time. And that restricted timeframe after about three days, their brains are so loaded with sleep pressure, they’re going to sleep through that 6 hours, and then they’re suddenly going to feel like a hero because they haven’t done that in years. 

Suddenly they feel like, “Man, my brain isn’t broken.” Okay, that’s the breakthrough of Cognitive Behavioural Therapy for insomnia. The key with CBT is you really got to get with somebody who can explain to you what we’re doing. The concept of sleep pressure is an important one. People need to understand why, and once they kind of understand what they’re working with, it becomes something that they can kind of use as tools and they understand how they work. 

Dr. Ron Ehrlich: [00:50:10] I love that. Dave And you’re living up to the name of empowered sleep apnea, empowering patients to… 

Dr. Dave McCarty: [00:50:16] That’s what it’s about. 

Dr Ron Ehrlich: [00:50:17] …to take control. It’s wonderful. Now, just finishing up because I know you mentioned that you attended the AAPMD, the American Academy of Physiological Medicine and Dentistry, of which I believe you and I are both members. And you recently attended a conference, an annual conference called Collaboration Cures. 

And I’ve actually had the President of that organization, Dr. Howie Hindman, on as a guest before too. Tell us about Collaboration Cures. What did you come away from at that conference? I mean, there’s something in the name that gives it away but tell us what you got out of it.

Dr. Dave McCarty: [00:50:55] Yeah, I think that really nails it, Ron. That the name Collaboration Cures speaks to the idea that sleep apnoea is a complex phenomenon, and we, the American Academy of Sleep Medicine, have done a very good job of kind of classifying and codifying this disease. We’ve got two different flavors of sleep apnoea, obstructive and central. That all kinds of guidelines. 

The problem is it’s much more complicated than just sort of these two basic flavors, and the obstructive flavor is what we really deal with with a CPAP machine. There’s a lot more to it than that. And so the American Academy of Physiological Medicine and Dentistry, the APMC, is an organization that was, as you said, founded by Dr. Howard Hindman, who is a dentist, and he understands that the complexity of this requires a team approach, and it’s going to require more people at the table than just sort of your local CPAP rep. We’ve got to be thinking about this in a much larger context. 

And the thing that I think is one of the most fascinating developments in sleep medicine in the last ten years is this field of dentistry that is emerging called airway-centered dentistry, which is different from just, you know, an oral appliance, which is apparently it’s considered a traditional treatment option. Now, dentist had been at the table for sleep apnea, management for decades now, but oral appliance therapy is only part of it. 

This is the device that pulls the jaw forward and helps sort of uncrown the back of the throat by pulling the tongue forward. That’s great. But we’re now seeing a different phenotype of sleep apnoea that’s emerging because of what civilization has done to the development of our jaw and facial structure. One of the things that I found fascinating is that our jaws and our faces are different today than they were 100 years ago. 

And it has to do with the way we eat when we’re little. The reduction in the amount of breastfeeding and the lack of kind of using jaws and chewing food from a young age. And these things change the way our faces develop. So overall, as a species, we have narrower faces with smaller jaws, and that phenotype of sleep apnoea is a lot more complicated than just the pick weekend syndrome, sort of obese, snoring, excessively sleepy in the daytime. 

That’s a different flavor of sleep apnea. We still see it. That’s still very treatable with CPAP, but this other skinnier version of sleep apnoea with a narrow face that’s a more complicated beast. Those people often reject CPAP because they tend to be sympathetically overdriven, and they often present with insomnia. And it can be very challenging for them to even sort of tolerate the idea of a CPAP machine. 

So what are Airway Centre Dentistry is doing? It’s coming up with reverse engineering ways to change the shape of the airway, which I find fascinating. And right now, we’re still in an early age of this art. There’s not a lot of published data, especially nothing as glorious as a randomized controlled trial. So there’s, there’s some disagreement as to whether this is the right thing to do or not. I think it’s fascinating, and I think that empowered patients should know that this field exists, but we should also know that it’s an early science. 

So we need to you know, these will be early adopters that are getting into this right now. But I’m paying close attention. And what the conference did is it brings everybody who has a seat at the table of this fascinating disease in disorder, including physical therapist, my functional therapist, dentist, sleep physicians like myself, pulmonologist, everybody is there, and they’re all talking about kind of what’s possible, not what we have in place and what’s rigid. We’re kind of talking about the future, and it’s a very good vibe. So I was really pleased to be a part of that experience.

Dr. Ron Ehrlich: [00:54:39] Hmm. Well, Dave, it’s always a very good vibe to be talking to you. And, you know, your whole empowered, patient-centered approach is one that resonates so strongly with me and what this podcast is about. So thank you so much for joining us again today. 

Dr. Dave McCarty: [00:54:55] Thank you so much for having me. It’s been a pleasure. 

Dr. Ron Ehrlich: [00:54:57] It’s interesting, isn’t it? When we put labels on things and people rather and, you know, difficulty in sleeping is not an uncommon problem. And I think the classification is that if you have three disturbed nights, nights a week for three months, then that is the official diagnosis. 

But it’s kind of academic in many ways. I think you can also get very stressed out by not sleeping. You know, it’s one thing I’m very conscious of this, too, that in our Unstress Health Platform, where we do say that sleep and breathe are the foundational pillars and they are your built-in non-negotiable, I believe, built-in life support system affecting your mental, physical and emotional health. 

Dr. Ron Ehrlich: [00:55:43] So if you’re not sleeping, it’s easy to get stressed by not sleeping. But I think you need to be kind to yourself. You need to take the long-term view. You need to recognize that lots of people go through lots of times in their life when they’re not sleeping well. But just to settle into it, I think having digital clocks where you just stare at the clock and watch the hours tick over is a real no-no in the bedroom. 

I mean, I don’t have a clock that I can see in my bedroom. And there are times when I’m not sleeping well. And I think there is great power in rest. So I sometimes may not sleep well, and I’ll lie there, and I’ll just say, “Well, I’m not going to stress about this, but I like the fact that I can just lie down in a comfortable bed and relax my muscles and practice my breathing”. And anybody that has been following the podcast will know that you can switch on your parasympathetic nervous system within a couple of minutes. 

That’s the rest and digest by just taking a slow breath in through the nose, a slow of breath out through the nose, and even a short breath hold. And that whole thing might take 3 seconds in, 5 seconds, and 4 seconds hold. What’s that? 12 seconds? You might repeat that five times in a minute and do that for a minute or two and come back to it at various times while you’re lying there, like just enjoying the rest and not stressing out.

Dr. Ron Ehrlich: [00:57:24] But also, it’s important to recognize that your sleep hygiene is an important thing. And as I said in the episode, I get this all the time, and that is I will ask a patient, “How are you sleeping?” And they will say, “I’m sleeping very well.” And then I say, “Do you wake up feeling refreshed?” “Oh, no, I never wake up feeling refreshed.” So it’s very easy for us because we only have our own experience to reference this, or maybe our partners. But to have a very narrow view of sleep that it is just the way it is. Well, it’s not. 

There’s a lot you can do about it. And Dave talked about being proactive one downtime. Well, that sounds like good sleep hygiene to me. And also, our Unstress Health Programme talks a lot about sleep hygiene, stimulus control therapy, getting devices out of your room, do not check your emails. As I said, this is no time to connect with the world. It’s time to connect with your pillow and do emails and have TVs and computers and laptops. I mean, I think it’s just not good to have that in the room. 

And I think finding a book that is soporific that you find enjoyable, not too stimulating would put you to sleep. And I find history is a great one for that. I love reading history books at bedtime. It’s really soporific. I mean, I genuinely do enjoy reading history books at other times, but when I read them in bed, it really puts me to sleep. Whereas I don’t like reading books about health and wellness because my mind just goes. 

And as we talked about with Rosemary Clancy, sleep psychologist, once you get the prefrontal cortex into play in bed and you start to think about what is going wrong. That’s when things start, really, you’re in a cycle that’s difficult to escape from. We will of course, have links to Dave’s wonderful site empoweredsleepapnea.com. And his book Empowered Sleep Apnea in the show notes. I hope this finds you well. Until next time. This is Dr Ron Ehrlich. Be well. 



This podcast provides general information and discussion about medicine, health and related subjects. This content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences and conclusions.