Show Notes & Links
📌 Guest Website:
🔗 Let Sleep Happen – Rosemary Clancy
📚 Books by Rosemary Clancy:
🔗 Let Sleep Happen: The Struggle is Over (Check her website for purchase links)
🎙️ Related Past Episodes from Unstress with Dr. Ron Ehrlich:
- Dr Dave McCarty: Empowered Sleep Apnoea
Dr Dave McCarty: Why You Need an Empowered Approach to Sleep and Insomnia
Timestamps for YouTube
00:00 – Introduction & Why Sleep is Crucial for Health
02:30 – Meet Rosemary Clancy: Sleep Psychologist & Expert
04:20 – What is Paradoxical Insomnia & Sleep Misperception?
07:35 – How REM Sleep Impacts Memory & Mental Well-being
12:00 – The Science of Sleep Pressure & Circadian Rhythms
16:30 – Technology & Sleep: Myths vs. Reality
23:45 – CBT for Insomnia: Gold-Standard Treatment Explained
31:15 – Sleep Apnea in Women & Why It’s Often Overlooked
37:10 – CPAP Therapy: Why Compliance is So Low & How to Improve It
43:50 – Mandibular Advancement Devices & Nasal Breathing for Sleep
49:30 – Overcoming Sleep Anxiety & Reframing Your Sleep Struggles
58:20 – Tinnitus & Sleep: Can Sound Therapy Help?
1:00:56 – Final Takeaways: Practical Steps for Better Sleep
Rosemary Clancy_1.mp3
Dr Ron Ehrlich [00:00:01] Hi, Dr. Ron here and I want to invite you to join our UnstressHealth Community. Now, like this podcast, it’s independent of industry and focuses on taking a holistic approach. To human health and to the health of the planet, the two are inseparable. There are so many resources available with membership, including regular live Q &As on specific topics with special guests, including many with our amazing Unstress Health Advisory Panel. Now, we’ve done hundreds of podcasts, all worth listening to, with some amazing experts on a wide range of topics. Many are world leaders, but with membership, we have our Unstressed Lab podcast series where we take the best of several guests and carefully curate specific topics for episodes which are jam -packed full of valuable insights. So join the Unstressed Health Community. If you’re watching this on our YouTube channel, click on the link below or just visit UnstressHealth.com to see what’s on offer and join now. I look forward to connecting with you. Hello and welcome to Unstress, my name is Dr Ron Ehrlich. Well today we explore sleep again and as we’ve said many times on this programme, a consistently good night’s sleep is arguably the most important part of the day and setting yourself up for a good night’s sleep is a worthwhile preoccupation that just ends up resulting on so many levels in better health. My guest, it’s a pleasure to welcome back Rosemary Clancy. Now, Rose is a sleep specialist clinical psychologist in Sydney, focused on evidence based sleep treatments. She is interested also in associated mood anxiety and substance use disorders, as well as insomnia and tinnitus. I spoke to Rose a year or two ago, it was on a platform, a programme called Let’s Sleep Happen, which is the very place you can find Rose on the internet, Let’s Sleep Happen. And it’s such a pleasure to have her back on and catch up and hear what is going on in the world of sleep. I hope you enjoy this conversation I had with Rose Clancy. Welcome back, Rose.
Rosemary Clancy [00:02:28] Thank you, Ron. Glad to be here.
Dr Ron Ehrlich [00:02:30] Rose, sleep, boy, if that’s not the most important part of the day, I don’t know what is. And I know a lot of people just accept the way they sleep as being that’s the way they sleep. And some may have an experience of being referred for a sleep study, but not many are familiar with a psychologist who focuses on sleep. I wonder if you might share with us what your role is in that whole process of improving people’s sleep.
Rosemary Clancy [00:03:00] Well, generally the pathway to me is via someone having had a sleep study and it being apparent that there is a discrepancy between their subjective appraisal of their sleep quantity and quality and especially quantity and the objective data that comes out of a sleep study, polysomnography data. And essentially it goes in one direction usually, which is the person believes that their sleep hours are much less than what the objective data tells us. And even, I mean, and this is called paradoxical insomnia or sleep state misperception, must be one of the few DSM -5 diagnostic categories that is about something that doesn’t exist there. It’s actually paradoxical insomnia. So the data looks normal range, but the person absolutely believes that it’s not normal sleep. And to give you an idea of just how much we distort this time data in our perception at night, 11 minutes awake on polysomnography feels to the person like over an hour awake. And they absolutely believe that that’s been over an hour awake in that time.
Dr Ron Ehrlich [00:04:18] So, Rose, let me just stop you because you’ve mentioned polysomnography and that is the gold standard of doing sleep studies, is it not?
Rosemary Clancy [00:04:31] Yeah, essentially, it shows you after, you know, with electrodes pasted onto the scalp, and this is something that most wearables don’t have, but those electrodes pasted onto the scalp are picking up brainwaves associated with the different stages of sleep that you’re in. And so the technician and then subsequently your sleep physician will be able to give you some information about how much time you spend in deep sleep relative to stage one and two light sleep or non -REM one and two light sleep and REM sleep. And essentially, the stages are divided into two categories of REM and non -REM because REM sleep is so categorically different from non -REM sleep. And the brainwaves in REM sleep are quite very active and close to those brainwaves that we see during waking hours in the daytime as we’re involved in this incredibly active process of watching movies behind our eyelids from left to right and in that process, emotionally processing and consolidating working memory to long -term memory. So and non -REM sleep involves both stage one and two light sleep and the deeper stage of sleep, slow -wave sleep or delta wave sleep.
Dr Ron Ehrlich [00:05:50] But Rose, it’s worth reminding our listener too, I think, that being in that deeper level of sleep, that REM rapid eye movement, REM REM sleep, is really an important one. You said something really important then about processing our memories and kind of putting it into the hard drive or, you know, it’s not worth keeping and it’s a really important part of our psychological well -being.
Rosemary Clancy [00:06:17] Yes, it’s interesting just hearing someone like, you know, Matthew Walker talk about the neuroscience in REM sleep and the fact that our visual cortex, the occipital cortex is extremely active during dream sleep as we’re watching those movies from left to right behind our eyelids and, you know, consolidating, you know, things that have happened in the last, you know, 24 to 48 hours, say, consolidating what’s important or emotionally salient about those two long -term memory and incredible, you know, isn’t it, it makes perfect sense that the hippocampus, the memory organ should be within the limbic system or emotion system of the brain and so at the same time, your REM sleep is accomplishing that emotion processing and so it’s a really extraordinary stage of sleep and essential for us to not feel irritable and emotionally dysregulated and, you know, impatient, short -tempered the next day as indeed we would feel if we missed out on our REM sleep.
Dr Ron Ehrlich [00:07:25] So you were talking about, sorry, you were talking about paradoxical insomnia, which I assume means you think you’ve got insomnia, but you actually don’t, is that?
Rosemary Clancy [00:07:34] Essentially, yeah. The other word for it is sleep state misperception and this is something, this kind of is a pretty straightforward trigger for, you know, referring someone to a sleep psychologist thereafter because, you know, that subjective perception is important because according to Professor Narva Zisapel at Tel Aviv University, our subjective perception has health and mental health outcomes. So it’s really important that we prioritise that because now we’re starting to talk about even within normal range of sleep hours, anxiety, dread and maybe diagnosable mood disorders. So we need to take this seriously and, you know, have a discussion and have an intervention around that skewed perception about sleep.
Dr Ron Ehrlich [00:08:27] And talking to people about that skewed perception is one aspect of it, isn’t it? But the other one is setting them up for a good night’s sleep.
Rosemary Clancy [00:08:39] That’s exactly your idea. So there are core habits, behavioural habits that allow us to, I mean, let’s think about this, right? Allow us to not even think about sleep, to not worry about it. These are the sort of things that we’ve been doing ever since, you know, when we were 10 and we didn’t need any particular intervention for sleep. It was, you know, it was just a habit, you know, provided, you know, our parents had helped us set up some sleep routines whereby, and we’d naturally fall into sleep because what we’d have is two ancient processes converging to get us into a high degree of sleep urgency or pressure. And those two processes are always part of our brain that governs our circadian rhythm, our response to the sun. And, you know, as you know, the sun turns off our sleep in the morning by suppressing, as soon as the merest rays of sunlight enter our retinal nerve, go along the retinal nerve to the suprachiasmatic nucleus, a sort of wake -up clock deep in the brain, immediately that melatonin sleep hormone is suppressed and a burst of cortisol is released into the bloodstream to give us the energy to start the day. And so that’s the sun turning off our sleep in the morning and then turning on our sleep through our serotonin mood neurotransmitter that, and that sunlight that we see this morning has optimised our serotonin mood neurotransmitter so that our pineal gland will use that serotonin neurotransmitter to manufacture melatonin sleep hormone when it gets dark tonight. And there’s the sun turning on our sleep. So this is that one ancient process that looks after our sleep and the other is our homeostatic sleep drive, which is a wave of sleep pressure that builds from the moment we wake and start the day. And so approximately 16, 16 or more hours later after we wake for the day, we’re going to feel this strong drive to sleep. And that will take us pretty readily as the two converge, we’re producing melatonin sleep hormone powerfully as it gets dark and then 16 hours after we’ve been awake, that homeostatic sleep pressure is converging with our melatonin production. And so we fall into sleep. And so, you know, we have both working for us to get us this sleep onset and you pretty quickly, you know, within 30 to 40 minutes, we find ourselves in slow wake sleep or deep sleep. And your deep sleep at the beginning of the night is specifically linked not so much to the sun, but to how long you’ve been awake in the day or days before it. So your deep sleep is specifically linked to your homeostatic sleep pressure.
Dr Ron Ehrlich [00:11:46] It’s interesting, Rose, just before you move on from sleep pressure, because one of the real aha moments I had when I heard about sleep pressure was the driver of that is something called adenosine. And adenosine is part of ATP, adenosine triphosphate, which is what is produced in mitochondria, which is why exercise, you know, the more exercise you do, the more ATP you produce, the more adenosine you produce, the greater your sleep pressure will be. And that’s the link with exercise and better night’s sleep.
Rosemary Clancy [00:12:20] Yes. Yes. And it seems that apart from, you know, has been much Googled by a number of Silicon Valley biohackers, you know, how do I get more deep sleep? Either, you know, spending more time awake or getting more exercise seem to be, you know, other things that will directly affect the amount of deep sleep you get.
Dr Ron Ehrlich [00:12:44] And isn’t it brilliant that our night’s sleep preparation starts almost from the moment we wake up the night before, you know, that morning?
Rosemary Clancy [00:12:53] That’s right. And it really is, you know, like a 24 -hour and somnia also is a 24 -hour issue for us. And it seems inescapable. So, and this is where I come in. If someone has, you know, has been diagnosed with insomnia because we know it’s not just their fear of not getting enough sleep during the night or their fear of being awake during the night, but it’s also their fears about daytime functioning and an alertness and their inability to cope during the day. And so, you know, this is why it’s not just the subjective appraisal of the sleep. It’s also their appraisal of their daytime functioning that we’d be working on.
Dr Ron Ehrlich [00:13:34] And what kind of interventions, I mean, yeah, what kind of interventions do you do as a psychologist?
Rosemary Clancy [00:13:43] Well, gold standard treatment and RACGP recommendation for insomnia treatment is first line of therapy, cognitive behaviour therapy for insomnia. And essentially that what that involves is the behavioural part is the increasing your sleep efficiency and building habits that help you associate or re -associate your bed with sleep in the same way that your bed would have been associated with sleep when you were younger. Say when you were 10 and you didn’t have to think about anything, you know, doing an extended bedtime routine to try to guarantee you that sleep. You didn’t have to try it all. You just did night after night a sleep habit of maybe brushing your teeth. And that was already enough of a sleep cue to help you drop off into sleep. And thereafter, once that happened, then the brain took over and took care of the sleep for the next eight hours. And this is one of the key things that we’re doing in the therapy is by setting up a behavioural habit with some sort of sleep routine, but not too much of a sleep routine so as to cause performance anxiety. But, you know, core sleep hygiene processes that are lifestyle and dietary change processes are going to increase your likelihood of sleep at night. And so a bedroom environment, cool dark quiet bed environment, some sort of wind down routine, and then you’re just at that point, you know, your brain and your midbrain in particular, the part of your brain that governs habit, the basal ganglia and associations will take care of the sleep process. And so, you know, this is something that’s one about as a midbrain function is an autonomic function, just like our involuntary muscle groups like heart and lungs, we don’t have to control heart and lungs, we can speed them up or slow them down by, you know, increasing our breathing rate or slowing it, but we can’t just stop them. So those autonomic functions, those midbrain functions, things we just we don’t even have to control, just like when we were 10 years old, we didn’t have to control them then, we don’t have to control them now. And so we set up the habits so that our bed is associated with sleep and not with waking and trying hard and intense emotions like anxiety and dread.
Dr Ron Ehrlich [00:16:29] Surely one of the biggest challenges to setting up a healthy habit of sleep that prepares you for sleep is the role that almost ubiquitous role that technology plays in our lives today.
Rosemary Clancy [00:16:45] Yeah, this is this is a big one, right? And it’s something that every parent is interested in because, you know, it’s generally the case that most teens are going to have their phones with them. They can charge them in their rooms. People, I mean, and pretty much like most of my clients will actually say they need it for their alarm in the morning. So, you know, it’s an ever present distraction, I suppose, that could actually and this is interesting. There’s it’s not necessarily a negative thing. And Professor Michael Gradisar’s are over in Flinders Uni this Unique Sleep Centre in South Australia and have done and his team have done a number of studies on teens and devices and have found that it’s it’s not a blue wavelength issue, you know, that is suppressing melatonin and keeping kids awake at night. It’s not even the emotional investment in in the content that’s on their devices. If there’s only a small subsection or some group of teens who are more at risk, you know, they might be emotionally more emotionally dysregulated and they find it and they and they need to cope with their phones. And in that way, it could stave off their, you know, their further sleep during the night. But for the vast majority of teens, that device is not problematic at night. You will find that even if and they gave the kids call of duty to to delay in the lab, they even that didn’t didn’t stave off their sleep onset. Kids just, you know, recognise that their sleep cues were coming and they felt their eyes getting heavy. They felt the heads getting heavy and they just put down call of duty. You know, it didn’t delay their sleep any further. So it’s actually, you know, there’s some mixed findings about the use of devices at night, even even in the bed setting.
Dr Ron Ehrlich [00:18:48] Yeah, I mean, I that’s kind of study to me, knowing what I know about the way evidence based medicine is conducted. The first question I would have is who funded that, who funded that research and if they didn’t fund it, I’m sure that laboratory could look forward to more funding coming their way for further research without any problem at all, because that would be music to the ears of the technology companies. But it seems counterintuitive to anybody’s experience. I mean, you know, when you ask people, oh, no, what I mean, the time for sleep is to put your for your head to connect with the pillow, not with the rest of the world. So putting aside the science logic would dictate it has to have an effect. But but anyway, great that you’re
Rosemary Clancy [00:19:35] absolutely right. I mean, you know, this is for me myself that this is why I don’t have the phone in in bedroom. I just I have it charging out in the kitchen. So it’s, you know, I went getting notifications. I won’t hear anything. So, you know, and I’m just, yeah, and I think I’m better off for it. But it’s kind of interesting that I mean, at Flinders, they actually had the hypothesis, too, that it was going to disrupt sleep. They started out from that hypothesis. And and, you know, it it’s there were multiple studies on this, too. And you can see why, because parents are so interested in this. You know, with three kids myself, I was worried about this exactly in this situation.
Dr Ron Ehrlich [00:20:19] But but with your own personal experience of knowing how it impacts on you, you’re not a maybe you’re definitely not a vulnerable teenager. I can’t say that with all due respect, Rose. You’re not a vulnerable teenager, but even you would know that I’d say even you, but you know that leaving the phone out of your room or turning notifications off and not looking at it will have a positive impact on your sleep.
Rosemary Clancy [00:20:46] Yeah, look, I think it’s just just anecdotally, yeah, I believe that. I mean, so I know I’d be far too distracted by it.
Dr Ron Ehrlich [00:20:58] One of the one of the problems, of course, with sleep is stressing how important it is. I just started by saying this is the most important part of the day. I really have to stress how important it is. Knowing how important it is, it becomes really stressful when you don’t sleep. It’s a chicken and egg thing, isn’t it?
Rosemary Clancy [00:21:16] Yeah, and this is a core part of the insomnia picture that we should value sleep. You know, because there is so much data out there that shows its importance for our physical and mental health. And we should value it enough to create a sort of, what, seven to nine hour opportunity or depending on your own personal baseline. And that differs night by night too, but we should value sleep enough to carve out some sort of opportunity for sleep most nights. And notice that’s an opportunity, it’s not a guarantee that most nights is adults, right? But once we creep into overvaluing sleep, then we start to become overprotective of it. And that’s where you could end up starting safety seeking actions or sleep protective actions that backfire to create what we call a sleep performance anxiety and hypervigilance. And then we get stuck in this hypervigilance loop during the night that incorporates, you know, cognitions like, I won’t be able to function tomorrow, I’ve got to get to sleep like right now, I’ve already lost three hours, and, you know, what if I become ill? What if I get dementia? This is a very big concern for many of my clients. And that brings in attentional processes that keep us threat scanning, just monitoring for, you know, why isn’t it working? I don’t understand. I did everything right. I did my sleep. I’ve looked after my sleep hygiene. And that brings up, you know, with that attention on and threat scanning, we then have an emotional response that then brings up, you know, a physiological fight -flight response. And then we try to take more control, not less. So we redouble our efforts to try to make sleep right and problem solve it and end up creating more performance anxiety and hypervigilance.
Dr Ron Ehrlich [00:23:08] Is that, I mean, I think this idea of cognitive behavioural therapy, I mean, there’s something in the name that kind of gives it away, doesn’t it, really? You consciously using your behaviour to prepare for sleep. But once you are in bed and you’re not sleeping, there’s another approach to psychology called acceptance and commitment therapy. Is that perhaps when you’re lying in bed and you’re not getting to sleep, is that when you should be employing another form of, you know, acceptance and commitment to say, is that valid? Do you think that’s a valid approach to it?
Rosemary Clancy [00:23:43] Absolutely. And this is the interesting part. And they work together, by the way. They’re not antithetical, right? The behavioural part still matters, right? The behavioural part, if you’re thinking about this, is mid -brain training. So when we do things like time in bed restriction and stimulus control method, whereby most people know it is like the 15 -minute rule, whereby, you know, if you can’t fall asleep within 15 minutes, then you get up and you do a reset out of the sofa and do something unstimulating out there until your central nervous system calms down again and you feel genuinely sleepy so that you can go back to bed and give it another go. But it cannot involve trying. And it can’t be time -based, right? It’s not, you know, you don’t stay out on the sofa for 30 minutes exactly and say, well, stuff that. I’ve been, you know, I’m sick of being out here and it’s warmer in bed. And so it’s got to be sleepiness cues -based because otherwise you’re going to be immediately frustrated about getting back to bed and seeing yourself wide awake again. So that part, that behavioural part is about training your mid -brain and the basal ganglia to re -associate and, you know, to create this habit of sleep where you re -associate the bed with sleep and not with waking and trying and frustration, right? So the acceptance part of this, by the way, I want to say just as a caveat here that part of acceptance and commitment therapy is actually about still making behaviour change which is going to get you closer to your goal. So in this case, you would still be doing the time in bed restriction because you’d be honouring the mid -brain need to re -associate the bed with sleep at a basal ganglia level. So, yeah, you’d get out of bed and it’d be like full acceptance that you’re awake at this point potentially poisoning the bed environment with this negative association and then thinking, okay, well, I’m going to do a reset and it’s okay, you know, I don’t have to get back to sleep immediately. It’s not catastrophic if I don’t sleep immediately and then I’ll go out and I’ll have some me time out of the couch and I’ll have a nice hot cup of milk and then just read something nice.
Dr Ron Ehrlich [00:26:15] I know that is the accepted way of advising people but in my own personal experience of N equals one, you know, like me, what I practise is acceptance and commitment and when I don’t sleep, well, I kind of accept I’m not going to sleep well but then I know about another thing called non -sleep deep rest and I’m accepting not only that I’m not sleeping well but there’s an alternative and the alternative is to say I’m not going to sleep tonight. I’m accepting that but I also accept that non -sleep deep rest is a valuable thing to experience and that allows me to stay in bed without the anxiety of not sleeping. Oh, my God, I’m not sleeping. Oh, my God, I’m not sleeping. I go, okay, well, I’m not sleeping but non -sleep deep rest is still a good thing. I’ll just practise that.
Rosemary Clancy [00:27:12] This is promoted by Guy Meadows potentially, you know, because I know he works with acceptance and commitment therapy over in the UK and this is helpful as long as you’re aware of your own levels and intensity of yearning, right? So even I have many clients who say, look, I don’t even I don’t even care about how this was so long. Look, I’m not even anxious anymore. I’m not worried. I’m just lying there, right? And so the next place I want to go and it is very under the radar emotion but yearning is a very powerful emotion and yearning comes with hope. Now, most people don’t want to get out of bed because they’re still hoping and they’ll essentially say, look, if I get out of bed, I’ll lose all hope of sleeping, right? At least if I stay in bed, I’ve still got some hope that I’ll get to sleep again. So then we’re going to start talking about yearning and longing, right? And really when you think of it intense yearning and longing is actually one step removed only from frustration, right? Just think about this in terms of unrequited love, right? This is, you know, if we’re yearning and longing for sleep at night, we’ll notice at some level that we can’t just kid ourselves that we’re okay with this situation and I’ll hear it in people’s tone as I just want to have a bit of sleep. I just want to get the same sleep as everyone else, right? I’m not anxious anymore. No, I just want to have sleep, right? And it’s almost, you know, you can see the yearning there. And so we want to kind of honour that and just say, look, this is real. This is real emotion, okay? But in fact, the hard thing about sleep effort and creating more sleep performance anxiety is that we need to turn off the sleep effort ultimately. And our goal ultimately is in order to get the sleep I want, I have to give away wanting it. And that’s, yeah, that’s the absence of sleep.
Dr Ron Ehrlich [00:29:20] Which is the midbrain training, which is why we’re focusing on that autonomic midbrain training.
Rosemary Clancy [00:29:26] Yeah, essentially, this is why we’re trying to reassociate the bed with sleep. So the behavioural part, the timing bed restriction and stimulus control method is still foundation. Okay, okay.
Dr Ron Ehrlich [00:29:37] Now, just to put a figure on this, I mean, how big a problem is this? Insomnia or, well, the difference, I guess there is real insomnia and the different types of insomnia might be worth reviewing. But paradoxical insomnia is another one of those types, isn’t it?
Rosemary Clancy [00:29:54] Yeah, and it’s hard to actually split up, you know, the different subcategories of insomnia in terms of prevalence. Generally, we’d say, and it depends on how you define it, but it’s thought to be something like, you know, in a number of sources are saying up to a 30 to 33 percent of the population. During COVID lockdowns, it’s sort of went as high as like 48 percent of the population. But Matthew Walker in his book Why We Sleep says that 60 to 70 percent of the population has a difficulty falling asleep one night a week every week. And that makes it normal, right? And I would count myself amongst that too. As a normal sleeper, someone who’s not particularly fearful or I’m not yearning overly for sleep, I trust that it’s an autonomic function and it’s going to work. And yet, you know, one night a week, I would, well, that was the norm until I started CPAP.
Dr Ron Ehrlich [00:30:55] OK, now, because this is the other thing that I was looking forward to talking to you about. And, you know, we’ve chatted about this before we came on the show is your own personal experience in this, which I’m always fascinated by because I think when practitioners experience something that they deal with every day, it takes on a different perspective, doesn’t it?
Rosemary Clancy [00:31:17] Yeah, suddenly, you know, you’re right in there in the thick of it and, you know, and you’re experiencing the same sort of dread and frustration that your patients are describing. And so this is the interesting thing, right? So I would say that, OK, I already knew that I had some sleep, some apneas, right? I’ve had three sleep studies over the past, say, 15 years. And in each case, it was like kind of, you know, mild as it is generally for a sort of relatively slim build woman, right? Until she hits menopause, right? And then then you can see this edging up of apnea rates. And so it’s, you know, then mild becomes mild to moderate and then a bit more towards moderate. And so the difficulty with women in midlife is that even slim women are going to have that loss of collagen, the loss of elasticity in the throat muscles and then be more likely to suffer apneas. And those apneas are either most likely hypopneas at first, like partial closure of the airway at night once the tissues relax and then potentially, you know, apneas full closure of the airway. And so this is just more likely, even if you’re a slim woman who would not be above the radar, who would not stand out to your GP as having sleep apnea or, you know, be at risk of sleep apnea. The ones who are screened and diagnosed fastest are the men who have more, you know, centrally located weight gain and kind of thicker neck volume. So, you know, they come to the attention of GP straight away once the partner complains of snoring and then they get treated straight away with the appropriate continuous positive airway pressure treatment. The ones who fall through the gap tend to be women in midlife. And the difficulty is, too, that women in midlife will probably have insomnia. Women are more likely to have insomnia, right, than men. And if you think about this, women as the caregivers, you know, there are many points during a woman’s life where, you know, hormonally alone there are going to be reasons for her being sleepless. So during ovulation, you know, PMS, when she’s younger, then when she, you know, childbirth, then, you know, before birth and then after. And, you know, feeding babies through the night. Disrupted sleep is just, you know, a part of that. And so there’s kind of an acceptance amongst women that, you know, this is what sleep looks like. It doesn’t get any better when your kids are teens and they’re starting to drive. And then before you know it, you’ve hit perimenopause and now you’re getting hot flushes. Disrupted sleep again. And a hot flush can raise your core body temperature enough to boot you out of deep sleep during the night. So that’s all fun. All right. And so this is the interesting thing, right? So women at midlife, though, are more likely to fall through the gaps just because they don’t look like the obvious obstructive sleep apnea sufferers. But it’s very real. And then the problem is if they have insomnia as well and if they’ve already started taking respiratory depressant sleep medications, then we’ve got two problems there. Well, we’ve got three. We have three potential diagnoses. One is obstructive sleep apnea that’s gone from being mild to moderate, maybe moderate to severe. Then we’ve also got insomnia diagnosis. Then we’ve also got maybe a substance overuse diagnosis if they’ve already been using prescription sleep medications for a while. And those three make it very hard to stay on CPAP, very hard to adjust to and to habituate to or desensitise to continuous positive airway pressure.
Dr Ron Ehrlich [00:35:30] Hi, Dr. Ron here. And I want to invite you to join our Unstress Health community. Now, like this podcast, it’s independent of industry and focuses on taking a holistic approach to human health and to the health of the planet. The two are inseparable. There are so many resources available with membership, including regular live Q and A’s on specific topics with special guests, including many with our amazing Unstress Health Advisory Panel. Now, we’ve done hundreds of podcasts all worth listening to with some amazing experts on a wide range of topics. Many are world leaders, but with membership, we have our Unstress Lab podcast series where we take the best of several guests and carefully curate specific topics for episodes which are jam packed full of valuable insights. So join the Unstress Health community. If you’re watching this on our YouTube channel, click on the link below or just visit unstresshealth.com to see what’s on offer and join now. I look forward to connecting with you. And the compliance, just to remind our listener who may be wondering these obstructive sleep apnea diagnoses, be they mild, moderate or severe, particularly in the moderate to severe range, the gold standard is continuous positive airway pressure, CPAP, but there’s a problem about compliance with that because wearing a mask, be it on the nose, the mouth or both, could interfere with one’s normal pattern of sleep.
Rosemary Clancy [00:37:13] Absolutely.
Dr Ron Ehrlich [00:37:14] What is the compliance rate or noncompliance rate?
Rosemary Clancy [00:37:19] It’s actually very low. It’s been suggested as being, depending on the reporting from 8 % to something like 30%. I’ve got to say even like, even say 10 years ago, I was describing compliance levels to patients as something like 30%. And then with all of the advances in mask comfort, mask design for comfort with surgical silicon, ultra soft fabrics, even with all the advances in the last 10 years in mask design and comfort, it still looks like around 30%. So 70 % of people prescribed CPAP who are not using it. And apparently it is something like 8 % give up after the first night and then 50 % give up after the first year of use, if they’ve managed. And this is really interesting for us in terms of habit formation because we would have thought that once you’ve been wearing something for getting towards a year, that you’ve truly cemented the habit, that you couldn’t live without it shortly. But even then it shows how fragile habits can be as well.
Dr Ron Ehrlich [00:38:27] I mean, that’s clearly a question of degree and impact because for those that swear by it, and there are patients that’s, oh, I couldn’t possibly live without my CPAP. They are being actually quite literal. They may well not live without their CPAP. That’s how serious it could be. So for them, it’s a no brainer. But I guess where it’s mildly impacting and you kind of think, how big a problem is this? Is this that big a problem? But that’s part of the process, isn’t it?
Rosemary Clancy [00:39:01] Yeah, well, I mean, there are people with severe sleep apnea who are non -compliant though, too. And they know this and they feel a great deal of shame about it. But at the same time, they’ll just say it’s just an impasse. They’ll even use the word impossible. I cannot do it. I cannot wear that thing. And for reasons of claustrophobia, really at that point, just mask fit. Most of these people would have gone through a series of masks. They could have gone through four or five of different masks to find the right fit, but none of them will be found sufficiently comfortable to allow them to accept that positive airway pressure. It just feels too aversive. And so people have this belief that I cannot defocus from this. I cannot take my attention off it and therefore I’m going to be awake all night. It’s going to stop me from sleeping. So you can see how it immediately worsens insomnia if the person had pre -existing insomnia, but also sensory sensitivities.
Dr Ron Ehrlich [00:40:16] They would need a psychologist, Rose, I’m guessing, to help them reframe the way they see their experience.
Rosemary Clancy [00:40:24] Well, let’s just say right from the outset that everyone has to habituate to CPAP. It’s normal to have difficulties at first and struggle with CPAP. I can’t recall any of my co -mesa, co -occurring insomnia and OSA patients who have not had some sort of, maybe days, but they still had to struggle with it and maybe took them the first week to really desensitise to it so that they felt comfortable. But I can say that, yeah, one of the best ways I’ve heard it said was from a medical student I was once supervising in a hospital setting who because of the shape of his jaw, he needed CPAP and he said he was finding it, again, so difficult because it felt like he couldn’t breathe out against the positive airway pressure and that he felt, ironically, and he said, I know this doesn’t make sense, I know, but it feels like I’m asphyxiating. It feels like I cannot get enough air.
Dr Ron Ehrlich [00:41:44] Well, I wonder whether, I mean, my background is in oral health in dentistry and I wonder whether a mask that’s not well fitting or too tight can be pushing a jaw back and literally obstructing the airway paradoxically.
Rosemary Clancy [00:42:01] So that’s a really interesting one and I think this is why dentists have been at the forefront of looking at the greater rates of usage of mandibular advancement splints and saying, look, with such low rates of compliance like 30 % or less with CPAP, why don’t we try people with mandibular advancement? So even if it’s a bit less effective than CPAP, at least it draws the airway or draw forward in the airway open enough to keep the air flowing during the night and so surely that’s better than nothing. Surely it’s better than people struggling with CPAP.
Dr Ron Ehrlich [00:42:42] Well, I know in my own practise when I was practising using the mandibular advancement splint and again, this is something I personally have used for over 20 years. The mandibular advancement splint together with mouth taping, which when we first talked about it 20 years ago, people looked at me and thought, this guy, is he really telling me to tape my mouth at night? Now there’s a whole industry in mouth taping and the science behind nasal breathing, nitric oxide production, bronchodilation, vasodilation make so much physiological sense. It may not be as effective, but it certainly has a much higher compliance rate and depending on who you’re listening to and again, I think manufacturers have their finger in the pie here. It could be anywhere from compliance wise, anywhere from 65 to 95%. You know, I think 95 would be a manufacturer sponsored, you know, study, but let’s take that with a grain of salt. But your own personal experience, Rose, has changed that slightly in how you advise patients. What’s been your experience? What’s been the impact of that experience?
Rosemary Clancy [00:43:58] Well, I mean, I’ve kind of, I’ve spent a lot of time in any case, like in insomnia treatment, looking at attention, right? Most people underestimate their ability to draw their attention away from something aversive, right? Especially when it’s close to them, like, you know, like tinnitus is a great example, right? And tinnitus retraining may provide some of the answer here. Because essentially in tinnitus retraining and what we’re doing is the same that we do in any sort of anxiety focus and that is desensitised to a feared situation there with, you know, aversive stimulus there and basically practise graded exposure to it. But it’s using mainly the attention. So as you can imagine, tinnitus goes with disturbed sleep. So I’ve written a whole chapter in my Unlearning Insomnia workbook about tinnitus retraining and how it can be applied for insomnia and especially noise sensitivity in insomnia, which is very prevalent. But you can imagine like 50 % of those people with tinnitus have disturbed sleep for, you know, a reason because the tinnitus drives increased central nervous system fight -flight and with that, that hypervigilant sleep and also a belief within that I will not be able to take my attention off this threat, you know, and it makes sense, makes evolutionary survival sense that you would be continuing to scan for that threat. The only thing is, though, that threat in tinnitus is pretty much unchanging, right? And the principle that our brain works on is if, you know, we want to scan for threat, we want to continuously monitor it until we find that it’s unchanging, right? If the stimulus is unchanging, then our attention can just waver, like it just kind of like wears off, shall we say. And that’s essentially what we’re making use of in tinnitus training. Then you also make it in order to turn off that hypervigilance loop. And essentially, we’re doing the same thing but for claustrophobic feelings in CPAP wearing. And again, you have to, you know, it’s the same with mandibular advancements splints, you know, you have to habituate to that too, right? It’s just not as frightening or it’s not claustrophobic in the way that CPAP is because CPAP necessarily covers your mouth and nose, you know, mouth or nose or mouth and nose if it’s a full face mask. So that’s the threatening thing for people.
Dr Ron Ehrlich [00:46:43] It’s interesting, isn’t it, about how we as practitioners frame things to our patients because I know when I was in practise, I was also focusing, and I do with my clients in health coaching, focus on sleep position and say that stomach sleeping is the worst position to sleeping for neck and jaw and lower back, et cetera, and airway. And I know as a stomach sleeper for the first 30 years of my life, I know that it takes a long time to change that habit. So whenever I would frame it to my patients or clients, I would say, this is something that is going to take you six to eight weeks to break this habit. But once you’ve broken it, you will not be able to believe you ever slept in this position again. Play the long game. It’s called life. Six to eight weeks is not a long time in your life, but this can make a big difference. Whereas if I say to them, don’t sleep on your stomach, sleep on your side, and they gave that a go for one or two nights, I go, nah, I couldn’t do that. But because I have framed it in a particular way, they knew that it was going to take six to eight weeks. Shouldn’t we be preparing? I mean, I guess we are preparing our CPAP patients, our mandibular advancement patients, our insomnia patients in the same way.
Rosemary Clancy [00:47:59] Yes, excellent. Yeah, because I think if you can, and you can normalise it, it’s going to take a period of time so the person doesn’t think there’s something wrong with them after the first three days of not habituating sufficiently and think, well, it must be just me. Everyone else must be getting along famously with this. Right. And so, you know, this is that if we can show that it’s not only those first few nights, I think the first week is crucial then just in terms of getting support and normalising the distress and the struggle. But, you know, four, five weeks on, having that recognition that you may still feel as though you’ve got to rehabituate every night because you can have that momentary panic if your nose is a bit blocked one night or because you had, I don’t know, some sort of glass of red wine that had the histaminergic effect and so now you feel as though your nose is too blocked to use it and therefore it’s not going to work or something. So, I think this is sort of one of those things that if we can anticipate for people and they know that it’s normal that there would be that continuous feeling of… It’s less over time but you still may start a night thinking, okay, here we go again, right? And that’s, you know, give it the full six to eight weeks.
Dr Ron Ehrlich [00:49:32] How has though, coming back to the original question there about how has your own experience changed? What specific skills have you now brought into helping your clients with that problem?
Rosemary Clancy [00:49:46] I think, one, it helps me ask the right questions and commiserate on the more difficult parts of this and also just the kind of minor aspects of it most people wouldn’t think that much about that are disconcerting and that are potentially surprising. Like, for instance, one of those would be the ramping pressure on the CPAP. Look, for most people that it’s set by the sleep physician and it’s generally sort of like five to 14 centimetres of water pressure over the night averaging about 10 but it starts off at about five and it ramps up slowly. So, you’ve got time to kind of habituate to it as you fall into sleep. Now, if you’ve got insomnia and it’s taking longer to fall asleep then you can be looking out for the ramping up and that could be disconcerting, right? So, this is the interesting part and the interaction between obstructive sleep apnea and insomnia and it’s that you can have more anxiety on a ramping pressure of five at 11 p .m. because of the sleep performance anxiety and thinking I’ve got to get some sleep pretty soon. I hope this is going to work soon compared to finding it relaxing at six in the morning and even doing some slow meditative breathing with the CPAP mask at six in the morning on a pressure of 12, right? So, which is vastly more than five, right? But to feel absolutely comfortable with the pressure of 12 because you’ve already habituated across the night, right? And such that you can feel completely relaxed with it at a much higher pressure at six in the morning, right? And yet it’s close to panic and close to pulling it off at 11 o ‘clock at night because of the fears that it won’t work and you won’t be able to get into sleep on set with the ramping up happening too fast.
Dr Ron Ehrlich [00:52:02] Because, again, the name continuous positive airway pressure and the idea of ramping is that the continuous positive airway pressure is at a lower level at the beginning of the night and increases through the night and that is what ramping is about.
Rosemary Clancy [00:52:21] Yeah, and it needs to be, it can’t be too low a pressure because otherwise it’s not going to free the obstruction. Whatever the obstruction is, whether it’s a recessive jaw, whether it’s adenoids or tonsils or whether it’s like neck, flesh volume or whatever the obstruction is, the pressure needs to be high enough and they try to set it at the lowest pressure that’s just enough to keep the airway open and still be comfortable. But it needs to not be too low because otherwise you’re not going to get the benefits. You’re going to get more apneas and hip apneas and then you’re going to feel, your blood pressure won’t drop, the snoring and choking will go on, you won’t get any improvement in apneas and your weight groggy and unrested.
Dr Ron Ehrlich [00:53:15] I mean, this would add, I can imagine you, Rose, doing this with using the CPAP, which for the ordinary patients is challenging enough but here you are as a sleep psychologist adding another dimension to the sleep performance. Well, not anxiety, but observation. Is that something that you have to deal with as a sleep psychologist using this?
Rosemary Clancy [00:53:43] Yeah, look, the anxiety is very present. Especially if you worry more about sleep onset. If you at least could get for the first three hours and then you’re waking during the night, so at least you had their sleep from 11 until 2 and then you could say, look, at least I’ve had my deep sleep and it’s not the worst thing in the world if I don’t sleep for the rest of the night. But most people who are going to have partial compliance with CPAP, they’ll use it. There’s enough sleep pressure to get them into sleep onset and so then they tear it off at about 1 AM or 2 AM and say, now I can sleep. They take it off and because it seems unbearable at that point and that’s when the anxiety starts up. So it depends on whether you have more anxiety and more distrust in your sleep onset at the beginning of the night or whether it’s middle of the night waking. But it’s anxiety that’s going to stop you. It’s going to cause you to just take the thing off again.
Dr Ron Ehrlich [00:54:52] Because this is another thing about insomnia, isn’t it? There is the onset insomnia, inability to get to sleep. There’s the waking insomnia. You’re waking up in the middle of the night and you can’t get back to sleep and then you’re waking up really early in the morning and you can’t get back to sleep either. So there are different kinds forms of it too, aren’t there?
Rosemary Clancy [00:55:14] That’s right and all of them create impairment, like massive impairment in terms of cognitive functioning, social functioning, work functioning, physical functioning, people who are describing they don’t have the energy or alertness to just even do their valued exercise in the morning. And there are many professionals who fear word retrieval difficulties. The memory is becoming impaired because of it and they just cannot retrieve words with the ease that they previously did. And so they worry about it. It’s then they attach further more catastrophic meaning to it forecasting dementia and that’s when I can help with that. Because most people have a catastrophic bias about this and they forecast catastrophically.
Dr Ron Ehrlich [00:56:02] So, Rose, we’ve covered so many. There’s been so much great information here. I wondered if you were leaving our listener with two or three points so that you’d want to pass on to someone about these issues. What would be a couple of hints or ideas that you could leave our listener with?
Rosemary Clancy [00:56:20] Okay, so I suppose if you did have both co -occurring insomnia plus obstructive sleep apnea and you just received this news and a prescription for CPAP, the first thing I’d like to say is that don’t underestimate your ability to habituate, to desensitise to this naturally. The central nervous system has this natural habituation process. It happens in tinnitus and it’ll happen in desensitising to CPAP as well. Just trust that this naturally occurring habituation process works. It just needs time and compliance. So please think about it exactly as you’re saying, Ron, about a six to eight week starting point and know that that’s normal. I suppose the other thing would be don’t underestimate your ability to defocus, right? It feels like at first you couldn’t possibly draw your attention away from something aversive and threatening and something that feels like it’s going to mess up or ruin your sleep probably forever because the doctor’s talking about it as a forever thing, right, the CPAP, but it’s actually something you’ve probably practised in your life already that you’ve habituated to things and even things that would have been more threatening initially and you’ve ceased to notice them, right? And there’s quite a number of people with tinnitus but there’s also people who overcome fears about, I don’t know, swimming in deep water, say, or getting on a bike and habituating to that. So there’s a number of things that we’ve probably already done throughout our childhood, through our life already in terms of being able to defocus from something threatening that proved not to be.
Dr Ron Ehrlich [00:58:20] And you mentioned, just finally, I was going to leave it at that, but I have to ask you one other thing about tinnitus because it is an issue that affects people particularly at night when it’s quiet. What is, I mean, I know that my daughters who have young children have used white noise to replicate what must be very noisy back there in the uterus, you know, with the heart pumping and the lungs and the blood vessels. So there’s a lot of noise that goes on as we develop. Is white noise a treatment for tinnitus?
Rosemary Clancy [00:58:55] Yeah, look, I mean, and many people with insomnia describe it as invaluable too because, you know, this natural masking process and the treatment for tinnitus is of course, it’s not silence, it’s noise, right? And yeah, like, I mean, or what we call sound enrichment, which would include things like pink noise. I like pink noise personally, not just like pink, but it’s just more, it’s like a soft suffering of waves on the shore, right? That’s what I love about pink noise. I find in comparison, if you compare them, right, you feel it’s less abrasive than white noise, right? Or white noise sounds abrasive in comparison to pink.
Dr Ron Ehrlich [00:59:33] I love sound enrichment. I love that.
Rosemary Clancy [00:59:36] Sorry, but you know, this encourages that natural habituation and masking process, right? That, and it, you know, it’s not, you don’t have it much louder than the tinnitus, the perceived decibels of the tinnitus in your ear, in your head, but it’s just enough to cover it And your attention now wanes and once your attention wanes, then your central nervous system arousal drops and the emotion intensity and you know and vigil around the vigilance drops to and the vigilance just stops and at that point, apparently the aversive sound is cut off even at the brain stem like I mean, it is just not a registration, it’s just not a registration, it’s just not a registration, it’s just not a registration, it’s just not a registration, it’s just not a registration, it’s just not a registration, it’s just not a registration, it’s just not a registration, it’s just not a registration, it’s not a registration of the aversive tinnitus sound at the brain stem. It’s just not salient anymore. It’s just not noticed. And so, you know, someone drew your attention to it and then you could focus all your attention on it and hear that aversive sound again. But soon enough, your attention is just going to wane again because it’s just not, it’s not a threat. Rose, thank you so much for joining us today and sharing your knowledge, wisdom and your personal experience with us.
Dr Ron Ehrlich [01:00:56] Thank you so much. Thank you. Thank you. It’s lovely to be on Ron and yeah, I’d love to catch up again soon. So, see you down the beach. Yes. Well, it is interesting to consider how one prepares for sleep and it’s interesting to think that from the moment you wake up in the morning, you are already preparing for that night’s sleep and it’s really important to get out in the sun in the morning and let the circadian rhythm kick in and signal to that part of your brain that the day has begun. Melatonin production can begin. That’s when it starts to be produced. And as you work your way through the day, moving, exercising, you get a build up of sleep pressure and then sleep happens. Or let sleep happen, as Rosemary’s site is called. I think it’s interesting to think of cognitive behavioural therapy as a more formalised approach to sleep hygiene, which we’ve spoken about many times on this programme. And the most important part of sleep hygiene is to prioritise it. So many patients, in my experience, just think the way they sleep is the way sleep is. But it can, for so many people, be so much more and make such a big difference. So when it comes to sleep, I think it’s interesting to think of cognitive behavioural therapy as a more formalised approach to sleep hygiene, which we’ve spoken about many times on this programme. I think it’s interesting to think of cognitive behavioural therapy as a more formalised approach to sleep hygiene, which we’ve spoken about many times on this programme. And the most important part of sleep hygiene is to prioritise it. So many patients, in my experience, just think the way they sleep is the way sleep is. But it can, for so many people, be so much more and when it comes to preparing for sleep, cognitively, consciously changing your behaviour and using that therapeutically is clearly something that’s important and moving it from a conscious effort to the midbrain where the autonomic nervous system is and making it part of your everyday habit is clearly important. Then we get into the problem of lying in bed because, of course, stressing how important sleep is can make not sleeping an incredibly stressful experience. But I think we need to play the long game here. And as Rosemary observed, she probably doesn’t sleep that well one night a week. And I probably would take that as well. So, you know, to imagine that everybody sleeps every night really well is not realistic. But a consistently good night’s sleep means you are getting on the average seven to nine hours of sleep for the majority of the week. And that is really important. And it can make a huge difference to absolutely every measure of health, including mental health. Now, you know, there’s another part of the brain that Rosemary didn’t mention, which is the amygdala, which is the emotional centre of the brain, which typically is quiet. But when we are emotional, when we are stressed, when we are aggressive or anxious, the amygdala is firing up big time. And guess what? Sleep, not sleeping well, makes that hypervigilant. And the other thing that happens when you don’t get into the deeper levels of sleep is your brain doesn’t clear out waste as well as it could or should. Now, it was in about 2013 that it was discovered that there is, in fact, a lymphatic system in the brain which drains out waste. They never thought there was until it was realised that the glymphatic system is actually occurs when you get into the deeper levels of sleep. Your brain cells shrink a little bit and the spaces between those cells opened up and waste can be removed. So the link between poor sleep and dementia is a very real one. But it is also another example of you may not be able to change many things, but you can change your attitude to them. And when I experience a poor night’s sleep, I mean, the gold standard is supposedly get up after 15 to 20 minutes if you’re not sleeping and then reset the whole thing. I always found that a little bit tedious. I have a great respect for another aspect of rest, and we’ve done programmes on rest before, and that is non -sleep deep rest. You know, this is a new breakthrough thing coming out of Stanford by Andrew Huberman, which is actually appropriating something that’s been around for thousands of years. It’s called yoga nidra where I might lie in bed and go, I’m not going to lie in bed and think, oh, my God, I can’t get to sleep. I can’t get to sleep. I can’t get to sleep. I lie in bed and I think, OK, well, tonight’s not going to be that night. But non -sleep deep rest will do me. I might not get to sleep. So let’s just close my eyes and start scanning my body from my toes to the tip from the tip of my toes to the top of my head and just practise a whole relaxation and rest technique and just enjoy the silence and the quiet, knowing that the rest is doing you good. But it is about not having sleep performance anxiety. Now, Rose also mentioned the polysomnograph, which is a sleep study. There are lots of other smaller devices, the Garmin watch, the WHOOP band, the OURA ring. These are all ways of measuring sleep and certainly give you a pretty good idea of how you are sleeping. But a polysomnograph also taps into the brainwaves. And that gives another perspective to it, because going into that deeper level of sleep, the fifth or deepest stage of sleep called rapid eye movement sleep where you dream is a really important part of the sleep process. And each of these sleep cycles goes through about 90 minutes. You go through stages one and two when you’re dozing off and then you’re in stage two, three and four. And then in stage five, they’re all non REM sleeps. But in stage five, it’s REM sleep. And that’s where the mental clearing out of memories and mood and all of that comes in. So consistently good night’s sleep. We will have links to Rose’s site. Let Sleep Happen. In fact, you can just Google it and you will find some great resources there in a book that she has written. Let Sleep Happen: the struggle is over, which is a compelling title and some great information there. I hope this finds you well. Until next time, this is Dr Ron Ehrlich. Be well. Feeling stressed, overwhelmed? It’s time to unstress your life. Join the Unstress Health community and transform stress into strength. Build mental fitness from self sabotage to self mastery. And together, let’s not just survive, but thrive. Expert led courses, curated podcasts, like minded community and support and much more. Visit unstresshealth.com today. This podcast provides general information and discussion about medicine, health and related subjects. The 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.
