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 am recording this podcast, the Gadigal people of the Eora Nation, and pay my respects to their elders past, present, and emerging.
Dr. Ron Ehrlich: [00:00:22] Well, today we explore sleep again. And I don’t think you can like breathe. I don’t think you can reflect on this too often. It’s something that we do each and every night. It is it has been described as your built-in. I believe non-negotiable life support system. So getting it right is critically important. But importantly, as you will hear today, overthinking it can be a problem, too. My guest today is Rosemary Clancy.
Dr. Ron Ehrlich: [00:00:49] Now, Rosemary has been a clinical psychologist in Sydney for over 20 years, treating sleep, mood and anxiety, and substance use disorders. Now that is substances that people take to try to get a better night’s sleep and we go into that quite a bit in this episode. Rosemary completed a master’s degree in clinical psychology at Adelaide University, then worked as a clinical psychologist at the South Western Sydney Area Health Service.
And since 2008 has been a senior clinical psychologist at the Sydney Clinic in Bronte, New South Wales. From 2014. She’s been the sleep specialist, sleep psychologist at the Sydney Sleep Centre, a clinic we at the Sydney Holistic Dental Centre have been working very closely with for many years, and I’ve done a podcast with the sleep physician from that center, Dr. Anup Desai, in fact, we might replay that episode this week to tie these two very important episodes together. Rosemary is also the director of letsleephappen.com.au. I hope you enjoy this conversation I had with Rosemary Clancy.
Dr. Ron Ehrlich: [00:02:07] Welcome to the show, Rosemary.
Rosemary Clancy: [00:02:09] Thank you, Ron. Lovely to be here.
Dr. Ron Ehrlich: [00:02:11] Rosemary Our The Unstress podcast has talked about sleep many times. It’s the most important part of the day, but we’ve never spoken to a sleep psychologist and I wondered if you might just tell us what is a sleep psychologist.
Rosemary Clancy: [00:02:27] Oh, okay. Thanks. Yeah, well, I mean, a sleep psychologist is trained at a university in how we learn. You know, operant and classical conditioning are basically how we build habits. And, you know, just as we imperceptibly build habits over time, also, we learn about how to untrain habits and these are not just behavioral habits. These are thinking habits and attentional habits as well. So it’s really all about, you know, how our brain learns habits of thinking and responding.
Dr. Ron Ehrlich: [00:03:01] And like it’s the focus on sleep and I and I think it’s you can never hear this more too often, but what is a good night’s sleep look like?
Rosemary Clancy: [00:03:12] So a good night’s sleep. And just also, can I add in on that last question? Any kind of associated distress we might have in relation to the habits that have got us into a bit of trouble? So, you know, psychologists will help with, you know, the emotions around those as well. Okay. So what is what’s a normal night’s sleep? Okay.
What I can say is it’s not without potential interruptions and it’s probably not quite what we think it is and what we would ideally expect it to be. Because I think one of the things that is important to note is even if we set aside a window of opportunity, say 7 to 9-hour window of opportunity to safeguard sleep, it doesn’t actually guarantee that there will be it that will be filled with sleep.
And also the amount of time we spend in each of the stages of sleep, the stages that look like a normal night of sleep, a pretty much also not what people expect or what I prefer, for to just give you an example of what’s normal sleep and you know, portion of our sleep stages which your brain decides we don’t you know, we spend about 60% of our time in stage one or two light sleep. We spend about 20% of our time in REM sleep or dream sleep that is rapid eye movements. And we only spend about 13 to 23% of our time in slow wave sleep or deep sleep.
Rosemary Clancy: [00:04:46] Now people generally aren’t happy with that and I don’t know if you’re aware that, say, Silicon Valley aficionados are trying to biohacker into getting more deep sleep at all costs. But, you know, really, this is it’s unnecessary to pre-empt what the brain is doing in this respect because the brain completes this miraculous flushing function that happens in slow-wave sleep via the lymphatic system of the brain. It completes it in just 13 to 23% of a night’s sleep and that achieves physical recovery.
Now people aren’t generally satisfied with that. But that’s all the brain needs to complete this incredible, you know, flushing function that will look after, you know, the tissue and cell repair, human growth hormone production, and your physical recovery generally. So, you know, even there is what we perceive to be what should be normal sleep. And then is what our brain does is a normal sleep and, you know, as long as those stages are met, I mean, there are people who are genetically short sleepers who can be quite refreshed and function well on 4 to 5 hours. And so there is a wide degree of individual difference in this, but the stages remain relatively constant.
Dr Ron Ehrlich: [00:06:13] What percentage? Now, that’s an interesting one, because I think a lot of people in the psychology of sleep delude themselves into believing that, you know, they one of those people that can get by on 4 to 5 hours of sleep a night. Just putting that into perspective, what does the research tell us about how many what percentage of people actually are like that?
Rosemary Clancy: [00:06:37] Right. No, that’s a good point, actually. And I’d also need to factor into this because I work in a psychiatric setting that there are times where people do need more. But in bipolar affective disorder, for instance, if people do become sleep deprived, it can trigger a relapse into a period of hypomania or mania. So, yes, there are considerations that are really important in terms of a person’s psychiatric health, the mental health, and physical health.
And so you can see already it’s a range. You know, normal sleep duration is a range, we might say anything from 6 to 9 hours. And then on the other, you the edge of that spectrum, there are those genetic short sleepers who are okay with a pretty long term, 4 to 5 hours a night and even that will differ, too. And in fact, a researcher called Amy Bender said did some research that showed that they summarised that they think you really need ten nights to assess sleep quality in an individual because not only the individual difference in sleep quality and quantity but also the intraindividual night by night variability in sleep quality.
So I used to tell patients that, you know, five, you know, try and think of that over a window of five nights rather than just judging one or two nights in isolation, and then you’ll get a clearer picture. But then I had to reassess that when I saw independent research and say, Well, it’s actually now ten nights in order to adjust your look at that way of homeostatic drive, which we talk about later, know that homeostatic pressure building up over multiple days to where in your brain judges what sleep you need and achieve that for you.
Dr Ron Ehrlich: [00:08:36] Hmm. Now, the other thing you mentioned there in passing, you use the word lymphatic. And I want to come back to that because it’s actually quite an important thing because, for a long time, I think people it was believed in science that the brain didn’t have a lymphatic system to drain out waste, which is interesting. And I think recently, that’s changed. Just come back to lymphatics and explain what that is.
Rosemary Clancy: [00:09:05] Well, I mean, Professor Navas, it’s appellate Tel Aviv Uni is doing a lot of research in this area with her team, and essentially the lymphatic system, as you said, works just like the limbic system that we are aware of around the body and that it works in the same way as an assuring system in the brain. And it is incredible to believe that in slow-wave sleep, the space between the brain cells actually widens that so that cerebrospinal fluid can flush through the space between the brain cells and flush out all those accumulated deposits of oxidative stress that build up during the waking hours.
And so that flushing function is very important after a period of sleep deprivation. And the brain does that naturally, and, incredibly, it does in 13 to 23% of the night’s sleep, and if it could make it any less, it probably would have evolved to do that because this is where we are truly vulnerable in an evolutionary survival sense. Deep sleep or slow wave sleep is where we are very vulnerable. You cannot be woken easily from deep sleep and you won’t hear if there are predators or. Intruders. So, you know, there’s a lot of you know, there’s evolutionary reasons why slow wave sleep seems to us so short.
Dr Ron Ehrlich: [00:10:33] Hmm. And actually, it’s interesting, isn’t it? Because if your sleep was constantly being disturbed, not allowing you to get into those deeper stages of sleep. Therein lies a potential problem.
Rosemary Clancy: [00:10:48] Yes and no. It’s absolutely essential that we have that slow-wave sleep. And we know this because of genetic studies on people with fatal familial insomnia. Now it transpires that there was a rather, I think, inbred Italian aristocrat who moved from Italy to Central America in the early 1900s. And all of his descendants, which numbers about 40 families in all now unfortunately have this genetic disorder that switches on the bit like Huntington’s disease switches on in middle age.
So they’ve already created and it’s something of a lottery for this family. They don’t know who is going to develop, you know, have this gene expression switched on in middle age and then they lose the capacity for slow-wave sleep. And they essentially didn’t. Not only do they not have deep sleep at night, but they don’t even have they don’t even like properly during the day. They’re in this sort of netherworld of slow of light, sleep day in, day out.
And you can see that it’s a degenerative neurological condition because they had these tic-like movements that showed that the prion diseases is building in, you know, the proteins misfolding in the brain, which will ultimately lead to a really quite rapid death. So that basically, once it switches on that disorder, this degenerative condition means that they’re dead within seven or 36 months. And so we know just how important slow-wave sleep is.
Now, I generally don’t talk about fatal familial insomnia with patients, but yeah. And if you think about the reassuring thing for all of us that is how can you not know? You know, you would know if you were in those families and you would know also the aunties and uncles and grandparents have been dying off this strange sleeping sickness, in fact. Gabriel Garcia Marquez writes about it in one of his novels. And yet you would know that it’s a genetic disorder. Right. And the researchers have just descended on this community.
Dr. Ron Ehrlich: [00:13:02] But putting aside that genetic disorder, if you didn’t get into the deep levels of sleep and if the waste wasn’t flushed out through the lymphatic system, doesn’t that make you also more susceptible to degenerative conditions like dementia?
Rosemary Clancy: [00:13:19] Yes, yes, definitely. And over at Surrey University in the UK, professor, I don’t pronounce this very well Jan Derk Dijk D-I-J-K if you can look up Surrey University UK, the current biology research team over there have done a lot of work in this and what they have published only in the last year or so is that they now know that slow wave sleep stage has to occur in Night-Time hours now generally cause right at the beginning of our night sleep right because of that homeostatic pressure that builds during the day.
You know, your slow wave sleep at the beginning of the night is specifically linked to how long you’ve been awake during the day, not to the sun so much. So, you know, you fall into slower sleep. But one of the things they found at Surrey University with those corona biology researchers is that that slow wave sleep, that cerebrospinal flushing that happens within the glymphatic system, has to happen within darkness hours. It doesn’t happen optimally during daylight hours because the cerebrospinal fluid is diverted towards other functions in the brain. So now and this is kind of the missing link to help them understand why shift work is so chronically.
Dr. Ron Ehrlich: [00:14:48] This comes at a price. A high price.
Rosemary Clancy: [00:14:51] Comes at a price. You know, this is and, you know, this is I think, you know, something that’s really important for us to know and it’s important to know the science behind this and that to know that, you know, like a research team is assiduously, you know, trying to find the answers for this. But, yes, you know, that anything that might affect slow-wave sleep and that lymphatic flushing potentially has the power to. To, you know, increase your risk for vascular dementia or you know, yeah, this is that cognitive deterioration, and it’s now become apparent that some medications, for instance, major tranquilizers have might affect slow wave sleep could also increase your risk of dementia.
Dr Ron Ehrlich: [00:15:47] Hmm. Another aspect of sleep, you mentioned REM sleep, and I’ve heard it also said that if you don’t if you never got into REM sleep, that also has some serious implications psychologically as well. Is that correct? Can you speak to that?
Rosemary Clancy: [00:16:05] I mean, REM sleep is really important for our emotion regulation and, memory consolidation. And if we, if we only look, I mean, the brain has this extraordinary need to assert its or know this drive to assert its need for REM sleep, which is why REM rebound occurs. If you’ve been on, say, a benzodiazepine medication for a long period or you’ve been suffering, say, obstructive sleep, untreated obstructive sleep apnoea for many years, and then you either, you know, as you come off a medication that suppresses REM sleep, you will find REM rebound occurs. And if someone finally has CPAP treatment for the OSA, then they get a better quality of sleep generally. But they also tend to get REM rebound because they’ve been missing out on REM sleep substantially as a result of the, you know, the constant wakings in order to breathe during the night.
Dr Ron Ehrlich: [00:17:12] Hmm. And is rem when we dream? Is that is that the main dreaming part of the sleep state?
Rosemary Clancy: [00:17:18] Yeah. I mean, Professor Andrew Huber wrote at Stanford University neurobiologist, has an excellent series of podcasts about the importance of REM sleep and just how important those functions are. And not just for memory, but also, you know, our emotional health is, you know, is so important in its figures, obviously, you know, psychiatric health. So, you know, REM sleep is where that happens and why if we can have unmedicated sleep and just allow that REM sleep might not be what we expect it to be.
And you then know that key acceptance is actually going to let us ultimately have a better sleep longer term. And the reason I’m saying this is because this some research came out of Northwestern University in the US last year that said people can hear and understand and respond to instructions during rem sleep. Right now we didn’t think that was possible before we knew this is possible during stage one or two like sleep. But Northwestern University’s multi-site study last year showed that the researchers were giving the instruction to people in their REM sleep multiple sleep labs on different countries.
And then the person who was in REM sleep was able to hear, evaluate that instruction, and then respond with the category movement. And that showed to researchers that, yes, you can hear for threat during that REM sleep, 20% of the night’s sleep. And let’s think about the evolutionary survival significance of that. Right. It’s not enough to be able to hear for threats during 60% of a night’s sleep. That is stage one. And to sleep, it’s also important for us to be able to hear during REM sleep and we might even incorporate some of those suggestions into our dream content.
You know, many of you can usually attest to this because, you know, they might have heard something that was said in the room, and then they’ve absorbed that into the dream. And it still carries that bizarre narrative. And, you know, this is part of dreaming. But, you know, that when you know that the capacity to assess threat is important because that means all up, then at least 80% of our night’s sleep, we can assess the threat.
Dr Ron Ehrlich: [00:20:03] Mm-hmm. Yeah, it’s interesting to think of that. We’re up to that. We can still respond and assess. I’ve never thought of it in an evolutionary sense, but it’s nice to put it in that perspective. You’ve mentioned already Homeostatic Drive and I think be good for you to expand on that a little. Could you explain what that means? I know on your I know you talk about this and you also talk about circadian drive. I wondered if we might just talk about those two drives also.
Rosemary Clancy: [00:20:32] So the best way to think of it, I think you know, this and this is unchanged from 40,000 years ago or more, right? Is that these are the two key processes that are going to look after our sleep and iron out any sleep wrinkles we have, you know, night by night, and the sun representing our circadian drive. And this wave of homeostatic sleep pressure will ultimately take care of our sleep. And we don’t need to second guess that.
So, you know, we don’t need to step in and control it because, you know, if we know that those two processes are so powerful that, you know, even if we reading a good book and we want to keep reading it because it’s a page-turner, this wave of homeostatic pressure and the fact that we’re producing melatonin because of circadian drive, we’ll just take it to take us over like a wave, you know, it’s just and then we fall asleep and we maybe wake up 2 hours later with our glasses askew and drool all over the page or something.
So, you know, this is the wonderful antidote to performance anxiety about sleep, having, you know, reading a good book at night, which is why I never actually prescribe a boring book to people with insomnia. But with this circadian drive is basically the sun. You know, as Surrey University’s researchers have found, 82% of our body’s tissues has a circadian rhythm and everything about us responds to the sun.
The sun is our core zip giver or time giver, right? And you know, we have a circa dm, you’re circa 24 hours, you know, it’s a little bit over circadian clock. So and the sun is a natural handbrake on any tendency we might have to face daylight. The sun is our major treatment tool or Chrono therapy tool to kind of push back on a delayed circadian sleep disorder where someone’s going to bed consistently at 3 a.m. and they’re sleeping 3 to 10 a.m. It’s the sun that’s going to help us match that back slowly.
So, you know, really the sun is kind of everything to us because the moment that you see the nearest rays of sunlight in the morning, even through your closed eyelids, by the way, the sun is already your retinal ganglion cells, which are very sensitive to the wavelength, yellow and blue wavelengths of light. When the sun is low on the horizon, it’s already affecting your SCN or suprachiasmatic nucleus. This little wake-up clock deep in the brain and the sun is already suppressing melatonin, a sleep hormone.
And at that point, you get a burst of cortisol that gives you the energy to start the day. You get that and now you know you’re ready to start the day. So pulling down that line at that point and trying to get more sleep is just really, you know, not helpful, you know, because seeing the sunlight in the morning not only resets your circadian clock, but it resets your mood. And it’s enormously protective against depression. And as Professor Colin Espie at Glasgow University says, “if you want to treat depression, get up an hour earlier”. You know, this is.
Dr. Ron Ehrlich: [00:23:50] That’s a great statement.
Rosemary Clancy: [00:23:54] Yeah. Yeah. You know, he’s really he’s got some great quotes on this so and he’s the one who originated Sleepio.com the CBTI interactive online course
Dr. Ron Ehrlich: [00:24:08] On hang on you just said what is that?
Rosemary Clancy: [00:24:11] Oh, Sleepio.com is like is evidence-based cognitive behavioral therapy course for insomnia. And if you go, if you’re a patient, insomnia patient in the UK now you go to your GP asking for medication, you will instead get a script for that digital intervention. You get a script which is, you know, a subscription, you know, short-term prescription to get on to Sleepio.com
Dr Ron Ehrlich: [00:24:41] CPI or CBI.
Rosemary Clancy: [00:24:43] Well, no, sorry. Sleepio
Dr Ron Ehrlich: [00:24:45] Oh, sleepio.
Rosemary Clancy: [00:24:46] Oh, yeah. Yeah, I know it’s a funny little word, but if you look at Glasgow University, it was originated at Glasgow University, but it now has in I.C.E. writings or guidelines. So it will be a recommendation to prescribe it for anyone who presents with insomnia because that’s the evidence, first-line evidence-based treatment.
Dr. Ron Ehrlich: [00:25:11] You know, we’re going to come back to insomnia. But this whole circadian drive and homeostatic drive is what is so interesting in this whole picture, because, you know, we’re basically pretty similar to what we’ve been for the last 40, 50, 70,000 more years. And yet our rhythms are very out aren’t they?
Rosemary Clancy: [00:25:33] Well, I mean, this is it’s just kind of interesting because you know, how our is really decided kind of by winter and the seasons I suppose you know because that may not be as out as we think, you know, because except for when we start to feel lower, you know, maybe more withdrawn. I mean, I know it kind of happens naturally come winter, but the loss of sunlight, especially up in the northern hemisphere countries during winter, has really quite pronounced effects on people’s mood. And it just shows us how important the sun is. We’re lucky to down here in Australia with the amount of sunlight you get during winter, but you know, you still see the relative loss in and seasonal affective disorder down here as well. So, you know, that just shows us how important the sun is for maintaining our emotional and mental health and that and that it converges powerfully with because with homeostatic drive when it gets dark at night, because your sleep tonight is enabled by the sunlight you see this morning and your once your suprachiasmatic nucleus the morning suppresses melatonin production. You get this post this of cortisol to start the day.
Then you’re going to start building a wave of homeostatic pressure. From that moment that you wake up this morning, whether it’s 6 a.m., whether it’s 7 a.m., your 10 a.m., you then count about 14 to 16 hours on from that. And that’s going to be probably sufficient. Homeostatic pressures make you start feeling sleepy at the end of the day, and then this you’re going to be producing melatonin naturally as soon as it gets dark tonight because of the sun affecting your serotonin mood, neurotransmitter and optimizing that during the day because that serotonin will be used by your pineal gland to manufacture melatonin sleep hormone tonight.
Rosemary Clancy: [00:27:42] So there it is. This melatonin production, by virtue of the sun and this wave of homeostatic sleep pressure that’s been building over 14 to 16 hours of wakefulness converge together to get you down into deep sleep. Within 35 to 40 minutes, unless you’re in danger. And then everything in your brain, you say, will try to debate within limits to try to put sleep aside. And that’s our key acceptance. All right.
As humans, you know, you can’t force this process. You have to let sleep happen, not make sleep happen. The moment you try to make sleep happen with sleep effort, then immediately your prefrontal cortex gets involved and tries to problem solve this, you know, and keeps checking. Is it working yet? Is it working yet? And then your brain assesses threat, unfortunately, and not an external threat, but internal threat.
And the internal threat and insomnia, unfortunately, is I have done everything right. This should be working. I’ve created enough opportunity. I’ve got all these sleep pillows, you know, these lavender to-sleep pillows, and I’ve got the weighted blanket. I’ve got everything right. Why isn’t it working? And that, unfortunately, is, you know, it’s assessed as threat, and then your brain who willingly try to put aside sleep.
So we need to centrally look at and this is probably you know, this is the job of the sleep psychologist to centrally look at control strategies that backfire. All right. And then we try to untrain those because people start layering up control strategies and they seem to work at first because the placebo right you know you get the weighted blanket or the level of the pillow or the, you know, and you do the herbal medication, the herbal tea. And because it’s been marketed for sleep, people have now raised expectation. So you can see the behavior or the thinking habits in this to people have raised. Expectations should work.
Now I’m doing everything right. I’ve got ten things layered up to help me sleep and now it worked the first time. Why isn’t it working now? And then people can’t get rid of any of these, you know, these control strategies. They’d already tried because they did seem to work at some point. And that’s a kind of helpless place to be because you think I’ve got ten things going now, and they’re all marketed for sleep. So why? Why am I overriding them?
Dr. Ron Ehrlich: [00:30:15] So When the brain gets too involved, particularly that free prefrontal cortex, we’re in trouble. And you mentioned insomnia and we wanted to talk about that, too. How big a problem is insomnia?
Rosemary Clancy: [00:30:30] Oh, look it I mean, it was thought to be depending on the criteria, diagnostic criteria used up to, you know, 45 to 48% population. And that was before COVID lockdowns. And then the loss of daily structure during the COVID lockdown seems to have exacerbated that. Look, Andrew, so it’s you know, the neuroscientist Matthew Walker says that 60 to 70% of people have a one, a difficulty falling asleep one night a week every week.
Now, you could almost call that enormously, really. You know, in answer to your first question, you know, it differs amongst individuals. But if 60 to 70% of people are having one-night difficulty falling asleep one night a week every week that’s looking pretty normal. You know, this is so it’s you know, we all subject to this sleep threat. And and if it’s to control it, if we think that our brain isn’t doing the job right, but it always brings in the prefrontal cortex and that gets busy. So, you know, I mean, I’m a good sleeper. And yet last week when jetlag, I was I really totally believed at one point I would never get my sleep routine back. And then it’s back at the end of six days or so.
Dr. Ron Ehrlich: [00:31:49] Which comes back to your point, which comes back to your point earlier about in order to get a true assessment of a person’s sleep, we really need to look at a ten-day, ten-day period.
Rosemary Clancy: [00:32:02] Yeah, you know, because of the homeostatic drive, you know, the need to put aside sleep when we’re just right but also the homeostatic drive ironing out, you know, over not only over 1-24 hour period but over multiple nights. Your homeostatic drive will keep building if you are, in fact, sleep-deprived.
Dr. Ron Ehrlich: [00:32:21] So when do we, what is the definition of a problem that we can call insomnia?
Rosemary Clancy: [00:32:27] Yeah. DSM five, of course, looks at difficulty falling, falling asleep, staying asleep or early morning waking with distress about it and interference with daily functioning, be that social occupational functioning, know, physical functioning, mental health functioning. So it happens more than three nights a week over a three-month period. This is acute insomnia where you know during.
Again, I think evolutionary sense here, right? You know, if you’re under a period of great stress at work and there’s a deadline looming, you know, you might have, you know, three or four nights of acute insomnia. And that tends to resolve after the difficulty finishes. But if it becomes a whole system or habit of control strategies that backfire, then that’s when we start to get caught in chronic insomnia. And more often than not, two, it seems because we see it so often in a sleep lab, it’s paradoxical insomnia or by other another name, sleep state misperception.
And that’s where your sleep quantity and quality at a sleep lab look objectively. No more, but we do not perceive it to be so. And one of the reasons that that happens, I mean, for instance, in an 11-minute awakening on Polysomnography feels to the person with insomnia, like over an hour away, that’s how we skew the time data. And one of the reasons for this is we don’t have a memory or awareness for the moment. We fall asleep. And that’s why it’s, you know, a microsleep on freeways on the freeway so dangerous, right? We think we do.
But because we don’t have a memory or awareness for the moment, we fall into sleep, we skew the data. Right, so that the awake time seems longer, much longer, and the sleep time seems much shorter. Add to that the fact that we can hear and evaluate sounds, you know, threats in the environment during now we know 80% of the night’s sleep and we would perceive that, well, I must have been awake if I could hear these sounds. I must have been awake. Right. So, you know, there are a number of reasons why we humans misperceive normal features of sleep.
Dr Ron Ehrlich: [00:34:47] Yes.
Rosemary Clancy: [00:34:48] You know, we come to a conclusion that we absolutely believe 100%, and then we get into control strategies that backfire.
Dr Ron Ehrlich: [00:34:54] Yeah. I mean, that definition of chronic insomnia, three nights a week of not sleeping for three months is the defining. And it comes in what, those three forms. Difficulty falling asleep, difficulty staying asleep and waking up too early, and not being able to go back to sleep there three types.
Rosemary Clancy: [00:35:17] Now both, you know, someone can start off with onset insomnia, and then it changes into maintenance.
Dr. Ron Ehrlich: [00:35:24] And this is where sleep psychologists come into their own, I’m guessing.
Rosemary Clancy: [00:35:29] Well, I mean, one of the things that we’re trying to do with the behavioral associate, the behavioral habit itself of staying, which is the control strategy, the backfires, the key one is staying in bed too long and getting frustrated, right? And laying awake, laying in bed awake for hours and hours in 80%. Frustration in frustration, intensity, anxiety, frustration, anxiety, dread.
And what we’re doing, in effect, is creating a negative condition dissociation, whereby the bed becomes a signal for waking, worrying, and frustration and anxiety. And what we need to do is untrain that conditioned dissociation. But most people it’s very under the radar. Most people don’t think in terms of habits or conditioned associations. So, you know, they’re thinking like, you know, I don’t understand why this is. You know, I just I’m trying really hard. I’m doing my meditation. I’m doing so much meditation and I’m still really wakeful.
And I think the thing that’s important about is to recognize once you learn a habit, it goes back to a part of the midbrain called the basal ganglia that governs habits and then an insomnia, a habit of waking and worrying is also governed by the basal ganglia. And once you have a midbrain habit, you can’t just think your way out of it or prefrontal cortex your way out of it. You know, you can’t just, you know, executive function your way out of it.
You know, you actually have to act your way out of it. You have to remove yourself from that bed. Or I used the word for people, you know, and poison the bed, and then we’re going to go and poison the sofa instead with that negative conditioned association. And it’s you know, it’s about the nearest thing that people can you know, it can really kind of grab a hold of to kind of motivate them to get out of bed because no one wants to get out of bed completely understandably and especially in winter, you know, because, like, you know, this day it’s downstairs, it’s cold on the lounge. I have to put on the heater. It feels lonely, it’s really isolated.
Everyone else is able to sleep. Like, why can’t I? You know, I must be the only one. Every, like, you know, in the district is off, you know? I can’t see the lights on. Cut from a few breastfeeding mothers, I suppose. But, you know, this is you know, it feels lonely and also, if you’re longing for sleep and, you know, you’re hoping this really good reasons to believe that if I get out of bed, I’ve lost all hope. At least if I stay in bed and lie here, I might be resting. That could be good enough. But at least I’ve got a hope. And that hope and that yearning for sleep keeps them in the bed, continually poisoning the bed with that association.
Dr. Ron Ehrlich: [00:38:30] But should we and this comes to, you know, the cognitive behavioral therapy and the acceptance and commitment therapy. What if one said, look, I’m just going to accept the fact that I’m not going to sleep, but there’s value in rest.
Rosemary Clancy: [00:38:46] That’s such an interesting question. I know because there are some acceptance writers who actually talk about staying in bed and practicing acceptance. And there are reasons to stay in bed like one would be the assessment of time like it generally. I don’t know if you’re aware of the 15 to 20-minute rule, which is the stimulus control method, and that’s about if you can’t get to sleep within 20 minutes, then in 15, 20 minutes they can get up and go out to another room where you can do the stimulating activity until the sleep cues come on again. And only then would you go back to bed.
Now, most people don’t wait for that, you know, because they’re so frustrated, even though it’s supposed to be a chance for the central nervous system to calm. Most people just make it time-based. They will have been out here 30 minutes now. That’s enough. I’m sick of this. I’m going back to bed. And then it’s actually even more kind of helplessness inducing when they go back to bed and find that, you know, they’re immediately awake again, even if they might have been getting some sleep cues or, you know, just feeling a little bit heavy in the eyelids, you know, they get back to bed wide awake and that’s the condition dissociation dominating again. So, you know, look, this is a really hard one.
And I think it’s important we can’t take away your from the take and can’t take out of the equation the fact of these negative conditioned associations and the need to act your way out of them rather than, you know, think your way out or meditate your way out of them. I really do believe that it’s important if you have very fragmented sleep, to compress the multiple wakings out of that and actually shorten or restrict the awake time spent in bed.
Rosemary Clancy: [00:40:39] And it’s mainly because that very intense emotion that people are feeling, you know that. And I suppose the hard thing about the question about just resting, well, if you’re at 70% frustration, intensity or you know, 70% anxiety or over, then it’s really not very restful is like it’s also a certainty you’re going to be awake in that point. Like I mean this is one of those questions that is really interesting.
Am I if you’re asking yourself or am I awake or at risk, if you’re not sure if you’re awake or asleep because we all go through that too and fragmented sleep, then you may be asleep. You know, if you have to ask yourself that, then there’s room to suggest you may actually be in stage one or two like sleep, but just evaluating your sleep from within. Right, and, that’s partly because of hypervigilance.
But if you’re at an intensity and motion intensity of over 70% of any emotion, be that you know, anger, dread, frustration, anxiety, then then you’re going to be in fight or flight and you notice that you’re going to be awake. You know, it’s unlike you’re just not going to be at that level of emotion, intensity and not be very aware of, you know, and awake and alert, because that’s the job of your brain to actually get you alert and away from danger if you’re worried.
Dr. Ron Ehrlich: [00:42:09] But it’s coming back to it, though, if sleep is the thing and I’m in bed and I’m just not sleeping, that’s an invitation to the prefrontal cortex to jump in and solve the problem. But if you ask a different question, which says, well, okay, I’m just not going to sleep, but I need a bit of rest, I’m just going to lie here and enjoy the quiet. Isn’t that I mean, changing the attitude? It’s like in life, isn’t it? We can’t change events and people, but we can change our attitude to them.
Rosemary Clancy: [00:42:45] Yes. Excellent. Absolutely. And if you were able to do this and notice, you know, sort of emotions not associated with it then. And this is fun because it may be that we’re misperceived in time and it hasn’t been that long. And we are just in that little ten-minute period between the next this sleep wave and the next wave, you know, absolutely normal. Then there’s 10, 15-minute awakenings. As long as we don’t fill them with worry and frustration.
So now I mean, yes, look, I mean, I’m never hard and fast about this, but I’d just like to know that people understand the role of conditioned associations. They will ultimately make their own choice about whether they get out of bed and go to the lounge or not. And you could actually risk that lounge to try and do something kind of nice out there. And we do actually spend a bit of time trying to make the lounge a nice place.
I have the sofa, the, you know, the place where you have your service of warm milk or herbal tea out there to make it soft, like the books already open at the right page and, you know, a nice warm angora wrap or something so that it’s actually inviting. And it’s actually possible to change the association and have someone looking forward to this sort of meet time that were previously been seen as really adverse. You know, if I had to get out of bed.
Dr. Ron Ehrlich: [00:44:25] I think I also read that one. Another approach was to actually deny sleep, to actually say, okay, I’m in some I’ve been an insomnia for whatever period of time I’ve now been defined. Three were nights in a week, three-time for three months. I’ve been going for years, someone might say, and the approach could be, okay, let’s do an experiment. Let’s just say for the next few days you’re not going to go to sleep for the next 24 hours. You’re not going to go to sleep.
Rosemary Clancy: [00:44:55] Yeah. You just need sleep deprivation and homeostatic drive yeah. Look, I mean, I certainly I wouldn’t suggest that if you if anyone who had a history of bipolar affective disorder and a history of hypomania, mania, because that, you know, could then just people start getting excited and then they start doing creative things and then, you know, to two nights turns into five nights and then they crash at the end. So, you know, this is look, it is absolutely possible.
And if you’re going through a period of stress, you might well have 2 to 3 nights of very short, very short sleep or maybe no sleep. It’s likely that on the third night, you know, people say, I’m not getting in and didn’t get any sleep for three nights. You’re probably going to find they’re still lying in bed with their eyes closed. And because they don’t have a memory or awareness of falling into sleep, you know, the year that they probably would have an hour or two. Look, the Guinness Book of Record holder for sleep deprivation is Randy Gardner with 11 days, night
Dr Ron Ehrlich: [00:46:00] Oh, my God.
Rosemary Clancy: [00:46:02] Now he’s still the record holder. And he had that record. And he was followed by Professor William Demen and his team at I can’t remember which university. Sorry. But in 1964, people have tried to better that record and they couldn’t. But what’s really interesting and shows just how malleable our brain is and how restorative about brains functions are, is that on as after 11 days nights he fell asleep and nothing was going to keep him awake. But in interestingly, only three recovery nights were needed for 11 days and nights lost.
So that what does that show you show is that we don’t need an exact correlation between your exact your parity between your nights lost and recovery nights. Right. That our brain is really good at compressing that need for sleep and getting us as happened in Randi’s case, commensurately more deep sleep and REM sleep on those recovery nights. So for the first night, he fell asleep for 15 hours.
The second night he’s up during the next day right. Second night he’s asleep for ten and a half hours. The third night he spent time he’s at 9 hours almost back to normal on those three recovery nights. And he had almost double the deep sleep or slow wave sleep and almost double the REM sleep on those recovery nights right, now, and fully halved light sleep, stage one and two sleep on those recovering on average, double those recovery nights.
So what’s really interesting about this, you know, I asked my clients, you know, what’s good about this? What does that show you about your brain’s capacity to regulate sleep, self-regulate sleep. Did Randi have any control over those, you know, the sleep stages he was in on those recovery nights? No, no.
All he had to do was fall asleep and his brain took care of a lot. But interesting that the lymphatic system spent more time during that flushing and slow-wave sleep This doesn’t make evolutionary sense, right? To have 35% of your night in slow-wave sleep when you can’t protect yourself. You know this is that it was absolutely necessary in those recovery nights after that level of sleep deprivation.
Dr. Ron Ehrlich: [00:48:15] So now I know that you’re working at the Sydney Sleep Centre with Dr. Anna Dessau, who we’ve had on as a guest on the podcast before. But you also involved in a hospital that looks at substance abuse and particularly in relationship to sleep, the things that people do take to get to sleep. What are some of those things and what are some of the problems associated with them?
Rosemary Clancy: [00:48:41] Yeah, look, I mean, and it’s really hard when someone’s had, you know, already had existing, you know, because two or three nights of poor sleep. And this is what drives people to go to the GP or psychiatrist and say, look, I cannot have tonight be like those last three nights. You know, you’ve got to give me something.
And you know, I’ve talked to GPs in a city who actually, you know, have been sort of intimidated by clients who are patients who are, you know, really maybe that they had a sleep medication once and a very quickly a positive external attribution develops that well my brain clearly doesn’t know how to do sleep because look how bad it’s been over these last two or three nights. But the medication can and you can see this positive retribution develops very quickly and it’s lasting. So even if they do and they generally do, because these medications benzodiazepines.
Dr. Ron Ehrlich: [00:49:39] You said like Valium, you’re talking benzodiazepines, something like valium?
Rosemary Clancy: [00:49:43] Yeah, that’s right. Valium or diazepam. And that one’s a very popular one because it also has anti-anxiety and muscle relaxant effects as well as hypnotic effects. So even if people do, it seems that even if people gravitate or try, the newer medications like the orexin neurotransmitter involved severe orexin or build somewhere, they may be dissatisfied with it because they are still looking for an anti-anxiety effect or a muscle relaxant effect.
And then they will go and they start looking and seeking Valium for that. So, you know, this is there are very positive attributions about it and they’re very hard to shake, even though these medications work on the reward circuitry of the brain and build tolerance over time so that people get these diminishing returns generally and they have to take more to get the same effect. And even then later on and I’ve seen people with been 20 years on diazepam with pretty prominent memory impacts, but you know, and they’re really just stopping withdrawal, you know, they’re just taking it and now, you know, and unfortunately compared to keep on taking the medication to just stop withdrawal, even though they’re not getting the same anti-anxiety effect they used to.
So, you know, it’s as if it’s possible. I mean, it’s to choose to do CBTI first, which is what the RCAGP prescribing guidelines are saying. Right. Part B saying, you know, the first line of treatment, CBTI, and then assesses if any medications are necessary if the CBTI doesn’t work. And that’s what they’ve been. And I see recordings of backing up over in the UK and the NHS is trying to put into practice and I think it’s only a period of time before we follow suit in Australia just because the evidence backing.
Dr. Ron Ehrlich: [00:51:49] And that CBTI, Cognitive Behavioural Therapy, what does the I stand for?
Rosemary Clancy: [00:51:54] Of Insomnia.
Dr Ron Ehrlich: [00:51:55] Insomnia, yeah. And that is all about changing your relationship with your bed and your expectation around sleep.
Rosemary Clancy: [00:52:04] Yes. Yeah. So you know those behaviors and thinking around and so yeah.
Dr. Ron Ehrlich: [00:52:09] But back to the substances because you know Valium is one, I mean alcohol is another. There’s a big difference isn’t there, between sedatives and sleep. Sedation and sleep.
Rosemary Clancy: [00:52:23] Yeah. And you know, this is the crux of it is it’s really you can absolutely see why people like sedation better than, you know, unmedicated sleep. Because unmedicated sleep has normal workings than that and it just looks more fragmented than sedation. You know, like when people say, I want to be knocked out, you know, just on 8 hours, it just means sleeping like a log with no, you know, there is, you know, waking up in that and certainly nothing that they can remember.
And so, you know, the memory effects are you have one feature of these, you know, sedative medications as with alcohol. And these are thought to be some of the said positive reinforcement that keeps people using it because they can’t remember any waking and it seems like it was a very solid sleep. And because many people have the belief that quantity equals quality, they don’t prioritize quantity of what appears to be solid sleep over quality any day. Right. I mean, it is it just looks you know, it looks better on your device to your graph and, you know, just.
You know, unless you actually had the electrodes sort of glued to your scalp, your wrist-based device is probably going to say, well, you know, if you’re not moving very much in its accelerometer like you, it that grows that lack of corresponding movement looks like you’re, you know, sleeping quite heavily. And so people, you know, we take that as a good sign. But I think, you know, what’s important to realize about this is that the benzodiazepine class actually reduces the amount of deep sleep or slow wave sleep that you get and suppresses REM sleep.
Hence, REM rebound upon withdrawal. So that’s why an important question for someone to ask the prescriber is does this medication I’m about to take cause REM rebound after I withdraw after I come off it? Am I going to have rebound? Because that means it would have been suppressing REM sleep during the active half-life.
Dr. Ron Ehrlich: [00:54:42] And does alcohol have the same effect?
Rosemary Clancy: [00:54:44] Yeah. Alcohol suppresses REM sleep as well and reduces slow-wave sleep.
Dr. Ron Ehrlich: [00:54:49] Rosemary, there was a study done some time ago called the Beach Study, which has real important implications. Could you just share with us a little bit about that study?
Rosemary Clancy: [00:55:01] So essentially the 2017 beach study data looked at reported versus actual prescribing rates in Australian GPS and found that 90% of people going to their GP office with an insomnia complaint were coming away with the script. And in 50% of cases, that script was for two men. Japan, which is a widely used benzodiazepine which suppresses deep sleep, slow wave sleep, and reduces deep sleep and suppresses REM sleep with the effect that the person will then suffer in rebound when they withdraw or stop using the medication.
So it did show us just how widely benzodiazepine medications are prescribed and also, shall we say, quite insistently demanded by patients. And in talking with a number of inner-city GPs, I’ve come to the conclusion that we could all potentially be Michael Jackson’s and be insistent upon getting sedative medication if we feel desperate enough about sleep. So I think this is something we should take notice of.
Dr. Ron Ehrlich: [00:56:19] I mean, I think that does actually speak to a problem and that is the time that a GP has to deal with these complex issues, isn’t it? I mean, I would be surprised if any of your patient’s appointments were somewhere between seven and 15 minutes long.
Rosemary Clancy: [00:56:37] Absolutely. Absolutely. It is just there are so many factors that are just conspiring to make it really difficult for GPs to resist, especially new patients. I remember talking to an inner city, quite petite female GP, very capable lady, and she said she was less intimidated by addictions patients who would just shrug their shoulders and go off and try another clinic and more intimidated by mood patients, you know, like say middle-aged or older women, often who are overrepresented in depression and anxiety statistics.
Right, who might have already had you previously used benzodiazepines like Valium and were now quite insistent that they should get another script and would not leave the office. And, you know, I mean that really insistent and believing it was their right to get these medications because they’d been using them responsibly, inappropriately, even though it was look, it sounds like your long term dependence. So I appreciate this is really difficult ground for GPs. It’s hard work dealing with quite insistent patients.
Dr. Ron Ehrlich: [00:57:57] And other medications imagine some of the psychotropic drugs would also, you know, anti-anxiety and.
Rosemary Clancy: [00:58:07] Yeah, it could be. I mean, so diazepam or valium is, you know, the key anti-anxiety medication sought after, you know, and it tends to be that one that people gravitate to if they’ve been on it in the past. And then they tried to switch over to melatonin or suprexin or one of the pieces arise like zolpidem was so decline still not so much to intervene you know then they want the muscle relaxant mentioned side effects of valium it seems I just noticed people keep. Gravitating back to that.
Dr Ron Ehrlich: [00:58:41] Yeah. You mentioned Stilnox and the others that I was thinking was anti-depressants, actually. What are the effect, of things like anti-depressants, SSRI inhibitors on deep sleep and REM sleep?
Rosemary Clancy: [00:58:56] Well, that’s really interesting issue to us and I wouldn’t comment on that because my main interest is in medications that are working on a reward circuitry, the brain to build tolerance, and that are sought after for the sedation and, you know, hypnotic effects for sleep. It’s our eyes don’t seem to have either. They didn’t tend to have that hypnotic effect. And so they’re not sought after by people with insomnia. so —
Dr Ron Ehrlich: [00:59:24] but–
Rosemary Clancy: [00:59:26] Well, there are older antidepressants, like no tricyclic that used in very small doses that seem to be helpful. And I know some that a number of, you know, very thoughtful GPs are actually trying to shift people off benzodiazepine plus medications because of the habit-forming state and get them onto one of these lower dose older tricyclic. And that seems to be, I think, you know it’s, it’s really laudable, the GPs are looking for something less you know, habit forming. Hmm.
Dr. Ron Ehrlich: [01:00:05] So just finally Rosemary, because you’ve covered a lot of territory here and it’s been terrific just for our listeners who might be thinking they haven’t been getting a great night’s sleep. They’re not sure whether they’re an insomniac or not. But what would be the three things or four things that you would say to them to try to improve their sleep tonight and for the next ten days at least?
Rosemary Clancy: [01:00:29] Yeah, I suppose, you know, just give it a more of a window to assess. Right. Don’t jump to an assessment of the sleep quality. know that we regularly as humans misjudge time at night and we misperceive normal features of sleep. Right. And when it happens to because our emotions are telling us that, you know, when, you know, our expectation hasn’t been met and therefore we’re frustrated and that makes us believe more strongly that we haven’t slept. Right. And then we want to start controlling it.
And at that point, if we can just recognize that it’s something we all do, but if we can just sort of stand back and let our brain get on with its job, then, you know, it will regulate, self-regulate, sleep well and we don’t have to kind of pre-emptively get in and control it because that’s when the problems are going to arise. And that just because that builds hypervigilance and performance anxiety about sleep.
So, look, I mean, certainly, I would say try and get up with the sun. You know, if there was one thing that you know is going to help and in a real sense, in terms of resetting your circadian clock and your mood, just get up with the sun. You know, and I’m not saying it has to be six as soon as it rises or, you know, just when the sun is lower on the horizon and that’s indifference to what Professor Andrew is saying.
And then look at me and try not to that during the day so you can build, you know, if during a period of insomnia you’re okay with a power nap that goes for about 20 minutes if you don’t have insomnia, but if you have a period of insomnia, then during that period don’t have naps during the day. So you can build a large wave of homeostatic pressure, you know, during the 40 to 60 hours away. And look, if you only have a short sleep, still get up at the same time, you can recoup that sleep the next day, not the next night because you will have so much more homeostatic drive building up.
I know that’s easier said than done because, you know, people do feel threatened about, you know, how it’s going to affect the daytime functioning at work. But, you know, it’s always likely to happen on a weekday when there’s a threatening meeting coming up rather than on a weekend that you’re going to see these short sleeves just because of the way it works, you know, the brain is approaching threat, so it wants to keep you alert and escape from it. So, yeah.
And if we can kind of have that key acceptance, I suppose that’s the final thing that if my brain is assessing, I’m in through it, then it just wants to stay awake and turn problems of me out of it, you know? So I’ve just got to sort of respect that and not try and force it or try and like second guess it. So. Yeah, I think. It’s I think it’s it’s important to kind of see how good sleep is rather than just kind of, you know, let me count the ways of how bad my sleep is. You know, and because ultimately, if we start through it scanning, we’re going to find more than what’s wrong with it.
Dr. Ron Ehrlich: [01:03:58] Rosemary, thank you so much for joining us today and sharing that wonderful, so much wonderful information with us. And we’ll, of course, have links to your website. And thank you again.
Rosemary Clancy: [01:04:09] Oh, look, thanks so much for inviting me, Ron. It’s just been a pleasure.
Dr. Ron Ehrlich: [01:04:15] Well, there’s always something new to learn about sleep. There’s always something new to learn. Just a full stop but I thought that was so interesting. Rosemary’s point about really to get a proper assessment of your sleep, that a ten-day period is something worth assessing and exploring, and I think we’re going to incorporate that or we have incorporated that into our Sleep Diary on the Unstress Health’s website. But interestingly, 60% of sleep is light stages of sleep.
Now, I should just back up here and say there are five stages in sleep, stages one and two are very light sleep, and that is when you are dozing off when you get to you just fallen asleep and you dozing off. So that’s stages one and two, stages three and four of the deeper levels of slow wave sleep. Now and then the fifth stage is REM. So stages 1 to 4, a nonrapid eye movement or non-R.E.M sleep.
And the fifth stage is REM sleep or rapid eye movement sleep where it is said most dreaming occurs where you have your muscles go into paralysis, probably to protect you from performing what you are dreaming about. But it also is an opportunity to rebuild and regenerate muscles. But it is interesting that the lighter levels of sleep stages one and two occupies 60% of your sleep rem that paralytic dream-like sleep, which is 20% of the time, and 13 to 23% of the time is those deeper levels of slow wave sleep.
So I thought that was really interesting and I’m certainly going to be looking up the research of Aimee Bender and exploring this ten-day assessment of sleep, which is a really important one. Look, there was just so much there about how we think about sleep when we overthink sleep. We were reminded again of the importance of getting out in the sun. And this kind of is another example of a public health message which has gone a little bit haywire. And that is that, you know, stay out of the sun, slip, slop, slap. You know this is so important, our relationship with the sun.
And we’re going to be doing more episodes on this because it is just so fundamentally, critically important for every cell in our body and this, as Rosemary reminded of this, 82% of cells in the body respond to the sun. I’m guessing we could even up that number to 100% because it’s so critically important to our health. Look we’ll have links to Rosemary’s site which is Let Sleep Happen and there’ll be links to that in the show notes.
And of course, don’t forget to go online and join the Unstress health community. We’re really are building a whole community of not only like-minded professionals, clinical experience built on science, built on clinical experience, backed by science but a whole range of other stuff. So 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.