The following is the full transcript of Clinical Psychologist Dr. Vyga Kaufmann’s TEDx Talk: Understanding “How do I Sleep Better” at TEDxBoulder conference.
Listen to the MP3 Audio here: Understanding How do I Sleep Better by Dr. Vyga Kaufmann at TEDxBoulder
The early part of my career as a clinical psychologist was spent in addiction research and treatment, and now I treat sleep. So when I reflect on my path, I feel as if I can legitimately say that I went from helping people become conscious to helping people become unconscious.
I love sleep treatment. I think that sleep is so fascinating and it’s exquisitely complex. For people navigating that sleep treatment world, though, trying to figure out what to do can be very daunting.
I was even surprised to find out that some of the most effective treatments for insomnia were over 20 years old. When I shared this with one of my clients, his response caught me off-guard. He said, “Why is it then that you are my last stop when you should have been my first stop?” The night of sleeplessness here and there is actually normal. Losing sleep over a broken heart, normal. Losing sleep because your mind pops awake with one more idea to add it to your big presentation tomorrow, normal.
But hopefully, we also know how great it feels to have a really good night of sleep. Because I know how great it is to have a good night of sleep, I always am struck with wonder that sleep only recently has joined the conversation when you talk about health and overall longevity. People even sometimes ask me, “Isn’t there some way I can hack into my sleep, to somehow squeeze it down significantly, so that I can just maybe go straight into, you know, the good stages, where the benefits are?” Fair enough. Good question. The answer is no.
So it turns out a great deal of housekeeping is taking place while we sleep. And sleep is much more complex than just a lack of consciousness. When you get into bed, and you pull up the covers, and you rest your head on the pillow, with your exhale of all the concerns for the day, as you close your eyes, sleep begins to unfold in a series of stages that increase in depths as the night goes on. And all those stages work together to orchestrate all the processes that are needed to derive all the benefits of sleep. For example, we know that sleep is incredibly important for immune functioning. Get a lot of consistent sleep, you’re more likely to resist infection. If you get sleep while you’re sick, you’re more likely to recover.
Recent evidence suggests that your brain even has its own dedicated waste removal system, the glymphatic system, and this is the system that works primarily while we’re asleep to remove the gunk out of our brains that seem to contribute to diseases such as dementia.
So really there is no consensus about why we sleep. We don’t really know why we spend the third of our life doing it. But one thing that I can tell you is just as the three trimesters of pregnancy can’t be whittled down to a convenient three months, it seems like sleep and the benefits of it also have an optimum period of gestation, which appears to be about 7 to 9 hours.
So, while some people are looking to get rid of sleep, there are other people that would do anything to get more of it. To them, sleep is not consistently rejuvenating, satisfying, it doesn’t leave them ready to go. This is insomnia. Now, that word doesn’t always resonate with people. If you ask them, they’re saying, “No, no, I don’t have insomnia. I just don’t sleep. I don’t look like this guy, so how bad off can I be?”
It turns out a diagnosis of insomnia doesn’t depend on how bleary-eyed you are, or even on the number of hours of sleep that you get. If you consistently don’t feel as if your sleep is rejuvenating, or if more days that not you feel as if you’re having a hard time falling asleep, staying asleep, or you’re unintentionally waking up too early, maybe you should get it checked out. And don’t fall into the trap of thinking that whatever is happening with you, that it makes sense that you have some chronic sleep loss.
Until recently, sleep problems that occurred in the context of major life stress, or medical or psychiatric conditions was largely ignored. It was thought that if some sort of medical issue were resolved, that eventually sleep would fall into place. That is clearly not what happens.
Sometimes, even when the primary issue is resolved, insomnia persists. And the reason for that is that insomnia and a lot of other symptoms are mutually exacerbating. What that means is that they’re intertwined. Take, for example, that half of the 18 million Americans who have major depressive disorder, also have insomnia. If you intervene at the level of depression, you might get symptom relief, and yet, the insomnia can persist.
But the evidence linking the relationship between insomnia and depression suggest that if you intervene on the level of sleep, that people can get relief from those symptoms of depression, and you can even prevent further episodes. Insomnia is not just a symptom; insomnia is a disorder. And when it occurs, it should be assessed and treated as the first-line problem.
Now, when people do seek treatment, they usually receive a medication, and medications are great. If you have a stressful meeting with your boss tomorrow, pop a pill; you’re going to sleep tonight. But oftentimes, people don’t want to have to rely on anything, especially over the long term, in order to get a good night of sleep. I have good news, and that is that healthy sleep is largely shaped by the things that we do: by our choices, by our behaviors. So in this way, the best sleep medicine is our behavior, behavioral medicine.
Cognitive behavioral therapy for insomnia, which is a really long name for a treatment, let’s just call it CBTI, has a substantial evidenced-base for the treatment of insomnia. And we know that not only does it work for most people, there are several different patient populations that can derive benefit: cancer survivors, people with PTSD, chronic pain, fibromyalgia, major depression.
Here, there is consensus: CBTI should be the first line of treatment when it comes to insomnia. And why is that? Why would something like therapy cure something that feels like a very physiological need? Well, in order to understand why CBTI works, you need to know a little bit about why acute insomnia becomes chronic, and has a lot to do with our behaviors.
The seemingly benign decisions we make in order to try to fix insomnia, actually perpetuate it. I blame our instincts. Let me give you an example. If you sustain an injury, you automatically apply pressure to any sort of bleeding wound. In this case, your instincts are helpful. But let’s say you’re going on a hike, and it’s a beautiful Colorado day, and you run into a bear. Every cell in your body mobilizes to react to your instinct to turn around and run. Your instincts are wrong. The bear will chase you, the bear will outrun you, the bear will catch you, and then — Well, it turns out that what your instincts should have told you to do is to make yourself look bigger, to stand tall, to puff out your chest, and talk to it on a loud voice, and in the very unlikely scenario where the bear actually attacks you, what you’re supposed to do is pick up a stick and fight back.
So this is the same thing that happens with sleep loss: we compensate for sleep loss because it tends to make sense to us. So what do we do? We doze off on the couch, we go to bed early, we sleep in late, we have an irregular sleep schedule, we become really preoccupied with whether or not we’ll be able to sleep, whether we’ve lost the ability to sleep, and this leads to a lot of hyper arousal, which is where CBTI comes in.
So there are several different components of CBTI that are tailored to each individual person, but in brief, what happens with sleep restriction is it takes someone’s existing sleep debt and grows it a little bit in order to consolidate sleep, so that people fall asleep faster, and they’re less likely to wake up. Stimulus control likes to strengthen the relationship between bed being a place for sleep, rather than other engaging activities, such as checking your email, plotting revenge, worrying, stress, or whatever else it might be.
Cognitive therapy helps people identify strategies that might be able to help them distance themselves from a mind that doesn’t seem to be able to turn off. How do they stuck up? How do medications and cognitive behavioral therapy compare with one another? Well, the evidence is in, and the results are clear. In the short run, CBTI and medications are equivalent, but in the long run, CBTI is the clear winner.
The problem with behavioral therapies is not a lack of evidence that they work; it is a lack of awareness that they exist. You could probably rattle off the names of several different sleep medications, but how many commercials have you seen for CBTI? If you have insomnia, take heart. The odds are squarely in your favor. Your sleep can get better. You can wake up rejuvenated, with mental clarity, who knows, maybe even enough energy to stand up to a bear.
But here, I think that what I’ll do is I will heed the advice of a great mind, who says that it’s more important to know what sort of person has a disease than to know what sort of a disease a person has. So, I know sleep science, but I don’t know you. We just met. I don’t know you or the relevant medical history that would have helped me design a treatment to help you cure your insomnia, but I can leave you with this: eat healthy, exercise, take care of your body, and do all that you can do to cap it all off with a night of great sleep.