Instant Genius - Overcoming insomnia, with Prof Guy Leschziner

Episode Date: March 26, 2023

If you suffer from insomnia, you’ve probably heard the same old advice before: don’t drink caffeine in the afternoon, get plenty of exercise during the day, and don’t take your phone to bed. But what if you do all that and still can’t sleep? To get more insight into insomnia and the techniques shown to overcome it, we speak to Guy Leschziner, Professor of Neurology and Sleep Medicine at King's College London. Learn more about your ad choices. Visit podcastchoices.com/adchoices

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author of the secret world of sleep and professor of neurology and sleep medicine at King's College, London. In this episode, he unpacked key tactics to overcoming insomnia, why sleeping pills are problematic at best, and also how your sleep tracker could be scuffering your shut-eye. Hello, Guy, welcome to the show. Hello, thanks for having me. So I'm going to start from the very top and with the term insomnia. So insomnia is thrown about quite a lot. But what does it actually mean?

Is it just people who have problems falling asleep or is there a more technical definition? Well, I think insomnia really encompasses a range of symptoms. But at the core of it is the inability to sleep when you want to sleep, but crucially associated with daytime symptoms. So symptoms like fatigue or tiredness or cognitive complaints. So it really encompasses people who have difficulty getting off to sleep at the beginning of the night, but also difficulty staying asleep during the course of the night, and occasionally individuals who wake up very early when they don't want to.

And so really it's the subjective experience of having poor quality sleep and of not being able to sleep when you want to. So how many people actually have insomnia? Well, this is incredibly common. And whilst many people who are awake in the middle of the night feel very isolated and alone, actually they're a member of a very large club. We know that about 30% of adults in any one year

will experience a period of insomnia. But about 10% of the adult population will experience chronic insomnia, which is where they, experienced insomnia on the majority of days for at least a three-month period. So this is a huge problem. So are certain groups more susceptible to suffering from insomnia? But we know it's a little a bit more common in women than men. We know that as we get older, insomnia tends to get commoner. And in part that may be related to other medical issues, to medications that we're on when

we get older to the fact that we're more likely to have pain, more likely to have things like bladder issues, and that, for example, if you have depression or anxiety, it's much more likely to occur. That's not to say that young people without depression or anxiety or any other conditions never have insomnia. Of course they do. So why is it that women could be more susceptible to insomnia than men? Well, I think that that's a subject of great debate. certainly there are conditions that seem to influence women more than men, and those are some of the conditions that are under hormonal regulation. So women are much more likely to experience symptoms that will feed into insomnia like Restless Leg Syndrome. In part that is hormonal,

in part that's because women are much more likely to have low iron levels, and we know that iron is very important for Estes-Legg syndrome. Certainly there are some psychological issues that tend to be more common in women than men, and there remains some debate as to whether or not that's primarily related to underlying biology or it's related to societal issues. There are other medical conditions that women are more likely to experience, particularly, once again going back to menstrual-related symptoms, pain or other symptoms, menopause, for example. So I'm going to ask the probably quite scary question about how insomnia impacts the body physically. So what happens if you consistently don't get enough sleep?

Well, it's important to start off that answer with saying that insomnia and chronic sleep deprivation are not the same thing. So we know that the majority of people with insomnia, so that subjective experience of poor quality sleep, when you measure their sleep quantity using techniques like monitoring brainwaves, that actually the majority of people don't sleep that much less than normal individuals. Their sleep may be fragmented, it may be disrupted, it may be broken, but actually the total sleep duration that they experience may not be that different. And in fact, we have very good evidence that some of the issues that we are very much concerned about when it comes to chronic sleep deprivation.

So these are people essentially who are burning the candle at both ends. Things like blood pressure issues, diabetes, obesity, heart disease are actually not applicable to the vast majority of people with insomnia. So insomnia is obviously very strongly associated with mental health conditions, but that association goes both ways. So we know that anxiety and depression can result in sleep deprivation or insomnia, but we also know that insomnia seems to be an important factor in the development of things like anxiety and depression. So there are the cognitive or the psychological consequences of insomnia.

There is also a growing body of evidence surrounding the association between insomnia and cognitive decline in the long term. So things like dementia. Now, that is also a rather complex relationship because it may, may be that actually some of the drugs that are used to treat insomnia might give rise to cognitive decline. It may be that actually one of the very early features of some of these conditions, conditions like Alzheimer's disease, may actually be insomnia. And that's certainly something that we're beginning to learn in other areas of neurology. So, for example, in Parkinson's disease, we are now understanding that there are sleep issues that will often precede the development of Parkinson's

disease by years or even decades. And so it's not impossible, actually, that in the extremely early stages of some of these conditions like Alzheimer's disease, sleep may deteriorate very early on as well. But it may also be possible that actually insomnia influences the likelihood of developing these conditions. And the reason why we think that that might be the case is because we know that one of the functions of sleep is to facilitate the removal of toxins or metabolize, or metabolism. Abolites, breakdown products of normal life from the brain. And so if you are getting disrupted sleep, poor quality sleep or limited sleep, that might influence those kinds of processes. So is there a strong relationship between insomnia and something like anxiety?

Well, I think there is a very strong relationship between the two. So if you think about it, what happened in anxiety? Anxiety is about an elevated level of perceived threat. So you are looking for threat in your environment. And of course, when you are in that sort of low-level flight, fright or flight state, then that is going to influence the quality of your sleep because your brain is not going to switch off. That's a survival instinct. You know, if you feel that you're under threat,

then the last thing you want to do is to go to sleep. So there is that direct association between anxiety and sleep anyway, but we know that if you have poor quality sleep, that is going to elevate your levels of anxiety. Even on a genetic basis, there is an incredible amount of overlap between the genes that influence the development of insomnia and the genes that influence the development of anxiety.

So from a genetic perspective, these are rather similar conditions as well. So I can't put it off any longer, and I really need to get into what people really, really want to know, which is how to overcome insomnia. and I think a good place to start will be talking about sleeping pills. Do any of them actually work? Well, they do. Yes, of course they do. I think one of the problems with many of the sleeping pills that are available either over the counter or even by prescription is that they have a number of issues associated with them. The first is that people very quickly develop a tolerance to these pills. And so whilst they may shorten your sleep latency,

which is the time from which you go to bed and fall asleep, and they may improve sleep quality to some extent. That effect is often very short-lived. And so within a few days or a few weeks, that effect wears off, and people tend to require higher and higher doses to get the same effects. People often will develop a psychological dependency to these drugs.

They will essentially become addicted to them. These drugs are not without side effects. So many of the drugs, particularly some of the prescribes, of drugs can result in significant cognitive problems, particularly in the morning, a hangover effect or can even lead to people having crashes when driving a car. So they're not without issues. And then there is this growing body of literature that is tying some of these drugs with increased risk of cognitive complaints. So, you know, that it may be that some of these drugs, when taken long-term are acting as a prelude or maybe increasing your risk of developing conditions like

dementia. Now, as I've already said, that is a very complex relationship, but certainly it's a good reason to at least consider alternatives to some of these drugs when it comes to fixing sleep. What should somebody do if they can't get to sleep? So it's lying in bed, waiting for sleep to come, and it just doesn't. I think this is probably one of the most common problems with people with insomnia. What should they do? Yeah. So I think the first thing to do is to focus upon aspects of your behaviour that we group into this horrible term called sleep hygiene. So sleep hygiene defines these kinds of behaviours that influence sleep. Things like, for example, alcohol use, caffeine usage, exercise during the day, not using nicotine in,

the hour or so before bed. Making sure that your sleeping environment is conducive to sleep. So, you know, quiet, a reasonable temperature and dark. Making sure that you are using your bed space for nothing other than sleep. So, you know, it's amazing, particularly with people working from home, how many people have, you know, got their home office set up in their bedroom and their, you know, their brain on a conscious or on an unconscious level associates their sleeping environment with working, with getting emails, with surfing the internet, with watching television. So these are all things that we term sleep hygiene. A lot of people say, well, you know, I've got chronic insomnia. I've tried all these sleep hygiene measures and it hasn't helped my sleep. And it's important to

stress that sleep hygiene on its own is probably not an adequate treatment for chronic insomnia. And in fact, there are many people who sleep very, very well who will have a espresso before bed or will watch Netflix on their phone until the last possible moment before they switch off the lights. And so sleep hygiene doesn't necessarily make the difference between somebody who's a great sleeper and somebody who's a bad sleeper. For people with chronic insomnia, actually the gold standard treatment that we recommend as first line is a treatment called cognitive behavioral therapy for insomnia. And we know that this treatment, which we call CBTI for short, is actually a very good treatment for the majority of individuals.

And it helps up to between 60 and 80% of individuals reestablish normal sleep patterns. And so if I had one piece of advice for people who suffer from chronic insomnia is to explore the possibility to get this treatment delivered to them. Yeah, it's really, really interesting. I think before I did this, podcast. I asked around the office if anyone had any questions about insomnia. And a few people were asking just, what can I do? I seem to be doing all the classic sleep hygiene advice. I get plenty of exercise. I go for, you know, walk in the morning outside, avoid caffeine past midday, going to bed, waking up at the same time every day, not using phone in bed,

but I still can't sleep. Is that the point where someone should be reaching out for sort of further help with CBTI? Yeah, absolutely. I mean, it's worth. It's worth talking a little bit about what we think is going on in chronic insomnia. We know that in chronic insomnia there are some psychological factors, but there are also some physiological, some biological factors. So those psychological factors can be conscious. And what I mean by that is that, you know, often people who have got chronic issues with sleeping will develop some specific sleep-related anxiety. So they will be anxious about the fact that they may not be able to sleep. They'll be anxious about the fact that they are expecting a horrible night ahead of them.

They'll be anxious about the fact that they may not be able to function properly the following day or may not be able to perform their work or social issues or whatever. They may even be anxious about the long-term health implications of not being able to get off to sleep. But there are also a number of unconscious factors. So we, in some respects, humans are no more glorified than Pavlov's dogs. And in that we exhibit this conditioned response to bed. Sleep, the association between bed and sleep is a learnt behavior as children. And any learned behavior can be unlearned. And so can be replaced by a negative conditioned response whereby we associate bed with being awake rather than being asleep.

And that is on an unconscious level as well as a conscious level. And so essentially what we need to try and do is to retrain the brain to associate bed with sleep rather than bed with wake. And that sleep retraining process is really at the core of cognitive behavioral therapy for insomnia. It's peak pollination season and my business is scaling fast. To keep the nectar flowing, I need a phone plan with top priority data speeds. That's why I chose GoogleFi Wireless. My connections stay strong even when the hive is buzzing.

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relaxing elsewhere and then only return to bed when you are feeling sleepy. Does that hold up? Absolutely. Essentially what this is trying to do is it's trying to minimize the amount of time that you are in bed awake. Because the longer you are in bed awake, the stronger that association becomes. And, you know, it's not unsurprising that many people with insomnia, what they do is they try and spend longer in bed. They go to bed a bit earlier, they have a lie in because they think, well, if I'm going to have rubbish sleep, then I may as well try and maximize the amount of rest or sleep that I'm getting by staying in bed for prolonged periods of time. Whereas actually, that is probably rather counterintuitive, one of the worst things

that you could do, because you are then strengthening that association between bed and wake, rather than building an association between bed and sleep. So does sleeping less effectively make you sleep better? In the short term, absolutely. In fact, one of the core features of CBTI is a protocol called sleep compression or sleep restriction. Essentially, what this aims to do is it aims to put you into a slightly sleep-deprived state whereby it utilises the brain's own mechanisms to drive sleep and tends to force your brain to begin to associate

drifting off or getting into bed, switching the lights off with drifting off to sleep and then trying to consolidate your nighttime sleep and over time, the amount of time you are allowed to spend in bed gets lengthened if your sleep quality improves. And that's a very effective treatment. In fact, it's probably one of the most effective

aspects of CBTI. In Australia, they've developed a treatment called intensive sleep retraining. And whilst I don't necessarily suggest this for people, because it's almost like something out of Guantanamo Bay, it's quite a useful illustration of this at its most extreme. So imagine that you have chronic insomnia and you can't drift off to sleep when you get into bed. So what they do is they say to you, well, the night before you come into the sleep laboratory, we don't want you to sleep at all. So you come into the sleep lab on that night, having not slept at all the night before. You're wired up to an EEG machine so that we monitor your brainwaves. And then every half an hour, the lights are switched off and you're told to try and

go to sleep. Now, if you haven't fallen asleep within about 15 minutes, the lights come on again, and they say, okay, stay awake until the next half hour, every half hour on the half hour. If you fall asleep, then after three minutes of sleep, it's verified by your brainwaves, you're woken up again. So essentially what this means is that over the next 25 hours, you have 50 attempts to go off to sleep. And if you do manage to go off to sleep, you're only allowed to sleep three minutes, so you end up being extremely sleep deprived. So for people with bad insomnia, they won't fall asleep at all over the first few trials, but by the end of that 25-hour period, because they are so sleep-deprived, they will literally

fall asleep as soon as they're allowed to. And so what this does is it's very good at rebuilding that association between your head hitting the pillow and lights going off with you drifting off to sleep rather than what you were left with before, which is when you were left with. you get into bed and your head hits the pillow, your brain suddenly becomes very active and wide away. And we know that even that very acute treatment can be a very good and effective treatment for people with chronic insomnia. It does sound like quite an extreme technique, but is there anything that somebody could do that's similar to that, that they can do from home? Yeah, well, I think that certainly compressing your sleep can be very effective. So,

What we generally tend to do is we ask people, well, how long do you think you are actually sleeping in total? And they will say, well, I sleep, for example, six hours a night. And one of the things to do is to say, well, if you are only sleeping for six hours a night, then what you should start by doing is just spending six hours in bed. So you go to bed at 1 a.m. and you wake up at 7 a.m. and whatever happens, you will not go to bed before 1am, and you will not get out of bed beyond 7 a.m. for a short period of time. So what that tends to do, initially, obviously that's quite difficult,

because you go to bed, you're taking ages to get off to sleep, your sleep may be a little bit broken, but over time what will happen is that you will start falling asleep relatively quickly when you get into bed and you will wake up as your alarm goes off at 7am. Now, once that is happening on a consistent basis, then you can start gradually increasing the amount of time that you are in bed. So after a couple of weeks, you start going to bed at 1230 rather than 1am and gradually increase it up to a point where you've kind of hit the optimal amount.

So in that circumstance, if someone's going to sleep at 1am, what should they be doing while waiting for sleep? So is the advice about, say, not watching TV? Does that hold, or is that actually a good way for people to unwind before then? Well, we generally tend to recommend that people try and do something calming and relaxing, and of course it depends what you're watching on television as to whether or not that's calming or relaxing. One of the big issues, of course, is light exposure, because we know that what happens with light exposure, particularly light that is rich in the blue part of the light spectrum,

is that it suppresses your natural melatonin. And melatonin is a hormone that your brain pushes out, which is a chemical signal to sleep. So we know that if you are exposing yourself regularly to bright light, particularly in the evening, that can cause fundamental changes to your body clock, and we can make it more difficult for you to drift off to sleep. So what we would generally recommend is reading on a book,

on an analog device rather than a digital device, especially not one that is backlit, and listening to music, listening to a podcast, obviously not something as interesting as your podcast, but something that's relatively unstimulating, these kinds of activities. What do you think about sleep trackers? Are you a fan? Are you not a fan? Well, I think the sleep trackers are very, very useful from a research perspective, really very useful from a research perspective. My major issue with sleep trackers is that people who tend to get very involved in tracking their sleep are often the people who already have some anxiety about their sleep.

And sometimes that sort of obsessionality about sleep can be fueled by the obsessive tracking of data. And so sometimes actually these sleep trackers can actually feed into insomnia rather than be helpful. In times gone by, one of the big issues was that these sleep trackers were very inaccurate. And so people would often get very anxious about data, which in itself was inaccurate, and would sometimes diagnose themselves with sleep complaints that they didn't actually have, which was a problem. I think these sleep trackers have become more accurate. There are still some issues in terms of their accuracy,

particularly when it comes to people who are not normal sleepers. so people who have sleep disorders. And so generally speaking, I say to people, look, if you are worried about your sleep, if you think your sleep is a poor quality, then please just put the sleep tracker away and go and speak to somebody about your sleep rather than obsessionally tracking it. What about meditation is? It's one of these sort of solutions that has often sort of banded around. Do you think there's any solid clinical evidence that meditation will help insomnia acts?

Yeah, I mean, I think meditation is another term for sort of spiritually based mindfulness. And we know that mindfulness-based therapies are very useful in trying to address that low-level fright, flight or fight response that is so negatively impacting upon sleep. And in fact, there are some mindfulness-based approaches that are part and parcel of cognitive behavioral therapy for insomnia. So I think as part of the overall treatment strategy, for chronic insomnia. I think these can be very useful indeed. Could it help with that anxiety that people have before bed? Earlier you were saying that whether people know it or not, they're having

that performance anxiety about sleeping? Yes, absolutely. I think that that is very much helpful for some of that sleep-related anxiety, and a variety of different techniques are used in standard sleep therapy to try and help, be that progressive muscle relaxation, other mindfulness-based approaches, distraction techniques, a whole range of things. So I think really, you know, if mindfulness or meditation works for you, then absolutely you should be doing that as part of your standard behaviour pre-sleep. You sort of mentioned a few then, but it'd be good if you could unpack it a bit about some of the other techniques that people could use to process that anxiety before sleep?

You've already mentioned meditation or meditation-based techniques. I think that there are a number of other strategies that people can use. So there's a strategy called progressive muscle relaxation, which is where you concentrate on various muscle groups within your body and you tense them and then relax them in an effort to try...

Well, first of all, it's about distracting you away from the process of getting off to sleep, but it's also quite a useful technique for relaxation There are visualization techniques. So, for example, imagining that you're in a pleasant place and journeying through. I think the key thing is that there are a lot of different ways in which you can try and distract yourself from the process of going off to sleep, including, as you said, listening to a podcast or an audiobook or something else. And, you know, essentially what we're trying to do is we're trying to avoid.

people focusing on the process of getting off to sleep because in individuals with insomnia, it's that process itself that creates anxiety. But by the way, one of the very common things that people with insomnia describe is that they will say, well, you know, I'm sitting on the sofa, reading a book or watching television,

and I will feel myself overcome with sleep and will feel myself dozing off. And then as soon as I get into bed, I suddenly feel wide awake. There's this sort of paradoxical alerting response. And I think that very much, illustrates the fact that when people are not focused on drifting off to sleep, they will drift off to sleep. But as soon as they're focused on drifting off to sleep, they'll be

unable to. What happens? What is going on if somebody's feeling quite sort of generally sleepy before bed, able to get off, fine, but then sort of still wake up several times a night with these anxious thoughts? So that can be obviously part and parcel of insomnia. And in some individuals, it seems that the brain is rather better than in other individuals when you're very sleep deprived at overcoming that insomnia, which is why you're falling asleep very easily. But then once that pressure has been taken off by a few hours of sleep, then the insomnia comes to the fall. But it's important to recognize that there are, of course, other sleep disorders that can give rise to recurrent awakenings at night. So conditions like obstructive sleep apnea,

where people have a problem with their breathing at night, and that results in recurrent awakenings. Conditions like periodic limb movement disorder, which is a neurological disorder that results in recurrent kicking or twitching, it's sometimes associated with a condition called Restless Leg Syndrome, and that can result in fragmentation of sleep and recurrent awakenings as well. So it's not the case that everybody who wakes up repeatedly at night and wakes up feeling unrefreshed has got insomnia.

They may have other sleep complaints. So if someone was looking to get diagnosed with a sleep disorder like that or were looking to find help about some of the techniques you mentioned, CBTI, is the best approach to go to their doctor? Yes, go into your GP. So, you know, one of the problems historically within the NHS has always been that CBTI has been very poorly provided for. but actually over the last couple of years there have been a number of different digital platforms so essentially these are web-based platforms that run through CBTI with you that you can actually access either free or free with a GP referral and so I think that if you are experiencing insomnia then absolutely the first thing that you should be doing is exploring one of these digital CBTI platforms going and having a chat with your

GP may well ascertain that there may be other things at play that might be giving rise to your sleep difficulties. A lot of these CBTI platforms have got a sort of pre-initiation questionnaire where they try and highlight those individuals that may have something else going on and may recommend that you go and see your GP before embarking on CBTI because there is a high suspicion that you may have another sleep disorder. This might be putting you on the spot bit, but what is the most misunderstood thing about insomnia that you can think of? I think the most misunderstood issue is the fact that people think that if they have insomnia, they should be spending more time in bed. The other issue is the fact that actually what we

know is that we are very poor witnesses to our own sleep. And that objective measures of sleep and subjective experience of sleep can often be vastly different. So essentially, you should be going to the doctor to see if you have one of these sleep disorders, if it's quite hard to tell objectively from the outside of what your sleep is like? Well, I think certainly if your subjective experience of sleep is very poor, then that tells you what you need to know about your sleep. So if you are sleeping what you feel to be an appropriate duration, but you wake up feeling unrefreshed or sleepy,

then that suggests you've got a problem. If you are unable to sleep when you want to sleep and waking up feeling very bad, then it suggests that you have a problem with your sleep. If you are sleeping okay and you have no daytime symptoms, then that suggests your sleep is okay for you. Is there anything that I should have asked but didn't? I think along the lines of what we were just discussing is, you know, a lot of people experience what we turn paradoxical in insomnia, which is when they feel that they have slept very little or slept very poorly,

but a recording of their brainwaves shows that they've actually slept. a very good amount. Now, we used to think of that as primarily as a psychological phenomenon, but I think that what that really illustrates is the fact that the brain can exist in different stages of wake or sleep at the same time. And I think that this phenomenon is responsible for many of the kind of weird and wonderful things that we see in clinical sleep medicine, like sleep paralysis or hallucinations at night or sleepwalking, for example. But actually in paradoxical insomnia, what we think is going on, is that there are small areas of the brain that actually are in much less deep sleep than other parts of the brain. And those parts of the brain are primarily responsible for awareness.

So whilst the majority of your brain is actually getting very good sleep, it may simply be that the parts of your brain that are responsible for awareness or consciousness are not quite in as deep sleep as they should be. Is there any way of telling if you have paradoxical insomnia? Well, I think the easiest way of telling if you've got paradoxical insomnia is to record your brain waves, which is not very easy to do. But the other way, for example, that it often comes to light is, for example, I will ask patients, well, how much do you think you slept last night? And they'll say, I didn't sleep at all. And then their partner will say, well, you snored all the way through

the night. I think that's a very good indication that they've got paradoxical insomnia, for example. That was Professor Guy Leicester, author of The Secret World of Sleep, and Professor of Neurology and Sleep Medicine at King's College London. Thank you for listening to this episode of Instant Genius, brought to you by the team behind BBC Science Focus magazine, which you can find on sale now in supermarkets and newsagents as well as your preferred app store. If you've enjoyed this episode, make sure to subscribe for more. And you can, of course, also find us online at sciencefocus.com. This podcast is sponsored by Name, Audio and Focal.

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