341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with CBT-I

1. 0:00 – 1:35

   Intro

   1. PAPeter Attia0:00

      Low end, one in 20. High end, one in 10 people, adults?

   2. AMAshley Mason0:03

      Adults.

   3. PAPeter Attia0:04

      Wow.

   4. AMAshley Mason0:04

      I guess most people at some point in their lives are going to have an issue with insomnia, whether people have difficulty falling asleep in the beginning of the night, waking up in the middle of the night, waking up too early in the morning. The people who can't fall asleep at the beginning of the night, their mind's just racing earlier than yours.

   5. PAPeter Attia0:20

      Mm-hmm.

   6. AMAshley Mason0:21

      Yours is just waking you up. Okay, this is really important to you. This is something you're doing all the time, all day. Guess what? What do we do with things that are really important to us?

   7. PAPeter Attia0:29

      Make time for them.

   8. AMAshley Mason0:30

      We schedule them, exactly. I always tell patients, "If you don't deal with what's causing you stress or anxiety during the day, it's going to demand to be dealt with in the middle of the night."

   9. PAPeter Attia0:39

      Let's talk about sleep supplements.

   10. AMAshley Mason0:42

       Ugh.

   11. PAPeter Attia0:43

       Right?

   12. AMAshley Mason0:43

       Melatonin's like the guy at the start of the race, right? He's the guy with the gun. He fires the gun. He doesn't have a car in the race. He's not, like, helping you stay asleep. He's telling you when to start the thing. So for a lot of adults, taking melatonin is really messing them up.

   13. PAPeter Attia0:58

       I think the, the time in bed restriction's pretty interesting.

   14. AMAshley Mason1:01

       I don't even do time in bed restriction that first week.

   15. PAPeter Attia1:03

       Mm.

   16. AMAshley Mason1:03

       Because for some people, setting awake time solves the issue.

   17. PAPeter Attia1:08

       Hmm. Let's go back to sleep hygiene for a second.

   18. AMAshley Mason1:10

       Caffeine withdrawal is not something I wanna deal with in my clinic-

   19. PAPeter Attia1:13

       Hmm

   20. AMAshley Mason1:13

       ... and I don't think it's necessary. So I tell people, "Do not change how much coffee you're drinking. Put it all before 11:00."

   21. PAPeter Attia1:19

       When does the treatment fail?

   22. AMAshley Mason1:21

       The treatment fails when people don't do it. [upbeat music]

   23. PAPeter Attia1:26

       Hey, everyone. Welcome to the Drive Podcast. I'm your host, Peter Attia. Hey, Ashley. Thank you so much

2. 1:35 – 7:15

   Defining insomnia: diagnosis, prevalence, and misconceptions

   1. PAPeter Attia1:35

      for, uh, for coming to Austin to talk about a lot of interesting things. Um, let's, let's start with, with the one that I think everybody listening can probably relate to at least once, which is insomnia.

   2. AMAshley Mason1:49

      Mm-hmm.

   3. PAPeter Attia1:49

      So, uh, where did your interest in insomnia arise?

   4. AMAshley Mason1:53

      Well, I've been interested in sleep for a long time. I was fortunate to go to the University of Arizona for my doctoral work, and when I was there, uh, the late Dick Bootzin was also there, and he's one of the co-inventors of cognitive behavioral therapy for insomnia. And I think I found it particularly interesting because it works so well. We have so many different psychological treatments, and they all have varying degrees of efficacy and effectiveness. And, um, the thing about cognitive behavioral therapy for insomnia is that it's kind of like a recipe. If you do it, it works, and this was always just so interesting to me because it was so different than so many other psychotherapies out there that had just so much more unpredictable outcomes. And [lips smack] I would say that I became much more interested in it after my post-doctoral work when I'd gotten to UCSF and, um, I was a post-doc at UCSF, but I started my assistant professorship at UCSF, and there was this gaping hole in treatment availabilities for people with insomnia. And I thought, "Oh, you know, like, this might be a, a good way for me to get back into some clinical work." I was doing just research at the time. And I fell back in love with it because there's almost nothing as rewarding as being able to see a patient seven times, and that seventh time, have them say something to you along the lines of, "I have my life back. I'm gonna go get my driver's license back. I'm not afraid to drive with my kids in the car anymore. I'm gonna go back to work. I have my life back." I mean, not much better than that. And so I grew the clinic that I do CBT-I in, and now I just... I love it so much that I do it on top of my job. Like, I do it at night with patients, um, after hours 'cause it's, it's the most rewarding thing, and you can have such a big impact, and people need it.

   5. PAPeter Attia4:03

      So before we dive into what CBT-I is and how it works and how profound it can be, let's maybe help folks understand a little bit about insomnia and maybe go through some of the definitions around the different types of insomnia, um, and, uh, maybe some of the different causes for it and, and maybe even what some of the other treatments are, pharmacologic and otherwise.

   6. AMAshley Mason4:26

      Yeah. So broadly speaking, most people at some point in their lives are going to have an issue with insomnia. I think some 90% of adults at some point are gonna struggle with insomnia and, and point estimates, I think, at any given moment might be between 5 and 10%. The interesting thing about insomnia is that it's a very clinical diagnosis, right? Um, there's no blood test for insomnia. There's no... We can't put you in a sleep lab overnight-

   7. PAPeter Attia4:57

      Mm-hmm

   8. AMAshley Mason4:57

      ... and do a test to see if you have insomnia, and we don't diagnose insomnia based on one night of bad sleep. If someone says, "Oh, I didn't sleep at all last night," or, "I haven't slept even for just the last week," that's not gonna get you a diagnosis of insomnia.

   9. PAPeter Attia5:11

      I see.

   10. AMAshley Mason5:11

       So, um, and there's a whole, whole suite of different insomnias that we could talk about, but I think the point that is the most salient is just that when you have a problem sleeping and when it's been going on for a long time, at least like three-ish months, and when you really feel it's a problem, that's when it's time to get help, um, because there's plenty of people who don't sleep a whole lot, but it's not distressing to them. It's not causing any problems in their life. They're not going to meet, you know, a definition of insomnia per se. Um, it's the folks who will tell you that, "I can't sleep. I haven't been sleeping for months. It's interfering with my life. It's really upsetting," and- They've started-- They've probably already started trying a whole bunch of things to try and help themselves to fix it, and this is where things get interesting.

   11. PAPeter Attia6:10

       And just to be clear, Ashley, when you say that a point estimate of five to ten percent of the population would have insomnia at any point in time, you mean according to that definition where it's been going on for months, it's causing distress, and it's impacting life.

   12. AMAshley Mason6:25

       Yeah, broadly speaking.

   13. PAPeter Attia6:26

       Wow. That's-- So it's one in... low end, one in twenty, high end, one in ten people, adults?

   14. AMAshley Mason6:32

       Adults. Ad-

   15. PAPeter Attia6:32

       Wow

   16. AMAshley Mason6:32

       Yes, yes. By the way, I do not do pediatrics, so please assume everything we're talking about today is adults. Insomnia in children is a totally different thing.

   17. PAPeter Attia6:40

       So that's a higher estimate than I would've guessed.

   18. AMAshley Mason6:43

       Yeah.

   19. PAPeter Attia6:43

       G- g- I mean, given your definition. If the definition was three nights of bad sleep, I would say, "Yeah, that makes sense." So-

   20. AMAshley Mason6:49

       Yeah

   21. PAPeter Attia6:49

       ... that's pretty startling.

   22. AMAshley Mason6:50

       But that's at any given point in time.

   23. PAPeter Attia6:51

       Yeah.

   24. AMAshley Mason6:51

       And insomnia is, for most people, probably quite episodic.

   25. PAPeter Attia6:57

       Mm-hmm.

   26. AMAshley Mason6:57

       It's not necessarily a permanent state. Um, people go in and out of it, and the question is, how quickly do people go out of it when they go in it? And that's what CBT-I is so beautiful for. It's helping people get out of it quickly. There's gonna be things in your life that are going to just happen, and they're going to put you over the threshold

3. 7:15 – 11:39

   How insomnia develops, and breaking the cycle with cognitive behavioral therapy for insomnia (CBT-I)

   1. AMAshley Mason7:15

      for insomnia. So maybe we can talk for a minute about how insomnia begins-

   2. PAPeter Attia7:19

      Yeah

   3. AMAshley Mason7:19

      ... and then how it's perpetuated 'cause these things are actually quite different.

   4. PAPeter Attia7:22

      Yeah.

   5. AMAshley Mason7:22

      So you and I and everybody have a certain level of predisposing factors that are gonna put us at risk for having sleeping problems, in particular insomnia, right? And then we may experience what's called a precipitating factor. That could be a major life event like losing your job, getting a divorce, getting in a car accident, some major unexpected unhappy life event that might throw you into a bout of insomnia, right? And that, that event will end, though. That event ends. The car accident ends. It resolves. The job loss ends. You get a new job or you don't. The divorce ends. You move on, right? But in the meantime, when you're dealing with that event, you develop behaviors to cope with it. And so you might, for example, pop a Benadryl to help you sleep or an Ambien, something stronger. You might start taking naps the next day after a bad night of sleep to try and cope with it, right? You might start reading in bed a lot or flipping through your smartphone in bed, doing all these different types of behaviors to try and help yourself calm down and actually get to sleep, which in the short term make a lot of sense, right? You're trying to help yourself in the acute moment. But in the long term, these kinds of behaviors aren't actually doing you any favors, and over time, that precipitating factor is gonna go away. But all of these behaviors that you've started doing to respond to the precipitating event, they're what stick around, and those are what are gonna perpetuate insomnia symptoms and problems.

   6. PAPeter Attia8:57

      Can you say more about the predisposing factors?

   7. AMAshley Mason8:59

      Yeah.

   8. PAPeter Attia8:59

      Are those genetic, um-

   9. AMAshley Mason9:02

      Yeah

   10. PAPeter Attia9:02

       ... you know, yeah.

   11. AMAshley Mason9:03

       Yeah. So there's, of course, genetic predisposing factors, right? I've had patients come and say, "I'm a really light sleeper. Can you fix that?" Mm, that's gonna be pretty tough to fix-

   12. PAPeter Attia9:14

       Mm-hmm

   13. AMAshley Mason9:14

       ... right? I'm gonna recommend something like earplugs, an eye mask, a white noise machine, what, what have you. But yes, there are gonna be predisposing factors. So if you are higher on the, on general psychological reactivity, right, you're going to probably get pushed over the threshold more easily than someone else, right? Some people might get in a car accident, a fender bender, and they're over it by the next day. The car's in the shop, whatever. Other people might feel antsy about driving for a while after that. They might feel more anxious as a result, a result of that event, and that's gonna differ from person to person. You can argue that that's genetic. You can ar- argue that that's based on early childhood or other experiences. Mm.

   14. PAPeter Attia9:59

       Mm-hmm.

   15. AMAshley Mason10:00

       But nature and nurture probably both contribute to that predisposition, and there's not a whole lot that we can do about that. But this is the beauty of cognitive behavioral therapy for insomnia. When people come in for treatment, they're often pretty focused on what caused their insomnia, and I actually don't ask people what caused their insomnia until, mm, the end of my first session with them. I'm asking them all these other kinds of questions about their behaviors now, and at the end I ask, "Okay, so when did this start? What do you think might have caused this?" And get their attribution for what's going on because at the end of the day, the intervention's the same, and that's what's beautiful about this and might differ a lot from the practice of medicine. I'm not, I'm not an MD. I'm a PhD, right? So in, in, I think in a lot of disease states, we often look at what, what caused what's going on. I'm not really concerned. I'm more concerned about what you're doing now that's perpetuating the problem-

   16. PAPeter Attia11:00

       Mm

   17. AMAshley Mason11:00

       ... and that's where I intervene, and that's why this particular treatment is so effective for so many different presentations of insomnia and causes of insomnia, whether people have difficulty falling asleep in the beginning of the night, waking up in the middle of the night, waking up too early in the morning, right? You might think on their face these people all need wildly different treatment, but that's not actually the case.

   18. PAPeter Attia11:25

       Yeah. That makes a lot of sense. So the focus is much more on the coping strategy and the behavior that came out of the predisposing factor or the precipitating event actually is really-

   19. AMAshley Mason11:35

       That you use to respond to the precipitating-

   20. PAPeter Attia11:37

       Yeah, yeah

   21. AMAshley Mason11:37

       ... event exa- exactly.

4. 11:39 – 21:16

   The different types of insomnia, and the impact of anxiety, hydration, temperature, and more on sleep

   1. PAPeter Attia11:39

      Okay.

   2. AMAshley Mason11:39

      Yes.

   3. PAPeter Attia11:40

      Um, can we talk a little bit about, you know, is there a difference, for example, between the individual who can't fall asleep, you know, this initiation of sleep in- insomnia versus the person, um, that I hear much more about-

   4. AMAshley Mason11:56

      Yeah

   5. PAPeter Attia11:56

      ... and frankly, I experience more, which is, "Eh, it's not that hard for me to fall asleep-

   6. AMAshley Mason12:01

      Mm-hmm

   7. PAPeter Attia12:01

      ... but boy, I will jolt up at 1:00 in the morning-

   8. AMAshley Mason12:05

      Yes

   9. PAPeter Attia12:05

      ... with some thought or anxiety that-

   10. AMAshley Mason12:08

       Yes

   11. PAPeter Attia12:08

       ... I can't get out of my mind, and my mind starts running, and I can't go back to sleep. Or I get up because I gotta pee-

   12. AMAshley Mason12:15

       Mm-hmm

   13. PAPeter Attia12:15

       ... but when I come back, I erroneously Just do something with my mind where I get thinking about the day's problem or whatever, whatever, whatever.

   14. AMAshley Mason12:24

       Yeah.

   15. PAPeter Attia12:25

       Um, so d- do you think of those as different or are they just same side of a different coin? Different side, same coin, I guess I'm... Yeah.

   16. AMAshley Mason12:32

       Great question. Great question. So, um, those people need the same stuff.

   17. PAPeter Attia12:38

       Hm.

   18. AMAshley Mason12:39

       And the people who can't fall asleep at the beginning of the night, their mind's just racing earlier than yours.

   19. PAPeter Attia12:44

       Mm-hmm.

   20. AMAshley Mason12:44

       Yours is just waking you up. And there's a whole suite of interventions that are part of cognitive behavioral therapy for insomnia, and there are m- a lot of ways that I could approach an answer to this question. So I think starting by addressing the racing mind issue. I always tell patients, "If you don't deal with what's causing you stress or anxiety during the day, it's going to demand to be dealt with in the middle of the night." It's going to say, "Oh, Peter, I notice you're, you know, laying there peacefully, not doing any work or tasks, and you don't have anything you need to do right now, so you're gonna pay attention to me." And it's going to demand your attention at that time. Other people, that happens right when their head hits the pillow at the beginning of the night. "Oh, you're relaxing now. Okay, here's your 10 things to worry about." Right? So one of my favorite interventions that's actually born of anxiety treatment, but that I've co-opted and I've moved into cognitive behavioral therapy for insomnia because it fits with the theoretical framework, is something called scheduled worry time. This sounds a little bit pedantic and silly, but hear me out. If a patient came to me and said, "Ashley, like, I worry all day. I have-- I'm worried about all of these things and th- my, my life is just a constant ball of worry." And I said, "Okay, I've got a solution for you and it's two words. Ready? Stop it." [laughs]

   21. PAPeter Attia14:09

       Yeah.

   22. AMAshley Mason14:09

       That wouldn't work, right? Doesn't work. So I take the opposite approach. "Okay, this is really important to you. This is something you're doing all the time, all day. Guess what? What do we do with things that are really important to us?"

   23. PAPeter Attia14:21

       Make time for 'em.

   24. AMAshley Mason14:22

       We schedule them, exactly. So I have my patient literally get a... We used to-- Back in the day of paper calendars, this was like a-- this felt like a different exercise. Now people get out their phones. But I have them get out their phone or whatever and say, "All right, we're gonna schedule worry time, and it's gonna be an hour a day for the next seven days. It is non-negotiable. I may or may not schedule an email to go out to you at that, at the end of that time, and you have to go and [chuckles] reply to it and tell me what you did." Right? Um, and what we find is that when people work with this during the day, it does two things. The first is, let's say it's nine AM and you are trying to do something in your life, and instead a worry pops up. You can actually think, "Oh, okay. I don't have to deal with this now. I'm gonna write this down 'cause at four o'clock I've got scheduled time to deal with this." Right? So that way you're uncluttering the rest of your day-

   25. PAPeter Attia15:17

       Mm

   26. AMAshley Mason15:17

       ... by moving all of the worry into that scheduled time.

   27. PAPeter Attia15:20

       So this could be a valuable technique even absent insomnia.

   28. AMAshley Mason15:24

       Totally.

   29. PAPeter Attia15:24

       Yeah.

   30. AMAshley Mason15:25

       I would t- I'd say that probably between a third and half of my patients who come in with insomnia, they've got some, some bad sleep stuff for sure, but for some of those people it's pr- it's a primary anxiety disorder and sleep is suffering also. Whereas other folks it's primary insomnia that's driving them anxious, right? But to rewind back to your earlier question about the middle of the night versus the beginning of the night. So the other thing that scheduling worry time does, besides uncluttering your whole day, is it helps you get it done during the day so that when your head hits the pillow-
5. 21:16 – 32:37

   The core principles of cognitive behavioral therapy (CBT) and how CBT-I is used to treat insomnia

   1. AMAshley Mason21:16

      when you're in your bed.

   2. PAPeter Attia21:17

      I wanna kinda go into more, many more of these 'cause I know this is, this is the exciting stuff that people are interested to hear about. But I, I do want to take one step back and just make sure-

   3. AMAshley Mason21:25

      Mm-hmm

   4. PAPeter Attia21:25

      ... we kind of understand how-- what, what constitutes cognitive behavioral therapy before we even get into cognitive behavioral therapy for insomnia. So we've, we've had a podcast where we talked about dialectical behavioral therapy, DBT, but we haven't covered CBT.

   5. AMAshley Mason21:40

      Okay.

   6. PAPeter Attia21:40

      Can you give us a little bit of the tapestry of what defines it and why it, of course, then has this, um, additional subset of, of treatment for insomnia?

   7. AMAshley Mason21:51

      Yeah. I, I shoulda done that first. That's a great, great question. So, um, cognitive behavioral therapy, my favorite way to think about this is in a triangle. We have thoughts, we have feelings, and we have behaviors, and you can think about this triangle as having these three pieces that are all connected. And cognitive and behavioral therapies, or cognitive behavioral therapies, generally will focus on one intervening on this process between thoughts, feelings, and behavior, thoughts, feelings, and behavior, on one of these, the sides of the triangle, right? So let me just spell out a quick example process, right? So let's say we have a patient with type 2 diabetes who has the thought, "I'm never gonna be able to get my blood sugar under control. I'm, I'm never gonna be able to manage this. I'm not gonna be able to do this." When a person has those thoughts, how do they feel? Crummy. They feel bad about themselves. When people feel bad about themselves, what do they do? Eat some chocolate cake. Eat some chocolate cake. What does that do? That reinforces the thought, "I'm never gonna be able to do this," right? So we've got this pattern of thoughts, feelings, behavior, right, r- on repeat, right? And cognitive behavioral therapies will choose where to intervene on a process in that triangle. So we might intervene... Cognitive behavioral therapy for insomnia, for example, is really focused on the area between thoughts and feelings in many ways because people will have a lot of thoughts. "I, I can't sleep. I'm, I'm, I'm never gonna be a good sleeper. I'm-- If I don't sleep eight hours tonight, I'm gonna lose my job," whatever, and then the big emotions that follow from that. We work on questioning a lot of those thoughts to then recalibrate the feelings that follow. Like, "Oh, if I don't sleep eight hours tonight, I won't feel great tomorrow, but I'll probably be okay at work," right? The feeling is much smaller than, "If I don't sleep eight hours tonight, I'm gonna lose my job tomorrow," right? They're noticeably different. Um, in terms of depression, an, an example that I like might be someone saying, "Oh, you know, I'm really depressed now, but when I feel better, I'm going to take my grandkids to the movies. That's what I'm gonna do. I'm gonna take my grandkids to the movies. I'm going to take them to the zoo. I'm gonna do all these things." So as a therapist, what I might do is I'd have the patient write all of this, this huge long list of stuff they're gonna do when they feel better, and then you know what I'm gonna do. I'm gonna get out their calendar with them, and I'm gonna say, "All right. I don't care how you feel. We're scheduling all of these things." So we're intervening on that behavior to thoughts line, right?

   8. PAPeter Attia24:26

      Mm-hmm.

   9. AMAshley Mason24:27

      So we're gonna make them take the kids to the zoo. We're gonna make them take the kids to the movies. And then the kids are gonna have a great time, and the patient's gonna come back and say, "Oh, you know what? I'm a, I'm a pretty kickass grandma. Kids had a great time. This was, this was pretty great." So we're intervening on the behavior to change the, the thoughts about the self, right? Like, "Oh, I'm gonna do these things when I'm better." Right? So a major feature of cognitive behavioral therapies is intervening on behavior to change thoughts, but also intervening on thoughts to change feelings, and there's just many, many applications for this. Cognitive behavioral therapy's been adapted for a whole host of disorders, for eating disorders, for insomnia, specifically for anxiety. That's gonna be more in the thoughts and feelings realm, too. Um, and it's a loved one.

   10. PAPeter Attia25:17

       So is that kinda running the triangle in the other direction, so you change behavior to change thought, you change thought to change feeling?

   11. AMAshley Mason25:26

       Yeah. So you can, you can change thought to change feeling. You can change-

   12. PAPeter Attia25:30

       Behavior

   13. AMAshley Mason25:31

       ... You can work on behavior to change thought. You can operate on any, any way of those-

   14. PAPeter Attia25:35

       Mm-hmm

   15. AMAshley Mason25:35

       ... um, with different techniques that have been just repackaged into different-

   16. PAPeter Attia25:40

       Yep

   17. AMAshley Mason25:40

       ... therapies.

   18. PAPeter Attia25:41

       And tell me a little bit about the history of CBT-I specifically. When did the, wh-when, when did the, um, idea come to, you know, uh, e-existence in a way that's, that it's been packaged, uh, more or less-

   19. AMAshley Mason25:55

       Yeah

   20. PAPeter Attia25:55

       ... the way it is today?

   21. AMAshley Mason25:56

       Yeah. So cognitive behavioral therapy for insomnia is actually old news. I mean, we can go back to the 1970s. I remember when I was learning cognitive behavioral therapy for insomnia, one of the most fun, um, studies to read about was this study of, I believe it was college-aged men who were not doing well academically. And the intervention that they did with them was one of the two pillars of cognitive behavioral therapy for insomnia, which is called stimulus control.

   22. PAPeter Attia26:29

       Mm-hmm.

   23. AMAshley Mason26:30

       And what they did with these young men is they told them, "All right. You're gonna be assigned a carrel in the library, and in this carrel is the only place you can study. You can't study in your dorm. You can't study outside, can't study anywhere else, just this carrel." Right? "And only this amount of time can you study each day. Even if it, if you're on a roll, we don't care, you have to stop. If you're miserable, we don't care. You just have to keep on, like, doing whatever por- portion of the studying over and over again that you're stuck on." Right? So they trained peop- these young men to just study in that one place, and it succeeded in helping these men.

   24. PAPeter Attia27:12

       And these men were struggling with anxiety or actual insomnia?

   25. AMAshley Mason27:15

       Academically.

   26. PAPeter Attia27:16

       They were, they were struggling academically.

   27. AMAshley Mason27:17

       This is just, this is the birth of-

   28. PAPeter Attia27:18

       Got it. Okay

   29. AMAshley Mason27:18

       ... this is just stimulus control-

   30. PAPeter Attia27:19

       Yeah. Got it
6. 32:37 – 43:52

   Implementing CBT-I: time in bed restriction, sleep scheduling, and the effect of napping

   1. AMAshley Mason32:37

      no dice.

   2. PAPeter Attia32:38

      Yeah. I wan- I wanna talk about both those a l- a little bit more.

   3. AMAshley Mason32:41

      Yeah.

   4. PAPeter Attia32:41

      Um, so and wa- and I wanna bracket sleep hygiene and come back to it 'cause I think-

   5. AMAshley Mason32:46

      Oh, yeah

   6. PAPeter Attia32:46

      ... again, the temperature and all that light stuff, we, we shouldn't, we shouldn't gloss over that-

   7. AMAshley Mason32:50

      Yeah

   8. PAPeter Attia32:50

      ... even though it's easy to take for granted. And I, I know that many people listening to this podcast will have heard other content where we talk about it, but I'd love to have it all in one place.

   9. AMAshley Mason32:58

      Sure.

   10. PAPeter Attia32:59

       Um, I think the, the time in bed restriction's pretty interesting.

   11. AMAshley Mason33:02

       Yes.

   12. PAPeter Attia33:03

       And, and, and in talking with sleep physicians-

   13. AMAshley Mason33:07

       Mm-hmm

   14. PAPeter Attia33:07

       ... who also implement this-

   15. AMAshley Mason33:09

       Mm-hmm

   16. PAPeter Attia33:09

       ... it seems quite draconian at the outset. Uh, it can be remarkably difficult. Uh, like, you know, they're giving people five hours in bed max, and, and they're really trying to force sleep pressure-

   17. AMAshley Mason33:21

       Mm-hmm

   18. PAPeter Attia33:21

       ... right?

   19. AMAshley Mason33:22

       Yeah, yeah.

   20. PAPeter Attia33:22

       So how do you, um, uh, how do you navigate that, and how do you decide how hard to squeeze the-

   21. AMAshley Mason33:28

       Yeah

   22. PAPeter Attia33:29

       ... the tube of toothpaste?

   23. AMAshley Mason33:30

       Let me draw a line in the sand between what CBT-I says broadly as a treatment and then how I've actually implemented it in my clinic.

   24. PAPeter Attia33:37

       Mm-hmm.

   25. AMAshley Mason33:38

       So what CBT-I will have you do is they will have you as a p-- and I say you as the royal you, your patient, they will have you fill out something called a sleep diary, and this is a paper diary that covers seven days.

   26. PAPeter Attia33:49

       We have it.

   27. AMAshley Mason33:49

       Right?

   28. PAPeter Attia33:49

       Love it.

   29. AMAshley Mason33:50

       Because if I asked you how well you slept four nights ago, you'd be like, "Um..."

   30. PAPeter Attia33:55

       Yeah, yeah, yeah.
7. 43:52 – 49:49

   Navigating family and partner sleep schedules, falling asleep on the couch, sleep chronotypes, and more [39:45];

   1. PAPeter Attia43:52

      we're on that topic-

   2. AMAshley Mason43:53

      Mm-hmm

   3. PAPeter Attia43:53

      ... what, what do you say to the legions of people watching who, um, fall asleep watching TV on the couch?

   4. AMAshley Mason44:00

      Ugh, the worst, right? So a lot of people fall asleep on the couch because they're just so overtired that they've, the ship has sailed. Like, their body's ready to go to bed, and they're just, like, letting it, and they're not getting up and doing the thing. I tell people, "Look, if you wanna prioritize your sleep, pay attention to your body. When you're watching TV, do you notice that you're starting to nod off? Do you notice your eyelids feeling heavy? Are your hands feeling warm? Are you starting to sag a little bit?" Like, okay, these are indicators that it's probably time to get off the couch and go to bed. And for people who can't figure that out, I say, "Okay, you wanna watch TV at night, sit on a stool. You're gonna figure it out real fast."

   5. PAPeter Attia44:46

      And what about just the social dynamic of it, which is when you have a couple-

   6. AMAshley Mason44:50

      Mm-hmm

   7. PAPeter Attia44:50

      ... and, uh, not that I'm saying this from experience at all.

   8. AMAshley Mason44:54

      [laughs]

   9. PAPeter Attia44:54

      And one, one part of that couple, uh, they wanna be together and watch TV-

   10. AMAshley Mason45:00

       Mm-hmm

   11. PAPeter Attia45:00

       ... but one member of that team falls asleep immediately while the other does not.

   12. AMAshley Mason45:05

       [laughs]

   13. PAPeter Attia45:06

       And the one that does not tries to tell the one that is to go to bed, but the, but that couple says, "But I..." But that one wants to be with the other. Like, I don't know if you can ever imagine a scenario like that.

   14. AMAshley Mason45:18

       Yeah. Yeah.

   15. PAPeter Attia45:18

       But I, I'm just making it up.

   16. AMAshley Mason45:20

       Mm. [laughs] Okay, good. I'm glad you're making that one up. No, I have a lot of these couple-level issues that come up in sleep clinic. This is not uncommon because what's more intimate than being completely unconscious next to another person, if you think about it? Like, evolutionarily-

   17. PAPeter Attia45:34

       Mm-hmm

   18. AMAshley Mason45:34

       ... that's probably the riskiest thing you can do, right?

   19. PAPeter Attia45:37

       Yeah.

   20. AMAshley Mason45:37

       So there is this desire for closeness in lots of couples, and it becomes a challenge when one of the members of the couple has a sleep problem, and the first step is remembering, like, that this is not necessarily permanent. We need to go about fixing this now, and then we can find a new winning solution. So in the interim, I'm assuming you've already tried, you know, maybe watching something different on TV that might be more exciting to the second partner, et cetera, um, and it's not about the boringness of the show per se.

   21. PAPeter Attia46:06

       Doesn't appear to be.

   22. AMAshley Mason46:07

       Mm. Okay, good. So if that's the issue, then I would say, "Hey, like, if this is a priority, what are we gonna do? We're gonna schedule it. We're gonna schedule time to be on the couch together at a time when I can definitely be awake and be spending meaningful time with you."

   23. PAPeter Attia46:22

       Problem is, sometimes other members of the family who tend to be smaller-

   24. AMAshley Mason46:27

       Yeah

   25. PAPeter Attia46:27

       ... also tend to be occupying all of the bandwidth during those earlier hours when the member of the family in question is able to be awake.

   26. AMAshley Mason46:38

       Mm. This is, this is a hard problem to-

   27. PAPeter Attia46:42

       Mm

   28. AMAshley Mason46:42

       ... to scale, but what I would just say is if you're ready to go to... If you're actually ready to go to bed and your body is saying that you need to sleep, you should probably do that. Um, it's more likely that then you'll be awake the next day and be a more pleasant, exciting partner to be around and be able to have more meaningful experiences with your partner that way. Otherwise, I tell people, "Look, this is an issue. If it's really an issue, what are we... We're gonna get a babysitter. Let's get, figure it out," right? There are ways to get around these things. People just often, you know, want it to work like they see in the movies. Like, "Oh, this should be easy."

   29. PAPeter Attia47:25

       Now, if the, if, if... Obviously, I'm talking about my wife here, so I'll stop double speaking.

   30. AMAshley Mason47:29

       [laughs]
8. 49:49 – 58:55

   Key aspects of sleep hygiene: temperature, light exposure, and circadian rhythm disruptions

   1. AMAshley Mason49:49

      work around that.

   2. PAPeter Attia49:50

      Let's go back to sleep hygiene for a second.

   3. AMAshley Mason49:51

      Yeah.

   4. PAPeter Attia49:51

      We talked about temperature. Um-

   5. AMAshley Mason49:53

      Yes

   6. PAPeter Attia49:54

      ... you know, nowadays we have these incredible devices that can cool our mattresses and-

   7. AMAshley Mason49:58

      Mm

   8. PAPeter Attia49:58

      ... and, and things of that nature. Obviously, we have air conditioning, uh, that, that can cool the room.

   9. AMAshley Mason50:04

      Mm-hmm.

   10. PAPeter Attia50:05

       Do you have a preference for one or the other? I mean, uh, clearly not everybody needs to, to, to buy a mattress cooling device if they can't afford it. That shouldn't be an impediment to sleep.

   11. AMAshley Mason50:14

       Mm.

   12. PAPeter Attia50:15

       Um, so do you, do you have a, a room temp set? We typically talk about the mid-60s as an ideal room temp. Do you adhere to that?

   13. AMAshley Mason50:21

       Yes. Mid-60s is terrific, and if people say, "Oh, this is just too cold," I say, "Well, what's too cold?" And often they will say, "My feet." And we have wonderful solutions for that. They're called socks. And we can get really thick socks, and I'm also not opposed to, you know those tiny little heating pads you can get? They're like this big.

   14. PAPeter Attia50:38

       Mm-hmm.

   15. AMAshley Mason50:38

       You know, like a foot and a half by a foot or something. Putting one of those in the foot of your bed, it's got an auto shutoff, it shuts off after like an hour or something to fall asleep with, I don't have a problem with that. There's no issue there. But yes, a cool room is definitely key, and, you know, insert my refrain about down comforters, duvets, et cetera. Get cotton blankets. Get cotton sheets.

   16. PAPeter Attia51:01

       And then let's talk about light. Do we need to have it so pitch black you can't see your hand in front of your face?

   17. AMAshley Mason51:07

       Mm.

   18. PAPeter Attia51:07

       Do we need to block the moonlight? Um, how, how dark do we need it to be?

   19. AMAshley Mason51:12

       Yeah. So this is a common question. You know, if you closed your eyes right now, you'd be able to tell that it's light in this room.

   20. PAPeter Attia51:19

       Mm-hmm.

   21. AMAshley Mason51:19

       Right? We can, we can sense light through our closed eyelids, and, um, many women would tell you that their eyelids seem to get thinner as they age, right? So I think an eye mask is a great addition, and a l- this is for a lot of people with early morning awakenings. Eye mask can be a game change because they don't realize that what's causing their early morning awakenings is a little bit of light getting into-

   22. PAPeter Attia51:42

       Mm

   23. AMAshley Mason51:42

       ... the wrong part of their eye, indicating it's time to be awake right now. And I don't know the details on what wavelength of light that is or what necessarily the light is coming from, whether it's a light in a, outside from the sun or the moon or what- whatever it might be. But the point just is a lot of folks with early morning awakening can really benefit from having something covering their eyes, whether it's a sleep mask or there's like hats that go down here now. Um, making... I'm a big fan of making your room dark. I am one of those people who travels with a roll of black electrical tape 'cause you go to a hotel room, and there's like 50,000 lights everywhere.

   24. PAPeter Attia52:18

       And you wouldn't, you wouldn't just get relief from the eye mask in that situation?

   25. AMAshley Mason52:22

       I do, but I'm one of those people who rips my eye mask off in the middle of the night, and I've tried every single eye mask, and it's coming off. [laughs] So I like to wear it. I start with it. I try and keep it on as much as I can, but I also... If there's egregious lights in a room, I cover them with ele- electrical tape

   26. PAPeter Attia52:37

       Meaning like you're gonna cover the alarm clock and/or whatever the-

   27. AMAshley Mason52:40

       Oh, yeah. No, there's none of that in my room.

   28. PAPeter Attia52:42

       Yeah, cool.

   29. AMAshley Mason52:42

       Yeah, I don't do that. But back to the, the cool thing for a second.

   30. PAPeter Attia52:44

       My, my trick is I unplug alarm clocks-
9. 58:55 – 1:04:30

   Blue light and mental stimulation before bed, and the utility of A-B testing sleep habits

   1. PAPeter Attia58:55

      um, blue light before bed?

   2. AMAshley Mason58:58

      Mm.

   3. PAPeter Attia58:59

      So, so I've, I've looked at these data quite a bit, and I, I would say that six years ago I sort of was in the camp of every light had to be red, so, you know, I had to have my phone shifted into a red light phase, my computer shifted into a red light phase. I had all of these apps that managed all of this stuff, so as soon as the sun went down, blue light was being removed from my electronics. Um, and I have to say I sleep subjectively and objectively better today. I say objectively if you can believe what a sleep tracker tells you.

   4. AMAshley Mason59:39

      Okay.

   5. PAPeter Attia59:39

      But, but we can bracket that and come back to it. We should. Um, paying, never taking blue light out of my devices, but instead paying attention to what I'm consuming. In other words, my new hypothesis has become it's not the blue light that is the problem, it's the stimulus-

   6. AMAshley Mason59:58

      [laughs]

   7. PAPeter Attia59:58

      ... that often comes with the blue light. In other words, not looking at social media [laughs] it, with, regardless of light color-

   8. AMAshley Mason1:00:08

      Mm-hmm

   9. PAPeter Attia1:00:08

      ... is a far greater positive impact on my sleep than looking at those things, but just making sure that there's no blue light coming through.

   10. AMAshley Mason1:00:17

       Yeah.

   11. PAPeter Attia1:00:18

       Um, so, so let's talk about that. What, what is the, what is the role of minimizing blue light, um, when it comes to preparing for sleep?

   12. AMAshley Mason1:00:28

       That's an excellent question. Well, first, I wanna completely agree with you. We didn't evolve for the neural experience of Instagram. That's not, we're not ready for that [laughs] right?

   13. PAPeter Attia1:00:39

       No.

   14. AMAshley Mason1:00:39

       And, um, I think regardless of what color light you're getting your Instagram on, that's probably not helpful before you go to bed. So I think that you're entirely right. I think the larger problem is not necessarily the blue light, but is the Thing that we're interacting with, whether it's an iPad or a phone or a computer, because typically those things are gonna involve social media, work, email, all of these other things that I think are much more potent disruptors of sleep than the blue light itself. I must caveat this, though. I have had a few patients who have found ... They were not using Instagram before bed. They were not doing email before bed.

   15. PAPeter Attia1:01:21

       Mm-hmm.

   16. AMAshley Mason1:01:22

       None of this.

   17. PAPeter Attia1:01:22

       Not, not doing anything stressful or stimulating.

   18. AMAshley Mason1:01:24

       No. But ... And I just finished with a patient recently like this, who found that using orange colored glasses, and I'm talking orange colored glasses, not those beautiful blue light blocking glasses that are clear lenses that I'm not sure what they're really doing sometimes. Like, I'm talking ugly, motorcycle looking orange lenses. And I found that a handful of patients wearing these two hours before bed, it completely ameliorates their sleep onset insomnia such that they were able to almost immediately-

   19. PAPeter Attia1:01:58

       Hmm

   20. AMAshley Mason1:01:58

       ... quit Ambien.

   21. PAPeter Attia1:01:59

       The, the beauty of these interventions is if you can isolate them to one change-

   22. AMAshley Mason1:02:03

       Yeah

   23. PAPeter Attia1:02:03

       ... at a time, you can be empirical about it.

   24. AMAshley Mason1:02:05

       Yeah.

   25. PAPeter Attia1:02:05

       And something like wearing glasses is benign.

   26. AMAshley Mason1:02:09

       Mm-hmm.

   27. PAPeter Attia1:02:09

       I mean, you're only out the money you spend on them. And if it works-

   28. AMAshley Mason1:02:12

       Mm-hmm

   29. PAPeter Attia1:02:12

       ... great.

   30. AMAshley Mason1:02:14

       Yeah.
10. 1:04:30 – 1:10:20

    Other simple interventions that may improve sleep

    1. AMAshley Mason1:04:30

       I will tell you, can I go over a couple more pieces of low hanging fruit-

    2. PAPeter Attia1:04:33

       Yes

    3. AMAshley Mason1:04:33

       ... on sleep hygiene?

    4. PAPeter Attia1:04:34

       Please. Yep.

    5. AMAshley Mason1:04:35

       So, okay, so back to the glasses. If you are a person who has trouble with what we call early insomnia, so difficulty falling asleep at the beginning of the night, and you're already not looking at your email, not doing Instagram, you're just annoyed that you cannot fall asleep at the beginning of the night, it's worth it to try these glasses for two hours a night for two weeks and see what happens. It's, it's t- it's so easy to do, right?

    6. PAPeter Attia1:04:58

       And to be clear, what-- is there a particular brand? I mean-

    7. AMAshley Mason1:05:03

       I have no affiliations with any of these things. I can tell you there's some really nice ugly ones from lowbluelights.com, I think.

    8. PAPeter Attia1:05:11

       Okay.

    9. AMAshley Mason1:05:11

       If they're still in business. But they look like motorcycle goggles. I do think that the wraparound feature is, is important.

    10. PAPeter Attia1:05:17

        Mm-hmm.

    11. AMAshley Mason1:05:17

        'Cause if we're going for it, let's go for it.

    12. PAPeter Attia1:05:19

        Yeah.

    13. AMAshley Mason1:05:19

        Right? Uh, so it's, it's a worthy thing to do. Another important thing to do is to talk to your physician. I'm not a physician, but I work with a ton of them, and I learned this from an anesthesiologist. All medications have circadian effects. All of them. Somehow, it's probably not known for all of them how they do, but they do. Make sure you are taking your medications at the same time every day and at the right time of day. For example, I once had a patient coming in saying that they were taking four hundred fifty milligrams of bupropion for depression before bed. No. [laughs] Right? That's gonna be a pretty stimulating dose of something-

    14. PAPeter Attia1:05:58

        Right

    15. AMAshley Mason1:05:58

        ... to take before bed. So make sure that you go over your medications with your doctor and that you're taking them at the optimal times of day, and be really consistent with your medications. And another one that is a particularly low hanging piece of fruit is something called decaffeinated coffee. Turns out there are speculations that decaf coffee can have as much as fifteen to thirty percent of the caffeine that regular coffee has. I haven't found that reference. I've dug. I've tried to find one that will show that. I haven't found exactly that. But there are some data from two thousand and six that were published saying that, you know, fifteen-ish percent. And but then again, more recent data have shown that Starbucks, I think, says that their twelve ounce has a hundred fifty-five milligrams of caffeine, but outside laboratory testing found like three hundred ten, something like that. So when you're decaffeinating coffee that's much more caffeinated than you started with, this can make a, an absolutely huge difference. I tell people we're done with caffeine by 11:00. That's my... 11:00 AM. That's my standard, unless we've got an extreme phase delay or phase advance. Uh, I should define those terms. A phase delay is when you go to bed really late and you wake up really late. A phase advance is when you wake up really early and you go to bed really early. So someone who's waking up at, like, 3:30 in the morning and going to bed at, like, 8:00 PM, that would be, like, a phase advance. Phase delay would be like, "I'm going to bed at 3:00 AM, and I'm waking up at, at 10:00 AM," right? So in those cases, I might do something differential with the caffeine, but for most people who are neither of those, I'll cut it off at 11:00, and it's, that includes your c- your caffeinated coffee and your decaffeinated coffee. And I never take people's caffeine away. Caffeine withdrawal is not something I wanna deal with in my clinic.

    16. PAPeter Attia1:07:47

        Hmm.

    17. AMAshley Mason1:07:47

        And I don't think it's necessary. You can cause a lot of damage taking away someone's coffee. People really don't like that. Really puts them in a bad mood, and it's not necessary. So I tell people, "Do not change how much coffee you're drinking. Put it all before 11:00." Right? Just move it all.

    18. PAPeter Attia1:08:05

        What fraction of people are such rapid caffeine metabolizers that they seem immune to caffeine and sleep?

    19. AMAshley Mason1:08:12

        Uh, I think that that person doesn't actually exist. I'm not, I'm not... I need to be convinced that there are people... I mean, what? The normal h- caffeine half-life is four to six hours, right? So even if we take someone who's four hours, that means after four hours you still have half of a cup of coffee, and after eight hours you still have a quarter of a cup of coffee. And if you have that coffee at 2:00 PM, and that coffee actually had 310 milligrams of caffeine in it, and it was only a tall coffee from Starbucks, I mean, there's a lot of contingencies to build in here. But I, I could tell you people, uh, someone we both just know actually stops using caf- decaf coffee after dinner, and it's, like, a world of difference for their sleep quality. People will say, "Oh, no, I fall asleep just fine. Doesn't affect me." Well, it is affecting you. It's affecting the electrical quality of your sleep throughout the whole night, and I would refer you to talking to, like, a sleep neurologist to interpret some of those sleep studies and, and talk with you more about that. For my purposes, all I need to know as the person who's trying to fix the insomnia is, oh, you're having two decaf coffees after dinner every night. That could add up, and that could be doing something.

    20. PAPeter Attia1:09:29

        Yeah.

    21. AMAshley Mason1:09:30

        And that could make your sleep less restful.

    22. PAPeter Attia1:09:32

        Okay. So-

    23. AMAshley Mason1:09:33

        Low-hanging fruit

    24. PAPeter Attia1:09:33

        ... just stop it at 11:00 to be c-

    25. AMAshley Mason1:09:35

        Stop it

    26. PAPeter Attia1:09:35

        ... like, do the experiment at a, at a minimum. Okay, so those are three.

    27. AMAshley Mason1:09:39

        But don't reduce it-

    28. PAPeter Attia1:09:39

        Anything else?

    29. AMAshley Mason1:09:40

        ... is the key thing.

    30. PAPeter Attia1:09:42

        Yeah. Anything, any other really obvious things to A-B test for two weeks?
11. 1:10:20 – 1:12:57

    Ashley’s view on relaxation techniques and mindfulness-based practices

    1. AMAshley Mason1:10:20

       although if this helps them sleep [laughs] .

    2. PAPeter Attia1:10:22

       Uh, um, one other thing I wanna talk about is on the realist- re-relaxation techniques.

    3. AMAshley Mason1:10:25

       Mm-hmm.

    4. PAPeter Attia1:10:25

       Where does, um, [clears throat] or does mindfulness-based practice come into it? So, um, anyone who's done mindfulness-based meditation-

    5. AMAshley Mason1:10:34

       Mm-hmm

    6. PAPeter Attia1:10:34

       ... probably appreciates how difficult it is.

    7. AMAshley Mason1:10:36

       Mm-hmm.

    8. PAPeter Attia1:10:36

       Uh, it's not like, you know, transcendental meditation where you're focusing on a mantra. You're instead focusing on a sensation, typically breathing. Um, but body awareness is, is a, is a, is, is a, a thing that you wanna focus on. Is that counterproductive, or is it productive as you're laying there awake?

    9. AMAshley Mason1:10:55

       So my unsatisfying answer to so many questions is always gonna be it depends.

    10. PAPeter Attia1:10:59

        Mm-hmm.

    11. AMAshley Mason1:10:59

        Because there's moderator variables, right? And when it comes to CBT-I, what we know is that what's been tested is progressive muscle relaxation, which you could argue is a form of a body scan, which is part of-

    12. PAPeter Attia1:11:11

        Mm

    13. AMAshley Mason1:11:11

        ... many mindfulness practices, right? Where you scan your whole body.

    14. PAPeter Attia1:11:15

        Mm-hmm.

    15. AMAshley Mason1:11:15

        You think about your hands. You notice how they're feeling. Are they warm? Are they soft? Whatnot, and you move through your whole body. With progressive muscle relaxation, you squeeze your hands, and you let them go. You squeeze them, and you let them go. It's more of an active process that you're paying attention to throughout your body. Doing this in bed right before you fall asleep for a few minutes is fine. That's kind of the one exception to the sleep and sex rule. I tell people that it's also fine to practice this in other parts of your house. You don't have to just be in bed. But the body scan and mindfulness in general has been studied in combination with CBT-I, and what the data have shown is somewhat fascinating. There's no actual differential improvement on sleep duration or metrics of sleep. But people like the mindfulness stuff. They report they're just more, they're more happy with it. They like, they like doing that, right? Um, but in terms of actual improvement on sleep outcomes, I don't think it really adds too, too much to CBT-I. The effects with CBT-I are pretty whopping. Um, when it's done well, you know, 50% to 60% of people can get remission, and 70% can get clinically meaningful improvement to their sleep. So that's, I mean, in the world of psychological treatments, that's really good. But to circle back to your question, mindfulness is great. I think there's a lot of practical uses for it for helping yourself when you're in psychological states you don't wanna be in. It's a great way to be in life. But when it comes to sleep, do I need you to start a mindfulness practice to improve your sleep? No.

12. 1:12:57 – 1:26:27

    The effectiveness of CBT-I, the role of sleep trackers, and best practices for managing nighttime awakenings

    1. PAPeter Attia1:12:57

       So you mentioned 50% to 60% of people are going to have a remission

    2. AMAshley Mason1:13:01

       Closer to 50, but yeah

    3. PAPeter Attia1:13:04

       70% will have a clinical, meaningful clinical improvement.

    4. AMAshley Mason1:13:07

       Mm-hmm.

    5. PAPeter Attia1:13:08

       Of the 30% that do not-

    6. AMAshley Mason1:13:10

       Mm.

    7. PAPeter Attia1:13:11

       Why? When does the treatment fail?

    8. AMAshley Mason1:13:13

       The treatment fails when people don't do it.

    9. PAPeter Attia1:13:16

       So in other words, we're really saying it-- 30% of people are not able to adhere to the treatment.

    10. AMAshley Mason1:13:22

        I wouldn't go that far. There are some people who are genetically short sleepers, and at some point this may become distressing for them. I had a great-- I had a story of a patient who was in her 70s and came to me say, saying, "I have a huge problem. I-- my sleep is not good." And I asked her, "Okay, so, so t-tell me all about, tell me all about this." She was like upper 70s, had a volunteer job in San Francis- like really active, full workout plan. I'm like, "You're crushing it, lady. What, what's the problem exactly?" She says, "Well, I joined this study, and I had to wear this wearable device."

    11. PAPeter Attia1:14:01

        [chuckles]

    12. AMAshley Mason1:14:02

        "And I woke up in the morning, and it s-says that things are not going well every morning, morning after morning, and it says I'm at risk for different things." I'm not gonna say which wearable company it was, but, um, and I said, "Oh, okay, okay, so there's re- so there's pr-"

    13. PAPeter Attia1:14:17

        There's an amazing treatment for that. Can I see the wearable device?

    14. AMAshley Mason1:14:19

        [laughs] Can I, can I please just have that wearable device?

    15. PAPeter Attia1:14:21

        Here's my vice grips. Boom.

    16. AMAshley Mason1:14:23

        Boom.

    17. PAPeter Attia1:14:23

        Yeah.

    18. AMAshley Mason1:14:23

        Exactly. So, um, and this, this was a while ago, but I, I, I took it away from her because I th- I think, you know... And, and the wearable devices now are not doing, doing this. Um, this was, oh gosh, [laughs] seven, eight years ago.

    19. PAPeter Attia1:14:39

        This is actually-- I, I actually wanted to ask. This is a-- I, I made a note to ask you this question-

    20. AMAshley Mason1:14:43

        Yeah

    21. PAPeter Attia1:14:43

        ... which is: When do you tell people? 'Cause we do this with our patients, which is take the tracker off.

    22. AMAshley Mason1:14:50

        Off.

    23. PAPeter Attia1:14:50

        We're doing a six-month tracker holiday.

    24. AMAshley Mason1:14:52

        Yep.

    25. PAPeter Attia1:14:52

        Done with the tracker.

    26. AMAshley Mason1:14:53

        Done.

    27. PAPeter Attia1:14:54

        So is that kind of m-mainstay part of your treatment is like, "Let's get all that anxiety out of there"?

    28. AMAshley Mason1:14:59

        For people with insomnia, I tell them, "Yes." And I do-- like with-- uh, who are coming to me in my clinic, the people who have bothered to wait a year and a half to [laughs] get into the clinic, those people, yes, I am telling them that. And so to go back to your 30% of people, the genetically short sleepers who become distressed about their sleep are not going to be helped by CBT-I. They're not.

    29. PAPeter Attia1:15:23

        But maybe they shouldn't be helped. Maybe there's nothing to fix.

    30. AMAshley Mason1:15:26

        Correct.
13. 1:26:27 – 1:32:29

    Guidance on intake of food and alcohol for good sleep

    1. PAPeter Attia1:26:27

       the loop on it, is food and alcohol-

    2. AMAshley Mason1:26:28

       Mm, mm-hmm

    3. PAPeter Attia1:26:29

       ... and how they pertain to this. Um, so what's your, what's the checklist you run through with the, with the clients?

    4. AMAshley Mason1:26:34

       So since we're dealing with so much life, I actually don't mess with their food. All I do is say, "Hey, really, let's try to not eat within three hours of going to bed."

    5. PAPeter Attia1:26:43

       Okay.

    6. AMAshley Mason1:26:44

       Right? Um, sometimes it's, it's rare that I'll have nighttime binge eating disorder, like, to deal with at the same time or a blood glucose issue that, you know, in diabetes that's poorly controlled at the same time, but I'm gonna put those cases aside for just a moment.

    7. PAPeter Attia1:26:57

       Okay.

    8. AMAshley Mason1:26:58

       So I generally will go with, "Don't eat for three hours before bed." And when it comes to alcohol, I tell my patients, "Look, this is five weeks of your life. I'm not gonna drink, and you're not gonna drink." So when I'm running a clinic, nobody's drinking. And the reason for this is that in order for me to actually see what's going on with your sleep, I need to see this with the least perturbation possible.

    9. PAPeter Attia1:27:19

       Mm-hmm.

    10. AMAshley Mason1:27:20

        And alcohol and marijuana are those things. Now, if people are using a lot of marijuana or a lot of alcohol, I'm not here to put people into withdrawal.

    11. PAPeter Attia1:27:30

        So they just don't enroll until they're-

    12. AMAshley Mason1:27:31

        No, no, no. I let them in. So what I'll do is before people come to their first group, I have them do a sleep diary so I can see what's going on. And before that, I will have done their intake, and I'll have them have told me their alcohol intake. And I'll have decided, "All right. Here's what you're gonna do. You're either gonna s- you're gonna not, or you're going..." Like, let's say someone... I just finished with some people. One of them was drinking between 16 and 20 ounces of wine a night. B- biz- uge. Okay?

    13. PAPeter Attia1:27:57

        Okay.

    14. AMAshley Mason1:27:57

        And I said, "Okay. So you're gonna drink two ounces of wine a night out of that same glass, and then you know what? You're gonna keep using that glass, and you're gonna drink something else, some other froufrou drink. I don't care what it is, right? Um, but I want it to be something that is, you don't drink during the day, so I want it to be, you know, overpriced juice or overpriced bubbly water or something like this."

    15. PAPeter Attia1:28:18

        Something special.

    16. AMAshley Mason1:28:18

        Something special, right? And you're gonna keep drinking it out of that wine glass. And I have them do that, right? Um, and I make sure they can do it before they start treatment, and they generally can because, again, the other part that I have going for me is that people have been waiting so long that by the time they get to me, they'll do what I say, which is just this lovely, um, lovely gift that I have. But, um, I'll make people be very consistent with that. They'll be like, "Oh, I have, I have to drink two ounces of wine a night?" I'll say, "Yes, you do. You must." I want this consistent, right?

    17. PAPeter Attia1:28:53

        [laughs]

    18. AMAshley Mason1:28:54

        That's the thing, consistency. Um, and so if someone's saying, "Oh, no, I drink three nights a week," then I'll say, "All right. Cut it out. You're gonna stop, I'm gonna stop, we're all gonna stop."

    19. PAPeter Attia1:29:04

        Are there any specific cognitive techniques that people are instructed to be working on when they first wake up?

    20. AMAshley Mason1:29:12

        No.

    21. PAPeter Attia1:29:13

        Nothing. There's nothing-

    22. AMAshley Mason1:29:15

        Nothing

    23. PAPeter Attia1:29:15

        ... no mind game to play.

    24. AMAshley Mason1:29:17

        No.

    25. PAPeter Attia1:29:17

        It's all behavior, behavior, behavior.

    26. AMAshley Mason1:29:19

        I'm all business. Yep. At CBT-I, I'm a purist, and I don't involve the cognitive techniques until week three of five-

    27. PAPeter Attia1:29:27

        Okay

    28. AMAshley Mason1:29:27

        ... of treatment, and that's when we get into things like scheduled worry time, working with the thought records, and then also one of my favorite things to do with patients who seem to wake up in the middle of the night, maybe at 1:00 AM, they jolt themselves awake, worrying about something in particular. And if I have a patient like that who every mor- every night in the middle of the night wakes up at 1:00 AM and says, " [gasps] I'm very worried about thing A," I'll say, "Okay, thing A. Here's what I'd like you to do with thing A. I would like you to track how worried you are about thing A all day, every couple of hours." This is called tracking degree of belief in a thought. And what you might find is that... I'll, I'll build on this with an example of a patient that I had, actually. This might be an easier way to explain it. I once had a patient with multiple sclerosis, um, early 30s, pretty debilitating disease-

    29. PAPeter Attia1:30:24

        Mm

    30. AMAshley Mason1:30:25

        ... to have when you're that young, uh, working a full-time job, who used to jolt awake in the morning, every morning at 7:00 AM, thinking, "I'm never gonna make it through this day. My whole body hurts. This is a mess. I'm never gonna be able to do this." And she would lay in bed for two hours until, like, 9:00, thinking these thoughts, just, "Ugh, I can't do this." By 9:00, she'd get out of bed, she'd shower, she'd get to work by 10:00 'cause in the Bay Area, all these startups don't start till, like, 10. [laughs] And then she'd ac- she'd get her coffee, work with her assistant, do her meetings. And if I asked her, "How, how much do you believe that thought, 'I'm never gonna make it through this day,' at noon?" she'd probably say, "Oh, like fif- 60%. Like, this afternoon's gonna be rough. I don't know if I'm gonna make it through." But if you ask her at 5:30 when she's done working or whatnot, "Oh, how much do you believe th- that thought, 'I'm never gonna make it through this day'?" She'll be like, "Oh, I made it, 0%." And day after day, she started realizing, like, "Oh-" I don't believe this thought at 7:00 AM because it's true that I'm never gonna make it through this day. I believe this thought because it's 7:00 AM, right? And once she was able to make that connection, we were able to recapture her mornings, and at 7:00 AM she went and sat on her couch and she started doing something she loved between 7:00 and 9:00, which for her was, uh, learning Italian with an app. She loved it. And 7:00 to 9:00 used to be her most hated part of the day. But by the end of treatment, it was her most beloved part of the day 'cause no one was bothering her and she could learn Italian and whatnot. And so one of the tricks, and not tricks, but cognitive tools that I've built into CBT-I in that cognitive package is tracking how much you believe a thought over a given day, and if you believe a thought in different levels throughout the day, how, how true can it really be? And it's really enlightening, and I would invite you to notice what you're thinking about at 1:00 AM and then just see how worried are you or how much do you believe this the next day at 3:00 PM.
14. 1:32:29 – 1:37:37

    Reframing thoughts and nighttime anxiety to reduce sleep disruptions

    1. PAPeter Attia1:32:29

       Let's talk about sleep supplements.

    2. AMAshley Mason1:32:32

       Ugh.

    3. PAPeter Attia1:32:32

       Right?

    4. AMAshley Mason1:32:33

       Okay.

    5. PAPeter Attia1:32:33

       So w- do you do a purge of supplements when people come to you and they say, "Hey, I'm, I'm taking, you know, a pound of melatonin every night. I'm on an ashwagandha drip."

    6. AMAshley Mason1:32:46

       Ugh. [laughs]

    7. PAPeter Attia1:32:47

       Uh, y- you know, just rattle 'em off. Let's... We could go through the list.

    8. AMAshley Mason1:32:51

       All right. Can I give you two links for the show notes to, uh, studies of melatonin supplements that found that these melatonin supplements either had none of what they said they had in them, or-

    9. PAPeter Attia1:33:00

       Yes, I think we wrote a newsletter on one of them.

    10. AMAshley Mason1:33:02

        Oh, great.

    11. PAPeter Attia1:33:03

        Yeah.

    12. AMAshley Mason1:33:03

        Well, there's been two.

    13. PAPeter Attia1:33:04

        Yeah.

    14. AMAshley Mason1:33:04

        And so when people come in and they say they're tak- taking melatonin, I'm like, "Okay, the alleged melatonin. How much of this is, are you taking?"

    15. PAPeter Attia1:33:10

        But let's assume, um, that, that they're... You know, because obviously, you know, one-

    16. AMAshley Mason1:33:14

        Okay, then give me a list.

    17. PAPeter Attia1:33:15

        Well, let's assume that they're taking, they are, are actually taking melatonin-

    18. AMAshley Mason1:33:18

        Uh-huh

    19. PAPeter Attia1:33:18

        ... because they're getting it from one of the, um, uh, companies that submits to third-party testing.

    20. AMAshley Mason1:33:23

        Okay.

    21. PAPeter Attia1:33:23

        And so now they know they're doing it.

    22. AMAshley Mason1:33:25

        Mm-hmm.

    23. PAPeter Attia1:33:25

        And, and again, let's further, um, posit that they're not taking a dose that is deemed too high. So if you look at some of the sleep literature, you know, there seems to be a, a kind of like most people would agree anything north of a milligram is probably just too much.

    24. AMAshley Mason1:33:42

        Mm-hmm.

    25. PAPeter Attia1:33:43

        Um, whereas kind of in the 3 to 600 microgram, you know, there, there might be some, some benefit, and, and more importantly not just benefit, but actually safety. Like it might be, you know, you're not sort of down-regulating melatonin receptors. You're offsetting the natural decline in melatonin levels over time. I can tell from your face you don't agree with any of this, so...

    26. AMAshley Mason1:34:02

        No. [laughs] I mean, it's, it's puzzling. So I, it's, it's, it's... My face is also because it's hard to know where to go with this question because, so some countries you need a prescription for melatonin, right?

    27. PAPeter Attia1:34:12

        Mm-hmm.

    28. AMAshley Mason1:34:12

        This is something prescribed by a doctor. It is regulated.

    29. PAPeter Attia1:34:16

        Yep.

    30. AMAshley Mason1:34:16

        Um, I don't remember all the countries off the top of my head, like Australia, New Zealand, whatnot. You want that, you're not gonna find it at their Walgreens. Um, but, you know, in the US, taking too much of it can't kill you, so here you go, right? Um, there are... By the time someone gets to me, if they've got a huge list of supplements, supplements and they still have a sleep problem, I say, "Okay, so clearly these aren't doing what you want."
15. 1:37:37 – 1:51:45

    Ashley’s take on sleep supplements like melatonin

    1. PAPeter Attia1:37:37

       So what about sleep medications?

    2. AMAshley Mason1:37:40

       Mm-hmm.

    3. PAPeter Attia1:37:40

       And let's talk about as many as you want, right? We can talk about benzos, we can talk about trazodone, we can talk about Ambien, we can talk about the-

    4. AMAshley Mason1:37:48

       Yeah

    5. PAPeter Attia1:37:48

       ... Orexin-based drugs.

    6. AMAshley Mason1:37:50

       Hmm.

    7. PAPeter Attia1:37:50

       Um, how many of the patients who come to see you are on, uh, are regularly taking one of these, uh, prescription-based drugs for sleep?

    8. AMAshley Mason1:38:01

       A lot of people take over-the-counter drugs and prescription drugs for sleep, and there was a huge shift, uh, that I noticed, um, in... when, when COVID started, and there was a ban on flying to different countries, Mexico and, and Europe. And it turns out there are a lot of people who will fly to Mexico to get their Ambien or, and fly to Europe to get various sleep drugs that you, you can't necessarily get here. So all of a sudden, I saw a wave of patients dealing with withdrawal in the, in the early months of the pandemic 'cause they couldn't go get more of their drugs. "Oh my gosh, I'm, I'm screwed. What am I doing now? How do I, how do I cope with this?" So there was a major sh-

    9. PAPeter Attia1:38:43

       And why, why couldn't they get them here in that situation?

    10. AMAshley Mason1:38:46

        Uh, oh, Ambien's prescription only, and in Mexico you can go buy it.

    11. PAPeter Attia1:38:48

        Oh, you're saying they were buying it without prescription. I got it. Okay.

    12. AMAshley Mason1:38:50

        Yeah.

    13. PAPeter Attia1:38:50

        Got it. And they just, they couldn't get a prescription while they were here.

    14. AMAshley Mason1:38:53

        Yes, because they were taking so much-

    15. PAPeter Attia1:38:55

        I see

    16. AMAshley Mason1:38:56

        ... that they were well beyond what they could convince someone to prescribe them. And a lot of physicians-

    17. PAPeter Attia1:39:02

        Wow

    18. AMAshley Mason1:39:02

        ... are, and a lot of my patients are physicians, and a lot of physicians are pretty reticent to go above FDA recommended doses when it comes to Ambien. A lot of people don't realize that, I believe, I believe this is the case, that Ambien is still the only drug that is differentially, um, prescribed to men and women. According to the FDA, the starting dose for women should be five milligrams. Starting dose for men is five to 10, um, for instant release, and then for extended release, I believe for women it's 6.25, and then for men it's 6.25 all the way to 12.5 because women metabolize it, uh, less efficiently. Um, so I mean, the people who I've seen, I've seen people taking 30 milligrams. Big, big doses, right?

    19. PAPeter Attia1:39:43

        Hmm.

    20. AMAshley Mason1:39:44

        Um, and gosh, this is a very loaded question, but there's a lot of patients who come to me who will say, "I've read something in the news. It turns out this medication I'm taking for my sleep is bad for my brain." And I'll be like, "Oh, [laughs] you, they saw that, huh?" "And, and I wanna quit immediately. I need to quit by next week." I'm like, "Oh, okay. And you've been taking it for how long?" "Oh, 20 years." "Okay. Right. That... Oh, mm-hmm." So that never works. That never works. And I don't have... I wouldn't say that I have any sort of extreme expertise in the different classes of sleep meds, but what I can tell you is the ones that people most often are coming to me saying, "I wanna quit this. I hate being dependent on this. What do I, what do I do?" These are gonna be the benzos-

    21. PAPeter Attia1:40:28

        Yep

    22. AMAshley Mason1:40:28

        ... which doctors are becoming less and less hip to prescribing for sleep. Ambien, the Sonata, Lunesta stuff, um, and then over-the-counter stuff like Benadryl, maybe your occasional doxepin, and then people are often prescribed Remeron for sleep.

    23. PAPeter Attia1:40:46

        Mm-hmm.

    24. AMAshley Mason1:40:46

        And they run into metabolic issues.

    25. PAPeter Attia1:40:48

        Yep.

    26. AMAshley Mason1:40:48

        And they need to get off of it. So I think that covers probably the mo- the, the broadest swath that I see of things people wanting to quit. Now, the Quviva and some of these newer ones, I don't see them as much yet. I, I'm sure it's coming.

    27. PAPeter Attia1:41:03

        Yeah.

    28. AMAshley Mason1:41:03

        I'm sure it's coming.

    29. PAPeter Attia1:41:03

        And what about trazodone?

    30. AMAshley Mason1:41:06

        Trazodone is the one that I'm the least concerned about-
16. 1:51:45 – 1:51:46

    How to safely taper off sleep medications like benzos and Ambien

    1. AMAshley Mason1:51:45

       magic.

17. 1:51:46 – 1:53:45

    Sleep problems that need to be addressed before CBT-I can be implemented

    1. PAPeter Attia1:51:46

       I mean, I think we've kinda covered a lot on CBT-I, and l- let's now revisit the idea of the, the types of things that people should be on the lookout for that need to be addressed first, right?

    2. AMAshley Mason1:52:01

       Mm-hmm.

    3. PAPeter Attia1:52:01

       So we haven't talked about sleep apnea.

    4. AMAshley Mason1:52:04

       Oh.

    5. PAPeter Attia1:52:04

       We haven't talked about-

    6. AMAshley Mason1:52:05

       Yeah

    7. PAPeter Attia1:52:05

       ... restless leg syndrome.

    8. AMAshley Mason1:52:06

       No, yeah.

    9. PAPeter Attia1:52:07

       We haven't talked about, I don't know, what are the other things where you just wanna have some sort of sign-off that says, "Hey, we've also confirmed that these things-"

    10. AMAshley Mason1:52:18

        Mm-hmm

    11. PAPeter Attia1:52:19

        ... "aren't present," or what, what gets your suspicion roused that says, "Hey, we gotta look at something else"?

    12. AMAshley Mason1:52:24

        Yeah.

    13. PAPeter Attia1:52:24

        'Cause you're presumably not doing polysomnography-

    14. AMAshley Mason1:52:27

        No

    15. PAPeter Attia1:52:27

        ... on everybody on the way in.

    16. AMAshley Mason1:52:28

        Mm-mm. Yeah.

    17. PAPeter Attia1:52:29

        So how do you navigate that?

    18. AMAshley Mason1:52:31

        Yeah. So I have the wonderful luxury of being able to look in people's charts [laughs] and see who referred them to me and why they are referred.

    19. PAPeter Attia1:52:37

        They can't be self-referred?

    20. AMAshley Mason1:52:38

        Uh, everybody needs a referral of some kind from... And it can be from anybody.

    21. PAPeter Attia1:52:42

        Okay.

    22. AMAshley Mason1:52:42

        But a- any referral. A lot of my referrals come from sleep disorder centers because they've already done all that workup, and they say, "All right, it's not in his head."

    23. PAPeter Attia1:52:50

        I see. I see.

    24. AMAshley Mason1:52:50

        "So here you go." If a patient tells me... I always ask a patient like, "Oh, does your, has your partner or anybody you've slept with ever told you that you snore or that you sound like you're gasping for air in the middle of the night?" So I, I do have a bunch of those types of screening questions, and I aggressively refer to colleagues with expertise in those areas it, b- before treatment with me. A lot of times people have a CPAP, and they say, "Oh, I don't really use it. I'm not sure about that." And I say, "Well, I'm here to tell you that you should be sure about it and that you should use it every single night. It doesn't fit? Cool. I'm gonna make a call because we're gonna get it to fit. There's a different mask you can probably get. There's a, you know-"

    25. PAPeter Attia1:53:26

        Yeah.

    26. AMAshley Mason1:53:26

        "... there's all these different issues that we can tackle." It just sometimes takes making a phone call, and, um, unfortunately, a lot of patients don't have great follow-through for their CPAP in terms of just help using it and, and figuring it out. Um, so sometimes I have to just make that extra connection.

18. 1:53:45 – 1:59:23

    The importance of prioritizing a consistent wake-up time over a fixed bedtime for better sleep regulation

    1. AMAshley Mason1:53:45

       Um, the one thing I think I wanna make sure that we put a bow on also is this obsession with bedtime. I can make you wake up at any time by setting a very loud alarm. I can anchor you into your day with a wake-up time, and that can be consistent every single day. I cannot wave a magic wand and make you fall asleep at the same time every day. So when people think, "All right, I'm gonna get a handle on my sleep, I'm gonna go to bed at the same time every night," no, no, no, no. Wake up at the same time every day. That's a much more important first step. And if you're waking up at different times throughout the week, that is the first thing to fix.

    2. PAPeter Attia1:54:28

       Yeah. What degree of social jet lag do you tolerate with, again, just for folks listening, social jet lag meaning the experience of changing your sleep time during weekends, which could be akin to jet lag if it differs by, you know, hours. Um, in an ideal world, there would be zero, right? In an ideal world, I wake up at 7:00 in the morning every single day of the week. For an individual who says, "Oh, but God, on the weekends it's just so nice to not have to get up at 7:00," do you say, "Look, give yourself a 30-minute grace," and that would still be considered perfectly healthy?

    3. AMAshley Mason1:55:01

       Great question. So during treatment, I tell people, "You need to wake up at the same time every day that ends in D-A-Y." So that means Monday, Saturday, Sunday. Yeah, right. So-

    4. PAPeter Attia1:55:12

       That's all of them.

    5. AMAshley Mason1:55:12

       That's, yeah.

    6. PAPeter Attia1:55:13

       Yeah.

    7. AMAshley Mason1:55:13

       That's during treatment. There-

    8. PAPeter Attia1:55:13

       I had to check.

    9. AMAshley Mason1:55:14

       Yeah, good. [laughs] There, there is no room for negotiation during treatment. We're, we're in the dictatorship, right? Um, but what I do teach people at the end of treatment is how to cope with the fact that life is going to happen when treatment ends. It happens during treatment, but there's a lot that pauses during treatment, to be honest. But let's say that you've got a major event on a Friday night. You're going to a concert.

    10. PAPeter Attia1:55:35

        Yes.

    11. AMAshley Mason1:55:36

        And you're gonna be out way later than usual. And what I tell people is, "Look, you need to pick which day of that weekend do you wanna suffer, and which day do you wanna feel good?" Because we can sleep in one day. You cannot sleep in two days in a row. That's gonna take you off the wagon. We're not doing it. So let's say Friday night you go to a concert, and you wanna feel good on Saturday. Cool. Sleep in on Saturday. Sleep in by an hour on Saturday. Okay, fine. Go to bed on Saturday night when you get tired. Spoiler alert, you're probably gonna get tired past your usual bedtime because you slept in, but then Sunday you have to wake up at your wake time, and Sunday you're gonna suffer. But let's say you wanna feel good Sunday. That means on Saturday you're gonna wake up at your usual time. Saturday's gonna be a struggle bus, but you'll make it to your bedtime and you'll go to bed at your bedtime, then you'll feel better Sunday. So you just have to choose, when do I wanna do the suffering?

    12. PAPeter Attia1:56:22

        Okay.

    13. AMAshley Mason1:56:23

        The immediate day after?

    14. PAPeter Attia1:56:23

        So basically, um, force the suffering into the narrowest place possible.

    15. AMAshley Mason1:56:28

        Mm-hmm. You can, but you can choose 'cause it's, it, you know, sometimes people don't want the suffering to be the next day. They want it to be the day after.

    16. PAPeter Attia1:56:34

        Mm.

    17. AMAshley Mason1:56:34

        So you get to choose that, but I tell people, "Look, don't sleep in more than one day in a row. It's gonna mess you up." And generally sleeping in past your bedtime, you're not really getting quality sleep when you sleep in past your, your bedtime, or, I'm sorry, your wake time.

    18. PAPeter Attia1:56:45

        Your wake time.

    19. AMAshley Mason1:56:45

        When that's, you know, when it's been a pattern for a long time, when you sleep in past your wake time, you're probably getting some extra stage two sleep. You're not getting more deep sleep, that's for sure. That's not happening.

    20. PAPeter Attia1:56:55

        We're recording this on a Tuesday. Sunday, two days ago, I was flying back to Austin from LA, and, uh, the flight got delayed over and over and over and over and over again, um, for reasons that are so asinine they're not even worth describing.

    21. AMAshley Mason1:57:15

        [laughs]

    22. PAPeter Attia1:57:16

        And then we finally got on the plane and taxied, and then the water was leaking out of the coffee machine.

    23. AMAshley Mason1:57:22

        [laughs] No.

    24. PAPeter Attia1:57:22

        So we had to go back to get another plane. I'm not making this up.

    25. AMAshley Mason1:57:25

        [laughs]

    26. PAPeter Attia1:57:26

        But I can, I can only tell you how ridiculous this is.

    27. AMAshley Mason1:57:30

        [laughs]

    28. PAPeter Attia1:57:31

        Uh, the punchline of the story is we didn't get home till 2:00 in the morning.

    29. AMAshley Mason1:57:34

        Yeah.

    30. PAPeter Attia1:57:34

        Which is long past my bedtime.
19. 1:59:23 – 2:02:07

    Process S and Process C: the science of sleep pressure and circadian rhythms

    1. AMAshley Mason1:59:24

       And we didn't really talk about Process S and Process C, but maybe I can just briefly tell you what those two things would be.

    2. PAPeter Attia1:59:30

       Absolutely.

    3. AMAshley Mason1:59:30

       Okay. So Process S is sleep homeostasis, and that's this sleep pressure idea that we are working on, right? And every day we build up sleep pressure until it's bedtime, and then we capitulate and we fall asleep, and then we, you know, our, our sleep pressure drains throughout the night while we sleep. And then in the morning we are full of, you know, then we, we build it up again the next day.

    4. PAPeter Attia1:59:54

       And this is just adenosine building up?

    5. AMAshley Mason1:59:56

       Yeah.

    6. PAPeter Attia1:59:56

       Is there something-

    7. AMAshley Mason1:59:56

       So you can think about that

    8. PAPeter Attia1:59:57

       ... is, okay, is there another way?

    9. AMAshley Mason1:59:58

       Yeah, think about it that way. And that's also why caffeine is problematic, right? So caffeine blocks adenosine receptors, so that's the, you know, the caffeine crash when it wears off and then all the adenosine floods the receptors and we experience that, oh, sleepiness, right? Uh, so, and that's why taking a nap is so difficult because what napping does is it basically kind of deflates your balloon a little bit of your sleep pressure. It robs you of some of that sleep pressure. So by the time you get around to your normal bedtime, if you've taken a long nap, you've reduced how much sleep pressure you would ordinarily have at that time. That's why napping can be dangerous. And then we have Process C, which is the circadian, uh, process, and that just marches on. It doesn't really care about your sleep pressure or how much you've slept. Have you ever... I'm sure you've pulled an all-nighter, but when people pull all-nighters, what they often will notice [laughs] -

    10. PAPeter Attia2:00:43

        How, how many all-nighters do you think I've pulled in my life?

    11. AMAshley Mason2:00:45

        Oh, hundreds.

    12. PAPeter Attia2:00:47

        I mean, yeah, I would need scientific notation to count them.

    13. AMAshley Mason2:00:49

        Yeah.

    14. PAPeter Attia2:00:49

        It's so pathetic.

    15. AMAshley Mason2:00:50

        It's a lot. So the thing to note about that is that it, you're, you're sleepy during the night when you're pulling the all-nighter, but in the morning you kind of have a burst of energy, and that's the circadian part speaking up, right? Um, and when we look at the, the sine curve of it, right, that, that's because your temperature is coming back up.

    16. PAPeter Attia2:01:09

        Your adrenal glands still make cortisol.

    17. AMAshley Mason2:01:11

        Everything still is function... Right. So your circadian process doesn't really care much about the sleep pressure. It says, "Oh, okay." If you line these two things up on a graph, they look like they talk to each other. They don't. But these two processes really determine a whole lot about your sleep. And there are things that we can do to support each of them, but CBT-I really focuses on the sleep pressure aspect by regularizing people's schedules.

    18. PAPeter Attia2:01:35

        Mm-hmm.

    19. AMAshley Mason2:01:35

        And then it supports the circadian aspect by some of these little things that I talked about that I don't even know if... You can't really call them standard CBT-I, like standardizing what time people are taking their medications, for example. Doing things that we know support circadian biology. Not eating right before bed. In my perfect world, you know, all of these different zeitgebers, which are- Timekeepers during the day would be consistent from day to day. You eat lunch every day at the same time, breakfast every day at the same time. All of these things would support your circadian biology and, and probably

20. 2:02:07 – 2:05:21

    How exercise too close to bedtime may impact sleep

    1. AMAshley Mason2:02:07

       improve your sleep.

    2. PAPeter Attia2:02:08

       Any rules about exercising? Do you have people that are showing up and you're, you're going through your intake and you realize, you know, based on their schedule, based on work, based on kids or other, uh, uh, obligations, the only time they're gonna get their workout in is in the evening. And is that in- in counterproductive, uh... Or put it, put it this way, if it is an issue, um, how do you, how do you adjust?

    3. AMAshley Mason2:02:35

       This is a really nuanced issue. I once had a patient who, a long time ago, who said, "Oh yeah, I take the 10:00 spin class in the Castro." And I was like, "Oh, okay," moving on. I, I assumed it was 10:00 AM. I was... That was w- wrong, and I learned that [laughs] the next week when we were talking about other things. But for some people, exercise at night is fine. For other people, it's super stimulating, and it also really depends on what kind of exercise we're talking about. And I think that one moderating variable here is also gonna be level of fitness. If you take a person who's extraordinarily cardiovascularly unfit and you put them in a spin class in the evening, do you know it could take their heart rate quite a while to recover. You could probably provide me a lot more information about that than I know, right? And what we know when you, in order to fall asleep is that your heart rate should be lowering, right? So if your heart rate is still elevated from a whole bunch of exercise you just did, that's not gonna help you. But if you're super fit and your heart rate recovers really quickly, it might affect you less.

    4. PAPeter Attia2:03:31

       Hmm.

    5. AMAshley Mason2:03:32

       So this, this matters. I think there was, for a long time, kind of this general suggestion to not exercise close to bedtime. I still think for the most part it applies, but I think that it's important to think about what kind of exercise you're doing. If someone tells me, "Oh, I'm going to a yoga class. I find this really relaxing and calming. It's a form of stretching for me, da, da, da," fine. Okay. And this is the only time of day you can do it. You got a job, you got kids, whatever, right? I'm not gonna tell you to not go just because of the time of day that it is, or weightlifting or, or whatnot. But if there's an option, if you wanna go to a HIIT class, I'm gonna say, "Well, could we not do it at 10:00 at night? Like, I think it would really be great if we could move it earlier." Um, we try, try to do that. Um, I do tell people, you know... I have some patients who've come in and said, "Oh, you know, like, I wake up, my, my body wants to wake up every day at, at 7:00, but I really wanna go to this 5:00 AM spin class every day." I'm like, "Okay, well, like, I understand exercise is very important. I, I'm a believer, right? Also, your circadian biology has you going to bed at 11:00 and getting up at 7:00. And even if you're getting up at 4:45 to get on your home spin bike to do this thing with this group, your body doesn't wanna go to bed until 11:00, and we're not gonna be able to change that. So you're gonna have to make that, you know, cost-benefit analysis with do you wanna lose that much sleep to do that thing?"

    6. PAPeter Attia2:04:57

       Yeah. It's, um... I, I... It was on my mind because I was... My, my brother-in-law plays in a men's hockey league and, you know, you only get ice time late at night.

    7. AMAshley Mason2:05:06

       Mm-hmm.

    8. PAPeter Attia2:05:06

       So I think they literally play Sundays at 11:00 PM or something. And he's always fried Monday because, you know, pretty hard to, to-

    9. AMAshley Mason2:05:16

       Mm-hmm

    10. PAPeter Attia2:05:16

        ... play a game of ice hockey and, and then, uh, and then fall asleep-

    11. AMAshley Mason2:05:19

        Mm-hmm

    12. PAPeter Attia2:05:20

        ... right after that. So

21. 2:05:21 – 2:11:58

    The structure and variability of CBT-I, Ashley’s approach, and tips for finding a therapist

    1. PAPeter Attia2:05:21

       [lip smacks] um, I wanna understand more, um, kind of how, what the, what the spectrum of CBT-I looks like.

    2. AMAshley Mason2:05:32

       Mm-hmm.

    3. PAPeter Attia2:05:32

       I mean, your process sounds super dialed in.

    4. AMAshley Mason2:05:35

       Mm-hmm.

    5. PAPeter Attia2:05:35

       But also it's quite bespoke. You know, you've brought a lot of your own expertise, um, to it, and you've created a system where you've got, "We're gonna do the intake, we're gonna do these five sessions," which I think are group sessions-

    6. AMAshley Mason2:05:48

       Mm-hmm

    7. PAPeter Attia2:05:48

       ... the way you described them.

    8. AMAshley Mason2:05:48

       Mm-hmm.

    9. PAPeter Attia2:05:49

       Then we do kind of the exit. Um, you, you, you bring so much rigor to it. Is that a, is that the way it is always done, or are there CBT-I therapists out there who function like psychotherapists and they say, "Yeah, we're just gonna engage with each other for... until your problem is fixed, and we'll see each other once a week or maybe once every other week"? Like, everything you're doing is, sounds formulaic, and I say that not in a bad way. I think that's probably a big part of its efficacy. Um, is that something people should expect when they are going to a CBT-I therapist?

    10. AMAshley Mason2:06:22

        It's something people should ask for. I... Before people start treatment, they fill out the Pittsburgh Sleep Quality Index, and they fill out the Insomnia Severity Index, and I tell them, "Look, we're gonna fill this out when you're done with treatment, too, and we're gonna see how this worked for you. We're gonna actually take measurements."

    11. PAPeter Attia2:06:37

        How, what type of scores are you getting on the PSQI?

    12. AMAshley Mason2:06:40

        I mean, it ranges from zero to 21. I get all the way to 21.

    13. PAPeter Attia2:06:43

        Wow, okay.

    14. AMAshley Mason2:06:44

        Yeah. And below five is considered, uh, no clinically significant sleep problems. I relax that to six or seven because if you have a prostate or if you're going through menopause and have hot flashes, you're gonna be, uh, um, [lip smacks] elevated on that scale-

    15. PAPeter Attia2:06:58

        Mm-hmm

    16. AMAshley Mason2:06:58

        ... by no fault of your own or s- or your sleep's fault.

    17. PAPeter Attia2:07:00

        Okay.

    18. AMAshley Mason2:07:01

        Um, and the Insomnia Severity Index, I mean, yeah, we see... I see all the way up to, what was it, like 22, 23, something like that. So I see all the way up to the most severe levels in both of these scales, uh, commonly. And the average point drops are, are huge, huge in, in clinic. So I don't know if it was, like, 10 points in the Insomnia Severity Index. Like, it's, it's, it's very high, very responsive to this treatment. But back to your original question is I, I think... I wish everybody did it this, this by the book. I think there's a lot of practitioners out there who wanna do it this by the book. I have a luxury to do it this by the book because I'm able to enlist help from my team to help me process sleep diaries every week and do probably two hours of work outside of my clinic of prep for me. So they feed me my stuff that's been built into the systems that I have, and I get to gr- and I, I'm prepping half an hour before A clinic, I see everybody for an hour and a half, and then I've got my, my notes, my templates, and things. But I think that it is very difficult to do CBT-I when you're not seeing patients weekly because I look at weekly sleep diaries, and I make changes based on that. So when you find a CBT-I therapist, I would say ask if you can set up a time in the future with that therapist and see them weekly for a set of whatever, five to eight weeks, and put it on the calendar that way with them. If they say, oh, they don't have bandwidth to do that for another month, say, "Okay, cool, I'll wait," and then get on every week. And a lot of practitioners also aren't gonna necessarily score your sleep diaries for you. You can score them yourself if you want to. I mean, it's not that difficult. If you just Google online, you can find a sleep diary calculator, and it's very easy to do the math yourself. Um, there's a book that I really like called Quiet Your Mind and Get to Sleep, which, written by Rachel Manber and Colleen Carney, and Dick Bootzin wrote the forward, and it's, it's kind of a guided way through the treatment, and you can use that workbook yourself to do it, and you can also use that workbook when you're working with a provider. But, um, I think there are a lot of CBT-I providers out there who can see you weekly and can do this. You'll probably just have to do your back-end work with your calculations because they don't have the billable time for that. Uh, they'll be busy during the sessions trying to teach you things. I would also note that between my sessions with my patients, I make them watch very annoying videos that I've made of myself giving a lecture about all of the science because I've found that if you explain the science to patients, you'll get the adherence. "Here's why we're gonna do this." People think, "Wait, I have problems sleeping. Now you're gonna make me not go to bed? This is not what I'm going for," right? And I have to explain to them, "Okay, here's why we do this, 'cause this will ultimately get you where you wanna go."

    19. PAPeter Attia2:09:53

        Mm-hmm.

    20. AMAshley Mason2:09:53

        But the principles of what I'm doing are not at all bespoke. I'm doing the, the, you know, time in bed restriction, stimulus control, the cognitive tex- techniques, the relaxation techniques, and, and the sleep hygiene. Those are the five major components. What is bespoke is the way that I set the wake time because that's not been standardized in the literature, the way I deal with standardizing medications, the way I deal with medication tapers, some of the anxiety tools that I bring in, like scheduled worry time, tracking degree of belief during the thought or tracking degree of belief during the day. I think that is actually pretty well incorporated into CBT-I. But some of those are a little bit more tilted toward my audience, which, which tends to be higher in anxiety, so I, I build those in. But otherwise, find someone on the, the website that we'll put in your note, show notes who knows how to do CBT-I, and I have a feeling you'll go far. The treatment works when you do it, and it doesn't work when you don't do it is what I tell all of my patients.

    21. PAPeter Attia2:10:53

        The book, um, Quiet Your Mind and Go To Sleep.

    22. AMAshley Mason2:10:57

        Get to Sleep.

    23. PAPeter Attia2:10:57

        Get to Sleep.

    24. AMAshley Mason2:10:58

        Mm-hmm.

    25. PAPeter Attia2:10:58

        Um, you mentioned that, um, that's something that people could do in therapy.

    26. AMAshley Mason2:11:04

        Mm-hmm.

    27. PAPeter Attia2:11:05

        But you also mentioned that it's something people could just do on their own. So if somebody's listening to this-

    28. AMAshley Mason2:11:08

        Mm-hmm

    29. PAPeter Attia2:11:08

        ... and they're thinking, A, I can't afford CBT-I-

    30. AMAshley Mason2:11:11

        Yep
22. 2:11:58 – 2:14:32

    The effect of sauna and cold plunge before bed on sleep quality

    1. PAPeter Attia2:11:58

       with, um, extreme temperature changes before bed? So people using sauna, people using cold plunge, taking hot showers, hot baths.

    2. AMAshley Mason2:12:05

       Great question.

    3. PAPeter Attia2:12:05

       Subjectively, from my experience, a, a, a sauna before bed really seems to help.

    4. AMAshley Mason2:12:12

       Mm-hmm.

    5. PAPeter Attia2:12:12

       Um, maybe it creates a great, a bigger gradient in temperature drop as I go from high body temp to low when I get into that super cold bed.

    6. AMAshley Mason2:12:20

       Mm-hmm.

    7. PAPeter Attia2:12:20

       But what, what, what is your experience with that, and how do you manage it through the process?

    8. AMAshley Mason2:12:24

       Well, let's first take cold plunge before bed off the table. Um, that's not a good idea because we know that when you get in the cold plunge, it's immediately cold on your skin, but then once you get out, your body is busy warming itself back up, and that's not what we wanna be doing right before bed, right? And then I'm gonna go into the sauna part by saying that it's another it depends. Some, uh, the, the theory, the, the outline that you just gave of the temperature gradient is beautiful. It makes a lot of sense. For people who are naive to sauna, who get in a sauna, and it increases their heart rate, increasing your heart before bed-

    9. PAPeter Attia2:12:53

       It might be the same problem as the exercise issue

    10. AMAshley Mason2:12:54

        ... it might be the same problem as the exercise.

    11. PAPeter Attia2:12:55

        Yeah, yeah. If they don't have the rapid recovery.

    12. AMAshley Mason2:12:57

        They don't have the rapid recovery. So that's something to learn about yourself.

    13. PAPeter Attia2:13:00

        And in fairness, I don't actually go straight from sauna to bed.

    14. AMAshley Mason2:13:03

        Mm-hmm.

    15. PAPeter Attia2:13:03

        It's usually sauna to 30 minutes of Netflix to bed, so.

    16. AMAshley Mason2:13:07

        Yeah. So it, it, that's gonna be person to person. Another thing to keep in mind is that some people who will go in the sauna at night then drink a whole bunch of water afterwards.

    17. PAPeter Attia2:13:17

        Yes.

    18. AMAshley Mason2:13:18

        And then that ends up causing them to wake up more in the middle of the night, so it defeats the purpose.

    19. PAPeter Attia2:13:22

        Mm-hmm.

    20. AMAshley Mason2:13:22

        So that's a consideration-

    21. PAPeter Attia2:13:23

        Yep

    22. AMAshley Mason2:13:23

        ... also if that's an issue for you. Um, but I would say just don't make it too strenuous. Some people find that it's really helpful. I do best with it a few hours before bed as opposed to right before bed. I think it's gonna be a do what works situation because we don't have enough data.

    23. PAPeter Attia2:13:42

        Mm-hmm.

    24. AMAshley Mason2:13:42

        But we are -- I just started an NIH-funded trial where we are looking at people who have difficulty with falling asleep, and we are giving them whole body heating at home before bed, and we're giving them cognitive behavioral therapy for insomnia through an app, and we're gonna have them do this whole home-based treatment that's gonna combine a body-based heat treatment for before bed- With the CBT-I treatment. And the idea here is what you explained, which is that by heating you up right before bed, if we're heating up your hands and your feet and we're helping you actually op- open the vasculature and dump some heat, it's gonna create that gradient, and we think that gradient might be important for people with the early kind of insomnia with falling asleep at the start of the night. So we're gonna see if that helps people in a very, like, you know, using a sauna blanket type thing.

    25. PAPeter Attia2:14:30

        Yeah.

    26. AMAshley Mason2:14:31

        Mm-hmm.

23. 2:14:32 – 2:21:17

    Key takeaways on CBT-I, and why no one should have to suffer from insomnia

    1. PAPeter Attia2:14:32

       Ashley, someone listening to us, uh, for the last two and a half hours might assume that the only thing you know about is CBT-I.

    2. AMAshley Mason2:14:38

       [laughs]

    3. PAPeter Attia2:14:38

       But it turns out that we've sort of only scratched the surface of your area of expertise, and there are other clinical areas that you, you have a lot of interest in that I think our listeners would have interest in as well. Um, so the, the good news is we've, I think, um ... When I say we, I mean you. Um, you've delivered kind of a master class on a topic that I've wanted to know much more about. You know, it's interesting. It's a bit of a black box because we send a number of our patients to CBT-I therapy around the country, and I would concur with what you said, which is based on their ability to comply, the efficacy has been unparalleled, simply stated. Right? So, um, you know, we're ... As far as regular old doctors, I think we're pretty good at helping people with sleep given the nature of our practice and how much attention we can pay.

    4. AMAshley Mason2:15:31

       Mm-hmm.

    5. PAPeter Attia2:15:32

       Um, and therefore, I think just by ourselves, we do pretty, pretty well. Um, but when we can't and we refer to CBT-I, I'm not ... I would have to think if there's been a patient who hasn't been helped. So that's, that's great. And, but, but truthfully, you've filled in all the gaps for me, and I think more importantly, I think you've really helped listeners understand this and I hope given people a lot of confidence. 'Cause what I also take away from this is there's really nobody who should be suffering from insomnia. It's, it's really not a necessary thing to suffer. We-- There's things we might have to suffer with in life, but this isn't one.

    6. AMAshley Mason2:16:10

       I think for very, a very large percentage of the population, that's the case. I always, I almost ... I'm afraid to say never because you just never know.

    7. PAPeter Attia2:16:18

       Of course.

    8. AMAshley Mason2:16:18

       But, but there are so many, so many people, countless, suffering from this who definitely don't need to be.

    9. PAPeter Attia2:16:28

       Uh, the drawback is we have kind of run out of time to talk about a few other things that are really interesting-

    10. AMAshley Mason2:16:34

        [laughs]

    11. PAPeter Attia2:16:35

        ... which is not uncommon on this podcast, which means we're gonna have to do a part two-

    12. AMAshley Mason2:16:38

        [laughs]

    13. PAPeter Attia2:16:39

        ... at some point to, to talk about, uh, eating behaviors, thermal regulation, uh, the impact that that has on, uh, depression or other things like that.

    14. AMAshley Mason2:16:49

        Mm.

    15. PAPeter Attia2:16:49

        So, um, apologies that maybe we spent more time on CBT-I-

    16. AMAshley Mason2:16:54

        [laughs]

    17. PAPeter Attia2:16:54

        ... than we intended to. But, um, as, as I kind of warned you before we started, we, we, we love to just meander where the discussion goes. So, um, is there anything else you wanna talk about on the CBT-I front? Um, those were ... Th- that ... I have a lot of notes on-

    18. AMAshley Mason2:17:12

        [laughs]

    19. PAPeter Attia2:17:13

        ... on kind of where I wanted to go, but I also realize there's probably something I've forgotten or there's an area you wanna double click on.

    20. AMAshley Mason2:17:19

        No, I think that it's really important for people just to remember with this one that even if you don't know what caused your insomnia, you can do this treatment. You don't have to have figured out, oh, this is where it started-

    21. PAPeter Attia2:17:40

        Mm

    22. AMAshley Mason2:17:40

        ... or this was the, the root of it all. You can start this treatment without that knowledge because this treatment is going to address what you're doing now that's actually perpetuating the problem. And don't wait. There's never gonna feel like a good time to do it. Now is the best time. Your life is always going to be crazy. You're always going to have 50 more things on the schedule than you wish you did. It's always gonna be too busy. You're always gonna have events. Just do it now, because it's so difficult to live with, live with insomnia and all the problems that it causes. I had a one ... I had this patient who was 87 who I finished treatment with last year, and she just said, "My, I wish I'd done this 40 years ago." You know? And it's ... So don't wait. Just, just do it. You won't regret it.

    23. PAPeter Attia2:18:36

        Are you under the impression that... Obviously, people are waiting a long time to see you.

    24. AMAshley Mason2:18:41

        Mm.

    25. PAPeter Attia2:18:41

        Um, that probably speaks to how good you are, um, and the resources-

    26. AMAshley Mason2:18:46

        Kinda the thing

    27. PAPeter Attia2:18:46

        ... that UCSF provides-

    28. AMAshley Mason2:18:47

        Yeah

    29. PAPeter Attia2:18:47

        ... maybe in combination. But if a person's listening to this and they're like, "Yeah, I, I wish I could work with Ashley, but I'm, I'm ... I just wanna work with somebody-"

    30. AMAshley Mason2:18:56

        Mm-hmm

Episode duration: 2:21:17