A good laugh and a long sleep are the best cures in the doctor’s book. So read carefully my dear gentleman. Your life is about to change.
- What is it in our body that makes us sleepy at night?
- What’s happening when we think we feel sleepy, but end up feeling awake once we get into bed?
- Fatigue vs. sleepiness and how to tell the difference between the two
- What is true sleep deprivation? What are its harmful effects? How is it different from insomnia?
- How much sleep do people really need at night? Is there a clear answer?
- The ways we make problems out of sleep that don’t really exist
- The fear around sleep and insomnia
- Differences between sleep perceptions and sleep realities
- What does good sleep hygiene look like?
- What’s the deal with sleep drugs?
Over the past decade, there’s been an emerging focus on the importance of sleep. Thousands of books and articles have been put out which drive home just how important sleep is to our mental and physical health. This emphasis on sleep has had the positive effect of motivating people to better prioritize it, but there’s been a downside to all the sleep talk as well: People are getting more stressed out if they’re not getting the kind of sleep they think they’re supposed to.
My guest today says that, ironically, stressing about sleep may be exactly what’s hurting your sleep. His name is Dr. Chris Winter, he’s a neurologist and sleep specialist, and the author of The Sleep Solution: Why Your Sleep is Broken and How to Fix It. Chris and I begin our conversation with why we get sleepy and how sometimes people confuse fatigue with sleepiness. We then get in the real dangers of sleep deprivation, but how you probably shouldn’t worry about them if you have common problems with falling and staying asleep. We then talk about how many hours of sleep you actually need and how you may be stressing yourself out trying to get more than is necessary, and why it’s best to compare your varying hunger for sleep or your varying hunger for food.
Chris unpacks when insomnia is, how it’s not just an inability to sleep, but your response to that inability and the extent to which insomnia is rooted in fear. From there we turn to the disparity that often exists between the perception and the reality of how much sleep we’re getting and the fact there is a good chance you’re actually getting more sleep than you think. We then discuss creating a plan for what to do when you can’t sleep, which may involve spending less time in bed or, in fact, relishing the time you spend lying awake in your bed at night. And we end our conversation with when you should and shouldn’t take a nap and when you should see a sleep doctor about your sleep problems.
Alright, so you are a neurologist and a sleep specialist, you have helped thousands of people from regular joes to professional athletes improve the quality of their sleep, and I’m hoping in today’s conversation, you can provide some insight and some advice to our listeners who are having a hard time sleeping so they can have a more restful night of sleep. But before we get to the advice, I think it’d be useful to understand a little bit about how sleep works. Specifically, let’s talk about what is going on in our body that makes us want to sleep, or makes us feel sleepy.
Chris Winter: So there’s a bunch of things. The two things we think about most are the longer we’re awake, the more we start to accumulate a chemical called adenosine in our brain. If you remember back from your biology days when you were studying the different parts of the cell, one of them was the mitochondria. The mitochondria is really sort of the energy furnace of the cell, it’s where we take theoretically food energy and transform it to energy we can actually do things like mow a lawn or run a race or something like that.
So when we talk about ATP, capital ATP, going into that mitochondria, it explodes with this fantastic chemical reaction, and now we have energy. What we don’t talk about is that there’s a by-product of that response called adenosine, and it’s adenosine that accumulates in your brain that makes us want to seek sleep. Therefore the longer we’re awake, the more we accumulate this chemical, the more we want to sleep. So that’s really the homeostatic chemical for sleep, which is why eventually everybody sleeps. It’s impossible to just make a decision, I’m going to stay up forever, because you accumulate so much of this chemical that eventually your brain will take the decision out of your hands and you’ll just fall asleep doing whatever you do.
So that’s one part of it. Another part is melatonin, which is a chemical that really has to do with our relationship with sleep and our environment. So if we sit out on our back porch all day and read a book or do our Zoom meetings, eventually as the sun starts to go down, we’ll probably start to get a little sleepy, yes, because as we lose light in our environment and our eyes see that loss of light, we start to produce a chemical called melatonin. So melatonin’s job is to take the sleepiness we’re all going to develop and try to regulate it in terms of timing. So theoretically, most humans are going to be more awake during the day and more sleepy during the night. Raccoons have the complete opposite response to melatonin. They want to be awake in your garbage can at night and sleep during the day, so those are sort of the biological underpinnings of sleep.
It’s a primary drive, it’s something that we can’t escape. So even the worst sleeper out there is going to sleep, humans are going to sleep about five to six hours every 24 they’re alive, and there’s not a thing we can do about it. So it’s important to understand that for an individual who comes to tell me… I had a guy tell me he’d been in Germany for nine-and-a-half months and never slept the time he was there. That’s not a true statement. It may be true from his perception, but the idea that there are people out there going nine-and-a-half months without any sleep just doesn’t happen.
Brett McKay: Why is it? I think everyone’s experience is like, they feel really sleepy. This happened to me this week, I feel really sleepy. I’m like, alright, time for bed, and as soon as I get into bed, I feel wide awake and I can’t go to sleep. What’s going on there? With their sleep drive, that causes that…
Chris Winter: There’s probably a bunch of things. I think number one, people poorly define the feeling of sleepy. So to me, sleepiness is drive to sleep. So if somebody says to me, I am so sleepy when I go to bed at 9 o’clock every night, and I ask them, how long does it take you to fall asleep, and they say two hours minimum, I’m going to argue that at 9 o’clock, they’re not particularly sleepy. So humans often use the feeling of fatigue as a surrogate for sleepy, meaning that you’re sitting there at night and you’re exhausted, you’ve got no energy. If somebody came up to you and said, hey, let’s go run a few miles or a few laps around a track, you would say to them, look, I don’t have any energy at the moment, I don’t have the energy to fold a load of laundry, let alone go for a run. That’s not the same thing as sleepiness.
In other words, when you’re running in the marathon and you get to mile marker 19, you might quit, but generally you’re going to quit because of fatigue, not because of sleepiness. Oh, I got to mile marker 19, doc, and I could barely keep my eyes open, so I lay down in the middle of the road and took a nap, said nobody ever, right. So that could be part of it.
The second is sleep is a skill, and like any other skill, there’s a performance that goes along with it. So maybe you are sleepy when you decide to go to bed at night, and once you get into bed, you’ve got some sort of performance anxiety that’s going to keep you awake a little bit longer, meaning, we’ve all come across an empty gymnasium with a basketball sitting there and started shooting some hoops and maybe, oh my gosh, you just made 10 straight free throws. Nobody’s in the gym. Nobody’s watching you, nothing’s on the line. You just made 10 free throws.
Chris Winter: Now, put that same individual on the free throw line for the NBA championship, so the entire team and the entire community is looking to you to make these two free throws. If you do, you’re the champion, you’re going to get a massive bonus, you’re going to be a hero in that city for the rest of your life; miss it, and everybody will remember you as the person who couldn’t make the free throws to win the championship. So it’s still no different than the activity that you were engaged in in that empty gym, it’s putting a rubber ball through an iron hoop, but now you’ve engaged in a completely different psychological action than you were when nothing was on the line. And so for people who really struggle with their sleep, they put a tremendous amount on the line when they get into bed, and that’s part of the problem that we have with our dialogues and discussions about sleep.
Yes, we know a lot more about sleep than we did even 10 years ago. Yes, it’s incredibly important for your health, but when you start going to bed at night with this feeling of, I’ve got to go to bed now, get my eight hours of sleep because some doctor said I needed to, and if I don’t, I’m going to develop dementia. That’s a really terrible way to initiate sleep at night. So I always tell people, look, get into bed, one of two things will happen, you’re going to fall asleep or you’re not. You need to be equally comfortable and happy with either of those outcomes, and if you’re not, we need to get you to a place where you are, because that’s where sleep problems really can dig their teeth into people, when you start fearing that activity of going to sleep at night and maybe not falling asleep immediately.
Brett McKay: And we’ll talk about some things that people can do to do that here in a bit. I want to go into this idea between the difference, even sleepiness and fatigue, because I thought this is really interesting. I think I’ve struggled with that distinction for a long time. Sometimes I just… I think I’m sleepy when I’m actually fatigued. How do you tell the difference between the two?
Chris Winter: I think it’s really about behaviors. If somebody says, I’m really sleepy, typically when I go to that 5 o’clock meeting on Friday, and they’re saying, I’ve got to walk around, or I have to eat Goldfish crackers or M& Ms and drink something, otherwise, I fall asleep and my principal makes fun of me. I would say that you’re exhibiting some signs of pretty excessive sleepiness at that time. Somebody says that when they drive, they will often wake up at a stoplight to the sound of the person behind them honking, ’cause the light’s turned green, or they love to read but it’s a very frustrating procedure for them because every time they sit down to read this book that they’re really interested in, they get half way through the first page and they fall asleep, so they’ve been trying to read this book for the last six weeks, all they do is read the same three pages over and over, ’cause every time they sit down to start to read, they fall asleep.
I had a young woman who built a desk on a treadmill, because if she sat to do work, she’d fall asleep, and she discovered that one trick was to be walking when she did work and that would help her stay awake. I would say those are great signs of somebody who’s excessively sleepy. And if you’re excessively sleepy, it’s happening through one of two mechanisms only: You are not getting enough sleep, you’re not spending enough time in bed to get to sleep. You like to stay up and watch Stephen Colbert and then you watch Seth Meyers, so now it’s 1:30 when you go to bed, you have to be up at 6 o’clock the next morning to go to work or get on your Zoom meeting or start your commute. So that individual is probably not giving himself or herself an adequate amount of time to get to sleep at night.
Or you’re somebody who’s sleeping nine, 10 hours a night and feels sleepy, well, that’s not an inadequate amount of sleep, that’s probably coming because your sleep is dysfunctional, or there’s something wrong with the quality of it. So you can kind of make up for a lack of sleep quality with more sleep quantity, to a point, but then it gets to a place where somebody’s sleeping 12 hours and still can’t control their drive to sleep during the day. And that’s how some people with severe sleep apnea and narcolepsy will get, tey can’t sleep enough. And even other people start to notice it, family members, partners, like, gosh, honey, you slept 10 hours last night, woke up, had breakfast and you sat down to read the paper and you fell asleep again. Like what’s going on? How are you able to sleep 10 hours and still be sleepy enough that you don’t want to go out and go on the hike with the rest of the family, you want to stay home and sleep, why? That doesn’t make any sense.
And it can really… These types of things can really drive a wedge in relationships. So sleepiness is always going to be defined as your drive to sleep. Again, somebody says to me, I am so sleepy and it takes me four hours to fall asleep every night. No, you’re not. That’s the same thing as saying, I am so hungry and I offer you a sandwich and an apple and you don’t want it. No, you’re not that hungry, ’cause if you were hungry, you’d need the food I was offering. In fact, if you were really hungry, you might eat this food out of a trash can. So drive to sleep is really easy to figure out.
Fatigue is different, fatigue is more of a body energy, motivation during the day, kind of the way you might feel if you were getting sick, sure, you might want to go to bed ’cause you don’t feel well, but sometimes you go to bed, you don’t fall asleep, it just feels good just to be in the dark, quiet, lying there, not having to do anything. So I always think about fatigue as the way you would feel after you ran 10 miles or mowed a big lawn or engaged in a Spartan Race or something like that. At the end of the Spartan Race, yeah, you’re done, you want your T-shirt and want to get on social media and start bragging, but you’re not necessarily thinking, oh, I’ve got to lay down here in this field and take a nap before I can do anything. It’s not a sleepiness that you’re describing.
Brett McKay: Alright, so a lot of people, they’re confusing sleeping this with fatigue, including me. And I can see how this can cause a lot of anxiety, because you’re tired at night, you feel like, oh, it’s time to go to bed, you go to bed, but because you’re not sleepy, you’re just tired, you just lay there and you can’t fall asleep, and then the anxiety compounds ’cause you start thinking like, o my gosh, I’ve read these articles, all these bad things that happen if you don’t get enough sleep, dementia, can get in a car wreck, my working memory is going to be bad. And then it just perpetuates, and it makes it harder and harder to fall asleep. So two questions here. The first one is, what are the downsides of not sleeping? Like what happens when you don’t get enough sleep, you’re sleep-deprived. And the second part is, do most people who can’t fall asleep at night or have trouble every now then, do they really need to worry about this stuff?
Chris Winter: Sure, so I think it’s important to understand that when we’re talking about the negatives of sleep deprivation, that we’re truly talking about sleep deprivation, meaning that an individual has the opportunity to get seven hours of sleep but has decided or it’s been decided for them by their boss that they’re only going to get two or three hours of sleep. I think it’s important to differentiate that from what we consider to be insomnia, where a person says, I’m going to bed at 11 o’clock every night, it takes me four hours to fall asleep. They’re really two very different things. But if somebody is truly sleep-deprived, either on purpose, and we meet people like that all the time who say, look, I go to bed at midnight, get up at 3 o’clock to work out, or something ridiculous like that, and they’ll tell you, well, I’m fine, I know it doesn’t seem like a lot of sleep. As long as I get my three hours of sleep, I’m really good to go. You’re really not. You’re really harming yourself over time.
So one of our little secret sayings, and we’ve got about 10 of them in our clinic, is, just because you can do it doesn’t mean you should. And I think that sleep deprivation kinda falls into that category, ’cause these are the people who are getting up at 3 o’clock in the morning to train for triathlons, and they die at age 51, and nobody can figure out why. The effects of long-term sleep deprivation are absolutely profound. In addition to just being sleepy all the time, such that every time you sit down to watch a TV show or read a book, you fall asleep, and obviously driving a car and being that sleepy aren’t terribly compatible.
It just erodes at our cardiovascular health, makes us much more likely to develop high blood pressure or heart attack, stroke, we tend to create issues with metabolism and gain weight. There’s a lot of cognitive issues that go along with sleep deprivation, including perhaps the development and the acceleration of dementing illnesses like Alzheimer’s disease. There’s great evidence to suggest that chronic sleep deprivation or chronic changing of schedules, kind of sleeping all over the place, could lead to cancer, so it’s really difficult to find an organ system that’s not affected by sleep loss and sleep deprivation.
And even the way we look has been shown that, you know, our skin sags more, we wrinkle more, bags under our eyes, we look older, we age faster when we’re not sleeping the way we should. Again, I’m just going to stress one more time, just because I think it’s often lost when there are discussions about sleep, if you’re listening to this and thinking, oh my gosh, I go to bed at 10 o’clock every night, and it never takes any less than an hour or two to fall asleep, we are not talking about you. This has nothing to do with the individual who’s giving themselves the opportunity to sleep, but they’re not taking it.
And that’s important because when you think of sleep deprivation, true sleep deprivation causes one thing above all else, it causes sleepiness. It’s like food deprivation causing hunger or fluid deprivation causing thirst. So if somebody says to me that they go to bed every night at 10 o’clock and it takes them two hours to fall asleep on a good night, it’s hard to make a case that that individual is sleep-deprived. They’ve got a sleep problem, they’ve got difficulty initiating sleep or they wake up in the middle of the night for a couple of hours, but that sort of behavior is inconsistent with the pattern that we see with sleep deprivation, which is my father, who every time he sits down, he goes right to sleep. That’s what sleep deprivation looks like.
And the problem is, the media message is all about insomnia, how long does it take you to fall asleep, do you struggle to fall asleep, do you need a little moth to fly into your bedroom at night and kiss you on the cheek to make you fall asleep, as the drug ad would tell you. So when my father sees those ads, he thinks, I I don’t know who those people are with sleep problems, I’m the best sleeper in the world, ’cause every time I sit down, I fall asleep. Sleep science is actually more worried about the person who falls asleep every time they sit down versus the individual who it might take them a little while to fall asleep. They’re really two separate entities.
Brett McKay: Alright, so the downsides of not sleeping, this comes from actual sleep deprivation, these are people who are sleeping two, three hours a night for extended periods, it’s not the people who are having a hard time falling asleep or they wake up occasionally throughout the night, they don’t have to worry about too much about it, because what’s going to happen, it sounds like, is that their body is just going to get sleepier and they’re going to sleep more and they’re going to get the sleep they need. But I can still see this is going to be nerve-racking for people even when they hear this, because as you said, that we have this culture around sleep that we’ve developed where we obsess about it, try to optimize it. And one number, one thing that people hone in on a lot when they’re thinking about optimizing their sleep is what’s the number of hours of sleep I should get, minimum. So sleep doctor, how much sleep do most people need to get?
Chris Winter: So how much sleep most people need, I want you to think about that question, and I want your listeners to think about that question as a similar question to how much food do we need or how many calories should I be consuming. The answer to that question depends incredibly on the I. Who are we talking to? Are you a 80-year-old retired accountant who’s basically inside your home because you’re nervous to go out and get the coronavirus, or you a 18-year-old gymnast in training for the Olympics, or a 300-pound football player for the Baltimore Ravens? So those questions have a context to them that we often don’t dive in to when we talk about sleep. Oh, you need eight hours. Well, okay, does the average person need eight hours? Maybe, I think seven-and-a-half’s the better average for a general mid-range adult population, but there’s nothing wrong with eight.
As long as people understand that eight is an average, it’s like the average person at a picnic eats two hot dogs and a hamburger. Okay, that doesn’t mean everybody’s buying, eating two hot dogs and hamburger, it’s a nice number to have, if you’re planning a huge picnic. It might be a nice number to have if you’re seeing patients who have sleep problems. But one of the biggest causes of “insomnia” in this country is an individual who needs 60 hours 50 minutes of sleep every night, getting in bed and trying to get eight. You are genetically not programmed to get eight hours of sleep, so you’ve got as much of a sleep problem as a person eating an extra large pizza every night and not being able to finish it has an appetite problem. Sure, that person could go to their doctor and say, I’ve got something wrong with my appetite, I can never finish my dinner.
I think a bad doctor gives that patient an appetite stimulant and doesn’t ask any more questions. A good doctor would say, oh, I’m sorry to hear you’re struggling, tell me more about your dinner. Well, it’s an extra large pizza, thick crust, deep dish, tons of meat. Well, listen, you’re a 5 foot 7, 140 pound guy, and I don’t know that it’s necessarily appropriate for you to be eating that much food at dinner at night, so I’m not sure your struggles to finish that pizza rise to the level of a medical problem that we need to treat. Even if the patient says, well, my friend eats a whole extra large pizza and he’s super healthy, I want to be like him. Yeah, well, he’s a linebacker for the Baltimore Ravens, it’s a completely different situation.
But when it comes to sleep, we often lose those pieces of dialogue. In fact, I have people all the time, I’m writing for this magazine and we want some great tips for our readers to help them if they wake up in the middle of the night, what are some tips they can use to get back to sleep? And I asked one writer one time, I’ll give you a tip, but I need a tip too. And she said, what do you need a tip about? I said, well, sometimes I get halfway through my sandwich, I get this sandwich every day from this restaurant for lunch, on occasion I get half way through it, I don’t want to eat the rest of it. So what’s a good tip for me to help finish that sandwich, so I don’t starve to death. And she laughed and said, I don’t think you need to finish the sandwich, I don’t think that’s a problem if sometimes every now and then you don’t finish that sandwich. I said, well, I don’t think the question you’ve brought to me is a problem either.
And I think we have to think about that as a society and a culture when we think about sleep, that if somebody wakes up at 4 o’clock in the morning and can’t get back to sleep, why do we have to treat that? What are we treating? What are we concerned about? Because to me, it might just be a brain that says it’s got enough sleep and doesn’t really want to sleep right now, so I don’t think that’s a big issue. I think we make some problems into much bigger issues than they are. And when you start fearing waking up at 4 o’clock in the morning and wondering if your pill that your doctor is giving you or pills is going to do the trick, I think we start to create more problems than we solve.
Brett McKay: Well, is that fear of sleep and being able to fall asleep or stay asleep, is that what insomnia is? What is insomnia?
Chris Winter: If you were to ask me what my definition of insomnia would be, I think for a lot of people, if you had to whittle it down to one word, it is that, it is a fear. Insomnia, if you define it with medical professionals, is not an individual who can’t sleep. So if you go out to an outdoor mall and these people walk by on a pretty day, ask, them, hey, can I ask you a real quick question for a survey? And they say, sure. If you ask them what’s insomnia, they’ll say, I don’t know, it’s when somebody can’t sleep. That’s the definition, can’t sleep. It’s really the definition of insomnia, because can’t sleep doesn’t exist in nature, really, it’s an individual who’s not sleeping in a way or a time in which they’ve decided they want to.
So they’ve decided 11 o’clock’s their bedtime, they’re going to bed at 11, it takes them an hour or two to fall asleep. So that’s part A. Part B is you have to have a negative response to part A. So when somebody says to me, hey, Chris, I’ve heard you’re a sleep doctor, so I go to bed every night at 10 o’clock, takes me two hours to fall sleep. My first question is, how do you feel about that? And if somebody says, oh, I don’t mind, then I don’t really think they have insomnia, I don’t think anything really needs to be done about that. In fact, I would say, yeah, sometimes it takes me a while to fall see too, and I don’t mind either. In fact, I like being in bed awake, I don’t have a problem with it at all.
If you start having a problem with being in bed awake, that’s really the origin of insomnia. We talk about insomnia as sort of runs kind of in people who are more predisposed to be a bit anxious, a bit more type A. These are successful people, they’re entrepreneurial in spirit, if there’s a problem, they’re going to figure out a solution right away. These are traits that you want in a partner or a spouse or an employee, they’re not great traits to have when somebody goes to bed at night, and then they are struggling to fall asleep. Now all of a sudden the wheels start churning and they are trying to solve the problem, which is unfortunate, versus just, oh, well, I’m awake, I’m going to sit here and use this time to think about what to buy for my husband for his birthday coming up.
Well, I’m going to use this to think about a way that I could deal with an employee who has very unusual political beliefs, but I’ve got to work with him, and I think that the way I’ve been kind of making fun of him is not a great way to move forward, and I’m going to really try to get inside his head and come to some understanding about thinking about the way he thinks. You can use that time. I embrace time in bed awake, I love it. And that’s why I always, when I lecture about insomnia, I always tell people, look, I’m never going to have insomnia in my life, and there’s always murmuring in the crowd. I say, well, wait a minute, I didn’t say I wouldn’t have sleepless nights.
A sleepless night is part of the human condition, we’re all going to get in bed and struggle to fall asleep from time to time. Insomnia is when we really care about it, when it’s upsetting and frustrating. If you want to really see a tour de force of insomnia or insomnia thinking, go on Amazon, find my book, it’s called The Sleep Solution, go down where the ratings are, and just look at the one-star reviews of the book. And you really start to get a sense of the word that you used, Brett, which is a good word, it’s fear. There are people out there who are traumatized by the condition, so when I say that inability to sleep or not being able to sleep doesn’t exist, that doesn’t mean insomnia doesn’t exist. Insomnia is a very real thing, we just often define it incorrectly, which leads to incorrect treatments.
Michael Jackson went to his doctors and said, I can’t sleep. And instead of probing that and redefining the problem, they said, okay, here are some drugs. And he came back and said, these drugs don’t work or don’t work anymore. I need better drugs. And eventually they got to a point where a surgeon was going to his house and anesthetizing him with a drug called propafol, which is completely problematic and just a terrible way to deal with somebody who’s got sleep problems. And we killed him. The sleep community or the medical community, not the sleep community, the medical community killed Michael Jackson, not on purpose, but they thought they were doing the right thing.
And that’s where we’ve got to get out from under these things and understand that, listen, I hear you when you are frustrated and fearful and dread going to sleep at night. You’ve created almost a PTSD situation. And when you read those one-star reviews, you can feel that PTSD. One person whose like Amazon name was Tired69 said it’s hell on earth. Which is a really interesting thing to think about. If somebody said to me, Chris, what is your hell on earth situation? I could give you a bunch of them, being captive in a hole or having a kid kidnapped or a kid going through cancer or something, there’s a lot of hell on earth scenarios I can give you.
One of mine is not, you’re in a climate-controlled bedroom at 68 degrees, the love of your life sleeping next to you and you’re awake and it’s 2 o’clock in the morning. Like, okay, that might not be the scenario I really want to be in the most, but I don’t care about that. It’s not really a hell on earth to me. And part of that comes with the belief that I know that just because I’m awake at 2 o’clock in the morning, I’m going to sleep, so there’s nothing to really be that worried about. So that’s where we’ve got to get people… So if you flip over and read the five star reviews of the book, you can see that change in thinking. I’ve had people say, like clinic patients say, just by talking to you, I feel like my insomnia is better already, because of the fears and misunderstandings that people take to bed with them. So I think fear is a great way to describe a lot of insomnia.
Brett McKay: Yeah, so it sounds like it’s more of a psychological issue, it’s not like… There’s nothing medical you need to do for insomnia, it’s more about changing… It’s like cognitive behavioral therapy.
Chris Winter: For a lot of people, there can be medical reasons for it, for a lot of people have restless leg syndrome, they don’t come to me and say, hey, I got restless leg syndrome, they say, I have trouble sleeping. So there is a psychological component to some of it, a lot of it, but not all of it, which is why if you’re like, look, Chris, I go to bed and I don’t care if I fall asleep or not, but these things are happening and I am super sleepy during the day, we always talk about if you have knee pain, you might buy a little brace at Walgreens or you might ice your knee or take some Advil or Motrin or something. But eventually if you’re feeling like, gosh, my knee is really hurting more than it did a few weeks ago, and none of the things I’ve bought at Walgreens or these remedies I’ve tried are helping, you’re probably going to go see your doctor or an orthopedic specialist.
So to me, yeah, if you’re feeling like, look, I’ve struggled with these things for a long time, even if they’re sort of fear-based kinds of situations, talk to a sleep doctor, there is a much better solution than some sort of pill to knock you out at night. Sedation and sleep are two very different things.
Brett McKay: Well, related to insomnia, it is kinda like a science. It’s not people are afraid of… But people who sleep or like people who think they’re not sleeping or they’re having bad sleep, but then they come to you and say, Doc, I’m not sleeping, my sleep is terrible, and they do a sleep study and their sleep’s fine. Like what’s going on there, where the perception is off between the quality and the quantity of sleep they’re getting, but what they think they’re getting?
Chris Winter: Sure, so a sleep study, particularly in these days when we’ve got home sleep studies, is not necessarily a guarantee that your sleep is normal. But your point is a good one, that another one of our secret sayings in the clinic is perception of sleep and reality are two very different things. So when the patient comes to me and says, I’ve been in Germany for the last nine-and-a-half months and I haven’t slept, he wasn’t sitting at home the night before saying, I’ve got this great idea, honey, I’m going to go to see the sleep doctor, I’m going to wait several months for my visit, and when I finally get in to see him, I’m going to lie about my sleep and tell him I’m not sleeping, when in fact I really am. It’ll be so much fun. Like nobody ever does that.
So when that individual comes… Or I had a circuit court judge… Right below the Supreme Court. She came in at one point and said, I’m not sleeping. I said, when you say you’re not sleeping, what do you mean? She said, do I stutter? I don’t sleep. You know, the husband had a kind of funny look on his face, and the funny look was, I don’t think that’s necessarily true, but I don’t want to say anything ’cause I’m living with her, etcetera. But that’s her perception. So we actually put her in a sleep center and she did a sleep study, and she came back and said, see, I told you, I don’t sleep. I’m like, ma’am, you slept for six-and-a-half hours and I showed her the video. And she said, Chris, that is absolutely not my perception of what happened that night. In fact, if I didn’t know any better, I would think that you superimposed my face digitally onto the body of somebody else who was actually sleeping because my experience was I was awake all night.
Now, it starts to make sense when you understand that she’s awake all night, yet she’s hearing court cases all day long, doesn’t feel sleepy. In fact, when she tries to nap, she can’t. So that behavior makes sense now. And so it’s important that we understand that how we feel about our sleep doesn’t always match up with the reality. In fact, that’s one of the wonderful things about some of the technology we have. Sure, it may not be great at determining REM sleep and deep sleep, but if you’re wearing an Apple watch or a Fitbit or a Withings band, trying to figure out how much sleep you’re getting, and you’re waking up every morning and writing in your sleep diary, I slept 28 minutes last night, but your Fitbit is saying, you up six hours and 17 minutes. No offense to you, and I understand that a Fitbit can be off, but I actually believe the Fitbit more than I do you, and I bet your bed partner does as well too.
So it’s sometimes nice to have an objective measure, because now that fear of, oh, my gosh, I am sleeping 30 minutes a night, and I have so for the past eight days, I’m going to develop dementia by the end of the month, my sleep is so bad. Now you have this objective voice saying, hey, don’t worry, maybe you didn’t sleep great last night, but you got six hours and 17 minutes sleep, which is a whole lot better than 28 minutes. So these things have started to play a real positive role in people’s lives, that they’re actually sort of a referee. Like I can tell you, look, you’re not in danger of sleeping 28 minutes a night. I had a parent who said their kid slept two hours a night, and I’m like, no, he doesn’t, not on average. Maybe last night he did, but there’s no way over a month’s time your 11-year-old son’s averaging an hour or two of sleep, it just doesn’t happen in nature. If you don’t believe me, buy him a Fitbit, stick it on his wrist and we’ll talk in a month.
Nobody ever brought a Fitbit back that says, oh wow, you’re right, one hour. If that ever is the case, the medical sleep community is going to be up in arms because we’ve been looking for that person for years, but have never been able to validate that somebody like that can even exist.
Brett McKay: And you what was one of the biggest takeaways from this book that helped me really right away, I’ve had those… When you wake up in the morning, you don’t feel great, you don’t feel refreshed, and you think, I didn’t sleep last night, my sleep is horrible. And I was like, well, I probably did sleep, and if I asked my wife, she’d be like, no, you were snoring when I came into the bedroom to get into bed. It’s like, okay, I did sleep, I did get the sleep that my body needed, I might not feel like it, but I did.
Chris Winter: Or you might even say that sleep quality wasn’t that great. So again, when a person comes to my clinic, for a lot of people, the first thing we have to agree on is you sleep, and for 90% of people that’s not a problem. Scientifically, sure. We have to eat. We have to drink. We have to sleep. So when you say to your wife, oh, I slept terribly last night, and she said, well, I think you slept better than you thought you did, because that time you thought you were awake, you were actually snoring. Sure, you did sleep. So if the question is, does Brett sleep or not, I’m sure he does, your wife agrees, there we go. Does that mean your sleep that night was as good as it could be? Absolutely not.
So when I’m telling a patient who has insomnia, look, you sleep. I am not saying you sleep well, but we do have to get to a place in our relationship where we can believe that you actually sleep, and like I said, if you go back to those one star reviews of the book, these are people who’ve read the book and are like, I don’t care with this smart ass sleep doctor has to say, I haven’t slept more than two hours a night, and I guess I’m the exception, and his book really didn’t help me figure out a way where I can get more than two hours of sleep at night.
No, it’s not going to do that. In fact, I’ve always had a great idea for a television show. I want to contact those one-hour sleepers, and I’m going to move into their home for the next 14 days, and now I’m in complete control of their schedule. We’re going to hook some cameras up in their bedroom and we’re going to get down to figuring out the problems these individuals have, but now we’ve got eyes on the situation, so if you’re truly not sleeping at night, we’re going to see it. And I’m going to make sure you’re up at 6 o’clock in the morning and eating right and exercising and getting sunlight and do all the secondary things we need to do for our sleep versus just hiding behind, well, I only sleep an hour and you’re frustrating me about this conversation, so good-bye, I’m going to find another sleep doctor who’ll just give me more Ambien. Which is something I wish I could control, but sometimes I can’t, because that perception can be incredibly strong in people.
Brett McKay: Well, let’s talk about things that people can do to, one, if they have insomnia, sort of mitigate that, and training themselves to sleep. You said sleep is a skill, what they can do, but also for people who are sleeping, they know they’re sleeping, they’re not sleeping great. What are some things they can do to improve their sleep. And I think this just goes under the rubric of… It’s called sleep hygiene. So what does good sleep hygiene look like?
Chris Winter: Yeah, I didn’t put a lot of effort into talking about sleep hygiene in my book, just because I feel like, man, if you don’t know a dark room is better than a bright room in 2020 for your sleep, you’ve been living under a rock. This is the stuff that everybody seems to focus on, a dark bedroom, a cool bedroom, get a good comfortable mattress, make sure you’re exercising and make sure you don’t have a computer screen in front of your face at night, and make sure you’re not smoking and drinking a bunch of coffee before you go to bed. I mean, the number of people who come to my clinic who I am solving their sleep problems by giving them sleep hygiene tips rounded to a whole number of zero. They’ve come in doing all those things.
So to me, A, do all those things, exercise, don’t smoke when you go to bed at night, don’t have a computer screen playing an episode of Friends right in front of your face as you’re trying to fall asleep, don’t watch any political television in the hour before going to bed, ’cause either side of the aisle you sit on, you’re going to be frustrated by the situation. So to me, once you’ve gotten past those things, bedroom’s dark, it’s cool, wife doesn’t snore, you’ve kicked the dog out of the bedroom, the kids sleep great, whatever, that’s probably the time to come talk to somebody before you plunk down another $3000 on a state-of-the-art mattress, ’cause you’ve already bought two of them in the last year. That’s the time where you say, look, this might be a problem that’s intrinsic and medical that you can’t fix.
You can wear the knee brace, you can ice your knee, you can take the aspirin, but if you’ve got a torn ligament, I’m not aware of a CVS fix it yourself, torn MCL ligament kid that’s available where you just walk yourself through it on a YouTube video. You need professional intervention at that time, and in that case, you might need a sleep study, because there is something intrinsically wrong with your sleep. Again, do you sleep? Everybody’s who’s listening to this right now, I can tell you that you do. Do you sleep well? Is there something wrong with your sleep? There very well could be, and the best way to figure that out is through some sort of sleep study.
Brett McKay: Alright, so let’s do a quick recap here. Some people are getting more or less sleep than other people, it’s different for everybody, and even the amount of sleep you need personally, that’s going to change or fluctuate throughout your life. Like some days you’re going need more sleep, other days you need less sleep because you’re not sleepy. And I like the analogy you made with food, because that really hit it home with me. Like some days you’re hungrier, so you need more food, other days you’re not as hungry, you need less food. Same thing with sleep. But regardless of the fluctuations in your sleep, everyone is going to sleep. So the people with insomnia, these are the people who are afraid to fall asleep because they’re afraid they can’t fall asleep, or they’re afraid they’re going to wake up in the middle of the night, what they need to do is sort of manage their expectations about sleep. Don’t stress out about if they can’t fall asleep, don’t put pressure on themselves that they need to fall asleep, and really just adjust their expectations for these natural fluctuations that happen with our sleep throughout our life.
Chris Winter: Absolutely, or maybe don’t have as much time in bed. It’s amazing. I mean, people tell me that. What time do you go to bed? 9 o’clock. How long does it take you to fall asleep? Two hours. When do you wake up? 6 o’clock. Okay, well, you’re seeking nine hours of sleep. You don’t go to bed until 11 o’clock most nights. Why not make 11 o’clock your bedtime and keep 6 o’clock your wake up time? That’s still seven hours. That’s plenty. So if somebody says they need nine hours, then by all means get it, but if you’re trying to get nine but you only need seven, those extra two hours, that difference is insomnia.
So again, if somebody says, well, I don’t mind lying in bed for two hours before I fall asleep at 11, then don’t. If somebody says, yeah, it drives me crazy, then hey, let me gift you the gift of two more hours in the evening to get some things done, or watch some more TV or finish up the Queen’s Gambit, whatever you’re interested in doing, like don’t go to the restaurant at 5 o’clock for dinner when you’re not hungry until 7. Just sitting in the restaurant, annoying the waitresses when they come by, what do you want to eat, I’m not hungry. And you go there every day at 5 o’clock. Why do you go to 5 o’clock? Well, 5 o’clock’s my dinner time. No, it’s not. You’ve determined it’s your dinner time, but there’s nothing about your behavior that would say it’s your dinner time. So if somebody says out there that they go to bed at 9, go to bet at 11. Now, keep your wake-up time where it is. That’s perfectly fine. So having those expectations and freeing yourself up from some schedule can be extremely liberating for a lot of people.
Brett McKay: Also, and one point you make in the book is if you’re having trouble falling asleep, don’t immediately go through, well, I’m just going to pop an Advil PM or NyQuil, ’cause, one, they don’t really do all that much and it can also disrupt your sleep, and two, there’s also long-term consequences of taking sleep aids.
Chris Winter: There can be, absolutely. Some of those… Anything that has a PM at the end of it’s probably just a antihistamine, and there’s some evidence that chronic use of antihistamines could lead to early dementia, because a lot of antihistamines have an anticholinergic effect, which means they block the chemical acetylcholine, which is integral in Alzheimers dementia. So to me, tonight, we’re all going to go to bed at some point, let’s have a plan. And the plan can’t be, I’m going to have a great sleep or else terrible things are going to happen. The plan’s either be I’m going to get in bed and right to sleep, or I’m not and if I don’t, what’s the plan.
The plan could be a Sudoku puzzle, the plan could be read my book. I always tell people it’s either the best book in the world on sleep and it’ll help you figure out your problem, or it’s the worst book on sleep, and it’ll put you right to sleep. So have a good book next to your bed, one you’re kinda interested in reading, like a Dan Brown, you know, he’s running around the Vatican trying to figure out the killer’s motives, so there’s all of these little clues or whatever. There are all kinds of good books out there to read. Something fun and light, it’s not tax theory or something divisive or upsetting, something relaxing.
The advice that always drives me crazy is if you’re in bed and you can’t fall asleep, give yourself 15 minutes and if you’re still not asleep in 15 minutes, get up and go do something else. Sure. I hate the 15 minutes or the 20-minute part because now it’s like a clock, tick tock, tick tock, tick tock, you have 15 minutes to get yourself to sleep or else, which never works. To me, it’s just, be in bed, and if you like being in bed and it’s relaxing and your eyes are closed and you’re thinking pleasant thoughts and planning out your next trip once we can get out from under this virus and travel again, great. You sitting there resting, meditating is doing something positive for your body.
If it starts to frustrate you or bother you or you don’t like sitting there in bed awake with your eyes closed in the dark, yeah, then go up and go do something, and don’t worry about it. I mean, okay, it’s midnight and you can’t sleep, so you get out and go out in the living room and check some emails or paint some little figurines or models that you like to build or clean out your work room or whatever you like to do, and finally, at 3 o’clock in the morning, you’re starting to feel sleepy, then go to bed, it’s 3 o’clock, go to bed.
Now, you’ve got to keep your wake-up time set, that’s the key, that just because you went to bed at 3 doesn’t allow you now to sleep until 11 and skip your first Zoom meeting of the day. No, you’ve got to wake up on time. And that’s the thing that keeps our brains on, is I tell people all the time, if I can’t fix you, go join the military, there is a wonderful drill sergeant out there and she will fix your sleep problem in about a week. It will not take her very long, because she’s going to put you in your barracks at midnight, she’ll wake you up with a beautiful horn at 5 o’clock in the morning, and she will not let you out from under her sight from 5 o’clock in the morning to midnight. You will run and do push-ups and eat these at exact place times every day, and there’ll be no opportunity for napping, there’ll be no opportunity to say, hey, Sarge, I’m a little tired, mind if I go take a nap while you all go do this obstacle course, and I’ll meet up with you all later, no that’s not going to happen. So you may have very different problems in a week, but one of them will not be an inability to fall asleep, because she’s going to take care of that very quickly.
Brett McKay: Well, speaking of naps, can naps get in the way of sleep? And if so, how do you nap without it messing up your nightly sleep?
Chris Winter: I think naps are for efficient sleepers who are still tired despite a decent night of sleep. So if somebody says to me, I got my eight hours, my seven hours, my six hours last night as normal, and I’m feeling a little tired today. I feel, for whatever reason, I’ve been sleeping very well lately, I felt really tired yesterday, I’m not exactly sure why, and fell asleep like at 8 o’clock watching TV, which is very unusual for me. So if somebody is a good sleeper and for whatever reason on this Tuesday feels a little tired and wants to take a nap, go for it, keep it short, try to keep it earlier in the day rather than later, but there’s nothing wrong with that. It’s like a snack. I had breakfast, and it was a pretty good breakfast, but I’m really hungry and don’t think I can make it to lunch without having a few crackers or a bite of an apple. Okay, great. Go ahead and have it.
What napping is not for is the person who says I go to bed every night at 9 o’clock, takes me until 5 o’clock morning to fall asleep. And so I’m tired when I wake up because I go to bed at 5 o’clock, I have to get up at 9 for work in four hours, and I can barely keep your eyes open. Napping is not a great idea for that individual. Your brain had ample opportunity to sleep at night and it chose not to, which is perfectly fine. We told our kids when they were little, you need to be in your room at 9 o’clock, 8 o’clock, 10 o’clock, whatever. But I don’t care when you go to bed, you’re eight years old, you’re practically an adult, you decide when you’re going to go to bed at night. Now, what I didn’t tell them was, stay up all night or go to bed on time, I’m still going to wake you up every day at 7 o’clock, and it’s not going to change. And I’m not going to be the parent that when you say, oh, Dad, I struggled last night to sleep, I was up till 4 o’clock, I couldn’t sleep because I’m so worried by my AP US history exam, can you take me to school at lunch time and let me sleep in? No, I can’t. I’m nice about it. It’s okay, listen, you’re 15 years old, you can handle a night of four hours sleep, it’s no big deal, and you’ll probably sleep great the next night.
So we acknowledge it, we don’t minimize it, but we don’t maximize it either, and we keep the schedule, just like that drill sergeant. We’re nice about it, though. But this idea that because you were up to 4 o’clock worried about an exam is going to give you some sort of Starbucks gift card and allow you to sleep in till noon and miss half your school day, it’s not going to happen. It’s not going to happen on the weekend either. And so now he’s going to go to bed the next night at 9 or 10 o’clock, having only slept a few hours a night before, suddenly that problem becomes a one-night situation versus, oh, we let him sleep in until noon, we took him to school at 1 o’clock, now it’s 11 o’clock, he’s not that tired to go to sleep ’cause he just woke at noon, and the situation perpetuate itself. My biggest record in my clinic is 58 tardies. One child in a half a year had 58 tardies because his parents were so concerned about his sleep, they’d let him sleep until he woke up in the morning, sometimes it was 2 in the afternoon. So that napping can really make a little temporary hiccup in your sleep into a much bigger problem if you’re not careful with that.
Brett McKay: So if you’re doing all this stuff, the sleep hygiene, you’ve taken care of the cognitive aspect of sleeping and the insomnia, but you’re still having trouble sleeping, that’s when you probably go visit someone like you, a sleep doctor, to see if there’s some other issue, like maybe sleep apnea, restless leg syndrome, etcetera. And those cases, those are medical conditions where you might treat them with some sort of drug or a CPAP, right?
Chris Winter: Absolutely. Yeah, so if you’re really struggling with your sleep, the first visit to a sleep doctor is we’re just going to talk. In fact, if you’re coming to my clinic, we’re going to talk over your computer because we’re completely virtual right now. So nobody’s going to hook up any wires to you, nobody’s going to probe you during your sleep, it’s just a conversation, that’s how we really diagnose sleep disturbances. What time do you go to bed, how long does it take you to fall asleep, how long has this been going on? What medications do you take? What does your partner notice about your sleep? How do you feel during the day? What other medications do you take?
Like to me, there’s a lot of information gathering that happens to start to understand where this problem is coming from and what of the 88 diagnosable sleep disorders might you have. So there’s really no risk for that first evaluation, could you need a sleep study? A lot of patients who come to see us do, but we work really hard to keep people out of the sleep lab or we have home sleep studies that we can do now where you take this little device home and hook it up to you and you sleep in your own bed, and we can get a wealth of information that way. So don’t let this thing be a chronic problem. I mean, if you’re somebody who’s not happy with the way you sleep, somebody out there can deal with it and fix it. It’s pretty rare to be given something as a sleep specialist who’s been in the field for almost 30 years, and I’m like, oh my gosh, I’ve never heard of that before. It just doesn’t happen.
And the nice thing about sleep too, is a lot of people kind of feel embarrassed about sleep and talking about what they do, and they say, I’m naked and I run around the house and scream things that embarrass me or whatever, but like I said, we’ve heard it a million times before, we’ve heard about the adult wetting the bed, we’ve heard about the weird sexual encounter you had with your partner that you don’t remember, and the weird things you said during that time. It’s okay, we are not here to judge, we’re here to fix, and we generally do a pretty good job of it. Sleep disorders are usually pretty easy to fix if you’re coming with a pretty educated open mind, and that’s really why I wrote the book, is I feel like if you educated yourself about sleep, you could fix a lot of your own sleep problems. It’s the fear and the not understanding what’s going on that usually lends itself to more anxiety, which more anxiety never helps with sleep problems, which is why in this current political landscape we’re in right now, we’re just exploding because of anxiety, it’s COVID and elections and all this stuff is pretty prevalent.
Brett McKay: Well, Chris, this has been a great conversation. Where can people go to learn more about the book and your work?
Chris Winter: Sure. So you can follow me on @sportsleepdoc on Twitter. I work with a lot of professional sports teams, that’s why I picked that handle, even though the majority of what I do is to see average patients. I’m not even that huge of a sports fan, I just think it’s interesting when you fix an athlete’s sleep problem, we can measure their performance a lot easier than we can a lawyer, for instance. And so I find them to be a wonderful laboratory for, does better sleep actually make us perform better. So I’m @sportsleepdoc on Twitter. You can go on Amazon, Kindle, Audible, and find my book, it’s called The Sleep Solution: Why Your Sleep is Broken and How to Fix It. I’ve got an upcoming book coming out about kids’ sleep, it’s called The Rested Child, so be looking for information about that. We’ve got a web page that kind of has links to various things, but I would just say talk to your primary care doctor and say, look, I heard sleep doctor talk on a podcast, and I think that that’s something that I could use. And if we can help you, that’s great.
If not, I can almost guarantee you there’s a smarter, more professional sleep doctor in your vicinity that’s ready to help you out and really change your life.
Brett McKay: Fantastic. Well, Chris Winter, thanks for your time, it’s been a pleasure.
Chris Winter: Hey, my pleasure, Brett, thanks for having me.
Brett McKay: My guest today was Dr. Chris Winter. He is a sleep specialist and the author of the book, The Sleep Solution. It’s available on amazon.com and bookstores everywhere. You can check out our show notes at aom.is/sleep when you can find links to resources where you can delve deeper into this topic.
Connect With Dr. Winter
Dr. Winter on Twitter