Improve Mental Health & Brain Fog by Improving Sleep

I'd like to welcome everybody today's presentation on the neurobiology of sleep and mental health. I'm your host, Dr. Donnelly Snipes. Poor sleep makes people up to 17 times more likely to experience anxiety, depression and or pain. So that tells us that a lot of the people that we're seeing are experiencing poor sleep either as a cause of or a consequence of their current symptoms. Making sleep screening and interventions a must have in your treatment toolkit is something that I recommend for all of my supervisees. Today we're going to learn about sleep, its functions, the sleep cycles, how much is enough, and the impact of lack of sleep on a variety of areas in each piece of our life. And then we're going to talk about different techniques for sleep hygiene. That's that mnemonic I told you about, neutrals. So I'm excited to debut that mnemonic. And we will also finish up by talking about some other evidence based interventions, including cognitive behavioral therapy for insomnia. Your brain. We've talked about circadian rhythms a lot over the past, you know, few months. Your brain has its own circadian rhythms. One of those rhythms is the alertness, your awakening response. In the morning, your cortisol goes up, your norepinephrine goes up and it gradually declines during the day. That's the awakening response that tells your body, hey, put the GABA away and let's get out the glutamate and the norepinephrine because it's time to get up and face the day. At the end of the day, when cortisol is low, serotonin tends to increase, so it can be broken down into melatonin. And that also triggers norepinephrine, helps with triggering the release of GABA to get us into our relaxation and sleep state. When our circadian rhythms are out of whack, those rhythms also get out of whack and can impact sleep. Now remember, circadian rhythms are not just sleep. They are our body's clock for which microbes are in the gut at a particular time of day. For when we're more responsive to sugar. And even when we salivate, we salivate more in the morning than we do at night. Who knew? So everything's on a circadian rhythm, including sleep. Disruption in sleep can disrupt circadian rhythms, just like changing your eating schedule can alter your circadian rhythms in terms of each sleep stage. We've all heard of them, but what do they really do? Why are they so important? Your light sleep stage is where your body organizes or your Brain organizes and consolidates memories from the day. Think about it as taking everything from the day and packaging it up. It's not really integrating it, it's not doing anything with it. It's just organizing it so it can pass it off. In deep sleep, your body goes through growth repair and detox. This is when we have neurogenesis. We start forming more neural connections. This is when your body, the whole body, repairs itself. This is when your body and your brain detox. In a lot of other videos we've talked about how our body's like a factory. And in the evening when we sleep is like when the factory is shut down and the cleaning and maintenance crew come in. If they don't come in and tune up the machines and oil the machines and clean away all the debris and the garbage from the day, eventually it's going to be really hard for the workers to do their job. The same thing is true for humans. When we're not getting enough deep sleep, the the brain can't do its job effectively because it's not clearing out all of those toxins and all of those plots, plaques and debris. In deep sleep, we also see a rebalancing of our hormones and our neurotransmitters. Our brain helps communicate to the rest of the body through our circadian rhythms and other things which hormones and neurotransmitters we need in what level. So when we're sleeping, when we're repairing our body rebalances and everything, and then back to that learning light sleep. We organized and packaged everything from the day, all of our experiences, everything we learned in deep sleep, we consolidate that fact based learning the facts. In this context. At this time, we are not learning how to apply it, we're not generalizing it. We're just learning the facts of what happened. So think about this as filing. That's kind of how I think about it. So you package it in light sleep, you file it in deep sleep. And then in REM sleep is when we learn new motor skills, when we integrate knowledge with experiences. So we take this experience we had during the day and what we learned from it, and we integrate it with prior experiences. This is also where we start developing executive functioning and processing stressful events. So we're taking that fact based knowledge and we're applying it, we're learning how to generalize it. And it's being added to that experiential vault as something meaningful that we can use, not just some random factoid Somewhere you can see how when people misunderstood any of these stages of sleep, it can start to be a real problem. A little bit of a note or a lot of bit of a note. Selective serotonin uptake inhibitors. SSRI increase sleep onset latency, which means it takes us longer to get to sleep. It also increases the number of awakenings and arousals, leading to an overall decrease in sleep efficiency, which is another way of saying sleep quality. So you may be in bed for eight hours, but the quality and effectiveness of that sleep, the, the ability of your brain to do what it needs to do, not so great. SSRIs suppress REM sleep by up to 84%. Now, let's go back to that last slide for a second. What happens in REM sleep? We learn new motor skills, we integrate knowledge with experiences, we develop executive functioning, and we process stressful events. So people who are not getting REM sleep or not getting enough of it may start having deficits in executive functioning, may start having deficits in their ability to learn from their experiences and apply that in the future. SSRIs change the frequency, intensity and content of dreaming. This is one of the reasons they hypothesize, and I'm not sure why. Don't ask me why. This is one of the reasons they hypothesize that SSRIs are somewhat effective at improving mood in people with depression, which doesn't make any sense to me, the fact that they're not integrating knowledge. But yeah, it's one of those things I've, they've seen, I've seen in the research. We don't really know why SSRIs work for some people and some SSRIs. It is important to note that some SSRIs are much less disruptive than others. And I'm not going to call out each one of them, but if your patient is on an SSRI and they are struggling with executive dysfunction, they are struggling with poor quality sleep, they are struggling with feeling rested. Okay. Encourage them to advocate for themselves with their prescriber because they may need to switch to a different ssri. Some of them have very minimal impacts, some of them have very significant impacts. But it is worth knowing when we're looking at the total picture to figure out, okay, why is this person having difficulty sleeping or. Or why is this person's energy staying low or why are they still having difficulty with impulsivity and acting out? Sleep problems may contribute to the development of mental health conditions and, or be a consequence of mental health conditions. And generally it may start in one place, but it's bi directional as Your mental health gets worse, your sleep gets worse. As your sleep gets worse, your mental health gets worse. So it turns into a, a cyclical pattern. In sleep problems increase negative emotions and make neutral situations feel more threatening. All right, so let's go back to basic biology here or neurobiology. When we don't get enough sleep, our brain registers that as a stressor. When our brain registers a stressor, it triggers the stress response, the HPA axis. When we are in fight or flight, when that HPA axis is triggered even a little bit, it borrows, steals whatever word you want to use. Blood sugar and energy away from the prefrontal cortex where we do a lot of our higher order thinking, where our brain can override the amygdala and say, you know what, Bubba, this really isn't that big of a problem right now. When our prefrontal cortex is offline, then everything we're using emotion based reasoning essentially. Now it's all a matter of degree, a little bit of sleep loss, we're going to be a little bit foggy, a lot of bit of sleep loss, you're probably going to be in a pretty significant haze. But when we are sleep deprived, we're in that fight orf flight place space at least somewhat, which means we're going to be more attentive to threats in the environment. And we're going to tend, through the emotional salience hypothesis, we're going to tend to perceive things as more threatening. This is true whether we're stressed because of anxiety or we're stressed because of sleep loss. We know that when we're stressed, neutral situations often feel more threatening. Sleep loss impairs the brain's ability to regulate emotions. That's kind of important. But again, in order to regulate our emotions, we have the amygdala, that is our more primitive area, if you will. That's where fear and all those emotions are stored. We have our hippocampus that helps try to contextualize what we're feeling and our sensory input. And then we have the prefrontal cortex which is sort of the, the boss, which can override based on facts and context. But when we're not able to override the amygdala and the hippocampus with facts and context, you can get a couple of nervous Nellies that are just run, running off wild. The hippocampus and amygdala can get into a, into a rhythm, if you will. So it becomes more difficult to regulate our emotions because we're not fact objectively analyzing what's going on. It disrupts, disrupts stress hormones and immune function. Something else we've talked about a lot when we're under chronic stress, and that includes chronic stress from sleep deprivation. Eventually the body starts adapting. Cortisol becomes less effective, we start seeing downstream inflammation, we see changes in the gut microbiome and we see changes in the immune system which all lead to increased systemic and neuroinflammation, all of which are associated with, guess what? Mood, cognitive and behavioral disorders. Lack of quality sleep also damages the hippocampus and I've already mentioned the hippocampus a couple of times today or I've mentioned the hypothalamus. But it also damages the hippocampus, which is a brain region critical for memory and mood regulation. It reduces insulation around nerve fibers in the brain's amygdala, which helps explain why sleep deprived people are more emotionally reactive. Depression, anxiety, trauma and other mental health conditions disrupt the brain system that controls sleep, making it harder to fall asleep, stay asleep and get restorative rest. Especially anxiety and trauma. Those things put us in fight, orf flight. Those things keep that HPA axis turned on just a little bit. Those things keep us hypervigilant. So it is difficult to down regulate, down regulate enough to get good quality sleep. Your body doesn't want to go into that deep sleep if there's a chance that a threat could come by. In terms of depression, a lot of what we're seeing is alterations in serotonin signaling. And since we require effective serotonin signaling to make melatonin and it can, it impacts our, it impacts our sleep. It is interesting to note in one study that when patients started to take control of their sleep issues, their mental health started to get better. Until they decided that they were going to make sleep improvement a treatment target. They were really having difficulty making progress. But once they started to take control, their mental health started getting better. Now was that because of an increase in self efficacy? Was that because we were clearing out the adenosine and all that other stuff so they were thinking more clearly and they were able to use their prefrontal cortex more effectively? Don't know there. The article didn't say, but it did say there was a marked difference. And let's talk about adhd. Because ADHD symptoms are very common in people who are stressed. ADHD symptoms are very common when our body has an active stress response. When we're in an active stress response, we're going to have more difficulty with attention, we're going to have more Difficulty with impulsivity, we're going to have more difficulty with emotion regulation. All the aforementioned reasons of that prefrontal cortex kind of going offline. ADHD symptoms contribute to sleep disturbances and sleep disturbances predict increased ADHD symptoms. So the worse the ADHD gets, the worse the sleep gets. The worse the sleep gets, the worse the ADHD symptoms get, just like most of the other things we've been talking about. Interestingly, though, people with ADHD show measurable sleep differences compared to their non ADHD peers. It takes them a longer time to fall asleep. They have more frequent awakenings, they have reduced sleep efficiency, so they wake up and they feel groggy. They're not getting through the sleep stages like they need to, and they often have less total sleep time. Now, somebody like me, I love my sleep, I really love my sleep. Eight hours is good for me, nine is my happy place, but I don't get that very often. So looking at how much time is this person actually sleeping? And they may wake up and they may feel rested for the moment, but we've got to remember that that hyperactivity part of the ADHD may be sort of masking the sleep deprivation. Sleep problems in people with ADHD worsen with age, and males with ADHD tend to have more severe sleep problems. Well, we can't stop somebody from aging. No. However, we know that ADHD symptoms worsen sleep and sleep problems worsen adhd. So we can do a better job to the best of our ability, helping people manage or mitigate their ADHD symptoms and helping them embrace some of those symptoms as superpowers, not faults. When people start to recognize the utility of some of those symptoms, it can feel more empowering. Now, not everybody embraces that concept, but. But for a lot of people, recognizing that they're not broken, they just think differently and they have different sensory needs is somewhat liberating. It's also important if you're working with male clients to understand that they may have more severe symptoms and more severe sleep problems. Brain activation patterns in ADHD and sleep deprivation found that both showed reduced activity in executive function regions, including those for attention and self control. Makes sense. People with adhd, we know they have some impulsivity and difficulty attending and all those things we went through. People who are sleep deprived are in fight or flight. When we're in fight or flight, what do we have? Difficulty with attention and potentially self control. We tend to be more impulsive, more reactive, more emotional. A 2025 meta analysis of 79 studies found that sleep loss produces significant Impairments in working memory inhibition and cognitive flexibility. If we can help people improve their sleep and for a lot of people, a lot of people helping them improve their sleep, hygiene is one of the best ways to do it. And, and we'll get there. But if they are better able to inhibit their impulsive behaviors and they have more cognitive flexibility, then a lot of times life doesn't seem as overwhelming. In children. Sleep dysfunction is associated with increased frequency and severity of externalizing behaviors, oppositional behavior and depressive symptoms. If you're working with children, let's step back and take a look. A lot of children, think about your kids that are in elementary school and this is a soapbox I get on pretty frequently. But a lot of youth don't get enough sleep. They go to bed. You know, especially if they've got extracurriculars or something like in middle school and high school they go to bed at maybe 9, 10 o'. Clock. Then they've got to be up at 5 in order to get ready for, for school and to catch the bus at 6. So we do want to explore the challenges. We also see the same thing in elementary school students when they go from kindergarten and or first grade. We sometimes see more externalizing behaviors because the child is not getting as much sleep as they used to. A brief behavioral sleep intervention that involves teaching sleep hygiene and behavioral strategies including circadian anchoring, improved impulse control and executive functioning with benefits sustained at 12 months. This study involved 244 participants, so it wasn't just some small one off study. Circadian anchoring means doing things at roughly the same time each day, but especially bright light in the morning and during the day. Dimming the light and eliminating as much of blue light as possible two hours before bed, creating a wind down routine and eating at roughly the same times each day. Eating is a circadian anchor, as are light levels. Sleep deprivation doesn't just make us more reactive, it makes neutral things seem negative. A study of 42 people examined the impact of getting only five hours of sleep per night for five nights. And I venture to say that a lot of you in the, in the chat room right now probably only got about five hours of sleep last night. That seems to be pretty common. A lot of people are only getting 5, 6, 7 if they're lucky, but that's usually on the weekends. Results indicate that if you only get five hours of sleep per night for five nights, that a lot of people perceive pleasant and neutral pictures more negatively than than when they are well rested. Getting a minimum of seven to nine hours of sleep per night. Sleep deprivation weakens the prefrontal cortex's ability to regulate the amygdala, leading to heightened emotional reactivity. And we already kind of talked about that. Brain imaging shows decreased connectivity between the amygdala and the prefrontal cortex and reduced REM sleep after just two days of sleep debt, which directly correlates with mood deterioration. If you have insomnia, if you have not enough sleep, this doesn't mean staying up all night, that means just not getting enough sleep, like only sleeping four or five hours for two days. We see a reduction in REM sleep and a reduction in the connection between the amygdala and the prefrontal cortex, which indicates that we've got higher levels of stress going on. Because remember, when we're under stress, all of our, not all of it, a lot of the blood sugar and get shunted away from the prefrontal cortex to other places in the brain and body to support the fight or flight reaction. When sleep deprived people perceive neutral situations as threatening, have difficulty regulating regulating emotion and experience emotional inertia. We've all worked with people and we've all probably experienced it ourselves. This emotional inertia, we get into a mood, anger, anxiety, depression, and we can't seem to shake it. We're just in a funk. That's the emotional inertia. It's harder to alter what's going on be when we are sleep deprived in terms of ruminations. And a lot of people with trauma, anxiety, depression experience ruminations during the day and especially at night. When they lay down, when it's cold, quiet, when they're trying to go to sleep, that's when their brain starts screaming and yelling all these thoughts. Ruminations are considered both a cause and consequence of sleep disturbance. The mechanism linking ruminations to poor sleep involves what researchers call pre sleep cognitive arousal. The content of pre sleep thoughts in insomnia frequently relate to planning, problem solving, worries, what ifs and are more unpleasant than in good sleepers. People who have more difficulty getting to sleep, they're laying there, they're awake, it's quiet, their brain's going, hey, now I can just start dumping everything that you were trying to ignore all day long because you're not ignoring it now. And that's when we start seeing pre sleep cognitive arousal. Once people start having that, then even the thought of getting ready to lay down to go to sleep starts triggering anxiety, triggering that stress response, which causes cognitive and physiological arousal. Because they're like, as soon as I lay down I know my mind's going to start racing and I'm not going to be able to turn it off. I know I'm not a lot of distress intolerant and disempowered selft talk starts happening and that ramps up people's anxiety, their sleep anxiety. Additionally, some ruminations in people with insomnia focus on the sleep problems themselves. Again, we've all had the situation where we've been laying in bed and we wake up, we look at the clock, it's two in the morning and we're like, I have only been asleep for four hours, I need to get back to sleep. I'm never going to be able to get through everything tomorrow if I can't get to sleep. And you just sit there and you're watching the clock and it doesn't seem to end well. Researchers say, and sleep specialists say that that's the worst thing you can do is to sit there and watch the clock. And helping people deal with their sleep focused ruminations and is really important. And that's one of the main focuses of cognitive behavioral therapy for insomnia in helping people deal with ruminations. Couple of things we can do cognitive restructuring. Feel the facts in this context. Any exceptions to what I'm thinking always or never happens. Are there alternate explanations to what's going on and what is the likelihood that the worst case is going to happen? These are. Cognitive restructuring is best relegated to daytime hours. It's not something we want. People laying in bed trying to restructure their cognitions, that's just going to keep them cognitively alert. But we can help them address some, some of their cognitions about their personal power, their safety, their sleep, whatever they're ruminating, we can help them try to restructure it during the day so it doesn't start nagging at them at night. With all of those what ifs and those permutations encouraging people to set a specific time earlier in the day that they can worry and in a different place. The bedroom is where you sleep. The bedroom's not where you do bills. It's not where you have arguments, it's not where you fill in the blank. It's where you sleep and have sex and that's it. Relaxation techniques, including guided imagery can be very helpful. If you think back to when you were a kid counting sheep. I remember my mother used to tell me to count sheep and I'm like that's, that's really weird. But what is counting sheep but guided imagery? You're sitting there, you're Envisioning sheep jumping over a fence and you're counting them. What does that do? That turns your brain's attention to these fuzzy little sheep that are non threatening and they're jumping over a fence. It helps your body down regulate. It helps your body turn its attention away from the threats. It helps occupy your mind so it doesn't have as much energy to about the wh ifs. Most adults are not going to count sheep, but encouraging them to identify guided imagery that can be helpful. I personally like doing a guided tour. I imagine going to my favorite cabin in the woods and then I get out of the car. What are five things I see, four things I hear, three things I I feel, two things I smell that can help orient me to where I'm at because I'm looking around in this virtual environment in my mind when I'm doing that I'm using a lot of cognitive energy, but it's relaxing, it's a place that I like to be. I feel safe, I feel empowered and all that other stuff. If anything is background noise, I'm generally not even having those thoughts as intrusive. If I do have an intrusive thought, I remind myself, not right now, not going to be thinking about that until tomorrow morning. There's nothing I can do about it at 10 o' clock at night. And then I go back to my guided image stimulus. Control means breaking the association between bed and wakefulness and worry. Which is what I why I said earlier. A lot of sleep specialists say if you wake up and you start worrying about something, if you can't turn it off, if you can't engage guided imagery, progressive muscular relaxation, whatever tools that may may help you. If that's not working and you're still awake after 15 minutes. A lot of times the recommendation is to get up, do something else for a few minutes and then come back to bed. Because laying in bed just increases the feeling of powerlessness over sleep and thoughts and everything else. Likewise, if you're laying there watching the clock and you're telling yourself I've really got to get back to sleep, oh my gosh, I've got to get back to sleep. I remember I did that when my, my children were little. I was like, oh my gosh, I need to get back to sleep before Sean wakes up and needs to be fed again. I need to get back to sleep so I can at least get two hours. And I would ramp myself up because then I would be stressed that I wasn't going to get back to sleep. And guess what? You're not going to sleep when you're stressed. Encouraging people, if you can't get back to sleep after a certain period of time or you start feeling frustrated, get up and then help help them develop a plan for what are they going to do when they get up. Sleep disruption impacts the brain's reward, impulse control and decision making system. The same systems that are hijacked by addiction. I worked in community behavioral health and addiction treatment centers for nearly a quarter century. And this is one of the things that we did not pay nearly enough attention to. It is so important to help people set their circadian rhythms. We did a pretty good job with that. And help help them improve their sleep and their sleep quality. Because their brain, their neurotransmitters are all out of whack anyway, which is in and of itself going to negatively impact sleep. And, and a lot of them are feeling anxious, angry, grief stricken. They've got a lot of stuff going on which further impairs their sleep. Helping them get the best sleep possible with good sleep hygiene is really important. And that's where helping people figure out, how do I get to sleep? Because a lot of times for, for many of my clients, the way they got to sleep was when they'd pass out. Sleep deprivation increases the preference for alcohol, methylphenidate and cocaine. Interesting. Which means that sleep deprivation is a huge relapse trigger for people, especially for those that used alcohol, methylphenidate or cocaine. Circadian disruption alters that dopamine and serotonin signaling. And sleep loss increases the activation of the HPA axis, the stress response system, and down regulates the prefrontal cortex. I know I sound like a broken record, but it's that important to recognize how sleep impairs our ability to use our cognitive functioning to regulate our emotions, our behaviors, our problem solving. Addictive substances and behaviors severely disrupt sleep architecture. A lot of people with addictions sleep weird schedules. They don't get enough sleep. They take naps during the day. They may use a substance to help them get to sleep, which impairs their sleep quality and their sleep structure. So most people in recovery from addictions have a lot of work they can do to improve their sleep quality and efficiency. Sleep issues are one of the strongest predictors of relapse. It's in the research. That's not just me saying it, folks. Improving REM sleep reduces a key molecular substrate that underlies craving. Interesting that there actually is neurochemical stuff going on there that makes cravings stronger in people who are lacking adequate quality sleep. Just being in bed for eight hours doesn't count. Sleep issues also contribute to fatigue, irritability, emotional reactivity, impulsivity, poor decision making, negative perception, which in addiction circles we call stinking thinking. And it impairs our ability to gate engage in sensory gating. So filtering out all of those triggers when people are well rested, Some of those ancillary triggers, like driving past a liquor store, they may not even notice it that much. But when they're sleep deprived, they're not able to filter out those triggers as effectively. And they've got those molecules going in their brain that are increasing craving. They drive past that liquor store and their brain goes there. So sleep can also help with sensory gating. And we've already talked about how it helps rebalance neurotransmitter systems, which are historically imbalanced in people with addictions who are in recovery. Sleep disturbances are common in people with dementia as well. Poor sleep accelerates brain aging. None of us wants to accelerate brain aging. But stress triggers the stress response, triggers the release of cortisol and glutamate. And norepinephrine, creates a neurotoxic environment that accelerates brain aging. Poor sleep is a stressor, accelerates brain aging. It impairs the brain's clearance of toxins, which impairs cognition and sleep. When we can't relax enough to get good quality sleep, we gotta get into that deep sleep for the detox. Deep and detox. You can remember it that way. We gotta get into that deep sleep for detox. And if we're not feeling safe enough to do that, then we're going to have a difficult time clearing out all of those toxins. And when we're stressed, we don't feel safe enough to do that. As these toxins build up, it promotes neuroinflammation. As we have sustained sleep deprivation that the body adjusts as we talked about. And we have the downstream effects of chronic stress itself, causing systemic inflammation and neuroinflammation. And it disrupts memory consolidation. Again, memory consolidation, depending on what you're talking about, is done in deep and REM sleep. We already know that sleep deprivation significantly impairs REM sleep. Melatonin supplementation has shown promise for improving sleep in people with cognitive decline. How much melatonin to use and how often to use it is a discussion that people need to have with their physician. Because depending on the medications that you're already on, whether you've got thyroid issues, if you're an older adult, if you've got Impaired liver function, kidney function. The amount of melatonin that's going to be useful is going to vary. I, I will tell you that the Sleep foundation recommends a level far lower than what most people take. The Sleep foundation recommends somewhere between 0.25 and 0.5 milligrams of melatonin, where a lot of people are taking much, much higher doses than that. One of the things they found is high levels of melatonin can actually leave the person feeling foggy and sluggish the next day. A Meta analysis of 72 studies with 50,000 people confirmed that sleep disturbance is consistently associated with elevated inflammatory markers. We know now that sleep, when we don't get enough sleep over a period of time, even a few days, we start seeing increases in a variety of inflammatory markers. Inflammation is a stressor triggers the stress response, just like sleep loss triggers the stress response. So now you've got most multiple things triggering that stress response. Chronic sleep problems lead to sustained inflammation. This is important, sustained inflammation that doesn't fully resolve even after catching up on sleep. Our immune system, and there's a whole field called psychoneuroimmunology that looks at how sleep and other things impact our immune system and our mental health. But it's interesting to understand that even after we catch up on our sleep, if we were sleep deprived for long enough to cause an increase in inflammatory molecules, we're not necessarily, we haven't necessarily completely gotten rid of them yet. It's going to take longer to down regulate chronic sleep problems, accelerate cellular aging, increase the risk for heart disease, diabetes, cancer and dementia, worsen depression, anxiety, neuroinflammation and chronic sleep problems worsen sleep. The more sleep deprived you are, a lot of times, the harder it is to get to sleep and get good quality sleep. As backwards as that sounds, a lot of our clients also experience pain. Pain impairs sleep, no joke. When, when we're talking about pain, we're talking about pain. If you're sick, if you've got a sinus infection, you're not going to sleep well. If you've got an injury, and that can include delayed onset muscle soreness after a really hard day at the gym, or pregnancy, or anything that causes you musculoskeletal pain, that will impair sleep. And of course illness itself is going to impair sleep. Sleep disruption lowers pain thresholds are people who are experiencing problems with their sleep because of their anxiety, for example, their pain tolerance actually drops. Their body becomes more aware of pain sensations. It's not all in their head it's not something that they're exaggerating. They actually feel more pain. Sleep disruption also amplifies pain sensitivity through the loss of slow wave sleep and activation of cellular inflammation. Even modest night to night changes in sleep quality determine day to day changes in experienced pain. A lot of people have pain and it could be from aging, it could be from autoimmune diseases, could be from fill in the blank. But this is a target we can help people recognize. Sleep is an intervention that may help, it may help you feel less pain tomorrow. That would motivate me if somebody told me that sleep also impacts the gut microbiome. The gut microbiome follows daily rhythms and sleep and or circadian rhythm disruption causes an imbalance. I said earlier, your gut has certain microbes that are more active when you're sleeping. They're more involved in the restoration rebalance repair than the microbes that are responsible for breaking down the food you eat during the day. Even 72 hours of inadequate quality sleep significantly changes which bacteria thrive in the gut. Thrive. So we have bacteria in our gut and the bad bacteria, if you will, the dyspeptic bacteria become stronger, they proliferate and in this environment and the good bacteria like Lactobacillus and Bifidobacterium, they start dying off. That's not good. Sleep deprived induced gut changes increase inflammation, which affects brain function and neurotransmitter balance that gut brain axis we've talked about in other videos. When the gut microbiome gets wonky, it impacts our hormones, our neurotransmitters, our mood, our stress response. Further, lower bacterial diversity in the gut is associated with poorer sleep quality. That good bacteria that we want in our gut helps us prepare to go to sleep. And when we don't have good bacterial diversity, we don't have all of the different types of workers we need in the factory, if you will, to help the factory function effectively. Time restricted eating, which is eating within a consistent window each day, can help restore healthy gut rhythms even when sleep is imperfect. As I mentioned, our body partly anchors our circadian rhythms based on when we eat. And time restricted eating means potentially eating from 6am until 4pm or 6pm so the body sets the circadian rhythm, so it expects food at those times. And it arranges the schedules for the gut microbes as well as everything else partially based on when the body's going to be fed. Regular meal timing does help anchor overall circadian rhythms. Interventions. Sleep focused treatments have been shown to produce rapid improvement in depression, anxiety, rumination, Fatigue processing biases. That means seeing things as more negative than they really are. Executive functioning, pain and inflammation. Oh my gosh, that's like half the symptoms in the DSM5TR. I'm exaggerating, I know, but think about how much this could improve the quality of life of any of our clients right now. Because my guess is almost every one of our clients has at least one or two of these symptoms right now. 88 to 97%. Now that's a big stinking percentage. 88 to 97% of depression and anxiety symptom reduction following behavioral insomnia treatment is mediated by improvements in the sleep quality itself. That's important. They, they did a regression analysis and found that improving sleep seemed to be the direct correlation. How much is enough? Newborns generally need 12 to 18 hours with between 2 and a half and a three. 3 and a half hours of deep sleep. 3 months to a year old. 14 to 15 hours. 2.8 to 3.0 hours of deep sleep. Now for the newborns and the toddlers, obviously they're not getting it all in one fell swoop. They take naps, we know this. That's okay. Their body needs to be on that rhythm where they have that nap in the middle of the day. But overall, this is what they need. Let's jump up to school age, 5 to 12 years old, elementary school age. They need 10 to 11 hours of sleep. How many of the elementary school students that you know of, think of your own children. How many of them were getting 10 to 11 hours of sleep per night? This is especially important when we get out of kindergarten and there's no nap time. Most of them probably aren't getting that which impacts their cognitive functioning, their cognitive flexibility, their impulsivity, their ability to focus. The list can go on. I believe a lot of behavioral issues could be significantly improved if we attended more to setting our school schedules to accommodate the sleep needs of children. But I digress. 12 to 18 years. So your high school, middle school, high school kids. Eight and a half to ten years I can tell you. Or ten years, eight and a half to ten hours I can tell you. When I was in high school I did not get anywhere near that amount of sleep. I had extracurricular activities, especially if we had away games. We would be gone until 9:30, 10:00 clock and, and then literally I'd have to be up at 5 or 5:30 the next morning to catch the bus at 6:30. So there's no way I was getting that. My son's best friend was in AP classes and he would be up doing homework until midnight every night. And then he'd have to be at school at seven the next morning. There's, that's not an eight and a half to ten hour window. Most of our youth are artificially, if you will, sleep deprived, which I believe has a significant negative impact on their mood and cognitive functioning. And then for those of us who are over 18 and sometimes well over 18, seven and a half to nine hours per night is supposed to be the sweet spot. Some people feel rested after seven. Some people prefer nine and a half to ten. Once you start getting more, needing more than nine hours of sleep, there's some research that shows that the person may have some underlying sleep disorder that's keeping them from getting their quality sleep at night. So they're in bed a lot longer because their brain's trying to do what it needs to do. It's just not nearly as efficient. Um, so if you have somebody who says, no, I need, I need at least 10 hours of sleep, a sleep study might be worth looking at or at least evaluating. How long does it take you to get to sleep? How many times do you wake up at night? How long does it take you to get back to sleep after you wake up? How rested do you feel in the morning, Et cetera. And here's that mnemonic I kept promising you. This is for sleep hygiene neutrals. Naps. People need to reduce their naps or confine their naps to less than 45 minutes. Naps that go over 45 minutes tend to start to get into a second phase of sleep. It's more than just light sleep. And that's when it starts throwing the circadian rhythms off. Interestingly, short power naps. There's some research that a power nap in the afternoon actually increases levels of focus and norepinephrine. So people can try different things. It may not work for them. It may. But reducing naps, making sure that their daily daytime naps are no longer than 45 minutes. Ergonomics. Make sure that they're sleeping in a comfortable position. If they're in pain, if they're uncomfortable, if their necks kinked up, they're not going to get good quality sleep. Urinating. I know. Make sure that they empty their bladder before they. Right before they go to bed. And try not to drink too much fluid within a certain period of time before going to bed. Some people can drink fluid up until like an hour before bed and not have a problem. Other people need to start restricting their fluid a Couple of hours before bed depends on the person. But encouraging people to try to limit their fluids so they don't have to get up during the night if they have an irritable bladder, if they have problems with incontinence, definitely they need to talk with their physician because having to get up multiple times during the night, we know disrupts sleep architecture. And making sure that whatever they're using to manage any incontinence is comfortable is important. Temperature, we want it cool at night. Think you want to hibernate like a bear? When do bears hibernate? In the winter routine. Having the same couple of things you do right before you go to bed. And it can be something very short. Like for me, I, I do things at night, you know, I watch TV with my husband, whatever. But then right before I go to bed, I brush my teeth, I wash my face, then I put on my little red light mask for 10 minutes and by the time I'm taking that sucker off, I'm about to pass out. So my body knows that that's the routine that we're going to use. Eliminate allergens from the bedroom. You may not be able to eliminate from the whole house, but. But from the bedroom is very, very important if you have sweet little kitty cats like I do. Ideally not having dogs cats in bed, especially if you're allergic to them. When children sleep in bed. My daughter, I swear she used to run a marathon when she would come to sleep in bed with with her dad and I. By the end of the night she would be sideways kicking me in the kidneys and laying her head on him. So that didn't help. She wasn't an allergen. But we do want to avoid sleep disruption. Having a HEPA filter in the bedroom can be very, very helpful. Light. Reducing blue light and bright light two hours before bed whenever possible is super important. So having those yellow toned candle light aura type lights at bedtime and minimizing if not eliminating devices phone screen, computer screen, etc if you have to use your phone or that's one of those things you want to play games. Get a blue light filter app for your phone or for your iPad. So you are at least reducing the exposure to blue light which is tells your body you're supposed to stay awake and then S stands for sanctuary. Make sure your sleeping area feels safe. You're not going to get awakened by loud sudden noises. It's not somewhere that's stressful. When you lay down, you think, oh my gosh, you know, whatever you think about the worst things and again, it's somewhere you feel safe. You can close your eyes and not be fearful. That all stands up for neutrals. Nat, naps, ergonomics, urinating, temperature, routine, allergens, light and sanctuary. I promised we'd talk briefly about cognitive behavioral therapy for insomnia. CBTI produces large sustained improvements in insomnia severity across different mental and physical diagnoses. The main techniques in CBTI include sleep restriction. And I know this sounds counterintuitive, but it is what it is. We want to increase sleep drive, encouraging people not to take naps for a couple of days if they're normally taking naps, so when they're going to bed at night, they feel tired. If you're going to do extreme sleep restriction where the person may stay up, may reduce their sleep one night to only four or five hours, so they're super tired the next night. There's pros and cons to that, but I would encourage you to work with a sleep specialist. For most people, just making sure that they spend eight hours in bed, then they get up can be very helpful at starting to set those circadian rhythms and, and increasing sleep drive at the right time. Sleep drive increases as cortisol decreases. If stress is still high, sleep drive is not going to increase. We need to help people recognize the connection. Stimulus control, strengthening the bed sleep connection. I mentioned this earlier. Keeping the bed area, keeping the bedroom itself. A place where people relax and sleep. Cognitive restructuring, addressing unhelpful thoughts about sleep. Remember, this is cbti, cognitive behavioral therapy for insomnia. So we're not addressing or restructuring all of the unhelpful thoughts. We're addressing, identifying, addressing and restructuring the unhelpful thoughts about sleep, such as, I know if I lay down right now, I'm going to lay awake and toss and turn all night long. Sleep hygiene education. This is where you teach them that. Neutrals mnemonic and relaxation techniques. As the body relaxes, it releases gaba. GABA is one of those neurotransmitters that helps cue our body in that it's okay to relax and we can start getting, getting sleepy. Engaging in relaxation techniques actually helps the body transition into that sleep rhythm. Couple of interesting little tidbits. Estrogen usually improves the quality of sleep, reduces time to fall asleep, and increases the amount of REM sleep. Now, we're not talking about too much estrogen, but regular amounts of estrogen. So our patients who've gone through menopause may be struggling with sleep, encouraging them to talk with their doctor or at the very Least working with them to improve their sleep to the best they can. Too little or too much testosterone may affect overall sleep quality. Cortisol, your stress hormone, prevents restful sleep because again, when cortisol is high, then serotonin is going to stay low and we need to flip that around in order to get melatonin, melatonin flowing. Additionally, thyroid hormones which are too high can cause insomnia and too low can contribute to fatigue and lethargy. Even if the person's getting enough sleep. Always, always encourage, I always encourage people to get hormones tested. Tryptophan is used to make serotonin. It's an amino acid, very common in most meat products. So if you're working with a omnivore, you're fine. Maybe something you need to address. If you're working with a vegan or a vegetarian to make sure they're getting enough, refer to a dietitian. Serotonin is needed to make melatonin, though if their serotonin levels are low, they may struggle. Melatonin, we know, helps us feel sleepy. Caffeine is a stimulant with a six hour half life. We want to make sure to try to stop caffeine by noon at the latest. Nicotine and decongestants are stimulants with a two hour half life. So again, making sure that four hours before we want to go to sleep, we quit using those. Antihistamine and alcohol both may help people feel sleepier, but they contribute to poor quality sleep. Insufficient quality sleep contributes to impulsivity, irritability, anxiety, depression, fatigue, difficulty concentrating, reduced reaction time and increased pain and inflammation. During deep sleep is when the brain rests and rebalances over time. Sleep deprivation can cause negative changes in each piece of life, but improving sleep quality has been shown to help improve symptoms in each piece of life. Are there any questions. At nobody special? One of the things that you may want to look at is the video that I just did on tinnitus. Obviously they don't know how to make it go away, but there are some interventions that may help help you mitigate it a little bit to improve sleep and recognizing that the more stressed you are, the worse the tinnitus is often going to be. Which can help you identify or potentially help motivate you to identify stressors in your life that you can mitigate. Or work with a therapist to identify stress management strategies that may help you reduce your stress so you can reduce your tinnitus symptoms. All righty everybody. Thank you so much for being here today and I will see you next Wednesday.