#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.

Ashley Mason delves into the complexities of insomnia, its causes, and its prevalence, shedding light on the nature of this sleep disorder.

Insomnia: Persistent Difficulties With Sleep Initiation, Maintenance, or Quality Causing Significant Distress or Impairment in Daily Life

Mason explains that insomnia is a clinical diagnosis, identified not through blood tests or sleep lab assessments but by a persistent pattern of sleep difficulties. It is diagnosed based on a prolonged presence of sleep problems, typically around three months or more, that result in significant distress or impairment in a person's daily life.

Causes of Insomnia: Genetic or Psychological Reactivity, Major Life Changes, and Sleep-Related Behaviors

The development of insomnia often involves a predisposing factor, which could be a natural inclination towards being a light sleeper, potentially due to genetic factors. Psychological reactivity, which varies among individuals, also plays a role; some people may react more strongly to stressful events, which in turn can impact their sleep patterns.

A precipitating factor, such as a significant life event—like losing a job, going through a divorce, or experiencing a traumatic incident—may trigger a bout of insomnia. As Mason notes, once the triggering event ends, the sustained use of coping behaviors could maintain insomnia. These behaviors might include taking sleep medications or engaging in activities like reading or using smartphones in bed past the initial event.

Mason comments on the commonality of this condition, mentioning that about 90% of adults will experience insomnia at some point in their lives, with 5-10% of the adult popul ...

Ashley Mason highlights the different components and techniques of Cognitive Behavioral Therapy for Insomnia (CBTI), focusing on how it addresses sleep-related thoughts, feelings, and behaviors.

Cbti Modifies Sleep-Related Thoughts, Feelings, Behaviors

CBTI employs various techniques, such as stimulus control, sleep restriction, cognitive restructuring, and relaxation, to realign sleep patterns and modify maladaptive thoughts. Mason insists on adherence to CBTI treatment for its effectiveness and emphasizes the importance of regularizing schedules and standardizing times for taking medication and eating to support the circadian rhythm.

Stimulus Control: Limit Bed Activities to Sleep and Sex Only

Mason underscores one of the pillars of CBTI as stimulus control, which teaches patients to strengthen their bed's association with sleep. She advises patients that the bed is only for sleep and sex, and no other activities should be conducted in bed. Mason instructs her insomnia patients to nap in bed—even when sick—rather than on the couch to maintain the bed's association with sleep.

Sleep Restriction Limits Time In Bed, Builds Sleep Pressure, Improves Sleep Efficiency

Mason describes the sleep restriction component of CBTI, designed to match the time spent in bed with the actual amount of sleep a person can produce. This method helps build sleep pressure and improve sleep efficiency. By calculating sleep efficiency each week from people's sleep diaries, Mason adjusts patients' bedtimes in small increments—typically by 15 minutes—if the sleep efficiency is above 85%.

Cognitive Restructuring Challenges Unhelpful Sleep Thoughts and Develops Balanced Perspectives

Through cognitive restructuring, CBTI challenges unhelpful thoughts about sleep. Mason has patients assess their belief in certain troubling thoughts at different times of the day, which aids in questioning the validity of those thoughts and developing a more balanced perspective. Mason incorporates scheduled worry time as a cognitive techn ...

Cognitive Behavioral Therapy for Insomnia (CBT-I) is an evidence-based treatment method for insomnia that Mason describes through a practical, structured, and patient-tailored approach in clinical practice.

CBT-I Spans 5-8 Weekly Sessions, Emphasizing Sleep Tracking and Adherence to Behavioral Changes

Ashley Mason’s CBT-I treatment typically consists of five to eight sessions. The process includes an intake, five treatment sessions, and a follow-up to tidy things up, implying a formulaic structure that contributes to its efficacy. Mason conducts group sessions, seeing eight patients at a time for 90 minutes each week to manage volume. She is strict about the one-week interval between sessions, believing that if a participant cannot follow the schedule, they should not be in the program.

Clinicians Tailor Wake and Bedtimes, and Sleep Restriction to Each Patient's Sleep Data and Circadian Rhythms

The first week of CBT-I involves patients being given a wake time but not a bedtime, to allow for natural sleep cycle assessment. Mason emphasizes that patients complete a sleep diary before starting treatment to tailor their wake and bedtimes to their individual needs. Using data from the sleep diary, Mason calculates a provisional sleep time, adding 30 minutes to the average sleep time noted. A patient-chosen wake time helps determine the advised bedtime for sleep restriction, indicating a bespoke approach that hasn't been standardized in the literature. Mason allows patients to feel they are choosing their wake time, but adjusts it based on actual sleep diary data, ensuring adherence to individual circadian rhythms. After the first week, she reviews how much patients are actually sleeping, then calculates their bedtime for sleep restriction commencement.

Medication Management Stabilizes and Tapers Sleep Medications

When it comes to medication management, Mason addresses the physiological and psychological dependencies on sleep drugs, working closely with patients and their physicians during the medication tapering process. A stabilization in medication regimen is prioritized before initiating a gradual reduction of dose. Mason’s approach aims to prevent relapse during stressful life events and ensure ...

Efforts to optimize sleep hygiene are crucial for enhancing the effectiveness of Cognitive Behavioral Therapy for Insomnia (CBT-I). Discussions with Ashley Mason and Peter Attia explore various lifestyle factors affecting sleep, emphasizing the need for personalized approaches and the potential impact of temperature, light, and routines on sleep quality.

Enhancing Cbti Effectiveness: Optimizing Sleep Environment Through Temperature, Light, and Routines

Reducing Evening Blue Light and Caffeine Improves Sleep

Ashley Mason shares sleep hygiene fundamentals, which include addressing both blue light exposure and caffeine intake. Mason suggests trying blue-light-blocking glasses for two hours each night if one has trouble falling asleep (early insomnia) and advises against consuming any form of caffeine later in the day, setting a clinic-standard cut-off time for caffeine consumption by 11 a.m. Peter Attia also emphasizes the impact of caffeine consumption on sleep, suggesting an early afternoon cut-off may benefit sleep hygiene.

Peter Attia highlights that he found reducing stimulating content before bed more beneficial than simply reducing blue light exposure. Meanwhile, for some of Mason's patients without stress or stimulating activities before bed, using blue-light-blocking glasses significantly helped alleviate sleep onset insomnia, sometimes allowing them to forego sleep medications.

Exercise Timing and Intensity Affect Sleep; Intense Workouts Near Bedtime May Disrupt Sleep Onset

Ashley Mason and Peter Attia delve into the nuanced issue of exercise timing. Intense workouts close to bedtime can be disruptive to sleep onset, especially for those who are cardiovascularly unfit, as their heart rate may take longer to recover. In contrast, those who are fit may not be as affected. Mason points to relaxing exercises like yoga as potentially beneficial before bed, whereas high-intensity exercises are discouraged late at night.

Consistent Wake-Up Time Regulates Circadian Rhythm During Cbti

Mason emphasizes the significance of a consistent wake-up time, which is critical for anchoring the day and maintaining a steady sleep pattern that aligns with the body's circadian process. Even after sleep deprivation or an all-nighter, an individual may feel a boost of energy in the morning due to their intrinsic circadian rhythm. Mason advises patients to avoid napping during the first week of CBT-I treatment and to maintain a consistent wake time, as this can help recalibrate their sleep cycle, leading to a natural induction of sleepiness at a consistent time each night.

Moreover, Mason stresses the importance of waking up at the same time daily, including on weekends, to regulate one’s circadian rhythm. She explains that altering one’s natural pattern, such as waking up earlier for a spin class, can lead to sleep loss that may not be recoverable by changing one's bedtime. The conversation suggests that keeping an invariable waking time aids the regula ...