47. Jade Wu, PhD: The Link Between Insomnia and Anxiety, Sleep Psychology & Sleep Hygiene

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in health care. Entrepreneur and author Eli Joseph Cosman once said the best bridge between despair and hope is a good night's sleep. Well, our guest today is Dr. Jade Wu, and she is a clinical psychologist and board certified behavioral sleep medicine specialist and researcher at Duke University School of Medicine. Her current research focuses on treating sleep disorders in those with chronic illness. She's a frequent guest on popular TV, radio, and podcast shows like NPR and ABC, and her work is featured in publications like New York Times and Hopkins Post. Dr. Wu's mission is to spread the gift of sleep so that people can be their healthiest, organizations can be their most innovative, and societies can sleep their way towards justice and healing. Now, obviously, if you have been with us at Medicine Redefined for some time now, you understand that we love to touch on sleep because we believe it is probably one of the most important factors that contributes to overall health, wellness, happiness, etc. And this is going to be no different in this episode except we are going to touch on sleep from a psychological perspective. And so we are going to delve deep into insomnia, right? Something that is sweeping across the globe, especially through America, and we're going to touch on how it is closely linked with anxiety. We know that mental illness is on the rise, especially with things like COVID, our stressful lives, and just the ever evolving nature of society and the way we live. So we're going to touch on insomnia, anxiety, we're going to go through the difference between sleep deprivation and insomnia. We're going to touch on cognitive behavioral therapy as well as what sleep hygiene might look like, and then possibly some long-term health complications that we should be looking out for. So get comfortable and enjoy the episode with Dr. Jade Wu. All right, everyone. Welcome back to another episode of Medicine Redefined. We have Dr. Jade Wu here with us talking about a very important topic, one that we've talked about many, many times on this podcast already, but we're going to spend it probably with a different perspective and that is going to be on the topic of sleep. So Jade, thanks so much for coming on Medicine Redefined. Thanks so much for having me. Yeah, absolutely. So, I wanted to start with your childhood. So it was interesting because you had exposure to sleep at a very young age with your father actually doing sleep research, I believe, right, with the Chinese astronaut or NASA over there. Tell us about that. Yeah, he was actually a sleep scientist with basically the Chinese version of NASA. So he was working with astronauts to look at potential circadian and sleep problems in space travel, which it just like was so cool to any five year old, right? So I actually visited a sleep lab when I was little and so I guess the seat was sewn very early because eventually I made my way back to sleep research after many, you know, trying many other things. So yeah. That's super cool. Was he strict with your sleep schedule? Um, you know, apparently I was a pretty good sleeper even as a baby, so I think I was just born with it. Amazing. Yeah. That's awesome. So as a father of a newborn, I envy that. I would love it. I would love it if my, no, I'm kidding. I can relate. I have a two year old and I'm about two in the next two or three weeks have another newborn. So congratulations. Thank you. Thank you. Yeah. So I can relate to your struggle. Awesome. So take us to your journey now, you know, as you get to Duke University and now you're a sleep psychologist, what was that like? What was your training like and how do you really figure that this is what you wanted to do? Well, so my background is actually clinical psychology and I focused on anxiety and depression to start in grad school. And I was, I was making my way through my PhD, um, I, just everywhere I looked, sleep was a common thread through depression, anxiety, Parkinson's disease, which is something that, you know, I, I kind of randomly got into but was fascinated by and I ended up doing my dissertation on sleep and circadian rhythms in Parkinson's disease. So basically everywhere I looked, any psychiatric and medical and neurological disorder had sleep problems as one of the major, you know, symptoms, domains. And I just thought, you know, if we could just improve everybody's sleep a little bit when that raised the water for all boats. So that's how I kind of got into sleep kind of sideways that way. And so I made my way to Duke to do my medical psychology residency and fellowship after that and do some perinatal psychology along the way. And it's just, um, just a, and a fascinating topic that you can't really exhaust. There's just so much we still need to know. Um, so that's why I'm passionate about it. Absolutely. I mean, I think that's why I've been ultra sure super excited about sleep as well, right? I mean, it's something that we've been doing since evolution many times, right? But now we're starting to slowly understand a little bit more and more. But like you said, the seed has planted almost everything you talk about, right? Like we just had Dr. Luis Nicola on our previous episode talking about athletes and sleep and recovery. Um, we've touched on sleep with pain and the interplay between the two. So I mean, like you said, even if we can raise the bar by one to two percent of, you know, worldwide with sleep, man, what a difference we'd see energy levels, emotions, mood, everything. Absolutely. Yeah. I want to ask you, I want to take it back all the way to evolutionary times now because when I was studying for the MCAT, actually, I had a passage on different theories of sleeping. And there were like three different theories and I've ever said I will never forget that passage. But I wanted to get your thoughts on why do humans sleep? Why do we actually sleep for, you know, whatever, six, seven, eight hours a night? Oh, there's so many good theories about that. And as with everything evolutionary, we can't really test these hypotheses, right? So my best guess is that we just need time to rest and recover and recover in a very intensive way, not just slow down and catch our breath, but actually take time to repair tissue and to release growth hormones and to emotion regulates and do all these things that we really can't multitask that we really need to just focus and just do that one thing. And, you know, so I think our brains just really need that. And also, I personally, I don't know how much this counts, but I think sleep is just enjoyable. You know, we just need some time to refresh. Like imagine if your day just kept going and going and going and you didn't have a chance to reset. I mean, when you have a newborn, that's what it feels like, right? When it's just non-stop disaster sometimes. And having that reset really, I think, allows us to emotionally and physically renew. So that's kind of how I think about why we sleep. Yeah. So I thought I'd ask you this now in the conversation in terms of bi-physics sleeping, because I think a lot of people might think, well, you know, as a hunter-gatherer society, why would we sleep for eight hours straight when, you know, we're keeping ourselves vulnerable to other animals or death or whatever might be? Is there, you know, the concept of bi-physics doesn't really make sense then in terms of sleeping made for three, four hours for a short period of time and then later in the day? I think it totally makes sense. And it doesn't necessarily have to be later in the day. So, you know, we are nocturnal, we're diurnal animals, so we do sleep at night. But I think it's perfectly normal to find to have two chunks of sleep at night with a big gap in the middle. And evolutionarily speaking, just like you said, you know, it's very vulnerable to be out all night, predictably for that big chunk of time. I mean, any saber-two tiger would just camp out, you know, and wait, right? And also, in terms of sleep physiology, it makes sense, too. We build up homicidic sleep drive adenosine throughout the day, and that is the drive for our slow-wave sleep, which is mostly happening in the first half of the night. And then for the second sleep, the second half of the night to happen, that's really our circadian rhythm driving that half of the night, not so much the homicidic sleep drive anymore. So it's almost like two qualitatively different types of sleep, and accomplishing different goals, and at different times of night. And, you know, if we can get the deep sleep done, and sort of that's our most important reparative sleep done, and then we wake up and realize we need to run away from a predator, that's okay. We can do away with the rest of the night, and then do that later. So I think that totally makes sense. Yeah, I don't think many people think of it in terms of like you said the two separate, you know, qualitative stages, at least, you know, I'll say stages loosely, because of stages sleep. But super interesting. Yeah. Thank you for that. Mm-hmm. So, Jade, just touching on that concept of the homicidic drive and the circadian drive. So is it, from what you said, is it plausible that you mentioned that stage, is it three and REM sleep, that's going to be more driven by the circadian drive, is that correct? It's just, it's non-REM, actually, that's more driven by the sleep drive. So especially slow wave sleep, yeah. What about REM sleep? REM sleep is less driven by, it's less driven by the homicidic sleep drive. I wouldn't say it's more driven by circadian rhythm, but it just so happens that it happens in the second half of the night when the circadian rhythm kind of takes over to keep us sleeping, even though the sleep drive has kind of run dry, if that makes sense. You think? Yeah, no it does. Yeah, yeah. I mean, I definitely had heard those concepts before, but I'm not sure I looked at the different types of sleep, the different architecture of sleep being compromised depending on which drive, right? That might be for lack of a better word, again, compromise throughout the day. But, you know, there's so many awesome things that you guys have talked about, right? I mean, so, you know, Dr. Matthew Walker, I'm pretty sure all of us have read his book that very, very popular, and he talks about how, you know, sleep is, this is his quote, is the elixir of life, right? And it's at the bedrock on, upon many of the illnesses are, again, for lack of a better word, founded, and you kind of touched on that, right? From your sideways approach in clinical psychology, you noticed that the common denominator was sleep. I want to focus, I think both of us want to focus a little bit more on the, you know, aspect of anxiety, insomnia, depression, you know, we had Patrick finding on here, and we went down this rabbit hole. And when I look at insomnia and sleep, and even more so pain, right, because at Darshan Eye, this is what we do in our world, it's kind of like these three tunnels that you can go down. I'm sure you'd argue that depression's in there too is a four tunnel, but for the sake of this conversation, let's just keep insomnia and sleep. Exx I'm sorry, insomnia and anxiety. Is there a way to determine whether, you know, pre morbid anxiety contributes to more insomnia, or is it the insomnia contributing more to anxiety, or is it just a vicious cycle that goes back in the world? How do you tease that out? This is like a very challenging question, I know. Very good question. I think it's definitely a chicken or egg thing. And the way we like to think about insomnia and behavioral sleep medicine is that we have predisposing factors for insomnia. So somebody may be just more prone to anxiety to begin with, wired a little, wound a little more tight, more prone to feeling anxious in the face of stress. That person is more prone to developing insomnia, but not every anxious person has insomnia. But once you have insomnia, you're much more likely to be anxious. And then we get on to that vicious cycle. So yeah, the two are very difficult to disentangle. And also, in my view, it doesn't really matter which came first. We treat it the same way. Yeah, I know that that is really interesting, right? Again, it goes back to the concept of sleep and pain that we know that the traffic flows two ways. And you know, Patrick was here last time and he said, you know, we're starting to learn that maybe the sleep is the traffic towards sleep going towards pain in terms of lack of sleep amplifies the perception of pain a little bit more. And do you have a sense of maybe if the same way the traffic is flowing heavier in one side versus the other or hard to say? Well, anxiety can certainly keep you up at night. That's pretty obvious. But then also when you're not sleeping well, it's harder to emotion regulate. And it's more and also just the content of the anxiety can balloon up because, you know, we're hearing so many scary things about what happens when you don't sleep well. So my patients who have insomnia are lying there thinking, oh gosh, I only have three more hours, not only have two more hours, not only have one more hour. So now they're getting anxious about all the things that are not going to go well tomorrow because they're not sleeping well right now. So then, you know, it's hard to say quantify which direction the traffic is flowing harder, but it certainly is a two way street. Gotcha. And for those who don't know, I mean, there's two types of insomnia that we characterize at least medically, right? I mean, you have sleep onset and then sleep, what's the other one called maintenance? Maintenance. So thank you. Thank you so much. And your experience to you find that anxiety, you know, is more entangled with one versus the other, like getting to sleep is a bit more challenging for people who are more prone to anxiety. No, I think that those two are really more differentiated by age. More generally speaking, the anxiety could really be either. Yeah. Same more about that. What do you mean, like, age? Yeah. So usually it's the younger folks who are like 20s and 30s who have the sleep onset problems. It's the, you know, 30s and 40s and 50s that have the sleep maintenance problems. And then older folks had the sleep maintenance and the early morning awakening. And that's because we tend to shift from being night owls to being morning larks as we get older. So, you know, if you need to be up for work at, let's say, seven o'clock, so you feel like, oh, I really should go to sleep, go to bed by 10 or 11. But if you're 20 years old, your, your chronotype is just not set up for that. Your circadian rhythm is not ready for that. But if you are 80 years old, waking up at seven o'clock, you probably won't even make it all the way to seven, but you're going to bed at seven, you know? So our chronotype changes over the course of a lifetime. So the type of insomnia tends to change with that. Awesome. So I think it's probably worth taking a step back and actually defining what anxiety is. I think, you know, most people that are listening to this podcast have heard the term or use the term, probably, hey, my anxiety is kicking in, my anxiety is kicking in. And I think what we're all discussing today is pathological anxiety, anxiety is very, very common. Would it be worth for you to define what actual pathological anxiety is? Definitely. Yeah. I think really it's pretty simple. It's just anxiety that gets in the way of life. It's anxiety that makes you very distressed, makes you feel like not yourself, makes it hard to function and hard to actually enjoy life and be in the moment and get that feeling fulfillment from your relationships and work and whatnot. So anything that gets in the way of that. Gotcha. Now, Jade, I know you talk about kind of sleep deprivation versus insomnia, right? And this, this play of anxiety and like we always hear the loose term anxiety, I think a lot of people always say, oh, well, I'm, I'm actually just sleep deprived right now. What does it actually mean to be sleep deprived versus being an insomnia? Yeah, that's such a fabulous question and super important. So sleep deprivation is when someone does not have enough opportunity to get the sleep that their body needs. Insomnia is when they do have enough opportunity, but for some reason they have trouble falling asleep, they have trouble staying asleep and notice that in the diagnostic criteria for insomnia there's nothing quantitative that says how many hours you're getting or not getting, right? So you could be getting eight hours of sleep a night and still have insomnia if you're lying there awake for two hours, very frustrated and anxious and trying to sleep and you can't write or you can be getting six hours of sleep and not have insomnia because that's just, you give yourself six hours and 15 minutes of opportunity and then you knock out like a light and you have no trouble falling asleep, no trouble staying asleep, you don't have insomnia. So the two are often used synonymously, but sleep deprivation is when someone, some external force is preventing someone from having adequate opportunity to sleep. Insomnia is something more internal, you have enough opportunity, but you're up when you don't want to be up. Gotcha. Now, when we talk about complications, right? Because I think a lot of people say, oh, well, if you're not sleeping well, you have complications that are going to lead down the road, especially chronic complications. What's the truth behind that? If you're an insomnia, should you be worried that, hey, if I don't get my sleep pattern correct, there might be trouble down the road or is that kind of a myth? Well, that's a complicated answer. And I want to answer this very carefully because people with insomnia already have enough anxiety and I don't want to add to it. But here's the truth. So we do know from longitudinal studies that there are worse outcomes for people with chronic insomnia than people who are healthy sleepers. So insomnia is not a completely get off scot-free kind of no impact kind of disease. Insomnia is very real is what I'm saying. So we are at higher risk for heart issues. We are at somewhat higher risk for anxiety and depression and things like that. But it is not nearly as severe as most people think because what most people are hearing are the detriment of what happens when your sleep deprived. And those are much more severe outcomes. So when we're talking about dementia, when we're talking about heart attacks and motor vehicle accidents and like really sort of more severe and big outcomes, then we're talking about sleep apnea, we're talking about sleep deprivation, we're talking about people who pull all nighters or do shift work, basically every other sleep disorder other than insomnia. So I want to be very careful to not conflate insomnia and disturb asleep or sleep deprivation or sleep apnea or sleep disorders like that because the outcomes are not equivalent. For insomnia, they're much milder and also the research is much less clear about the direction of causation. So we don't know that insomnia is causing more depression. We just know that insomnia and depression tend to correlate over time. And insomnia and higher blood pressure at night tend to correlate over time. It's not necessarily causal. In fact, one of the big studies I'm working on at Duke is trying to figure out, you know, does improving insomnia actually lower nocturnal blood pressure? And so that's an open question. We don't know if it's actually causal. Does that kind of answer what you were getting at? Yeah, I just, I'm trying to wrap my mind a little bit around like the physiology I guess, right? Because let's say you have an insomnia who's maybe only sleeping five hours, but then you also someone sleep deprived who might be four and a half five hours, right? Like, aren't they still losing the same amount of sleep? You know, obviously physiological differences in terms of how much sleep they need. But I guess is it more psychological than that's kind of leading down these two different paths? Well, if you don't mind, I think that premise is actually perhaps not 100% correct. So two people who are getting five hours of sleep, one might be sleep deprived and the other might not be. So few reasons for that. One, we all need different amounts of sleep at different times of our life, depending on lots of factors, depending on the season or latitude of where in the world we live, so many factors, right? Age is a huge one. Like, if you have a 20 year old and an 80 year old and they're getting five hours of sleep, I'd be much more worried about the 20 year old, who is definitely sleep deprived. So it may not be that they're sleep missing the same amount of sleep. And this is a tricky one to communicate too, but people with insomnia almost universally are misperceiving their sleep. And I do not mean that they're making it up or they're exaggerating or they should not be trusted. That's not what I mean. I 100% believe the experience of my patients with insomnia. It's just that having insomnia, especially having had it for a while, literally changes your perception of sleep and time. So if I have insomnia and you don't and we're in the lab side by side and every time you're in stage two sleep, they poke you awake. Wait, did I say you have insomnia? You don't have insomnia. And if I poke you awake during stage two sleep, you'd be like, whoa, I just fell asleep. Whereas if I have insomnia and you poke me awake during stage two sleep, I'd be like, I was waiting for sleep to happen. I was just twiddling my thumbs. And guess how much of the night is supposed to be stage two sleep? 20% I believe, right? Or no, it takes two, I'm thinking, these look like, yeah, yeah, yeah, I'm sorry. Half the night is supposed to be stage two sleep, which means there's a lot of opportunity to feel like you're not sleeping when you actually are sleeping. So to get back more directly to your question physiologically, sleep deprivation and insomnia do very different things to our bodies. So even as basic as, you know, which one raises body temperature versus which one decreases body temperature, you know, which one actually slows down our reaction time and makes us, you know, like how the worst cognitive functioning, you know, I always tell my patients who have insomnia that I would rather get into a car with them driving than some random stranger off the street driving because an insomniac is a better driver than someone who's like, that I have no information about because they're hyper aroused. So they're actually paying more attention, they're more awake. They couldn't take a nap if they wanted to. So yeah, I would mother be a passenger in their car. Yeah, it's funny that you mentioned that actually today I had a patient who came in with insomnia and he's like, yeah, doc, like, you know, I just can't sleep. I was like, all right, is it, you know, sleep on set or sleep maintenance? He's just like, I don't know, and his wife's like, he sleeps all night. Like, yeah, so just to just to talk about your point right there and I how insomnia kind of don't know, you know, inside kind of stuff. And it's not, it's truly, I want to emphasize that it's not that they're making it up, but there's something like crazy about it. It's, it's really a different perception. And that's because of anxiety and hyper arousal because when you have hyper arousal, you don't perceive even time passing during the night the same way. And you don't perceive wakefulness or sleep the same way. So and your sleep quality is legitimately worse if you have hyper arousal. There's more cortical activation. You know, there's more cortisol. There's more higher body temperature. So, you know, these things are real and physiological differences is just that, you know, we're, we're discounting sleep. That happens. You know, if you look at the clock when it's two and then again, when it's two thirty, you think you've been awake for 30 minutes. But I, for every insomnia patient I have, I haven't listened to an audio book with a plot. And the next day, rewind and see how much of the plot they actually remember. And it's amazing how often people say like, oh, I have no idea who this character is. I must have fallen asleep way earlier than I thought I did. So yeah, it's very interesting. Are you concerned with that tactic that the type of book might be too stimulating and keep them up? Or is it, I'm sure at this point you have something that wouldn't do that? Oh, no, I tell people to listen to whatever they desire, whether it's a murder mystery or like espionage. I personally love the spine novel. There's nothing, there's no book that's going to be more stimulating than the anxiety in your own head when you're not sleeping. So, if you're lying, they're having insomnia and like worrying about how you're going to function tomorrow and being really pissed off that you can't sleep. No matter like, whatever 007 book you're listening to is not going to be more stimulating than that. That's interesting, right? Because like, let's just take on all these apps, right? We have calm.com that they have a whole sleep library of like really soothing waves and sounds and all these things. But from what you just described, it really doesn't matter. It sounds like, right? Yeah, it's really about shifting attention. It doesn't have to be a special binaural beat or like a pink noise or white noise. I mean, those are nice too. And for people who generally have healthy sleep, there is research that, you know, pink noise can like give you just a tad more of an advantage with sleep. And, you know, if you really want to like optimize or whatever, go for it. But within insomnia, it's really about shifting your attention away from the internalized anxiety. Yeah, that's such a powerful thing, right? The internal struggle. It's challenging as a clinician or really anybody to be able to appreciate what somebody's going through what their internal state is, right? And on the surface, it could look like everything is amazing. But that internal struggle, like you're describing, can be devastating, right? How often do you get patients that walk into a clinic where they're concerned about insomnia and you instead diagnose with just sleep deprivation? What percentage? Oh, so low, so low. Because it's very interesting because people who don't have enough opportunity to sleep also don't have time to go to a sleep doctor. You know, these are like the single moms working three part time jobs or like college student who's just having too much fun or studying too hard. You know, so it's kind of an ironic self-selecting group that the people who are anxious enough about their sleep problems and also have enough resources and time to go seek help for it are the ones with insomnia, not the ones with insufficient sleep syndrome. Thank you for that. I mean, I think that's really important for us to appreciate. I think that probably over the last, I don't know, five years or so, that volume, the discussion of the importance of sleep is much more form-front, right? In the media, there's been best-selling novels, international bestsellers. I mean, you know, a lot of really great books out there. And I think that, you know, especially with social media, the discussion of the importance of sleep, it's getting the appropriate, I think, the appropriate attention. As a clinical psychologist who sees the harm, and I put that in quote, that these books and this knowledge can do, do you think that the the amount of information we're getting sleep, both the benefits and negatives of not getting enough sleep is to, are we getting to a stage where maybe we're paying too much attention to it just generally? That's such a great question. I think overall, I like that people are paying more attention to sleep. Just like I like that there are more sleep trackers and consumer wearables that are that people are using. They're getting more curious about their sleep. They're looking up information about it. I think overall, that's a good thing. I think the challenge is to target the right message at the right person. Because like you said, kind of what's happening is that all the people with insomnia who are already anxious about their sleep are like soaking up the headlines about what happens when you have sleep deprivation, which is exactly the wrong message for them to hear and not applicable to them. And also the sleep hygiene tips that come along with these articles are not going not only unhelpful, but maybe backfiring for these people with insomnia. But these messages are important for the, you know, 25-year-old who's trading crypto into 2 a.m. and not going to bed or like the teenager that, you know, like, goes with sleeps in by five hours on weekends and stays up really late on weekdays. These are the people that actually need to hear those messages and they are either not receiving those messages or they're receiving them in like TikTok videos that are like very piecemeal. So I think really the challenge is to get the right message to the right person. I love that. I mean, we talk about this all the time. Context is everything, right? And that's what you're touching on. So you brought up trackers in what context do you recommend them to maybe your patients? The best, the ideal person to be using a sleep tracker is someone who maybe has circadian issues. So if you're in night owl or you just have a very inconsistent schedule or you feel like, you know, maybe you have ADHD and you feel like you don't have enough guardrails in your life to keep your routine kind of on track, having a sleep tracker could be a very good way to get a bird's eye view of your own data of, you know, am I going to bed and or getting up at approximately the same times? Am I doing a feast or famine pattern with my sleep or sometimes I sleep for 11 hours, sometimes for four, just to get like a big bird's eye view pattern that can give you some targets to work towards to get things a little bit more consistent and consistency as we know for sleep is very important. So that would be the perfect candidate for sleep tracker. Now the the the opposite, the worst person to be wearing a sleep tracker is someone with insomnia who is anxious about their sleep but does not have enough knowledge really about sleep to understand their sleep tracking data and they're getting an arbitrary score or they're getting data about what percentage deep sleep they got last night or REM sleep and they have no idea what's an appropriate amount of deep sleep so they freak out because it's only 15 percent not knowing that that's absolutely the exact right amount to get and then they compare their own data to their spouses data and they see that they slept less in their spouse and they think they're going to get dementia before their spouse does it like that's where we get into trouble. That would be the bad thing. It's okay to get dementia after a spouse but definitely. Yes. Exactly. Okay, so I'm getting are there any particular ones that you seem to favor that you'd like to commercially available products? To be honest, I have not looked deeply enough to really endorse one or the other. I do know from the most recent meta meta analyses that their different brands are kind of good for different things. Some overestimate sleep a little bit, some underestimate. Most of them have not even been really like systematically tested on people within Somia but like I think maybe Fitbit or Aura Ring has been so I don't want to speak too much and too specifically because I don't want to accidentally endorse the wrong thing but I think there's not basically there's not enough of a difference between them to really endorse one over the other. I'm out of the more legitimate ones and also it really more depends on the context of what you're using it for. Yeah, no it absolutely does. I think that it's you know people used to ask me okay what's the best way to get a body fat percentage right? I have a background kind of just in the fitness industry and we would of course tell them look the gold standard is X, Y and Z and you can do a DEXA, you can do you know check MRI and do all that kind of stuff but really it's about doing something and staying and using the same method and being consistent with it and just tracking your progress over time or I think and I suppose it's as much the same I was actually looking at the validity studies for the Aura Ring because that's the one that I have. Darsha is a whoop and I noted that as well that all of the whatever was documented in healthy subjects so I do think that's very very important for us to appreciate when it comes to that. Absolutely yeah and but the problem is most consumers don't know or they wouldn't know to ask that question about like you know who you who are the participants who's data went into testing this product and does that matter for me you know so yeah that's a very good point. Yeah Jay you know on the topics of wearables right it's a way to gather data and that can influence people's behaviors. Speaking about behaviors what are some of the common and I'll put this in quotes mistakes because you know I don't want it to make it seem like it's a bad thing that Insan Nex were trying to do obviously I get it my dad had this issue for quite a bit and he was trying everything underneath the sun but what are those common mistakes again I'll say that you see your clients do on a nightly basis that might not be the best or at least might not even help with their sleep. Right yeah so people within insomnia they are trying really hard to help themselves and they are often doing a lot of research and you know doing the all the right things and that put right in quotes because you know there's so many recommendations of sleep hygiene for example that you know even very reputable sources like the Mayo Clinic you know we'll put on their website but but these sleep hygiene tips do not help people with insomnia they could backfire so what are some of these common ones go to bed early or go to bed at a consistent time. If you're not sleepy and you're going to bed that's guaranteeing insomnia right and because sleep is an involuntary activity you cannot turn it on and off it happens to you at best you can allow it or not allow it but you can't manufacture it so going to bed early is not necessarily good idea going to bed at the exact same time every day also not necessarily good idea another one is you know even well so so this this one is not necessarily a sleep hygiene tip but often my patients will say so and so told me that even if I can't sleep I should lie there and rest because rest is at least half sleep right but what happens is they're not actually resting what they're doing is lying there being anxious and being frustrated and associating their bed with anxiety and frustration and teaching their bodies automatically fire up that program of getting anxious and turning on that racing brain when when they go to bed so yeah staying in bed when you're not sleeping that's a big one oh and making up for lost sleep so if you have a bad night of insomnia trying to really sleep in or trying to take a big long nap um probably not helpful that probably perpetuates insomnia because then you know you're eating into that sleep drive and not allowing yourself to build up enough sleep drive for the next night and also that disrupts circadian rhythms and as we all know rhythms love to stay consistent our our master clock is the happiest when it can predict you know when things are happening in the 24 hours cycle so these are some common ones um one more I'll just throw out there is kind of a broad category is just trying too hard like investing thousands of dollars in mattress or buying the Himalayan salt lamp and trying different types of lavender mist or like meditating the crap out of your evening like that is not helpful because you're actually feeding into the hyper arousal by trying so hard it's like I always tell people you know sleep is your friend a very loyal friend that will stick with you till the end but she's a shy friend if you become too overbearing and get too on top of her she will run away from you so just chill and relax and like wait for her to come to you with open arms because if you're trying too hard you're you know sabotaging your sleep yeah I really love that that you phrased it up sorry we're a little off here but I really for I love that you phrased it that way though you know I often find that anything in today's day where just information is so readily available before people go see an expert in the matter right whether it's a physician like myself or you know a clinical psychologist like yourself regarding the issue they're facing they have to google it like they will google it and they got to try the the low hanging fruit first you know you you mentioned a lot of things that aren't super helpful when it comes to quote unquote sleep hygiene all these things that are mentioned easily on you know these are now in institutions and everywhere what are some again quote unquote sleep hygiene tips that's safe that's maybe not doing more harm than good yeah I think the best category of sleep hygiene tips are the consistency ones but consistency on the morning and get up at the same time every day lots of activity during the day lots of light during the day I think this is actually the most underrated tip of all time is that we need to get lots of light exposure during the day there's a lot of talk about minimizing screens at night and minimizing light at night but it's actually a lot more important to get bright lights during the day so even if you have if even if you go for 20 minute walk on an overcast day that is enough to offset whatever TV you're watching or iPad games you're playing in the evening so much more bang for your buck to get lots of bright light during the day and things like minimizing the unhelpful substances like if you're drinking a lot of coffee all day long you know obviously curtailing that would be helpful but don't go crazy with it you know some people have cut out caffeine including chocolate completely from their life just for the sake of sleep that's trying too hard you know so yeah things like maybe cutting down on late binge drinking if if there's you know other recreational drugs involved that are messing with sleep probably minimizing those will be helpful I I want to come back to this concept of getting light exposure more throughout the day I've somewhat recently come to learn the importance of it but what I'm hearing is it's extremely important to try to get that light exposure like whatever a hundred thousand bucks before a certain time of the day you want to get it early in the morning as as possible do you agree with that or you just want to get it as much as you can throughout the day I would say in general as just get it as much as you can but morning tends to be a little bit better especially for younger people who tend to be a little bit more night hourly um and they have a harder time getting up in the morning or harder time keeping that same wake up time in the morning then that early morning burst of light is going to be most helpful but if someone is already a really early morning bird like they're waking up at four every morning and they're 80 years old and they you know they're waking up too early I wouldn't turn on the bright lights right at four I would maybe wait a few hours um so basically think of it this way uh whenever you get light is when i get whenever you're going to be most stimulated and that's the direction that your circadian rhythm is going to go so if you don't want to become even more of a morning person then don't get too much bright morning light but if you do want to become more of a morning person then boots on the ground same time every morning and get lots of light immediately yeah i mean it sounds like that that's a way for you to anchor your 24 hour circadian rhythms right exactly do you give again i have a sense of what your answer is going to be here but i'm going to ask anyway do you think there's merit to investing for just from the light piece of it like one of those artificial light stuff if like for instance we live uh we all live on the east coast now and then daylight saving times is something that's insane i don't know why to do it anymore but there are times in the winter and it out right like where if you do get up at five o'clock you don't see the sun for three hours and darshan i go to the hospital or go to whatever we don't see the sun until sometimes we never see the sun we get out so in your opinion in that type of context again is there some merit to those things absolutely a hundred percent i have a light box i use my light box i love my light box i went to grad school in boston there were months where i would never see the sun you know and in grad school i didn't have a window either so yeah it's absolutely crucial actually um to get blue and rich light during the day if you're not going to get it from the sun so yeah have it at your desk you know and clear clear with your physician make sure there's you don't have i problems and all that yes please instructions and you know of course um but in general like as long as you're medically cleared to have it and you don't have risks like uh like a history of bipolar disorder or pronestive bipolar disorder or cedar disorder absolutely uh bright light light boxes great investment jade you earlier you alluded to shift workers right how that can be again quote unquote problematic i mean look sometimes external factors we touched on that right you have no control i mean darshan i were both trainees and you know we got to do 24 hour calls here and there and sometimes you you got to get up in the middle of the night even if you're at taking home call um and then other folks who sometimes will do seven days on at night time seven days and so that can be very challenging how do you work with somebody who is a shift worker maybe not complete polar opposite like seven not nocturnal seven daytime um but adjusting either that bed time routine or wake up time you know a couple hours forward a couple hours backward like that's got to be very challenging and i'm just wondering how you go about that yeah shift work is i think in my opinion that most challenging um sleep issue to work with because there's really not any good solutions like there are some things we can do to mitigate the effects a little bit but you hit a pretty hard ceiling pretty quick um so i i want to be very kind of clear right about that and i know that's not welcome news to many people like yourselves who have to do shift work um but i would say if you must do shift work here's a couple of tips uh one is if you can decrease the frequency of shifting back and forth um like rotating shifts are the worst um and if you are like three days on four days off that's worse than if you're like two weeks on two weeks off right so the less frequent uh you can make the shifts rotating um that the better and if you do have to change your shift try to change with the clock so make your shifts later and later rather than earlier and earlier because it's much easier to adjust to a later shift than to go in the other direction um and what else so so i mean there's sort of two categories of of intervention we can do the first category is how do we minimize the damage that shift work has on you overall and those two two pieces of advice are fallen to that category um and just in general as much as you can avoid doing shift work and try to have your schedules match as much as possible between on days and off days the better the second category is when you're already doing shift work in the middle of it how do you mitigate the cognitive impairment and the you know risk for accidents and things like that lots of caffeine lots of that no but really um yeah caffeine um but but not throughout your entire shift because you do need that caffeine to leave your system eventually so that you can sleep after so use caffeine judiciously use light light is actually a better stimulant than caffeine because it doesn't have that lingering chemical effect um so using the bright light to wake yourself up um and trying to design systems such that you have at least like 15 to 30 minutes between being woken up and having to do a really high stakes task because we know from sleep inertia research that even if you feel like oh the alarm went off and i'm a firefighter and i'm sliding down pole and i'm ready to go within 30 seconds because i'm trained to do that right even if you feel like you are ready to go uh you're really not at your 100 percent until 30 minutes later so if we can build it it build in systems such that not everybody is going from sleeping immediately to like doing surgery that would be ideal yeah i mean those are all awesome and i'll just add from personal experience is i mean we know that exercise and activity which you touched on earlier can build up that adenosine right then the body and adenosine is again like like people describe it's that's the pressure right and as we know caffeine is an inhibitor and so it kind of just lets off that what the the top of a pressure cooker essentially is dr. Matthew Walker talks about um just anecdotally for you know me personally and some of my core residents and people that have worked with like when we would be on nights you would try to be a bit more active earlier in the night um and and try to not be as active towards the backhand like six seven in the morning because if you're getting off at seven in the morning obviously if there's a code or something like that that completely gets erailed uh so again that's you know whatever you have in your control uh is the best that you can do right um so i really really do like that um we you mentioned earlier that maybe spending thousands of dollars on equipment that hasn't really been proven to be helpful or even mattresses and things of that nature uh maybe that's not the best way to you know it's put your resources right that being said though i do think there's something right like uh luise nicole was recently on talking about how she tells her athletes when they're traveling all the time from city to hey take your pillow with you right um or you know evaluate mattress quality and stuff um do you do you believe that there's something you said about the quality of the mattress and stuff like that in terms of how it will affect somebody's sleep quality yeah sure um definitely just like if you're sleeping on a haystack you probably won't sleep as well as on a feather mattress or something um so i would say the really the the thing is if you have insomnia do not invest your efforts in finding the perfect mattress because that's actually gonna backfire because the whole process of doing that is sleep effort is making you have more insomnia but if you don't have insomnia you're generally a good sleeper you're an athlete you're whatever um and you have the resources and you feel like experimenting with different types of mattresses and pillows why not you know go for it and if you particularly like something that works with your body you know take that with you when you travel absolutely and if you sleep well at home take that association with you when you're on the road right that that can certainly help sleep and for people with special needs to like for example some of my menopausal women patients they might want to use a chili pad you know to help regulate their body temperature um or if people have particular types of back pain um or pregnant patients you know i myself am having some positional problems because i'm carrying like an extra 30 pounds on my belly um you know having positional pillows and different types of things can can be helpful for that um so yeah it's certainly worth experimenting with i i love that and i'll share the story with you because i think you might find amusing i've mentioned it before that you know a couple years ago um i'm very lucky that insomnia has not been an issue for me sleep deprivation clearly has just because i'm a profession right and of course going through medical school and you know the more sleep deprived you are the more you want it you know it feels great and i spent a lot of time going down this mattress rabbit hole and and i told these guys that there was a night after several nights of being up until maybe two in the morning or whatever my wife woke up at one night and she was like do you see the irony of the situation they're staying up till two a.m researching mattresses and um uh to get the best quality sleep and your sacrificing sleep and i just thought always that was really funny yeah i always think about that but um so do so don't you know do as i say not as i do type of situation here well perfect example jade uh i want to thank you so so much i know you're short on time and i think that you know there there are so many different ways we could continue going this conversation hopefully we'll be able to bring you back in the future so we can dissect a couple of these issues a little bit more um i think that the one take home message from everything that we've talked about over the last 50 minutes or so is that this is a very complex issue um and you know we we talk about that sometimes they don't have the simplest solutions it's not just simply doing this or doing this and it requires an extremely thoughtful and nuanced approach something that you've offered and i want to thank you for that and i want to thank you for being a diplomat for sleep thank you so much well thank you for the opportunity this was really fun two last question for you we want to ask uh what's next for you and you know work in our listeners find you and um you know what are you up to um so they can find me at my website at www.jadewphd.com and i'm actually working on a book and i actually just submitted the manuscript to my publisher a couple weeks ago so um congratulations well that thank you the book will come out later this year so i'm really excited to share that with the world it's four people with insomnia written with lots of love and compassion and evidence-based behavioral sleep medicine um the best that research currently has to offer so i'm i'm looking forward to that um and you know you can find me on social media twitter linkedin i'm on instagram i'll give you the info so you can put in the show notes um but yeah i'm i'm looking forward to connect with everyone and answer questions as much as i can awesome well thank you so much we're looking forward to that and um you know we're definitely gonna have you back on here so get talk a little bit more about it and i can't wait to pick it up last question uh which is kind of the mission of the show and and we've touched on it a little bit is how do we add the health back in health care i think we need to start from a place of understanding and trusting our own bodies um instead of from a place of when something goes wrong how do we fix it right like before things go wrong can we build a good relationship with our bodies and our sleep so that we can cultivate that relationship and invest in health as an overall long-term investment rather than a you know i'll take the card to the shop when it's broken love it thank you so much ed yeah thank you so much for having me thanks so much for tuning into this episode dr jade wooh is just an awesome resource when it comes to understanding sleep psychology insomnia sleep deprivation and it's linked to anxiety and i cannot tell you the amount of times that icy patients come through the doors with some sort of sleep issue you know it might not be labeled as sleep deprivation or insomnia but there is a very heavy component of anxiety that drives these patients to maybe not feeling like they're getting the best sleep that they deserve now if you know anyone whether it's your parents or brothers or sisters friends or family that might be suffering from insomnia or some sleep related issues i highly suggest that you share this episode with them again dr jade wooh is an awesome resource we are going to link her bio and her links all in the show notes all right now time for the medical disclaimer so everything in this podcast is for educational purposes only it does not constitute the practicing medicine and we are not providing medical advice no physician patient relationship is formed anything discussed in this podcast does not represent the views of our employers we recommend that you see the guidance of your personal physician regarding any specific health related issues and as always if you can take the time to create and review this podcast it would do us a huge huge huge favor we'll see you next week