I've seen patients cooking a meal in

their sleep driven in their sleep

committed crimes in their sleep so what

is the story of Kenneth Parks he drove

several miles to his in-law's house

bludgeoned his mother-in-law to death

and then tried to kill his father-in-law

but it was deemed he was sleepwalking

and he was actually acquitted that's

crazy Dr guy leser is a leading

neurologist in sleep physician at one of

Europe's largest Leep clinics and with

over 25,000 studies of over 100,000

patients his pioneering research and

sleep medicine has provided the answers

we need to improve our sleep so many

people are chronically sleep deprived

30% will experience insomnia and 80% of

people in the UK don't know that they've

got sleep annea this is the problem but

the majority can be helped so let's get

into that is there such a thing as

healthy sleep somewhere between 7 and 8

and 1 half hours a night now what's

difficult to explain is why your Ora

mortality goes up if you're sleeping

more than 8 and 1 half hours is there a

link between sleep deprivation and

weight gain increases so even a single

night of sleep deprivation can result in

a dramatic increase in calorie intake

and that's because what hope would you

offer insomniacs there are very

effective treatments for insomnia for

example if you we know that helps about

80% of individuals are you a fan of

sleep tablets as a general r no because

there are many non-d drug-based

techniques what are these techniques to

improve our sleep the gold standard

treatment now is

guy why do we dream that's a really

important question the honest answer

is we've just hit 6 million subscribers

on the DI of a SE um so me and my team

would like to do something we've never

done before as little thank you and

we're calling it The dire of a SEO

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works every episode this month we're

going to pick three current subscribers

at random and we'll send one of you a

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live with our team and one of you will

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heart for allowing me to do something

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it is the greatest honor of my lifetime

and I hope it I hope it continues uh off

into the Future Let's get to the

[Music]

episode

guy should I say doct

guy what is it that is at the very sort

of heart of your personal curiosity

because as I look at your work and how

what you've committed your career to

there seems to be a bit of a through

line as to sort of the subject matters

that have captured

you so I've always been fascinated why

we are the way that we are and obviously

from a scientific perspective the core

of that is our brain and in the course

of my clinical practice I come across a

a whole host of individuals who really

sit at the extremes of The Human

Experience you know people who are

sometimes afflicted by very serious

neurological conditions who experience

the world in a very different way to how

we do so really the the at the core of

what I do particularly in the public

facing work that I do it's looking at

those people at the extremes of The

Human Experience and trying to work out

what it tells us about all of us about

how we all work when you say the

extremes of The Human Experience what

does what does that mean so individuals

who have who see the world in a very

different way experience the world in a

very different way understand the world

in a very different way so you know from

when it comes to individuals who have

very extreme Sleep Disorders to

individuals in whom their perception of

reality is very different from our own

or to people who behave in a very

different way so when it comes to things

like uh aggression or um the way their

relationship with food or um their

personality traits I think in in every

area of clinical neurology you see

individuals in whom something has

happened to their brain that

fundamentally changes the way they see

the world interpret the world or behave

within that world and what's your sort

of day-to-day and and if you if I was to

take a look at your CV what would I see

on your CV I uh studied medicine at

Oxford and then at Imperial uh and very

early on in my career started training

in the world of Neurology did a PhD at

Imperial in Cambridge what is neurology

neurology is the clinical study of the

brain so the brain in its disease state

so we see individuals with epilepsy with

Parkinson's disease with nerve problems

um with certain types of sleep disorders

basically any disease or disorder that

influences how the brain and the nervous

system works so I did a PhD at Imperial

and Cambridge looking at the genetics of

epilepsy and then started working uh as

an NHS consultant in

2010 and you're a consultant of neur um

neurology and sleep medicine that's

right yeah I've never heard the phrase

sleep medicine before well sleep

medicine has been around for a long time

um I was very lucky in the early on in

my training period I rotated through a

hospital where one of my now colleagues

had come from the United States he'd

been based in La where sleep medicine

was really starting out and he'd set up

a a sleep medicine unit and that was at

St Thomas's Hospital in London opposite

the house of parliament um and certainly

over the last 20 or 30 years this been a

really exploding area of uh of medicine

uh partly mirrored by the fact that we

are much more aware of the impact of

sleep on a range of biological and U

mental health issues um but actually in

the world of Neurology there are many

sleep disorders that have their basis in

the brain conditions like narpy like

people who Sleepwalk or act out their

dreams people who have uh episodes at

night that may or may not reflect

certain types of epilepsy so that's

really the primary focus of my work now

between 2013 and 2023 you ran gu St

Thomas's Hospital Sleep Disorder Center

that's right yeah what is that so the

the Sleep Disorder Center is probably

one of the largest sleep disorder

centers in Europe actually so we have 10

inpatient beds so every night 10 people

are brought into the Sleep laboratory

and we study their sleep it's got uh now

about 15 Consultants that's got a staff

of about 50 people and we see a range of

people with conditions like sleep apnea

which is where people stop breathing at

night and then some of the conditions

that I I've talked about conditions like

restless leg syndrome extreme

sleepwalking narcolepsy and other

related issues how many patients have

you had in your sleep disorder Center

that you've studied gosh uh an awful lot

so we do about

2,500 sleep studies a year and we've

been going for well a long time sort of

15 20 years so every year we see about

uh 10,000 patients in total so very very

large numbers if you had to estimate how

many you've seen I I I would imagine

somewhere in the region of upward of

100,000 if we're talking about 10,000

patients a year and and how many sleep

studies have you conducted in that

Center so we've been at the current site

with 10 beds for about 10 years mhm um

and so we're probably talking about 25

5,000 studies why sleep of all the

things that you could commit so much of

your time to because it appears you've

been really thinking and working on the

subject matter of sleep for about sort

20 OD years two decades roughly yeah

something like that yeah what why well I

think the first thing is is that um we

spend a third of Our Lives doing it and

yet we whatever people like me will tell

you we still understand relatively

little about it we understand relatively

little about you know what it's for

um what it does to our biology obviously

that's changing very very quickly now um

it's uh it has a great deal of overlap

with the world of clinical neurology so

I also do uh I do Specialist Clinic

specialist clinics in epilepsy and I do

specialist uh clinics in in general

neurology so and and sleep and the Brain

intersect every single level of course

you know it's not me saying this but a

famous statement is sleep is of the

brain by the brain and for the brain

it's in intimately linked to every

aspect of how our brain works so one of

the really exciting things is that

because it's a relatively new area our

understanding of it is exploding in ways

that are not paralleled across other

areas of clinical

medicine is it important is it important

yeah um I I think it is of fundamental

importance you know the fact is that if

sleep wasn't important it would be a

very stupid thing for evolution to

create in us the fact that we are

essentially SL Switched Off from our

external environment for a third of our

lives and actually there's a whole host

of evidence when you look at how um

certain animals have developed the

ability to be able to sleep with only

half their brain at a time you know

animals like aquatic mammals or certain

Birds dolphin and dolphins that very

much suggests well you know that must be

of great importance if it's if sleep is

um a risk for our survival because if

you're an aquatic mamal like a dolphin

and you're sleeping and you're unable to

surface or unable to see what predators

are around you that the that the the

evolution has designed a system whereby

it enables you to sleep with half of

your brain at a time so that in and of

itself tells us it's important the the

the the fact that the Circadian rhythm

so that 24-hour cycle that a whole host

of biological rhythms have is so

intrinsically linked to life itself that

actually every single um life form

exhibits features of this 24-hour

circadian rhythm tells us that this was

something that was prioritized at a very

very early stage in life's Evolution on

Earth so yes it's important and over the

last few years we've understand

understood precisely why it's important

I say precisely but we know that it's

important for pretty much every aspect

of our waking lives be it our immune

system be it our um cardiovascular

system or blood pressure risk of

diabetes um mental health so depression

and anxiety even how we perceive pain so

it really is fundamental to every system

that we uh rely on during our waking

Lives having seen you know thousands and

thousands and thousands of people that

struggle with sleep that have been sent

to your Center do you think the the

average person on the

street over or underestimates the

importance of sleep in their day-to-day

life well I think it's changing I think

it was not that long ago where you know

comments like sleep is for wimps uh Was

Heard fairly frequently and that there

were some bragging rights associated

with how little you sleep I think that

there has been a transformation over the

last sort of 15 or 20 years whereby

people have become much more aware of

how important sleep a sleep is and have

started prioritizing it a little bit so

you think where do you think we stand

then overestimate underestimate I think

that there is still in the general

population an underestimation of how

important sleep is but I think there are

certain uh segments of the population

that are much more aware of it and

perhaps even dare I say overestimate it

overestimate it yes I think so I I think

that there is a danger at the current

time that we tend to obsessional IE

about sleep and um and think that it is

the the the be all and end all it's of

course part of normal life for our sleep

to fluctuate depending on what's going

on in our external and our internal

lives and I think the danger is that if

you overemphasize the important of

importance of getting eight or eight and

a half hours sleep every night then you

actually uh risk problems later down the

line exacerbating things like insomnia

can you give me an overview of the

current state of sleep in terms of the

percentages stats of people that are

struggling with their sleep the variety

of ways that we struggle with our sleep

the different disorders associated with

with our sleep and just like a breakdown

of society at large is current sleep

health so we think that about 20% of the

adult population are chronically sleep

deprived so that they are not sleeping

enough and that's largely as a result of

Lifestyle factors and lack of

prioritization of sleep we think we know

that about 30% of the adult population

in any one year will experience a period

of insomnia so insomnia is different

from chronic sleep deprivation insomnia

is the the state whereby you want to

sleep where you're lying in bed and you

can't sleep which is very different from

you know burning the candle at both ends

and about 10% of the adult population

will have chronic insomnia so that's an

ongoing issue with

not being able to sleep for more than 3

months at a time so you know very very

high numbers there are some other sleep

disorders that are incredibly common so

a condition called obstructive sleep

apnea which is essentially a part of the

spectrum of of snoring but in

obstructive sleep apnea your Airway

Narrows uh you have difficulty breathing

it partially obstructs and you have

recurrent brief Awakenings sometimes

that you're not aware of that disrupt

your sleep

and estimates were vary wildly depending

on where in the world that they've been

done but I think you know our best guess

is something like 10 to 12% of adult

males experience sleep apnea clinically

significant sleep apnea and somewhere in

the region of about 6% of of women

experience clinically significant sleep

apnea so we're talking about very very

large numbers and the majority of

individuals with sleep apne are

undiagnosed so it's estimated that about

80% of people in the UK with with sleep

apnea don't know that they've got sleep

apnea and I've never seen anybody about

sleep apnea there are other conditions

like um restless leg syndrome which is a

neurological disorder whereby people

experience an urge to move a fidgetiness

in their usually their legs although it

can affect other body parts as well um

that can give rise to very huge

difficulties getting off to sleep and

actually staying asleep because a lot of

these individuals kick at night when

they are asleep and kick themselves

awake and that probably affects

somewhere in the region of about 5% of

the adult population even sleepwalking 1

to 2% of the population so lots and lots

of these conditions very very

common how many of the people that walk

in your sleep center do you think could

be helped and could you help well I

think the majority can be helped um a

cure is something different but the

majority can be helped in some shape or

form and if and if we talk about getting

someone that has walked in your clinic

with some kind of sleep disorder to a

state where they are a healthy sleeper

what kind of percentage do you think

well I think it's important to to

precede what I say by the fact that

actually we don't see many people with

insomnia we tend to divert people with

what we term primary insomnia or or or

insomnia without any underlying causes

to assist a service if you look at

insomnia chronic insomnia as a whole we

know that there are some very good

treatments for chronic insomnia and

actually most of those treatments are

focused on non-drug based treatments

psychological based treatments and we

know that those kind of treatments will

significantly improve sleep in up to

about 80% of individuals so that's a

very large number actually and there are

other treatments available it doesn't

just rely on these non-drug based

treatments there are some conditions

like for example

narcolepsy which is what's narpy so

narcolepsy is a a brain disorder that is

triggered by your immune system is that

where you fall asleep during the day

when you fall asleep very very quickly

during the day you're excessively sleepy

you have very vivid dreams you will

often hallucinate as you drift off to

sleep or as you wake up you'll

experience something called sleep

paralysis where you wake up and you feel

that you are completely paralyzed you

cannot move and a lot of these

individuals also experience a condition

called cataplexy which is where usually

with strong emotion like laughter

sometimes it can be the telling of a

joke and they lose muscle strength and

will sometimes collapse to the ground so

it's a very pure neurological disorder

because we know precisely where that

area of immune attack occurs within the

brain and it knocks out a very small

number of brain cells to generate this

this is a you know once you have it at

the moment it's a lifelong condition but

actually it can be treated there are

many treatments available and even in

the Last 5 Years or there have been many

new treatments that have become

available so actually all of these

conditions are treatable they're

manageable um they're not necessarily

all curable is there something at the

heart of culture and how we're living

that's causing so many of us to struggle

with sleep the way that modern society

is at the moment certainly I think is

rather conducive to insomnia in fact you

know when uh researchers have looked at

um at pre-industrialized societies so

you know for example um tribes in um in

Eastern Africa or in South America

actually insomnia is relatively rare and

some of these tribes don't even have the

word for insomnia so I think that

certainly insomnia seems to be

correlated with the changes that have

occurred in our in our society sleep

apnea is often associated with weight

gain and obviously that is very much a

function of our modern societies so yes

undoubtedly some of these conditions can

be attributed to the way that we lead

Our Lives some has anybody ever put like

a sleep tracker on a tribe yes that has

been done there's a chap called Jerry

seagull who is based in the east coast

in one of the ivy league universities

who has spent his life doing that and

what did he find out so he found out

that actually sleep does vary a little

bit according to the seasons that uh

they don't necessarily sleep all the way

through the night but actually their

sleep is rather different to the sleep

of modern society in what way they will

not necessarily so this view that we

sleep when it gets dark and or used to

sleep when it gets dark and wake up at

dawn is incorrect um that they uh that

there is some fluctuation between the

seasons but not

necessarily um uh you know directly

related to the number of hours of

daylight and that insomnia is relatively

rare when so that are they waking up in

the middle of the night then uh I I

think it's normal to wake up in the

middle of the night that we all wake up

in the middle of the night it's very

rare that you uh for example do a sleep

study on somebody and you don't see

periods of awake in the middle of the

night it's normal to be awake for up to

about 30 minutes over the course of the

night that in itself is not a marker of

pathological

sleep when I say awake I mean I mean I

guess I mean getting up and walking

around and stuff but yeah I mean I think

that there are some individuals that do

that there's a there's a a chap called

Robert eirk who has spent a great deal

of time looking at Medieval texts and

seeing how they described sleep and he

has put forward a hypothesis that in

medieval times uh people would have a

first sleep and a second sleep now I

think that that theory is not

universally accepted but certainly for

some individuals getting up and walking

around is is you know certainly within

the Realms of normality I I think there

are different sleep hands if you look

for example at um Mediterranean Europe

the Siesta culture so people sleeping

for an hour or two at lunchtime but

sleeping slightly less at night so um

there are a range of sleep patterns that

sit within the spectrum of normality for

human beings is there such a thing as a

healthy sleep as in you know see these

sort of different sleep behaviors and

such but is there from a neurology

standpoint or clinical standpoint a

perfect sleep or a perfect sleeping

habit or you know right so I think the

first thing to say is that sleep is

different for everyone we know that

there are genetic factors uh that

influence for example your timing of

sleep your circadian rhythm whether or

not you're a uh a morning lck or an

evening hour there are also genetic U

influences over how much sleep we need

so for example there are one or two

families that I've seen in my clinical

career in whom every single member of

that family sleeps for 4 hours a night

and has no ill effects and does not seem

to have any long-term consequences from

that they don't feel tired they there's

no evidence that they're doing their

physical health any harm and there have

been some genes that have been

identified that Define that trait now

it's a rare trait and I wouldn't suggest

that most people who are sleeping 4

hours a night think oh I must be

genetically blessed because the reality

is probably somewhat different so I

think that in answer to your specific

question is there a perfect night's

sleep no there isn't because it depends

on the nature of who you are and what

your genetic inheritance is but but

certainly we can say on a population

basis well you know sleeping somewhere

between 7 and 8 and 1/ half hours a

night if you look and a stress on a

population basis we see ill effects in

terms of sleeping less than 7 hours or

sleeping more than 8 and a half hours if

you look at for example all cause

mortality or if you look at

cardiovascular disease now there are

various potential explanations for that

um certainly if you're sleeping

relatively little um you uh we can see

that there are changes in terms of how

your physiological system works that

might give rise to things like blood

pressure issues weight gain

cardiovascular disease stroke those

kinds of things what's a little bit more

difficult to explain is why your

mortality and other uh ill health goes

up if you're sleeping more than about 8

and 1 half hours and I think that that

is probably a much more complicated

picture in that we know that there are

certain drugs that people will be on and

when you're on drugs that's a marker

that your health is not necessarily 100%

already that will make you a bit more

drowsy than you normally are and will

extend your sleep time it may be that

you have a sleep disorder which is

causing you to sleep more but there's an

another interesting potential

explanation in that we know that for

example in certain diseases of the brain

there are changes to your sleep many

years before sometimes even decades

before for a really good example of that

is Parkinson's disease so we know that

in people with Parkinson's disease many

individuals will start acting out their

dreams at night sometimes even three

decades before they then go on to

develop Parkinson's disease so is it

that our sleep intrinsically changes in

as a precursor to certain conditions

like Alzheimer's disease and there is

some emerging evidence now that actually

a change in your sleeping patterns

either in terms of How Deeply you sleep

how long you sleep whether or not you

nap during the day that may be a what we

term a prodromal feature of Alzheimer's

disease do you see anything interesting

happen when someone has a baby in terms

of their I was wondering this the other

day cuz I have a friend who's had um a

couple of kids and I was looking at

their sleep tracker and it seems like

they have this inherent ability to

survive now that they've had kids on

like no sleep I was wondering if there's

some sort of evolutionary mechanism that

makes parents I don't know require less

sleep yeah I'm not sure I can

specifically answer that I've certainly

seen a lot of people whose sleep has

gone to pots after they've had kids and

you know a lot of people say that their

sleep has never returned to normal after

they've survived having a couple of kids

um but you know what you have to

remember is that the brain is a

remarkable organ in that it has all of

these adaptive mechanisms that enable us

to cope with changes in our

circumstances changes in our environment

so if you put put somebody in a sleep

deprived State sleep also changes so

what what the brain does is it

prioritizes the very deepest stages of

sleep stage three slow wave sleep over

other stages of sleep and you know what

we can see that in the sleep lab so if

somebody's very sleep deprived before

they come in and we put them in the

sleep lab we see a sort of huge increase

in their slow wave sleep which is the

stage of sleep that's most associated

with restoration with healing with

feeling uh feeling more refreshed than

other stages of sleep like for example

REM sleep or dreaming sleep so the brain

is prioritizing restoration faster than

it would because the person sleep

deprived absolutely yeah

H so what is the you as you were saying

there you've seen families that just

require 4 hours sleep and they're

apparently great is that is that a lot

of people no it's as I said it's very

very rare very rare cuz I've looked at

people sleep trackers before and I've

been astonished by how little sleep they

seem to require but how active and great

they seem to feel and I've and I I had

this the other day cuz one of my fellow

dragons I said this to her she requires

very little sleep but then she gets up

at 5 a.m. and goes for like a 10m run

and I was like I was looking at her

sleep tracker thinking you've been in

bed for like 5 hours and you are

extremely more awake and energetic than

I am and you just did a 10mile run and

I'll go in bed for seven hours

and my it says that my you know stage

three stage four sleep is higher than

hers but for some reason she's like you

know bouncing into the room well I I

think there's two explanations for that

the first is um maybe she is one of

these genetically short sleepers

although as I said that seems rather

unlikely I think the other explanation

is we we know that that you know I

talked a little bit about how genes

influence our sleep we know that there

are genes that influence how resistant

you are to the effects of sleep

deprivation uh and what I mean by that

is that there are there seem to be some

individuals who don't feel or or who

feel less sleepy than other people when

they are sleep deprived but that may be

separate from the cognitive effects of

sleep deprivation so she might just not

feel it she might not just feel it but

she may exhibit those cognitive effects

of sleep deprivation in the same way as

you or or I for example she's 10 years

older than me as well does that have

well I think that certainly we do see

some reduction in sleep requirement as

we get older um we're also a little bit

less about less good about maintaining

sleep as we get older and that's because

the brain mechanisms that stabilize

sleep are becoming a little bit weaker

so so this view that we need much less

sleep as we get older is probably

incorrect although there is a a slight

reduction in sleep requirement you

mentioned earlier that when people don't

get enough sleep the chance of obesity

and weight gain increases how how does

that happen what's the mechanism so what

there are probably many mechanisms but

one of the the ones that is best

understood is that we know that when

you're sleep deprived or indeed when

your sleep is disrupted by anything else

like for example sleep apnea there are

changes that occur in terms of hormone

levels of of uh hormones that regulate

our appetite and our satiety and so even

as single night of sleep deprivation can

result in a dramatic increase in your

calorie intake uh overnight there have

been some studies done for example in um

nurses so uh there was a study done that

followed up nurses for 18 years and they

looked at their weight and how much they

slept on a regular basis and what they

found is that those nurses that were

sleeping less than about 6 hours a night

on a regular basis first of all started

off at the beginning of that 18year

period uh at a slightly higher weight

but over the course of those 16 years uh

18 years they put on much more weight

than other groups so there is a very

clear correlation between sleep duration

Sleep Quality and weight gain we see

that for example in individuals who we

treat with sleep apnea so one of the

treatments for sleep apnea is a mask

like device that you wear that stops

your Airway from closing down at night

and and for some very overweight

individuals actually when you treat

their sleep apnea they do manage to

successfully lose weight where in the

past they found it absolutely impossible

to do

so okay so if I'm underslept I'm more

likely to eat more calories the next day

yes am I also more likely to to reach

for foods that are like high in sugar

and bad for me certainly some studies do

suggest that I think it's also important

to say that sleep disruption or sleep

deprivation has some fundamental effects

for example on um uh your glucose

tolerance so your insulin resistance um

which of course is a particular issue

for people with diabetes but it affects

us all so if you're very sleep deprived

there are changes to the way that not

only your appetite or what you're

reaching for but also how your body

processes the breakdown of those food

stuffs interesting CU I anecdotally I

think I can I can clearly say that if

I'm if I'm underslept I'm much more

likely to eat something that is high in

sugar or well I think we can we can all

testify to that can't we you know I

think everybody has known that situation

where they're very sleep deprived and

they think oh well I just need a bit of

chocolate or um you know what what

what's going on in the brain though why

is that is it is it something to do with

the amigdala the prefrontal cortex the

like the emotional center of our brain

and the yeah I I don't I don't think we

know I think it's probably to do with

the reward mechanisms that underly our

our behaviors that uh there is something

about sleep deprivation that alters the

rewards that we're seeking but I don't

think I can give you a clear answer on

that you you also talked about circadian

rhythms if I if I was a 10-year-old what

do I need to understand about the

Circadian rhythm what it is what it does

and why it's important so within pretty

much every cell of our bodies there is

this 24-hour clock and in fact if you

take a single cell and stick it in a

Petri dish about 40% of the genes within

that cell will exhibit this sort of

24-hour cycle and that 24-hour cycle

really controls pretty much every

biological system within our bodies be

it how our liver Works how our heart

Works how our lungs work there is one

particular area of the brain called the

supermatic nucleus that is viewed as the

Master Clock it's the clock that

coordinates all the other clocks within

our within our bodies and that

influences uh not only all of these

other clocks that are occurring within

the cells throughout our bodies but

influences our Behavior as well so

influences generally speaking when we

feel tired and when we want to go to bed

and when we wake up um and also

influences things like you know when we

feel most mentally alert when we want to

eat when we want to drink when we feel

most a able to cope with work for

example um now that circadian rhythm

that circadian clock for most people uh

confers the Sleep onset of somewhere

between 10: p.m. and midnight if you're

an adult and waking up somewhere between

6:00 and 8:00 a.m. now the timing of

that body clock is governed by two

things it's governed by our genetics so

whether or not we are um genetically

predetermined to be slightly later in

terms of our body clock or slightly

earlier and we see that in families

where lots of people with for example

will say well you know I've always gone

to bed late and woken up late but so is

my father so is my grandfather etc etc

um but it's also influenced by what's

happening in our environment about 50%

of the uh definers of our circadian

clock are governed by what's going on

around us be that in terms of when we're

exposed to light so we know that light

is a very

important driver of our circadian rhythm

when we're eating when we're exercising

when we're doing a whole range of other

activities and also one of the markers

of our Cadian rhythm is the secretion of

melatonin so there's a very small gland

in the center of our brain called the

pineal gland which secretes a a hormone

called melatonin that hormone tends to

start being secreted in most people at

around 6:00 in the evening it Peaks at

the time that we want to go go to sleep

and then it starts dropping down a few

hours before we wake up it's almost a a

chemical marker of our Cadian Rhythm but

we also know that giving people

melatonin in tablet form for example can

influence our Cadian Rhythm so there's

this sort of feedback loop between our

own body's secretion of melatonin and

what our supermatic nucleus our

masterclock is doing so by giving people

melatonin at particular times of the day

we can shift your cadan Rhythm forward

or or back so that Master Clock in the

brain where is it positioned the

supermatic nucleus is in a small area of

the brain called the the hypothalamus

and is that linked to the eye there are

links from the back of the eye to the

hypothalamus so there are some cells in

the back of the eye in the retina that

are not involved in Vision not involved

in conscious Vision but what they are

involved with is detecting blue light in

particular which is the part of the

spectrum of light that is most important

in terms of regulating our Cadian clock

and there are direct links between these

cells that are called retinal gangan

cells and the supermatic nucleus so

exposure to light to Blue Light in

particular is really very important in

reinforcing or adjusting arcaden Rhythm

now of course we live in a in a world

whereby the seasons change and the

amounts of light that we're exposed to

changes so if we were on a set Rhythm

all the time that was immovable and un

unadjustable then there would be times

where our Cadian Rhythm might not be uh

might might be at odds with our

environment so there does need to be

some slight adjustment of that Cadian

Rhythm and light is probably the most

important adjuster blue light is that

the light that comes from my smartphone

uh so it's so blue light obviously the

the strongest source of blue light is

Sun yeah um but yes these kinds of

devices your smartphone your iPad in

front of you a range of electronic

devices also have Blue Light Within them

so so that's why if I'm if I'm up on my

phone till 1: a.m. in the morning

staring into the screen I'm kind of

tricking that sort of optic nerve which

is then impacting my master clock and

I'm I'm telling it that it's a different

time yeah so so the thinking on that has

changed a little bit over over the last

few years so it you know it was said

that using these devices will trigger

insomnia as of as a result of blue light

actually it's likely that the amount of

blue light that these devices put out is

probably insufficient to do that

directly but there are two effects of

using your Gadget until 1:00 a.m. the

first is on a on a long-term basis if

you're doing that regularly it will

result in an adjustment of your

circadian clock and push it back so you

will want to go to bed a little bit

later and wake up a little bit later

which is fine if you're self employed or

you don't have any restrictions on your

time but most of us need to be up at a

certain time in the morning and if your

circadian rhythm is delayed

significantly the net effect of that is

that you're going to end up sleep

deprived I mean there's also the issue

of being you know on Twitter or being

engrossed in a in a movie on Netflix at

1:00 a.m. that is going to make you

delay sleep anyway so there are those

two it's arousing it's arousing and it

grips your

attention well what do you make of these

people me being one of them that watch

you know serial killer movies when we

fall asleep well I think that that's

only an issue if it's stopping you from

falling asleep do you see because I have

this argument a lot with my partner she

she can't understand why I I need to

watch this like really stimulating stuff

when I fall asleep she likes quiet and I

need to I I tell myself I need to like

listen to something do do you see like

variance in in this kind of thing and is

there a better approach or this comes

down to

individualized approach to sleep and

that's why I'm always very reluctant to

say this is the perfect night sleep

these are the rules for sleep you know

for example there are some people who uh

for whom caffeine doesn't really

influence their sleep and can have a

double espresso an hour before bed and

still have no problems getting off to

sleep for most of us that's not the case

um if you are somebody who can watch

something very stimulating very scary

and then switch it off and roll over and

go off to sleep then I I guess that's

not a problem for you for most people

that's probably not the best thing to be

doing at night I think that longterm one

of the issues is with all of these kinds

of activities in bed at night before you

go off to sleep is that they weaken the

psychological associations between bed

and sleep and so if you start

associating bed being a place where

you're mentally active where you're

engaged then if you have an underlying

predisposition to insomnia for example

then that can sometimes set the stage

for developing insomnia later on the

average person that you've treated

worked with in your clinical practice

that's struggling with sleep is at the

heart of the issue just poor sort of

sleep hygiene like you've said there

yeah because I've got so many friends

that say to me that they struggle with

their sleep um many of them have

struggled with it for years and I I

doubt that there's some sort of genetic

reason why this many people are

struggling with sleep so I imagine it's

just some kind of Behavioral reason so I

think that the genes that predisposed to

insomnia are pretty widespread but

obviously you know in pretty much all

areas of medicine there is an

interaction between genetics and

environment and certainly poor sleep

hygiene and that's a it's a horrible

term I hate that term but it's the term

that is most widely used and understood

can certainly put in place certain

aspects of behavior that then can give

rise to Chronic insomnia in the long

term so if you've got very bad chronic

insomnia then suddenly putting good

sleep hygiene in place it's unlikely to

fix it but it may be that that poor

sleep hygiene in the first

instance gave rise or at least

predisposed you to developing insomnia

and what is um poor sleep hygiene if I

wanted to be the worst possible

sleeper okay in the world what would I

have to do so I think you would probably

have to uh um set up your home office in

your bedroom okay you'd have to have um

you know your TV on in your bedroom all

the time okay uh have be surrounded by

electronic devices drink a lot of coffee

late in the evening alcohol uh drinks a

little bit of alcohol so alcohol in the

short term of course is is quite

sedating it's a central nervous system

dep uh depressant but it does

dramatically um worsen the quality of

your sleep and for various reasons the

direct chemical effect fact that you've

got a full bladder um the fact that

you're probably snoring a little bit

more so alcohol's not a good thing um

you know not having a wind down period

so you

know gambling on the stock market until

1:00 a.m. switching your laptop and then

trying to go to bed uh those kinds of

things so that's you know the

quintessential very very bad sleep

hygiene what about when I eat so uh you

know eating is perhaps less important

but avoiding a very large large

carbohydrate meal carbohydrate Rich meal

before you go to bed for two reasons one

is that we know that it can cause some

fluctuations in terms of your blood

sugar and also if you've got a bit of

reflux it can make that much worse okay

what about sleeping in bed with somebody

else well I think that for some people

they and again this goes back to no one

rule for everybody you know if you've

got a a a sleep trait termed sleep

reactivity which is where your sleep is

very liable to your environment and then

obviously sleeping next to somebody

who's snoring loudly or who gets up in

the middle of the night two or three

times to to to urinate can be can be

very disruptive to your sleep if you've

got very little sleep reactivity you may

actually find it comfortable more

comfortable to sleep with somebody in

the same bed as you I was um I was

thinking the other day because where

I've currently moved into there's no

blinds or curtains in my bedroom and I

was wondering if that might be a good

thing because it at least means that in

terms of my circadian rhythm I'm waking

up at the same time every day because

I'm waking up when the sun comes up yeah

but the sun comes up at different times

uh at on different days firstly um so if

you were doing that routinely um you

might find yourself really rather sleep

deprived um in the summer months um and

also there is some emerging evidence

that exposure to light at um at night in

your sleep is not very good for you so

there was a very recent study that

implied that light exposure at night

increases your risk of diabetes so um it

certainly is not good for the quality of

your sleep and the likelihood is that

you won't wake up as soon as it's light

you'll wake up uh an hour or so after

it's got light but during that hour or

so it may have had a negative impact on

the quality of your sleep so having a

dark bedroom is really part of good

sleep hygiene as is having a quiet

bedroom that is not too hot or too cold

what if you wear a sleep mask does that

solve it yes it does I mean I wear a

sleep mask I think it's you know

particularly if you don't have good

blackout curtains or blinds in your

bedroom using a sleep mask particularly

in the in the summer months is probably

very helpful indeed does that mean that

the only light receptors we have are

behind her eyes well I think that there

was a the there were some rumors uh on

the internet that there were um light

receptors elsewhere but certainly the

the only ones that we um know to be of

significance in terms of defining our

Cadian Rhythm are the ones in our

retinas because I I did psychology when

I was in uh secondary school and I

remember reading one of the psychology

books maybe my psychology teacher told

me this I think it was Mrs ly that there

was some studies where they shined a

light like underneath someone's knees

yes and people would like wake up when

they Shine the lights there I I think

that that's been that's been very much

discounted now it it's a bit strange

though that the only light receptor

would be behind the eyes it just feels

like I don't know feels like poor design

that there's only one place where we

figure out if it's night or day so so

you know you see that for example in

people who've lost their sight right so

so uh in uh some individuals who have

lost their sight completely then they

lose the regulation of their circadian

rhythm and they develop circadian rhythm

disorders something called a non 24-hour

rhythm disorder whereby um their

circadian rhythm is on a for example a

25-hour cycle and so every night they

will go to bed 1 hour later uh than they

did the previous night and will go right

the way around the clock you know every

month or so um so you know that's a very

good piece of evidence that actually

it's those cells in the in the retina

that are of crucial importance for

maintaining the stability of Arcadian

Rhythm I I've wrote that down it I wrote

down in one recent study 40% of totally

blind indiv ual had a non 24-hour

circadian rhythm which really kind of

for me also highlights just how

important it is

to um think about my circadian rhythm

and how much impact it's having on my

whole body the the other part you

mentioned was the biological element to

our Cadian rhythms which which people

refer to as chronotypes yes and I this

idea of chronotypes which is essentially

from my understanding that genetically

we all have a slight sort of disposition

to sleep in at certain times yes and to

wake up at certain times yeah so there's

these names right there's like the

owl the L or whatever else I think I'm

an owl but that also could just be bad

habits yeah so so the you know certainly

there's that sort of genetic

predisposition there's also these

environmental factors but there's also

age in that our circadian rhythm changes

a little bit as we go through different

stages of life so you know it's not at

all uncommon for teenagers to become

more evening chronotypes and then as we

get older we tend to shift back to the

morning so that's part and parcel of our

aging biology as well so so I think that

you know genetics is really important

but so but so are other factors as well

studies in twins um suggest that up to

50% of our chronotype is under genetic

control so does that suggest that we are

likely to have a similar chronotype to

our

family we are likely to but obviously

our environment is not going to be

exactly the same as our parents or you

know what we do our behaviors are not

going to be uh um identical to our

parents or our siblings so yes we more

frequently see that for example people

have a evening chronotype that runs in

families um but that doesn't mean that

you know look we we we're more than just

the destiny of the genes that we hold um

obviously our genes are really important

um but so are other factors as well if

someone came to and they said I'm

struggling with my sleep you know

multiple nights in a row I haven't been

able to sleep I'm getting in bed and

nothing's happening and then I'm waking

up and I'm just sat there thinking about

you know sleeping and um I feel horrific

where would you start so I would start I

think by trying to understand what it is

that is causing their sleep issues

because a lot of the individuals that I

see who have been referred in with that

sort of picture assume that they've got

insomnia and they may not always have

insomnia so I I think a key issue is

that we are really really poor witnesses

to our own sleep and what I mean by that

is that we

often our experience of sleep is very

different to the reality of sleep when

we bring in people into the Sleep

laboratory it's not at all unusual and I

will almost always ask this question

when I'm going through a sleep study

with one of my patients is how much

sleep do you s you got over the course

of that night and it's not at all

unusual for people to say to me well I

think I got two or 3 hours sleep

occasionally even they say well I didn't

sleep at all and then you look at their

brain waves you look at the best

objective marker that you've got of

their sleep and you see that they've

slept s and a half eight hours so

obviously what people are experiencing

is really important because ultimately

from my perspective I want to improve

people's experience of their sleep and

what it is that they're they're they're

complaining of but it's important

to understand that what they're telling

you may not necessarily be the objective

truth now that's really important when

it comes to insomnia because it's not

unusual for me to see individuals who

you know they give you a story of very

clear insomnia but actually when you

look at their sleep objectively you find

that although they say they haven't

slept at all they've slept 7 hours but

that 7 hours has been completely

disrupted by conditions like periodic

limb movement disorder which is this

these leg kicks associated with restless

leg syndrome or sleep apnea for example

now sometimes it's very evident from

what people tell you that actually

that's not the case that they've just

got very clear insomnia so so that's

really the starting point to try and

decide whether or not you feel confident

enough in your clinical evaluation of

them that that you know what the issue

is without doing a sleep study and if

you think that they do need a sleep

study then that's the point at which we

we we arrange for that it's also trying

to understand some of the factors that

might be driving their sleep

difficulties so for example was their

sleep were their sleep difficulties

triggered by a life event did they have

sleep reactivity before this insomnia

started so were they one of those

individuals who could sleep anywhere at

any time whatever they wanted uh

whenever they wanted to put their head

down or were they kind of an individual

who the night before an exam before a

job interview before a

a presentation would lose sleep because

that often is a very strong marker for

developing insomnia uh later on in life

uh and then it's also about trying to

understand how the rest of their health

is impacted by their sleep but also how

the rest of their health impacts on

sleep so it's not at all unusual for me

to see individuals who have been started

on medications for other reasons that

have generated sleep issues for

example you talked about this sort of

obsession with sleep and I was wondering

in the case of the patient you've just

described would you encourage them to

wear a sleep tracker so first of all I

have to say that I'm not ideologically

opposed to sleep trackers in general I

think that they are really really good

for example in research um you know

fantastic for research it allows us to

track sleep in very very large numbers

of individuals and try and work out how

that correlates with whatever we're

interested in one of the major issues

with sleep trackers is that the people

who often use sleep trackers are

individuals who already are concerned

about their sleep so if you know that

you're sleeping relatively little and

you wake up feeling tired then you

probably know you're not sleeping enough

you don't necessarily need a sleep

tracker to tell you that if you're one

of these individuals who has insomnia

who is spending plenty of time in bed

but simply cannot get the amount of

sleep that they need um then what a

sleep tracker will do is it'll increase

your

concern your anxiety around your sleep

it's a very different picture from for

example using a a step tracker if you're

sitting on the sofa and you look at your

step tracker and you realize you've only

done whatever it is 5,000 steps it's

very easy to get up and go for a walk

and do another 5,000 steps if your sleep

tracker is telling you you slept really

badly and you know you slept really

badly and you're already worried about

how badly you sleep there's nothing that

you can do on the basis of the

information that your sleep tracker is

giving you to suddenly go and get a

little bit more sleep and It's

Complicated by the fact that you know

sleep trackers are pretty good at

telling you how much time you spent in

bed they're reasonably good at telling

you how quickly you dropped off to sleep

the reliability the accuracy of these

devices most of these devices drops off

significantly when it comes to for

example defining nighttime Awakenings

defining stages of sleep those kinds of

things so then you have that additional

is in the mix which is that sometimes

your sleep tracker may be giving you

information that is not factually

correct and that may increase your

anxiety further so I'm really very very

keen for people who have issues with

their sleep rather than just burning the

candle at both ends to put away their

sleep tracker and actually go and have a

chat with their GP or somebody who knows

a little bit about sleep rather than

relying on this sleep tracking

technology do you think sleep trackers

have had a net negative NE ative or

positive impact on sleep

culture I think that for those

individuals who can fix their sleep in a

very straightforward Way by spending

more time in bed so the kind of people

that I talked about that 20 years ago

would be saying well you know I only

sleep 5 hours and you know because I'm

busy doing x y and Zed and I can get

away with it I think it's probably

encouraged them to spend a bit more time

in bed because they know they have a a

very clear um very clear bit of

information that's telling them that

they're not sleeping enough but for the

people that I see the people who are

already concerned about their sleep uh

and who have difficulties with their

sleep I think it's been a very negative

impact um and I have some reservations

about well people like myself um sitting

on these kinds of podcasts or writing in

newspapers telling you well you know if

you don't get enough sleep you're going

to die early you're going to have all

these negative Health consequences

because for a subgroup of individuals

who are already very concerned about

their sleep that actually can cause

problems and I have seen individuals who

for example have read books on sleep and

how important it is on sleep who have

ended up going into a spiral of insomnia

and very catastrophic depression and

anxiety as a result so so it's very you

know it's very important to be clear

that the all of this is a double-edged

sword it's interesting with with sleep

trackers um um I can see I think it's

worth me saying that I am both an

investor in whoop and I'm also sponsored

by whoop okay but I also agree with the

things you've said so I've seen this

this sort of variance in how a sleep

tracker can improve some people's lives

and it can make other people more

anxious in a way that's not helpful so

for me my sort of testimony on it is um

I was one of those people described

earlier that thought sleep was take it

or leave it and when I started seeing a

sleep track it's kind of like that when

I saw my brain for the first time I did

a brain scan and I didn't even kind of

like realize it was there and that I

could influence it and that things I was

doing um without really thinking much

were having this big impact and for me

what it did is it allowed me to finally

make this link between how much sleep

I've had and then how I behave now I

thought my behavior was random before

but seeing that when when my sleep um

scores were down I was way more

emotional I was way more likely to eat

crap uh and the other thing that I saw

which was really interesting was that

when I had a glass of wine or two

glasses of wi three glasses of wine that

it just like destroyed my sleep and I

never knew that before and I was in

search of reasons to quit alcohol anyway

and when I saw that I quit alcohol

forever so I've not drunk since so and

then for me I have to also say there are

moments in my life where life happens

and I know I'm not going to sleep and I

don't pay attention to my sleep tracker

but there are other moments where um I

have a bit more control and that's when

I kind of tune into my sleep tracker

I've also had Parents message me a lot

and say listen I've got a one-year-old a

2-year-old a three-year-old whatever

there's no point me wearing a sleep

tracker because listen I'm not going to

get any sleep and I also completely

agree with them that there's really no

point in that situation I think there's

a point when there's something you can

do about it and that's kind say that's

absolutely key yeah so so the the the

the point of doing anything like that is

if there are very clear things that you

can do on your own to close that Loop

there's no point having information

without being able to act upon it and I

guess if you are one of those

individuals like yourself who very

clearly can correlate certain things

that they're doing in their daytime

lives with their sleep and and and how

they feel subsequently then then great

you know I guess I have a little bit of

bias in that the people that I see are

already struggling with their sleep

already and so it goes back I guess

we're completely in agreement yeah yeah

we are yeah and it's so interesting cuz

I that's been a developing idea cuz

obviously my bias is always like

wouldn't you rather know cuz that's you

know but then from doing this podcast

I've I've seen the comments and I've

seen the struggle in from speaking to

parents that struggling with their sleep

and it's kind of sometimes just makes

them feel worse about it um I think

Nuance is necessary on this issue um and

I'm sure there's a lot of a lot of

things in my life that I wouldn't like

to be able to track because either I I

don't have control of them right now or

you know um maybe they'd make me feel

more anxious there's this thing called

the glymphatic system which I find

really which when I discovered this I I

it really helped me to understand the

importance of sleep can you explain what

the glymphatic system is as if I was a

10-year-old yeah so um within our bodies

there is a a system a very similar

system called the lymphatic system so

people will have heard of lymph nodes

for example and this is a system whereby

fluid that comes out of the blood

vessels and into the tissues is then

collected and transported back into the

the cardiovascular system and we used to

think that there was no equ equivalent

system in the brain but actually you

know over the last 20 years we've

understood that whilst there are no sort

of lymph nodes or things like that there

are these very small channels between

the cells that are responsible for

draining fluid from the brain and um

those um systems are responsible for

removing certain toxins or metabolites

chemicals that have built up as a result

of metabolic activity within the brain

and removing them from the brain

substance

itself now it's like a car wash um like

like a drainage system you know like

like like a gutter for example um you

know that takes the suds from the car

wash away and puts them into the drain

um in about 2011 if my memory serves me

correct there were some studies done

that looked at that lymphatic system in

different stages of sleep and what they

described was that that lymphatic system

opens up significantly by about

60% in very deep sleep in the deepest

stages of sleep and so and so subsequent

research showed that for example one of

the proteins that was being removed was

a protein called betoid that is that is

intimately tied to Alzheimer's disease

and so the view that deep sleep was

particularly resp responsible for

housekeeping of the brain for chemical

housekeeping of the brain came about it

gets a bit more complicated because

actually only two or three weeks ago

another study suggested that that 60%

increase in the lymphatic system was not

the case and so I think that this

remains an area that there is some

uncertainty about but actually there are

many reasons to tie in sleep in general

separate from the lymphatic system into

a general housekeeping role of the brain

and I think that um certainly this is an

area that is going to keep researchers

very very busy over the next 10 or 20

years this uh association between sleep

cognition and cognitive decline in later

life that that protein that seems

to Spike if we are sleep deprived beta

ameloid beta amid yeah and that's linked

to alzheimer's it is yeah so in

Alzheimer's disease we see beta ameloid

deposition within the brain substance

itself what does deposition mean so uh

it's deposited within the brain if

someone has Alzheimer's they have a sort

of the build a buildup of buildup of

beta ameloid in the the brain substance

is there a link between sleep

deprivation and Alzheimer's do we see

high numbers so there is some evidence

to suggest that uh both chronic sleep

deprivation and insomnia are associated

with cognitive decline and conditions

like dementia it goes back to what I was

saying earlier which is but by the way

there's also some studies that have

suggested links between sleeping tablets

and conditions like Alzheimer's so it

goes back to this issue of whether or

not it's the insomnia or the sleep

deprivation that causes Alzheimer's is

it sleeping tablets that causes

Alzheimer's or is it the fact that

Alzheimer's many many years before

causes changes to our sleep and and so I

think that that story is not yet been um

has not yet come to fruition in terms of

our fundamental understanding of the

links between sleep and Alzheimer's

disease and whether or not it's directly

causative do you

recommend slash are you a fan of you

reference sleep tablets there sleep

medicine medication yeah so as a general

we know because I think that there are

um good now non-drug based techniques

for trying to improve sleep in the

majority of people with

insomnia um there is some evidence that

for example if people don't respond to

these non-drug based methods giving them

sleeping tablets alongside these

non-drug based methods makes it more

likely for the psychological route to

help but you know unfortunately as part

of my clinical practice I see lots of

people who've been struggling with their

sleep for many many years and they've

tried all non-drug based

treatment and the risks of them sleeping

so little in terms of their mood their

anxiety their ability to function are so

great that actually you have on a caseby

casee basis to make a judgment call as

to whether or not to say well I give up

on your sleep or actually you say well

look there are a number of drugs that we

can try to try and improve your sleep

and it's not going to get you back to

normal but it's going to potentially

make the difference between you you know

end up very depressed or or or or highly

anxious and unable to cope in your life

or actually get some decent sleep um and

the risks of those drugs and that needs

to be judged on a case-by casee basis

and is part of clinical medicine

whenever we prescribe any medication for

anybody for any condition we have to

evaluate what the potential benefits are

versus the potential risks a lot of

people seem to be taking melatonin yeah

tablets is is that healthy is that free

from side effects so it's not entirely

free of side effects um but it's

generally a pretty well tolerated safe

drug as far as we know there are some

specific issues surrounding melatonin um

but a question really would have to be

well why are you taking that melatonin

is there something that you can do to

fix your sleep without relying relying

on an exogenous substance something that

you've bought off the shelf or being

prescribed is is the my hesitation and

reservation with taking things like

melatonin is always that I just assume

that my body will become a little bit

reliant on it yeah well fair I I think

whether it become whether you become

come physiologically biologically

Reliant upon it or psychologically

Reliant upon it it it it remains

unanswered but certainly that you know

there are individuals who for example

will say well as long as I know that

I've got a bottle of melatonin or you

know the sleeping tablets in my bedside

cabinet I sleep fine as soon as I know

that I haven't got access to them I

don't sleep very well at all and so that

I think exhibits that this is almost

like a psychological crutch knowing

something that they've got uh next to

their bed that they can reach for in

order to achieve a good night's sleep is

sometimes as important is as important

as the biological effects of taking that

tablet I mean that kind of leads to the

non-medical techniques to improve our

sleep so you said typically with with

someone that comes to your sort of sleep

center instead of going straight to

medication as the answer to their sleep

issues you would suggest and or try

non-medical interventions yes and you

said that these work well yes what are

these non-medical intervention so the

gold standard treatment now for insomnia

is a treatment called cognitive

behavioral therapy for insomnia okay so

a lot of people have heard of CBT

because they will have heard of it in

the context of depression and treatment

of depression or anxiety now CBT for

insomnia is not actually directly

related to the CBT that's used for

depression and anxiety it borrows from

the principles of CBT and applies them

to sleep and it serves two purposes the

first is to try and address some of

those conscious psychological factors

that are driving insomnia and when I

talk about conscious factors I'm talking

about things like the frustration or

anxiety of the night ahead of lying in

bed at night feeling that you can't get

off to sleep and the frustration and

anxiety that that engenders of having

your partner snoring away in bed next to

you whilst you're struggling to go off

to sleep of worrying about how you're

going to be able to function the

following day or potentially even the

long-term effects of your insomnia so

those are the conscious psychologic

factors and cbti aims to address those

but it also aims to restore

normal um

unconscious factors that give rise to

good sleep so if you've spent a great

deal of time in bed at night awake then

those normal associations that good

sleepers have between bed and sleep so

for a good sleeper they will associate

bed with being a place of comfort with

being a calming relaxing place a place

that they associate with a good night's

sleep if your sleep has been disrupted

for a period of time and you've spent

long periods of time in bed awake then

that positive association between bed

and sleep is replaced by negative

association so you you begin on a

unconscious basis

pavlovian conditioning it's called um

you associate that bed environment with

being awake with being wired and that's

often what gives rise to this sensation

of having lost the switch to be able to

get off to sleep in fact some people

with insomnia will say well look you

know if I'm sitting in front of the

television and I'm sitting on the sofa

and I'm not thinking about sleep at all

I'm not thinking about bed I will often

find that I've dozed off and then I'll

go upstairs get into bed and as soon as

my head hits the pillow ping I'm wide

awake and I suddenly feel wired so

that's very illustrative of that sort of

unconscious association between bed and

being awake rather than being asleep and

so cbtr aims to address that as well how

does it how does it do that so it uses a

variety of different techniques so uses

some standard sort of relaxation

techniques to try and reduce the level

of vigilance of physiological of mental

arousal that you have when you get off

to bed but also it aims to utilize a a

variety of techniques to reprogram your

brain to associate bed with sleep so one

of the ways in which you can do that is

you can actually utilize your brain's

own

mechanisms um that drive you to go off

to sleep so that's something called the

homeostatic mechanism which we'll all be

very familiar with but not in those

terms so the more you've been awake the

stronger the chemical drive for your

brain to go off to sleep so one of the

features of cbti is to compress your

sleep or to restrict your sleep for a

period of time essentially what that

means is well if you are an in somebody

with insomnia and you estimate for

example that you're only sleeping a

total of 6 hours a night in bed um but

you're spending 8 hours a night in bed

then you for a period of time you say

well look I want you to get into bed at

midnight and whatever happens I want you

to get out of bed at 6:00 a.m. so to

restrict the time in bed to 6 hours so

the first few nights

most people with insomnia will sleep

really badly because they know that

their alarm is going off at 6:00 and

they know they have to get off get out

of bed at 600 but after a little while

they become so sleep deprived that the

brain starts forcing you to go off to

sleep much more quickly and over time

more and more of that 6 hours a night

will be spent asleep in bed and that's

the first step in Breaking that negative

association between bed and wake and

rebuilding a positive of association

between bed and sleep I mean at its

extreme there is a technique that was

developed in Australia which is called

intensive sleep retraining and in that

technique people who've got very bad

insomnia are brought into a sleep

laboratory having been awake for the

night before they come in so they come

in in the evening having been awake for

now probably 36

hours every half an hour they're given

the opportunity to drop off to sleep

they have some wires on their heads

their brain waves are being tracked um

but as soon as they've been asleep for 3

minutes based on their brain waves

they're woken up again and that happens

every half hour for 25 hours so over the

course of that 25-hour period they have

50 opportunities to nap now for most

people with insomnia having been awake

even having been awake the previous TW

uh 36 hours they will still not be able

to get off to sleep for the first few

naps but as they get more and more sleep

deprived every time they're given the

opportunity to drop off to sleep they

will start falling asleep more quickly

and at the end of that 50 naps they will

be dropping off to sleep very quickly as

soon as the lights go off um and

actually the evidence suggests that

that's a very good um short-term

treatment for chronic insomnia and in

some individuals it works extremely well

in reassociating your head hitting the

pillow with drifting off to sleep I

wouldn't suggest it for most people cuz

it's basically a form of torture but I

think it illustrates the power of trying

to get people into a more sleep deprived

state if they've got insomnia it's

interesting because much of what you

said makes me think that we we all have

our own sleep identity and when I say

sleep identity I mean a story We Tell

ourselves about our relationship with

sleep and it makes me think that our

sleep identity is much more powerful

than I think we think cuz if you speak

to anybody anybody in this room upstairs

wherever and you say what do you like at

sleeping they will deliver their sleep

identity they'll say I'm a bad sleeper

and I wonder how much of that is

self-fulfilling because I I think I've

always told myself that I'm a good

sleeper and therefore I find sleep easy

um and I've got friends who will say oh

I'm a really bad sleeper and I'm

wondering how much that's impacting

their ability to sleep and or if they

they even know objectively if they are

actually a good or bad sleeper it's just

this identity we've embodied do you do

you see that a lot do you see that how

someone sleep by density kind of

determines how they actually sleep I

think all of that is true undoubtedly uh

and I think this comes back to the

earlier bit of our conversation about

sleep trackers because obviously sleep

trackers reinforce that sleep identity

whether whether they are 100% accurate

or not um and so yes that would that

sort of sleep identity would undoubtedly

influence both those conscious and

unconscious factors that give rise to

sleep you know if you're a good sleeper

and you've always been a good sleeper

you don't worry about any of these

things you probably don't even worry

about any aspects of sleep hygiene you

quite happily you know like you watch a

horror movie in in in in bed before you

drift off to sleep but for those

individuals who are who are not um yes

absolutely that that the way that you

view sleep and your relationship with

sleep is of fundamental importance it is

again coming back to genes we know that

there are undoubtedly genetic factors

that influence whether or not you're

likely to develop insomnia so again as

with all aspects of sleep it's that

combination of genetics environment and

when I talk about environment I'm also

talking about your own psychological

internal environment I am the other

thing I was think we talked about sleep

happen here earlier on but it seems that

a lot of people believe they have a

deviated septum is it called deviated

septum uh septum yeah septum yeah septum

I've heard some people say that that's

the reason that they can't sleep and

they've gone off to get surgery to kind

of correct the deviated septum

MH what's your thoughts on that is that

is that true because I wonder I'm like

we can't all be being born broken with

these deviated septums or whatever I

think it's normal for us to have some

asymmetry in our noses and a lot of

people have a deviated septum septum as

a result of having broken their nose for

example um you know I'm a little bit

suspicious about you know operations for

that kind of thing unless there are very

clear abnormalities that might be

responsible for sleeping poorly so one

of the major issues for example in sleep

apnea is sleep apnea the obstruction is

in the throat it's not in the nose and

so uh issues with nasal congestion or

difficulty breathing through the nose do

not directly cause obstructive sleep

apnea what they can do in some

individuals is they can encourage them

to people to breathe through their mouth

and breathe with their mouths open which

Alters the position of the jaw and

create a bit more narrowing in the back

of the throat so for some individuals

who have very prominent nasal congestion

at night and who have evidence of sleep

apnea sorting out their nasal congestion

and correcting a deviated septum may be

one way of doing that there is

undoubtedly a rational for sorting that

out I think that there are probably

quite a few individuals who are having

unnecessary operations makes sense I um

so we've got the cognitive behavioral

therapy for insomnia as one cure we've

got that extreme torch therapy that they

did in Australia yeah we've got

melatonin

um magnesium people have mentioned

magnesium so so anecdotally magnesium

can help some individuals um and you

know anecdotally also magnesium is a

very good treatment as testified to by

some of my patients for conditions like

restus leg syndrome so restus leg

syndrome is this sort of neurological

disorder whereby people um and it's

often associated with things like

pregnancy or low iron levels but it's

under genetic control as well people ex

uh experience a number of different

things so the first thing is that they

get an urged to move at night um and

it's typically at night rather than

during the day often associated with

unpleasant Sensations that if they try

and keep still that sensation builds and

builds and builds until they have to

move that if they do move they get some

transient relief and it's often

associated with kicking at night in your

sleep um it's very common very common in

pregnancy um very common in people who

are anemic and in people who've got

problems with their kidneys but it's

common in the general population as well

and so uh for people with restus leg

syndrome magnesium does sometimes help

significantly and it what's it doing is

relaxing us I don't think we actually

know precisely what it's doing okay um

when you look at an underslept brain so

if I was sleep deprived what what would

the difference in my regular sleep

activity be what would you see would you

see my brain is like not active would