- Is there also differences by
individuals who prefer morning, night,
and then maybe as well, in terms
of not just the hours of sleep,
but the time of the day in which you sleep?
- This comes back to a concept
biologically well-defined, called your chronotype.
So are you a morning type, evening type
or somewhere in between?
Depending on the data,
it's about a third/third split across the population.
I am, unfortunately, just like the rest of my pedantry,
in terms of personality, I'm desperately boring.
I am completely vanilla.
I'm a neutral, I'm sort of like an 11 to 7 kind of guy.
But your chronotype as to when you want
to go to bed and wake up,
it's not your fault, and it's not your choice.
Because it turns out that it's genetically determined,
and we now know that there are at least 9 different genes
that will dictate your morningness versus eveningness
preference, in terms of being a sleeper,
what we call, are you a night owl or are you a morning lark?
It's gifted to you at birth.
It's hardwired and it's very difficult to to change.
And by the way, if you want to know truly what type you are,
you can go online and you can search
for something called the MEQ, which stands
for the morningness eveningness
questionnaire for chronotype.
And it takes about 3 or 4 minutes, really easy,
and you get your type.
You can also do it in a quick fashion.
You can just say, look, you know
if you or I were on a desert island, nothing to wake up for,
we could go to bed whenever we really wanted to,
and whenever we really desired to wake up
rather than when society forces us
to go to bed and wake up, what time would that be?
And for most people, that time
as to when they would like to go to bed
and like to wake up is very different
than what time they actually are currently
trying to go to bed and trying to wake up,
which suggests that modernity has inserted a wedge
of a mismatch in terms of our sleep timing
based on our chronotype, because society
is desperately geared towards and biased
towards morning types.
You know, it's this, the early bird catches the worm.
Those are the people that are praised.
That leaves out in the cold and chastised wrongly so,
as if it's their choice, the evening types.
And the early bird may catch the worm.
But I would also say that the second mouse gets the cheese.
And so, you know, there's, lots of ways
that we should be much more kind to ourselves
and others in society, regarding evening types.
The practical part of it comes to people that I'll see
at my sleep center here who will say,
"Look, I just have terrible insomnia.
I have difficulty falling asleep.
I go to bed and I'm just wide awake for the first hour.
I just cannot fall asleep."
And then I'll ask them a little bit more
about their chronotype.
And it turns out that they're someone,
who at the weekend finally,
they would normally be going to bed about midnight, 1:00 AM,
but during the week, because of their schedule, of course,
and understandably so, they're forcing themselves
to get into bed at 10:00 PM,
which is a 2 to 3 hour difference,
relative to your natural chronotype.
So no wonder your biology is not even yet ready
to try and help you fall asleep,
but you are sitting there in bed just wishing it to happen,
and you can't wish for sleep to happen and make-
it's not like a light switch in that sense.
And so it masquerades almost like what we call
a form of sleep-onset insomnia.
There's also something called sleep maintenance insomnia.
So do you have difficulties falling asleep?
Or difficulties staying asleep?
And they're not mutually exclusive, by the way.
but people with a chronotype who are night owls,
they can sometimes have that challenge.
They're in bed too early, and they can't fall asleep.
- That's probably one of the most important points
to discuss today, because as a primary care physician,
obviously insomnia, whether it's the start of sleep
or disrupted sleep, not being able to fall asleep
afterwards, upon waking in the middle of the night,
it's easy for me as a physician to either look
just to lifestyle changes, talk about sleep hygiene,
discuss caffeine usage, alcohol usage,
things that would impact sleep from my training level,
and maybe even mental health.
That would be a step further that I go
that most physicians probably don't even get to
in their 15 minute visits, unfortunately,
in our current healthcare system.
- Yeah.
- But should we be, as physicians,
thinking about chronotype more?
- I think we should certainly be asking that
as part of the equation and being sensitive to that,
in terms of understanding it.
It turns out that there's a whole field
of chronobiology and chronopharmacology
because as we've now started to understand,
drugs can have different potencies of effect
on the basis of different times
during the 24-hour cycle, and there may be more
or less potent times for you to provide that medication.
You know, sometimes for hypertensive medications
there's some evidence that time of day is important.
There's a big field demonstrating
that cancer medication can have a chronotype dependency,
non-trivial in terms of its efficacy.
So I think that that's important.
I also, you know, I love the way that you think about
not just going to sleep hygiene, which is critical,
and being mindful of alcohol, which is no friend of sleep,
and caffeine equally so, and then moving to mental health,
because what we know is that perhaps one of the biggest
common central pathways through which your body instigates
this thing called insomnia is having an overactive
fight-or-flight stress system within the body,
which is part of your, the automatic nervous system.
It's called the sympathetic nervous system.
It's anything but sympathetic.
It's very agitating, aggravating.
It's the fight-or-flight branch,
Together with something called the HPA axis,
which is part of your hormonal axis,
particularly regarding a hormone called cortisol,
which is a stress-related hormone.
And when those things are switched on,
which sort of high levels of anxiety, worry, and stress
will very much do, sleep is almost impossible.
And it results in people-
the phenomenon that I would describe as tired but wired
where they are so desperately tired,
but they're just so, from a mental health perspective,
to your point, they're just so wired
that they can't fall asleep.
And until you actually target the treatment
of the mental health component,
it's going to be very difficult to-
I mean, one could just simply offer, you know,
sedative sleep agents to try and knock the cortex out.
But we know that there are increasingly better ways,
and I think one of the things that physicians
have maybe started doing is becoming aware
of the the current recommended alternative
to sleeping pills, which is something called
cognitive behavioral therapy for insomnia,
or CBTI, for short.
And I would say that for any sleep, sorry,
for any general physician, any GP,
who is facing a patient who is saying
that they are struggling with sleep,
trying to at first direct them
towards cognitive behavioral therapy for insomnia
and trying to find a provider for that.
I know it's difficult.
It turns out, if you look at the number of people
who can provide it,
there is a mismatch between demand and supply.
There's not enough supply for the demand.
Nevertheless, being aware of cognitive behavioral therapy
for insomnia is critical.
There are now some apps that you can use as well
to help with that, to make it more convenient.
That's the only thing I would add to that equation.
- Yeah, absolutely.
I'm a big proponent of CBT.
I even have been able to institute some introductory,
I wouldn't say they're introductory sessions,
but maybe basic understandings that I can pass along
to my patients until they're able to see
a mental health provider about what CBT is,
- Amazing, gosh. - How it works.
Where we work on thoughts as opposed to feelings.
Because in reality the mind-body connection
is so much connected that we give it credit for
that patients oftentimes are ready to get
a physical diagnosis and are really surprised
or even shocked when everything comes up normal.
The imaging, the lab tests, and it's only until
we get to their mental health do we figure out
that's where the problem is,
at least beginning and then showing itself.
So sleep is definitely one of those.
- That's so powerful.
You know, to think that a physician in this day and age,
and I know, I'm not pointing any fingers,
the job that you have is so immensely difficult
within these compressed, zip-file time periods.
You're supposed to go through
this complex biological organism in front of you,
quickly make, make a diagnosis,
understand the treatment path outcome,
prescribe and get a-
you know, so that someone like you
is being already able to think
about cognitive behavioral therapy,
and then give the stepping stone components to help them
on their journey as they start to seek out that further.
I mean, how much better would the world be, you know
if that was more common practice?
I can't imagine.
- I think it would improve health outcomes significantly.
That's why I'm a big proponent of increasing funding
for primary care because the struggle
that a lot of physicians have is those 15 minute visits
with patients that are unknown to them,
that they don't have a history with.
Like the urgent care model, where a patient comes
in to see a doctor they've never seen before,
and somehow in 15 minutes this physician's
supposed to create a rapport with this patient,
learn about their condition, their symptoms,
potentially connected to some sort of cause,
create the treatment, make sure
that the patient understands the treatment,
that they can afford the treatment,
they have access to the treatment,
and then document that entire interaction in 15 minutes.
On what planet?
And then make sure the insurance approves that treatment.
(laughs)
- Right. Right.
You know, what are we, what are we doing if our goal
is to try to care for other human beings
in the most medically sound way possible.
So you are, I mean, heroes to keep doing that
and thank you for what you do.
- Thank you.
I appreciate you saying that.