 Hi, I'm Meredith Maher at the University of Maryland Sleep Disorder Center. Today we're discussing ways to beat insomnia with sleep specialist Dr. Beverly Fong and Director of the Insomnia Program here at University of Maryland, Dr. Emerson Wickwire. Thank you for being here today. And thanks to all of you for watching. We invite you to leave your questions for our sleep experts in the comments section below for them to answer during this live broadcast. And also a reminder to please like this video if you're watching. Dr. Wickwire, why don't you start us off with discussing what exactly insomnia is and how you can diagnose someone with insomnia. Meredith, insomnia is typically conceptualized as trouble falling asleep, trouble staying asleep, or both. In other words, it's a subjective diagnosis of dissatisfaction with quantity or quality of sleep. And that sleep complaint must be associated with the daytime consequence. Now those daytime consequences span a very broad range. This can involve increased stress levels or physical pain or depressed mood or poor brain function, difficulty concentrating, for example, and other somatic bodily kinds of complaints. Insomnia diagnosis is based on a clinical interview with an expert such as Dr. Fong or myself. Great. And how common is insomnia? Historically, between 9 and 12% of the US population is diagnosed with chronic insomnia. Several years ago, the most rigorously conducted epidemiologic survey called the American Insomnia Survey actually found that 24% of the US adult population met diagnostic criteria, according to at least one of the three major nasologies. And what we mean by that is those are the books that doctors use to categorize and define different medical conditions. Dr. Fong, would you say someone has insomnia if they just every now and then have trouble falling or staying asleep, or does there have to be a certain pattern of poor sleep or insomnia like tendencies in order for it to be diagnosed as such? Yeah, I mean, that's part of the issue is trying to differentiate between having insomnia symptoms, which is very common, and having an actual disorder. So part of what Dr. Wickwire was saying was it's affecting the quality of your sleep, as well as the quantity, but it has to be over a certain percentage. So a majority of days for a majority of weeks over a three month period of time is a standard diagnosis. Are certain people more likely to experience insomnia than others? Yeah, so certain populations, women, as people age their sleep doesn't usually get better. People with lower social economic backgrounds. So certain categories, people tend to have more insomnia. People with a lot of medical issues, mental health issues, substance abuse issues, they tend to also have a lot of insomnia. So in addition to those other health conditions, Dr. Wickwire, what are some other health conditions that you typically see that are comorbidities with insomnia? Meredith, 85% roughly of insomnia is what we call comorbid insomnia. In other words, it's taking place in the context of a primary, so-called primary medical or mental health condition. So as Dr. Fung mentioned, those really do. You see commonly cause insomnia outside of a health condition per se, but other things that are going on in someone's life that typically can affect sleep. What would some of those be? I would say modern society. I see a lot of people burning the candle at both ends where they're working like two jobs or raising a family. They just haven't allowed enough, they haven't protected their sleep time, which is very important in terms of functioning from day to day. I think that that's exactly right. There's just a lot of general stress. Sometimes there are acute stressors, loss of a loved one, job transition, hospitalization. But other times when we ask patients, well, when did your trouble sleeping start, they're not really sure. And they'll just say, Doc, I just know that it's been bad or it's been getting worse for months or years. So there can be acute stressors, but there can also be what I call cumulative stressors, but it's really just the sum of ongoing low-grade kinds of stress that eventually push our sleep system into the insomnia zone. Is there a certain time of year you've noticed where people's sleep is worse or could it just happen any time? I think there can definitely be a seasonality with sleep, whether it's typically more sleep in the winter time, less sleep in the spring time. Yeah, or again, some seasonality with worsening allergies, so that could also be spring and fall time. There's a lot more allergens in there. I think that's a really good point, particularly about allergies. And I tell all my patients, especially from about the middle of November on, that the holidays are a stressful time of year. It doesn't matter if you grew up in the Cleaver household. There are families and work stress, and it's just a very busy time. So there's absolutely a seasonal component to sleep disturbance. We're much busier in January than we are in November and December if people want to come in and get their sleep promise resolved. And is insomnia something that can affect all ages, or do you see it mostly in adults? Definitely all ages. All ages. So in kids, it's a little bit different because they live in a family. A lot of their schedule is determined by their caregivers. Definitely in adults and in the aging population as well. Why is it that the aging population typically notices a sleep difference as they get older? There are two broad reasons. Some of those are external factors and some of those, Meredith, are internal factors. And what I mean by that is that as we go through different transitions in life, our external worldly demands change. For example, after retirement, we no longer have the structure. We no longer have the schedule of needing to be up and at work by a certain time. We're coming home after work and beginning our evening wind-down at a certain time. So these are external kinds of factors where our professional obligations change, our social commitments might change, our travel schedule might change. And we see a great number of patients, both right before transition to retirement, if there is such a thing these days, and then also after transition to retirement. That's a ripe time for the development of sleep complaints. There are also internal factors that take place as we age. We talked earlier about the comorbidity of sleep complaints with other medical and psychiatric conditions. There are also medication interactions that can lead to sleep troubles. And as we get older, we experience more medical problems, more mental health problems. We're taking more medications, and there's also evidence that actually structures in the brain change as we age. And we can talk more about that as we move forward. Going back to children, does insomnia manifest differently in children than it does in adults? How would a parent know if their child is truly experiencing insomnia? Parents will know. So it's the same, you know, if the child is having problems falling asleep. That would be pretty obvious, or staying asleep. So multiple awakenings, being the parent to be in a room, in order to kind of wind down to actually fall asleep. So it's probably more likely that the parent won't be motivated to bring the child in than the child itself will be. Like, oh, you're not having problems sleeping. Right. What are a few quick things that parents can do for children, and also that adults can do for themselves at home to help improve their insomnia? I think one of the most important things is to follow the consistent routine. And as you're thinking about routine, again, we want to think about creating what I call a greased chute to sleep. Although it's easier to think about children the same principles apply for ourselves in terms of our own self-management. For example, at what stage in the evening do I wash the dishes, or at what time of the evening do I brush my teeth, or change into my pajamas? If you are a parent, where are you in the house as you do these things? So that as we are helping our children stair step down towards relaxation, we're also moving closer to the bedroom. So we might have a good night hug downstairs, and then as we move upstairs, we change into our pajamas, and we enter the bathroom to brush our teeth. And then when we go to bed, it's been very clear that there's a progression towards relaxation. And then for adults themselves, they can stay off their cell phones or bright lights. What are some other things for them? So creating sort of a wind-down time for them as well. Yeah, a significant amount of time before their actual bedtime. So yeah, device is off. Is there anything they can do during the day that can help contribute to their sleep that night? Sometimes people will like, if their mind is racing or they have a lot of anxious thoughts throughout the day, they actually set aside time during the day to actually kind of write those down or just kind of get them out of their system. Or specific times during the day to like practice meditation or stretching or any other kind of wind-down DQ set arousal that might happen more around their bedtime. And for significant others or spouses who are struggling with their loved one who's experiencing insomnia, how can they support that person or even help maybe contribute to a more relaxing or more successful nighttime sleep? I think one of the most important things is that by the time you or a loved one are aware that there's a problem, there's probably been a problem for some time. And self-help kinds of remedies can be fantastic, although I'd encourage our viewers of course to view Dr. Google with skepticism. But folks do like to do a lot of reading and many of the patients that we see have read a lot about sleep basics, for example. However, if there's a persistent problem that has technically lasted more than one to three months, it's probably time to talk with your family physician or your primary care provider to see if there might be a condition warranting more attention. What are some of the treatment options available professional help-wise for those with insomnia? So there's definitely behavioral sleep medicine where people work on behavioral strategies to help with sleep. That's the first-line mainstay treatment. There's also medications to help with sleep, whether it's falling asleep or staying asleep. You just want to make sure that there aren't any other sleep issues or other kind of making sure that the medical issues are resolved. Do you want to go into what cognitive behavioral therapy is a little bit for those who might not know much about it? Sure. I think the easiest way to understand CBT is exactly what I tell my patients every day. That you have gotten a lot of practice at being a lousy sleeper and you've gotten really good at it. So if the problem is that you have gotten very good at being a bad sleeper, the solution is that we need to retrain your body how to sleep. And that's essentially what CBT does. It's a fancy way of saying that we are going to enter a structured, supervised sleep training program to retrain your body's natural sleep system. How long does that training take? Typically a total of six treatment visits, but in reality it's probably bimodal. And what I mean by that is that we see her insomnia patients either for three to four visits or for seven, eight or nine visits. It just depends on what other medical conditions are taking place. Are medications involved? Does the patient have another sleep disorder? Each patient, we really want to provide individual tailored treatment. Can CBT be used as a modality on its own or does it typically accompany medication as well? Again, it's really all based on individual patient presenting symptoms and also patient preferences. Both Dr. Fong and I believe that medication and behavioral treatments can be combined. The majority of patients, I shouldn't say the majority, many patients have strong feelings one way or the other about medications and we want to honor those feelings when we can. So if someone were to go through this training program and they notice a difference and they're sleeping better, does this last for life or is this something that they might have to revisit a few years later or a decade later, who knows? Or is it like you're cured once you've gone through this training? I think insomnia is usually a chronic issue. There's going to be exacerbations and explanations, but I think the training definitely gives you the tools to kind of manage it once it arises again. So it's not as bad or as significant. Maybe it'll be completely resolved and that's various. That's one of the biggest differences also between medications and learning how to sleep. I tell my patients that no pill can teach your body how to sleep and that's really our goal. When patients come to see us it really is time to make sure that we identify the causes and address those causes. That's not to say that medications don't have an important role in the management of sleep disorders. It just means that we really, at the University of Maryland, we want to get to the root cause and give patients the best chances for long-term success. Does every sleep center or sleep physician offer this sort of training program or these services or is this something that is unique to University of Maryland? It's very rare to have an integrated sleep medicine team. Excuse me Dr. Fung, I didn't mean to step on your toes. It's very rare to have the kind of integrated team that we do. Who else is on the team? So you're a sleep psychiatrist, you're a sleep psychologist. Who else is on the team that patients can benefit from seeing? We have a pulmonary, maternal medicine. We definitely work pretty closely with dental school here. Staff from neurology. Pediatrics, pediatric pulmonary. And pediatric sleep, that's pretty rare to have as well. Pediatric sleep experts are the ability to do pediatric sleep studies and that's something that we do here. Great. Do you want to talk about the sleep study process a little bit? Sure, like how someone gets to sleep. Yeah, and how do you first identify that somebody is qualified to have a sleep study, that it would benefit them, and then what happens during the sleep study and what happens after? Sure. So we get referrals, either we see a patient who comes into our sleep clinic, we determine that a sleep study is needed. The sleep studies are done here at Midtown. We also get referrals from cardiologists or other primary care physicians who can order studies as well. So we might see a person after they've already had a study. So the studies that we do here are overnight studies. So they're called polysomnograms. So they give us a lot of information. They monitor EEG, so amplified brainwaves. We look at eye movements, we look at nasal pressure to determine whether they have sleep apnea, an oxygen monitor, a simple EKG lead, chest leads, and there's also a video camera to catch any parasomnias. How long is a typical sleep study? Usually people come in around nine, and they usually leave around 6 a.m. We do studies seven days a week, so it's flexible for people's work schedules. And then what's the follow-up like after the study is completed? I think that the one important point to make is that the sleep test is not what we call a polysomnogram, is not like going to get an x-ray. That this really should be conducted as part of a comprehensive management plan. And so working with a sleep disorders expert is the most important first step. It's far more important than the testing itself. In other words, the test can only be understood by someone who knows the patient and can help develop a comprehensive management plan to interpret and address the results of that test. So the follow-up is going to depend on what the diagnosis is. Patients always want to ask about treatment. It was the first question that you asked us earlier about treatment options. But really medicine moves in a three-step process. We have assessment and diagnosis and treatment. So the assessment and then the follow-up are more important for long-term success than just the test itself. And typically for insomnia, a sleep disorder is not generally needed unless it's refractory or you suspect that there's something else going on. Do you suggest that someone with insomnia keep a sleep diary of any sort? Absolutely. In fact, what we want to do is we want to measure sleep from multiple perspectives. And although many patients are surprised to know that their own subjective recollection of what time they went to bed, what time they woke up, how long it took them to fall asleep and several other questions that we ask, it's highly reliable. And so it's a very helpful way for us as sleep providers and patients both to get a better understanding of sleep patterns and trends over time so that we can identify both triggers as well as progress. Okay. So before we continue, I'd like to do some introductions of our staff behind the scenes. We have Hannah Braun and Angela Jackson behind the camera. And just a quick reminder, we're here discussing insomnia with Dr. Beverly Fong and Dr. Emerson Whitwire. You can continue to leave your questions in the comment section below for them to answer during this live broadcast. Angela, do we have any questions from the audience? We do. We have one audience question left by Jeff C. And he wants to know, is there any advice on what to do when waking up nightly and being unable to fall back asleep? So if someone wakes up every single night in the middle of the night, first of all, what does that mean if they're waking up around the same time? And also, how can they get back to sleep if it seems to be a nightly pattern? Well, they can come and see Dr. Fong and get behavioral treatment. Awakening at a particular time of the night could be due to increased arousal associated with insomnia. Awakening during sleep is not uncommon. So when people are in the REM sleep, it tends to be a very active form of sleep. And so people tend to have more awakenings at that time. They might be waking up because of sycophant events or nightmares or a variety of different reasons. So that's probably a good reason to come in and see one of us. There are definitely medications for nighttime awakenings that have a shorter half-life, and you could take it if you wake up in the middle of the night. So medications is something that he's looking for. We could talk about the benefits and risks of medications. I think Dr. Fong hit the nail on the head that we really want to understand what's causing the arousal and then identify a tailored treatment approach. I would add that the way the brain works, just because someone wakes up in the middle of the night doesn't mean that they're doomed to spend the rest of the night awake. So what we want to do is avoid stimulation. One of the most high, low effort, high reward changes that folks can make is to stop looking at their alarm clock when they wake up in the middle of the night. Because even though it only takes a split second to look over and see that it's 3.04 or whatever time it is, that activates the thinking frontal cortex regions of the brain, which in turn can prolong the wake up. So we want to protect sleep as a time and space. What if someone does wake up and they're finding it hard to fall back asleep, what are some things they can do, just laying there in the bed that can help them ease back into sleep? Hopefully they won't be spending too much time in bed. I'm not sleeping. So it depends on not being exposed to light. It's helpful if you wake up in the middle of the night. I would also suggest no devices or anything with a screen on it. Are there any breathing exercises or anything that can help them quickly get back to sleep? I think the most important thing is to not practice having insomnia. So once you are sure that you can't fall back asleep, in other words, you don't need to use the clock. It's okay to just trust your gut. Once you're sure that you can't relax and that sleep is not going to return on its own, you don't want to prolong that experience. So what we encourage patients to do is to get out of bed whether they sit in a chair next to the bed or go to the other room quietly. That's when we might listen to classical music or read a boring book or practice meditation or deep breathing, whatever it might be that's not a stimulating activity, and then we're going to wait for sleep to return. So what we want to do is practice falling asleep quickly and staying asleep. Otherwise, the more that we lie in bed and fight and get frustrated, the more that our bodies learn through repetition that bed is a place to be awake, which is of course the problem we're trying to solve. Okay. Is there anything else you think people should know about insomnia? We didn't already touch on. It's the most common sleep complaint amongst adults. It is very normal to have sleep complaints, and we're happy to help you if you do. And how can they get in contact with you for consultation? Do we promote our phone number? Yeah, you go ahead. Well, first of all, where do you see patients? Yeah. So we're here at the beautiful University of Maryland Midtown Medical Center. The Sleep Disorder Center is right upstairs in the seventh floor. We see patients here. The Sleep Disorder Center is open three days a week for consultations and follow-up visits and treatment. The Sleep Laboratory, where we have nighttime studies, seven nights per week. And daytime studies, two days per week is right here. Dr. Fong also sees patients. Tell me, do you talk about Columbia? Sure. So we also see patients at the Waterloo Columbia Clinic right now, just one day a week, but we might be setting that up in the coming months. Great. And what's your phone number for patients to call? 410-706-4771. Remember, repeat that just one more time. We'll put it in the comments. 410-706-4771. Great. We look forward to seeing you soon. Great. All right, that's all the time we have today. But if you still have questions for our experts, you can leave them in the comments section, and we'll reply to you within 48 hours. Thanks so much for watching.