Beyond Sleep Hygiene

Host: 00:00
From the Mount Sinai Health System in New York City this is Road to Resilience, a podcast about facing adversity. I'm Jon Earle. My guest today is Dr. Rafael Pelayo. He's a Clinical Professor at the Stanford University School of Medicine in the Division of Sleep Medicine. He is also the author of the new book, "How to Sleep: The New Science-Based Solutions for Sleeping Through the Night." Poor sleep is associated with everything from obesity to depression, and it makes us less resilient. A 2016 study found that insomniacs in the military were sicker and less fit for service than the good sleepers. So it's no surprise that the U.S. Army Surgeon General put sleep up there with nutrition and physical activity as being the keys to good health. And so the age old question: How do we get better sleep? Maybe sleep hygiene? Well, it turns out it's both simpler and more complicated than that, and Dr. Pelayo covers all of that in our conversation. And he answered some of my burning questions, like about napping and blue lights and lucid dreaming. Plus, he talks about the dream chambers of Ancient Egypt, which is so weird and so cool—you're going to want to hear that. So here's my conversation with Dr. Rafael Pelayo. I hope you enjoy it. Dr. Pelayo, welcome to Road to Resilience.

Dr. Rafael Pelayo: 01:21
Thank you so much for having me.

Host: 01:22
In your book, you write about an epidemic of sleep deprivation, and you say it's getting worse. Can you help us to wrap our minds around the scale of the problem, the cost to society, and what's to blame?

Dr. Rafael Pelayo: 01:36
Let's work backwards. To blame is the fact that we've made sleep an inconvenience more than a priority. We've got to think of sleep as a biological necessity, and lately the way I've been describing it to people is that it's the ultimate form of self-care. It's how the body really heals, the brain really heals itself. But we're not fragile creatures. There's a robustness to our sleep system that allows us to have some flexibility. We can sleep more or sleep less under certain circumstances. But because we have this flexibility built into our system, people early on learn that they can get by with less sleep. But you're getting by, you're not at your best, but you're just getting by. But you can get by with less sleep, and that leads to a cultural trend of getting by with as little sleep as possible.

Host: 02:17
Is there any sense that sleep deprivation as a societal problem is getting worse?

Dr. Rafael Pelayo: 02:21
This has been looked at in different ways. There are different ways of measuring it, but the answer is, yes, it is getting worse in the sense that people are getting less and less sleep over time. The Centers for Disease Control [and Prevention] has been tracking sleep in teenagers, and they have found over the past 20 years, there's been a tendency to get less and less sleep among teenagers. And, in fact, teenage girls are very sleep-deprived. About 75 percent of them aren't getting enough sleep. So any of you that work with teenagers, or have teenagers in any way interacting in your lives as educators, as parents, anybody who interacts with teenagers, just know in general that you're dealing with a sleep-deprived population. And when people are sleep deprived, the first signs of sleep deprivation are people being inattentive and grumpy, irritable. So if you know any grumpy teenagers, you know that they're not getting enough sleep. That's what's happening to them.

Host: 03:07
Sleep problems in general are linked to so many diseases. I'm not going to list them all off, there's a lot. This is a time of a pandemic. It's particularly important to have a strong immune system, and insomnia works against a strong immune system. Can you explain how?

Dr. Rafael Pelayo: 03:21
So what happens is that lack of sleep is viewed by our system as a stressor, and stress creates an inflammatory reaction. So already lack of sleep primes the system like something is wrong. And it could be simply that you want to stay up and watch a movie. But to the brain something is wrong. You're not getting sleep, why would you be doing this? So lack of sleep prompts an inflammatory reaction, a low-grade inflammation. So if you already have a low-grade inflammation going through your system, you add on top an acute infection, you can overwhelm the system. So they've actually done these experiments well before we knew about the current pandemic, which has been horrible, they had volunteers—imagine who would volunteer to do this, probably college students, people volunteered to get a cold, to have the rhinovirus injected into their noses. And they had two groups: one group sleep-deprived, and the other one that was not sleep-deprived. And, of course, as you'd expect, the group that was sleep-deprived got more cold symptoms and was more likely to get the cold with a lower viral load. So the explanation of the how, which is what you asked, is thought to be that chronic sleep [deprivation] is already a stresser to the system as an inflammatory reaction. And that you're adding something on top of it. The other way I think about this, though, is sleep-deprived animals die of sepsis. And what happens is, we're really multiple organisms inside of us. You're one individual, but we cannot exist without a whole bunch of other bacteria living inside of us. We need these bacteria. So we have a symbiotic relationship with these bacteria. Well, when we're not getting enough sleep, the bacteria somehow, maybe it's evolution, somehow knows something's wrong with this particular host, he's not getting sleep. And what attacks us is our own gut bacteria. The gut gets leaky. We actually are attacked not by outside infections necessarily—they can attack us too—but our own buddies, our friends, our friendly gut bacteria will also attack us, and that's how we can get septic. So I think it's almost like the bacteria saying, 'We gotta get out of this body because this guy's not getting enough sleep.' That's how I think of it.

Host: 05:20
I also came across a study from 2016 that linked insomnia to less resilience. This was a study of military service members. And they found that the insomniacs had lower self-rated health, more lost work days, higher odds of early discharge from the military, and they needed more healthcare. I don't think any of this will surprise you.

Dr. Rafael Pelayo: 05:42
Think of what it's like to live your life with chronic insomnia. We should define insomnia so all the listeners are on the same page. Insomnia is trouble falling asleep or staying asleep to the point that bothers you the next day. Trouble falling asleep or trouble staying asleep to the point that it bothers you the next day. Chronic insomnia, by the way, is defined as having insomnia for just three months. We typically see people with years, decades of poor sleep. Just three months is enough because once you've slept poorly for three months, you start to anticipate sleeping poorly. You don't look forward to going to sleep. Think about what that's like. You have to sleep every single night, and in the back of your mind you're thinking, "Tomorrow depends on how well I sleep tonight. I got a big day tomorrow. Tomorrow is an important date. I have to get my sleep. How do I know what kind of day I'm going to have tomorrow? Depends on how I sleep. How do I know how I'm going to sleep unless I sleep lightly to monitor my sleep, because how else am I going to know?" So the fact that you try to predict tomorrow makes you sleep even lighter because you're trying to anticipate what's happening. And it's every single night, night after night, "How bad will it be tonight? I'm single, I have a new bed partner. What's this person gonna think of me if they know that I'm kind of weird and can't sleep? Are they going to think it's strange of me to do this? How do I let them know this? Or what if I move and disturb their sleep? Or what if my significant other has insomnia, and I'm the good sleeper. What do I do to make them sleep better?" So you can see how this wears on people's minds every single night.

Host: 07:00
It sounds like an anxiety disorder.

Dr. Rafael Pelayo: 07:02
It's a focused anxiety about sleeping. That's what it is. And that's how we approach it. And the way you know you have this pattern is, for example, if you find that you're drowsy or sleepy in some other part of your home, in the living room and you're yawning, but as soon as you get to bed, as soon as your head hits the pillow, you're wide-awake. The thought of sleeping will wake you up. And people with insomnia have certain behaviors that demonstrate this. For example, people with insomnia often sleep better away from home. Most of us sleep better in our own homes because the bedroom should be a sanctuary. But if you sleep better away from your home, something's up. Because, again, they create negative associations. Sleeping has become a time of uncertainty, a time of torture, and they associate that with their bedrooms. This happens in the sleep lab. We’re putting wires on people's heads, face, toes, chest, they're wired up completely. We have cameras on them, and a stranger's watching them sleep. And under those circumstances, most people will have trouble sleeping, with all these wires, instrumentation, and the cameras. But the insomniacs often say that they slept better in the sleep lab they do at home, and they ask about our mattresses. They want to know what brand of mattresses we have because they think it's the mattress. It's not the mattress.

Host: 08:06
I had a guest on recently who's a paleoanthropologist, and he shared some examples of what to us seem like weird sleeping arrangements that he's encountered. And his point was that there are lots of different ways that humans have adapted to sleep, and so this idea of the "perfect way to sleep"— this gets into those sleep rules—is seriously suspect. And so the first thing I wanted to ask you is, do you have an example of a sleeping arrangement that is normal for some people, and may seem very strange to us.

Dr. Rafael Pelayo: 08:35
There's so many of them. For a long time, people have viewed—since antiquity—that the gods are sending us messages in our dreams. So if you were in the dream-interpretation business, or if you were in the divining business, if you were a cleric, you needed to provide dreams to interpret and tell people and get visions. So the more uncomfortable you are, the more likely you are to remember your dreams. So in Ancient Egypt, they had a dream chamber, sleeping chambers for the people— whatever the right term is—for the clerics, and if you look at how they slept, it didn't look too comfortable. But it makes a lot of sense because you only remember dreams if you wake up during a dream. So if I can make you a little bit uncomfortable, like a little pebble under your mattress kind of thing, if I can disturb your dreaming just a little bit, you're more likely to report more dreams. Another example that's interesting is going to prehistoric tribes. They noticed that people are waking up throughout the night all the time. If sleep is the most dangerous thing we do as animals, then we have to protect ourselves while we're sleeping, then periodically in a tribe of people waking up at different times, we'll look out for each other's safety. And when women go through menopause, they typically sleep very poorly. Menopause is characterized by very fragmented sleep, hot flashes for example. You say, well, why is that happening? If we were in this purely animalistic way of thinking, well, if a woman's going through menopause, then she cannot reproduce, when why is she there? What's the value to society? Which is a horrible way of thinking about it. But in reality, there's an argument that says that as women go through menopause, they become more protective of the group because their sleep is more fragmented. So just like we have teenagers who sleep very deeply, it's hard to wake up a sleeping teenager. So you have this young group of people who are biologically designed to shift to sleep late at night. They sleep later so they can watch over the fire at one point. And then you have another group in the tribe that has this choppy sleep. And overall the society works well for us, even though the individual person may be suffering from their sleep, as a group you see how collectively it protects us. So there are a lot of examples of that. And I like this topic of paleontology and how we evolved and anthropology of sleep in general.

Host: 10:46
Let's take on the sleep rules. So the old sleep rules that everybody has heard—don't read in bed, don't drink alcohol before bedtime, those sorts of things—have been in place for many decades at this point. You're skeptical of them. You cite research that says that they're not even that effective, really. What's wrong with the rules?

Dr. Rafael Pelayo: 11:05
The sleep hygiene rules have become too successful. They've been too popular. They're good rules for everybody in general. But the reality is when you deal with patients, which is different, most people don't have sleep disorders. Most people sleep just fine. Sleep hygiene rules make sense for them. But if you're dealing with patients, things are different. Because the more logical you are, the more common sense you apply, the more analytical you are to a sleep problem, the more likely you are to screw it up, because the correct approach is counterintuitive. This is an audio podcast folks, but I can see my host, I see Jon, and he's just wincing at me. I see him on camera. He's wincing when I said that. The right approach to most sleep problems is counterintuitive. For example, it's logical if I can't sleep, I should lay in bed and rest. That makes complete sense. But what you're really doing then is getting your body used to being awake in bed. And you're creating an association with being awake and frustrated in bed. So the more time you spend in bed, your body then reacts by sleeping even lighter, and the insomnia gets worse. Logic is if I can't sleep, I should go do something. What could be more logical? I can't sleep, I should go check my email. I can't sleep, I should get something done, I should go do some chores. Well, what did you just do by doing that? You just rewarded the insomnia by getting something accomplished. So you don't want to do that. So typically most insomniacs are being driven to their insomnia by maladaptive thinking, misconceptions about sleep, and the reason the sleep hygiene rules are important to point this out is because when people have sleep disorders, they're already tried the sleep hygiene things in advance and they don't work for them. So there is no data that sleep hygiene by itself helps people with sleep disorders sleep better. It doesn't work that way.

Host: 12:48
Is there a single piece of advice that you find yourself giving the most often?

Dr. Rafael Pelayo: 12:52
So different tips for helping sleep—the first thing is to lock in a wake-up time. People often focus on falling asleep, but it's easier to force you to wake up than to fall asleep. So I really like locking in the wake up time. I like people to do something they enjoy first thing in the morning. Do something that's fun. You shouldn't be dreading your day. People who are like, "Argh." They're unhappy with things. I go, "What do you like to do?" I'll have teenagers go play video games first thing in the morning. Parents want to take away their video games. I'm like, "Well, play first thing in the morning." And it gets bright light in your eyes, it's something you enjoy. People want to play musical instruments. There are a lot of things people can do, if they can, they can try to accommodate and put it to good use. I had a painter who was having trouble sleeping. I said, "Can you start painting some sunrises?" She started painting sunrises, and her sleep got better. Because now she has something she enjoys first thing in the morning. I always tell people sleeping should be silent. You should not snore. Your sleeping should be refreshing. You should not wake up tired. You don't leave restaurants feeling hungry, you should not wake up feeling tired. So those are some of the key concepts for me. There's more to it than that. If you wake up tired no matter how much sleep you get, though, if you're always tired, no matter how much sleep you get, then you definitely want a sleep test.

Host: 14:00
You have a great—I think it's the first line of your book—it's something to the effect of, "We've been sleeping longer than we've been breathing." Do I have it right? What is it?

Dr. Rafael Pelayo: 14:07
Yeah. If you think of it, it's kinda weird, because I'm a sleep doctor, right? And why do we even need sleep doctors? Because you've been sleeping longer—it's one of the oldest things we've ever done. Because you were sleeping in utero, which means that we were sleeping before we took our first breath of oxygen, we were sleeping long before we ever had our first bite of food. So that's how long you've been sleeping for and that's how long it's been built in. We were sleeping in utero. In fact, in utero we have more dreaming time than practically any other activity we do. About half of our time in utero is dreaming. What are they dreaming about? Who knows? But the first time I gave a talk on this topic—I'm from New York City, and I came from the Bronx—when I got to California, the first time I gave a lecture, and I mentioned that babies are dreaming a lot in utero and nobody knows what they're dreaming about, some lady raised her hand in the back of the room and said, "Well, they're dreaming about their past lives." And I'm like, okay, I'm in California now. You can't argue against it. There's no empirical science saying that they're wrong or they're right. But that's the point—that we have all this activity of dreaming and sleeping going on, which lets you know how foundationally important it is for us to do this. The other quote in the book, in the beginning of the book, I quote another sleep scientist who said, "If sleep has no function, it's the biggest mistake evolution ever made." Because it is a really weird thing to do. So logic would be for us not to sleep at all. If you were to design—I'm in Silicon Valley right now. There's a bunch of meetings going on all around me, I'm sure, people trying to raise money for different ideas. There's not a single person meeting to come up with an idea for a robot that sleeps more. Nobody wants a sleeping robot, right? There's no value to it. However, there is some data from artificial intelligence work that if you make an artificial intelligence machine have dreaming properties to it, they actually become more efficient, and they incorporate dream theory into artificial intelligence, and the machines work better. So there's stuff to this. There's a reason we ended up doing it this way.

Host: 16:07
Alright so I want to end with a rapid-fire round in the spirit of your book, which has a Q and A section. Lucid dreaming—Is it a real thing? Can you do it? Should somebody try?

Dr. Rafael Pelayo: 16:20
Yes, lucid dreaming is a real thing. People who've had the experience don't doubt it. People who've never done it question it. If you've ever been able to manipulate a dream during a dream you know it's real, you won't forget it.

Host: 16:29
Can you do it?

Dr. Rafael Pelayo: 16:31
That's actually how I got into sleep originally when I was 12 years old, I had a lucid dream. And that kind of sparked my curiosity about why we dream. As I've gotten older, I've not been able to do it, but I know plenty of people who do it. It is a learned skill. But young people tend to just do it. So I've had that experience. And it sounds from your question, Jon, you've never done it.

Host: 16:48
I have, when I was a kid, I used to be able to do it. I can't do it anymore.

Dr. Rafael Pelayo: 16:50
So it's a real thing then! If you remember what you did. The most common thing people do is fly.

Host: 16:55
I remember it just being a lot of fun. But I know it has an aura of being potentially very profound.

Dr. Rafael Pelayo: 17:02
It can be mystical for some people. I met one man who trained himself to do it who decided to imagine his death and visit his own funeral. And he was in tears when he woke up. But he thought it was a profound moment in his life, because he had some insights into what's happening. It's pretty much a hybrid state, because when they look at fMRI data, the brain is not in the same way, typically, as when it's asleep or when it's awake. It's a hybrid state where you're getting more blood flow to the—usually when we're dreaming, the associative cortex has more blood flow and there's less blood flow, less activity in the frontal lobe executive functions. That's why we don't question reality in our dreams. But in the lucid-dreaming state, there is more activity in the frontal lobe than you typically see in dreaming sleep.

Host: 17:45
Question two: Naps, good or bad?

Dr. Rafael Pelayo: 17:48
It's like saying is snacking good or bad. Yes, I think naps can be very good if you are not getting enough sleep. But if you're somebody who does not sleep well at night, then just like, if you won't eat your dinner because you're snacking before dinner it's bad, napping then is going to interfere. But we all visit people's homes that we don't want to eat at their house, we don't trust their food there, so having a snack before you get there helps you not show up hungry at somebody's house. So naps are just that, they really are like snacking, and it can be good or bad depending how you use them.

Host: 18:18
Should I get a new mattress?

Dr. Rafael Pelayo: 18:20
Well, you know, the mattress is interesting. Because mattresses gain weight over time. Your mattress is heavier now than when you first bought it. If you buy a new mattress, I'd advise you never to buy a used mattress. Only get a new one. It's a luxury. And as people have more disposable income, mattresses have become higher end, and there's technology in mattresses. I just got a new mattress. So it can be fun to get a new mattress, but you only need a new mattress if something is wrong. When we're little kids, you slept anywhere. When you were five or six years old, you had a sleepover, you'd beg to sleep on the floor of your friend's house. And when you're teenagers, you'd crash on their couch. Sleeping surfaces only really matter as you get older for a lot of people.

Host: 18:57
I have a feature on my phone that turns down the blue light in the evening. Is that a real thing that's useful or is that a bunch of nonsense?

Dr. Rafael Pelayo: 19:06
I think of the blue light filters as being like filters on cigarettes. What's keeping you awake is not necessarily the blue light, it's the content of the information that you're obtaining, the fact that you're not making sleep a priority. That's the bigger problem. So our brains are cued into blue light for circadian shifts, but it's not the only reason we stay awake. We also stay awake because of the content we're receiving. You could lose sleep reading a good book. So it's not just the light, but it's also the content that you're receiving. So yeah, it helps, but it's not the whole picture.

Host: 19:37
Is there an ideal number of hours that someone should aim for?

Dr. Rafael Pelayo: 19:42
The National Sleep Foundation recommends seven to nine hours of sleep, and there's a range. And I think if you talk to anybody about their sleep needs or sleep desires, they'll give you two numbers. They'll say, "I like to get eight, but I can get by with six." And they'll tell you that they sleep more in Alaska in the winter than during the summer. So there's some seasonal variability to our ability and the need for sleep. But in general, what you want to do is wake up feeling refreshed. That's what you want. And that's what you're going to know. You should wake up feeling refreshed. You know you're not getting enough sleep if you tend to sleep in on weekends a lot. Because why would you need to catch up on sleep if you're getting all the sleep you need. So seven to nine hours is the number to shoot for. I get about seven and a half has been my trend.

Host: 20:20
Can you get by with less sleep?

Dr. Rafael Pelayo: 20:22
You can get by with less sleep, but you're not at your best. Of course you can get by with less sleep. Every physician, we were forced to get by with less sleep. But is that the point of life is to get by? You're not at your best. So, yes, you want to be your best self, you want to get more sleep, but yes, you can get by with less sleep. But you're going to pay the price. You may be inattentive, you may get in car accidents, you may kill somebody in your car because you fell asleep at the wheel and took somebody out when you did that. So be careful.

Host: 20:48
And lastly, what do you recommend to somebody who often wakes up tired? What should they do?

Dr. Rafael Pelayo: 20:52
I tell anybody who's not satisfied with their sleep to seek out a board-certified sleep doctor. Modern sleep medicine has reached a point where it's unusual for patients not to improve. If you're tired no matter how much sleep you get, insist that your doctor have you see a certified sleep doctor, not just get a sleep study, but get a sleep history, get evaluated properly in which somebody takes time and talks to you and does a full consultation. Because you should not be waking up tired at all.

Host: 21:18
Thank you so much, Dr. Pelayo. It's been a pleasure talking with you.

Dr. Rafael Pelayo: 21:21
Pleasure's all mine. Thank you, sir.

Host: 21:24
Dr. Rafael Pelayo is a Clinical Professor at the Stanford University School of Medicine in the Division of Sleep Medicine. His new book is "How to Sleep: The New Science-Based Solutions for Sleeping Through the Night." That's all for this episode of Road to Resilience. We are a production of the Mount Sinai Health System in New York City. The podcast is made by Nicci Cheatham, me, Jon Earle, and our sleep-savvy Executive Producer, Lucia Lee. From all of us here, thanks for listening, and we'll see you next time.