How to Sleep Better | Diane Macedo
Diane Macedo, ABC News anchor and author of "The Sleep Fix," shares her journey overcoming chronic sleep issues, including circadian rhythm disorder and insomnia. She details practical, drug-free solutions like light therapy, cognitive behavioral therapy for insomnia (CBTI) techniques, and addressing sleep myths.
Deep Dive Analysis
12 Topic Outline
Introduction to Sleep Struggles and Diane Macedo's Journey
The Role and Risks of Sleeping Pills like Ambien
Understanding Sleep Apnea: Symptoms, Screening, and Treatment Options
How and When to Find a Sleep Specialist
Diane's Personal Breakthrough: Addressing Circadian Rhythm and Anxiety
Conditioned Arousal: The Brain's Misassociation with Bed
Techniques to Overcome Insomnia: Reverse Curfew and Constructive Worry
Reading in Bed and its Impact on Sleep
Mindfulness, Meditation, and Sleep: Timing and Expectations
Restless Leg Syndrome: Symptoms, Diagnosis, and Treatment
The Influence of Food Timing on Circadian Rhythm and Sleep
Debunking Common Sleep Myths
11 Key Concepts
Sleep and Sedation
There is a distinction between actual restorative sleep and drug-induced sedation. While drugs like Ambien can make you unconscious, the quality of sleep achieved is generally not the same as natural, drug-free sleep, and it does not address the underlying sleep problem.
Sleep Apnea
A disorder where a person repeatedly stops breathing during sleep, sometimes up to 100 times an hour. It can affect anyone, not just older, overweight men, and often goes unnoticed by the individual.
Secret Sleep Disorders
Conditions that disrupt sleep without the individual realizing it, leading to daytime sleepiness despite believing they are sleeping through the night. Sleep apnea is an example of such a disorder.
Circadian Rhythm
The body's natural internal clock that regulates wakefulness and sleepiness over a 24-hour cycle. It can be influenced by external cues like light, dark, food timing, and exercise, and can be disrupted by shift work or inconsistent schedules.
Conditioned Arousal
A phenomenon where the brain begins to associate the bed with wakefulness and frustration, rather than sleep. This happens when individuals spend too much time in bed awake and trying to force sleep, leading to a 'mental autopilot' that keeps them alert in bed.
Sleep Seesaw
A metaphor illustrating the balance between 'sleep drive' (the physiological pressure to sleep) and 'wake drive' (the physiological pressure to stay awake). When the wake drive, fueled by stress, anxiety, or circadian rhythm, overpowers the sleep drive, it leads to wakefulness.
Sleep Drive
The physiological need for sleep that accumulates the longer a person is awake, similar to hunger. It is powered by the buildup of adenosine in the brain, which dissipates during sleep.
Sleep Confidence
The belief in one's own ability to fall asleep. Developing confidence in one's sleep capabilities can psychologically and physically aid in falling asleep more easily.
Sleep Deprivation vs. Insomnia
Sleep deprivation is simply a lack of sufficient sleep, while insomnia is characterized by inefficient sleep, meaning a person spends significantly more time in bed than they are actually sleeping.
Restless Leg Syndrome (RLS)
A neurological disorder characterized by an uncomfortable sensation, typically in the legs, that creates an irresistible urge to move them. Symptoms are worse at night or during periods of rest, making it difficult to fall or stay asleep.
Tryptophan and Carbohydrates
Tryptophan, an amino acid known for its drowsy effect, requires insulin to effectively reach the brain. Carbohydrates trigger insulin production, which helps clear other amino acids, allowing tryptophan to cross the blood-brain barrier and convert into serotonin, aiding sleep.
14 Questions Answered
While sleeping pills can induce unconsciousness, the quality of sleep is generally not the same as natural sleep. They are often viewed as a temporary 'crutch' or bridge to a long-term solution, rather than a solution themselves, and should be used strategically under a sleep specialist's guidance.
Sleep apnea is a disorder causing repeated breathing cessation during sleep, sometimes up to 100 times an hour. Anyone who snores loudly, or experiences daytime sleepiness, dozing off in waiting rooms or while watching TV, should consider getting screened, regardless of age, weight, or gender.
While full-blown overnight lab sleep studies are available, sleep apnea can often be tested for at home using devices sent by sleep specialists. These home tests involve wearing a sensor on a finger or a nose cannula, which sends data directly to the specialist.
Although CPAP machines are the 'gold standard,' other options exist, especially if a patient struggles with CPAP use (which 50% do). These include custom mouthguards designed to push the jaw forward, which are FDA-approved for some individuals.
For insomnia, it's ideal to find a behavioral sleep specialist trained in Cognitive Behavioral Therapy for Insomnia (CBTI) through organizations like behavioralsleep.org. For sleep apnea, any sleep specialist can typically provide straightforward treatment, but patients should be aware of alternative options beyond CPAP.
Light is the most powerful tool for circadian rhythm. For shift workers or those struggling to wake/sleep at desired times, using a therapy light that mimics sunlight upon waking can signal to the brain that it's morning, helping to set the body clock and align wake/sleep signals.
Conditioned arousal is when the brain associates the bed with wakefulness and frustration due to repeated failed attempts to sleep. It manifests as feeling wide awake the moment your head hits the pillow, even if you were sleepy on the couch, with your mind racing with thoughts.
To increase sleep drive, it's counterintuitive: avoid sleeping in, napping, or going to bed earlier after a bad night. Instead, stick to a consistent bedtime (even if it's later than usual, a 'reverse curfew') and consistent wake-up time to build up sleep pressure, making it easier to fall asleep the next night.
A technique called 'constructive worry' or 'brain dump' can help. By writing down worries and the very next step to resolve them before bed, you alleviate the brain's need to process these thoughts in bed, helping to lower arousal and break the cycle of repetitive thoughts.
Reading in bed can be advisable if it helps you relax and unwind without revving you up or causing you to lose track of time. The goal is to avoid anxiety in bed, so if reading contributes to a calm state and helps you recognize sleepy cues, it can be beneficial.
Meditation can help develop a healthy relationship with thoughts and lower arousal, but it's not about 'turning off' the brain. Dr. Jason Ong suggests meditating during the day when naturally calm, rather than at night when struggling to sleep, to build the skill and associate it with relaxation.
RLS causes an uncomfortable sensation, usually in the legs, leading to an irresistible urge to move them, especially at night or during rest. Treatment can involve lowering arousal levels, and in some cases, magnesium or iron supplementation has shown great results.
Eating breakfast at a consistent time can help reset the body clock, especially for shift workers or travelers. Additionally, consuming complex carbohydrates closer to bedtime can aid sleep by facilitating tryptophan's journey to the brain, which then converts to serotonin.
No, the idea that everyone needs eight hours of sleep is a myth. The National Sleep Foundation indicates that while 7-9 hours is average for most adults, anywhere from 5 to 11 hours may be appropriate for some. The key is to assess how you feel during the day; if you feel fine and energetic, you're likely getting enough sleep.
24 Actionable Insights
1. Prioritize Sleep
Recognize sleep as the ‘apex predator of healthy habits’ because poor sleep negatively impacts health, focus, productivity, happiness, success, and relationships. Make prioritizing sleep a conscious effort.
2. Identify Your Specific Sleep Problem
Undertake a ‘personal investigation’ to identify what specifically is keeping you awake, as different issues (e.g., circadian rhythm, anxiety, physical disorders) require different solutions.
3. Assess Sleep Quality, Not Just Duration
Focus on how you feel during the day rather than just the number of hours you sleep. If you feel fine and energetic, you’re likely getting enough sleep; if you constantly need naps or doze off, something is wrong, regardless of hours.
4. Seek Sleep Specialist for Complex Issues
Understand that primary care physicians often lack sufficient sleep education (average four-year med school spends two hours on sleep). For complex or persistent sleep problems, seek a sleep specialist rather than relying solely on your PCP.
5. Rule Out Underlying Medical Conditions
Before focusing solely on sleep disorders, consult your doctor to rule out any other underlying conditions like chronic pain or severe acid reflux that might be causing or exacerbating your sleep issues. Push harder if your doctor isn’t providing solutions.
6. Don’t Rely on Sleeping Pills
View sleeping pills as ‘crutches’ rather than a ‘solution’ for sleep problems. They may offer temporary sedation but often don’t provide quality sleep or address the underlying issue, can be habit-forming, and may even worsen some sleep problems.
7. Consult Sleep Specialist for Meds
If taking any substance regularly to aid sleep, seek guidance from a sleep specialist. Sleeping pills should be used thoughtfully and strategically, ideally as a bridge to a long-term solution, not the solution itself.
8. Don’t Force 8 Hours of Sleep
Dispense with the myth that everyone needs exactly eight hours of sleep. The appropriate amount varies (7-9 hours for most adults, but 5-11 hours may be appropriate for some); forcing more sleep than your body needs can lead to insomnia.
9. Screen for Sleep Apnea
If you snore loudly, constantly feel like you need a nap, or doze off during moments of stillness (e.g., in a waiting room or watching TV), get screened for sleep apnea, as it can affect anyone regardless of age, weight, or gender.
10. Consider At-Home Sleep Apnea Test
If you suspect sleep apnea and meet risk factors, ask a sleep specialist for an at-home sleep study. These tests are simple, involve wearing a device on your finger or with a nose cannula, and send data directly to the specialist.
11. Explore Non-CPAP Apnea Treatments
If diagnosed with sleep apnea but unwilling or unable to use a CPAP machine, discuss alternative FDA-approved treatments with your doctor, such as a specialized mouth guard, or try different CPAP mask fits, as adherence is key.
12. Check for Restless Leg Syndrome (RLS)
If you experience a discomfort or fidgety sensation in your legs (or other limbs) that compels you to move, especially at night or during periods of rest, ask your doctor about Restless Leg Syndrome. Treatment can include lowering arousal, magnesium, or iron.
13. Find a Behavioral Sleep Specialist
For insomnia or other non-apnea sleep disorders, seek a behavioral sleep specialist, ideally one trained in Cognitive Behavioral Therapy for Insomnia (CBTI). Resources like behavioralsleep.org can help locate accredited specialists.
14. Utilize Self-Help CBTI Resources
If direct access to a CBTI specialist is limited, explore self-help methods such as specialized apps or books (like ‘The Sleep Fix’) that detail CBTI techniques. These can be effective if you are disciplined in their application.
15. Address Conditioned Arousal
Recognize and address ‘conditioned arousal,’ where your brain associates your bed with wakefulness and frustration due to prolonged periods of being awake and anxious in bed. This is a key element to solving insomnia.
16. Implement ‘Reverse Curfew’ (CBTI)
To power up your sleep drive and break conditioned arousal, set a ‘reverse curfew’ by not going to bed before a specific, slightly later time. Maintain a consistent wake-up time daily, even after a bad night, and avoid naps to build sleep pressure.
17. Practice Sleep Restriction/Compression
Utilize CBTI techniques like sleep restriction (initially limiting time in bed to actual sleep duration, then gradually expanding) or sleep compression (starting with a comfortable window, then gradually cutting back until efficient sleep is achieved) to reduce time spent awake in bed.
18. Get Out of Bed When Frustrated
If you are in bed for long enough to feel frustrated and awake, get out of bed. Engage in an enjoyable, relaxing activity elsewhere and return to bed only when you feel sleepy to reinforce the association of bed with sleep.
19. Use a ‘Worry List’ (Brain Dump)
Before bed, perform a ‘constructive worry’ exercise: divide a notebook page, list worries on one side, and the very next actionable step to resolve each on the other. This helps process thoughts outside of bed and reduces racing thoughts at night.
20. Meditate During the Day
To effectively use meditation for sleep, practice it during the day when you are naturally calm. This builds the skill of noticing distractions without judgment and helps your brain associate meditation with relaxation, making it a more effective tool for occasional stressful nights.
21. Therapy Light for Circadian Rhythm
If you have circadian rhythm issues (e.g., shift worker, night owl), use a therapy light that mimics sunlight in the morning while getting ready. This signals to your brain that it’s morning, helping to set your body clock for appropriate wake and sleep times.
22. Adjust Food Timing for Sleep
Consider food timing to aid sleep and circadian rhythm. If you wake up hungry, opt for light, comforting, easy-to-digest snacks like plain oatmeal. If you struggle to sleep on an empty stomach, eat a sleep-friendly snack (e.g., toast, oatmeal with complex carbs) 1-2 hours before bed.
23. Optimize Macronutrient Timing
If you have trouble sleeping, consider eating protein earlier in the day to store tryptophan, and then consume complex carbohydrates at the end of the day. Carbohydrates trigger insulin, which helps tryptophan reach the brain to produce serotonin for sleep.
24. Evaluate Reading in Bed
If reading in bed helps you relax and unwind without making you anxious or losing track of time, it can be beneficial. Avoid activities that are overly stimulating or cause you to ignore sleepy cues, as these can disrupt sleep.
9 Key Quotes
Sleep may be the apex predator of healthy habits.
Dan Harris
There is a difference between sleep and sedation.
Sleep researcher (quoted by Dan Harris)
Sleeping pills aren't necessarily the enemy, but they should be used in a thoughtful and strategic way and not painted as a solution to the problem because they can make some sleep problems worse.
Diane Macedo
If you had someone smothering you in your sleep 100 times an hour, you would probably make it a top priority to solve that problem.
Diane Macedo
The CPAP is not going to do my patient any good if I know my patient's not going to wear it.
Sleep ENT (quoted by Diane Macedo)
Bed becomes this place where, oh, I know where we are. We're in that place where we have to be alert.
Diane Macedo
The more confident you feel in your ability to sleep, the more likely you are that you're going to just go to bed and hit the pillow.
Diane Macedo
The word Buddha means awake. This technology was not designed to help you sleep.
Dan Harris
Your mind is not actually supposed to be quiet.
Diane Macedo
4 Protocols
General Approach to Addressing Sleep Problems
Diane Macedo- Consult your primary care physician (PCP) to rule out any underlying medical conditions (e.g., chronic pain, acid reflux) that might be causing sleep issues.
- If your PCP's advice or solutions are not effective, push for further investigation or a referral to a sleep specialist.
- Attempt to identify the specific problem interfering with your sleep, as different issues require different solutions.
- If you suspect insomnia, seek a behavioral sleep specialist trained in Cognitive Behavioral Therapy for Insomnia (CBTI).
- If you suspect sleep apnea, seek a sleep specialist who can diagnose and discuss various treatment options, including alternatives to CPAP.
Constructive Worry / Brain Dump (for racing thoughts before bed)
Diane Macedo- Take a notebook and divide a page down the center.
- On the left-hand side, write down anything that is on your mind, especially worries or thoughts that swirl in your head when trying to sleep.
- On the right-hand side of the page, for each item, write down the very next concrete step to resolving that issue (not the ultimate solution). If an issue is out of your hands, write down that you accept it and will move on.
- Continue until you cannot think of anything else on your mind, then stop.
Reverse Curfew / Sleep Compression (CBTI-based for Insomnia)
Diane Macedo- Set a 'reverse curfew' by deciding you cannot go to bed before a specific time, usually a bit later than your normal bedtime, to build up sleep drive.
- Maintain a consistent wake-up time every single day, regardless of how well you slept the night before, avoiding sleeping in.
- Avoid napping during the day to ensure sufficient sleep drive builds up for the night.
- If you are in bed for an extended period and feel frustrated or wide awake, get out of bed immediately. Go to another room and do something enjoyable and relaxing.
- Only return to bed when you genuinely feel sleepy, reinforcing the association of bed with sleep.
- For sleep compression specifically, start with a comfortable sleep window (e.g., 7-8 hours). If sleep efficiency is low, gradually reduce the time spent in bed (e.g., by 15 minutes per week) until you are sleeping efficiently. Once efficient, slowly expand the window if more sleep is needed without losing efficiency.
Food Timing for Circadian Rhythm and Sleep
Diane Macedo- Eat protein earlier in the day to help store tryptophan in the body.
- Consume complex carbohydrates (e.g., toast, oatmeal) within one to two hours before bedtime.
- If you wake up hungry in the middle of your intended sleep period, opt for a light, comforting, and easily digestible snack (e.g., plain oatmeal with a little salt and honey/applesauce) rather than a large meal, to avoid disrupting your body's sleep signals and acid reflux.