#107 Why You Can't Sleep (and How to Fix It) | Dr. Michael Grandner
Dr. Michael Grandner, Director of the Sleep and Health Research Program at the University of Arizona, discusses distinguishing insomnia from poor sleep, effective CBT-I strategies, detecting sleep apnea, and leveraging advanced sleep hygiene for optimal sleep and performance.
Deep Dive Analysis
18 Topic Outline
Distinguishing Clinical Insomnia from General Sleep Problems
Understanding Conditioned Arousal and Chronic Insomnia
Cognitive Behavioral Therapy for Insomnia (CBT-I) Explained
Practical Stimulus Control Strategies for Sleep
Sleep Restriction Therapy: The 'Worst Name, Best Solution'
Prevalence and Non-Obvious Signs of Sleep Apnea
Sleep Stages: NREM 1, 2, 3 (Deep), and REM Sleep
Impact of Untreated Sleep Apnea on Sleep Architecture and Health
Non-CPAP Interventions for Sleep Apnea
Advanced Sleep Hygiene and Circadian Rhythm Optimization
Strategic Timing of Morning Light and Caffeine Intake
Melatonin: Dosing, Timing, and Misconceptions
Impact of THC, CBD, and Alcohol on Sleep
Late-Night Eating and Sleep Deprivation's Effect on Food Choices
Strategic Napping and Caffeine Use for Shift Workers
Effective Strategies for Minimizing Jet Lag
Accuracy and Pitfalls of Consumer Sleep Tracking Devices
Using Sleep as a Cognitive and Athletic Performance Enhancer
7 Key Concepts
Insomnia Disorder
A persistent difficulty initiating or maintaining sleep, or waking up too early, occurring at least three nights per week for at least three months, causing daytime functioning problems, and despite adequate opportunity to sleep. A common rule of thumb for difficulty is taking at least 30 minutes to fall asleep or being awake for at least 30 minutes during the night.
Conditioned Arousal
The primary cause of chronic insomnia, where the act of trying to sleep or being in bed becomes predictably stressful. This stress creates activation (cortical, cognitive, or physiological) that makes it harder to fall asleep, strengthening the negative association and creating a self-perpetuating cycle.
Sleep-Wake Dimensions
Sleep and wakefulness are not opposite ends of a single spectrum but rather two separate dimensions. Sedatives boost the sleepiness signal, while insomnia often involves an overly high wakefulness signal, which CBT-I aims to reduce.
Stimulus Control Therapy
A core component of CBT-I, based on the idea that if a place (like your bed) is predictably tied to a limited number of activities (primarily sleep), your brain will associate that place with those activities. It involves reserving the bed strictly for sleep and sex to strengthen the 'bed equals sleep' association.
Sleep Restriction Therapy
A CBT-I component that involves initially limiting the time spent in bed to match the actual amount of sleep obtained, thereby increasing natural sleep pressure. Once sleep efficiency improves (filling the allotted time), the time in bed is gradually increased, similar to building an appetite for sleep.
Melatonin as Hormone of Darkness
Melatonin is a hormone signaling nighttime, not a direct sedative. It helps strengthen the body's natural nighttime signal, which can promote sleep in humans. Its effects are dose and timing-dependent, and it is largely ineffective for treating clinical insomnia caused by conditioned arousal.
Orthosomnia
A term for the unhealthy obsession with sleep data from wearable devices, leading to increased anxiety and stress about sleep. This fixation can paradoxically worsen sleep quality and contribute to insomnia by creating conditioned arousal around sleep metrics.
12 Questions Answered
Clinical insomnia is defined by persistent difficulty falling or staying asleep, or waking too early, occurring at least three nights a week for three months, causing daytime impairment, and despite adequate opportunity for sleep. Difficulty falling asleep or being awake for over 30 minutes during the night are common indicators.
Stress causes acute insomnia, but if the stress about not sleeping persists, it creates 'conditioned arousal.' The brain learns to associate the bed with stress and wakefulness, making it harder to fall asleep even when tired, perpetuating a cycle independent of the initial stressor.
Beyond classic snoring and daytime sleepiness, non-obvious signs include waking up in the middle of the night due to stress or for no reason, feeling like sleep is shallow, or experiencing frequent awakenings that are remembered, especially if accompanied by gasping or snorting.
Untreated sleep apnea can dramatically reduce slow-wave (deep) and REM sleep, increase light sleep (stage one), and make sleep generally shallower. The intermittent hypoxia and repeated arousals cause oxidative stress, leading to problems in various organ systems, including increased risks for neurodegeneration, heart issues, and metabolic problems.
Non-CPAP options include mandibular advancement devices (retainers that push the jaw forward), myofacial therapy (exercising airway muscles), electrical tongue stimulation devices like ExciteOSA, and implantable pacemakers for the tongue muscle (Inspire).
Bright morning light helps set the circadian clock, initiating a timer that prepares the body for sleep 16-17 hours later. It also strengthens the circadian amplitude, leading to a more robust nighttime sleep signal, and inoculates against the negative effects of light exposure at night.
It's recommended to wait at least an hour after waking to consume caffeine, as adenosine levels are lowest in the morning, and the peak effects of caffeine occur about 30 minutes after ingestion. This strategy leverages natural alertness and saves caffeine for when it's most needed, typically stopping four to six hours before bedtime.
THC can help with sleep onset and maintenance initially, but its sleep-promoting effects often fade over time, leading to dose escalation. It can also be a potent REM sleep suppressor and may cause an insomnia and REM rebound (vivid nightmares) upon cessation.
Sleep-deprived individuals tend to consume 350-600 extra calories per day, primarily through increased snacking after dinner. This occurs because the brain, when awake past its desired sleep time, seeks reward and calorie-dense, palatable foods, while decision-making and reward processing are impaired.
Wrist-based devices are highly accurate (around 90%) for distinguishing sleep from wakefulness and heart rate data. However, sleep stage detection is a ballpark estimate (60-80% accurate), and metrics like 'sleep score' or 'readiness' are often based on proprietary, unpublished algorithms, making their interpretation and utility for actionable insights questionable.
Athletes can enhance performance by gradually extending sleep duration (e.g., 15 minutes earlier bedtime) and 'sleep banking' good sleep in the weeks leading up to competition. Sleep deprivation, insomnia, and daytime sleepiness are significant predictors of injury risk, highlighting sleep's role in recovery and cognitive function.
The most effective way is to address underlying causes of nighttime awakenings, with untreated sleep apnea being a leading cause. Additionally, people can train themselves to not immediately go to the bathroom upon waking if it's not truly necessary, reducing the conditioned response to awakenings.
58 Actionable Insights
1. Prioritize CBTI for Insomnia
Recognize Cognitive Behavioral Therapy for Insomnia (CBTI) as the gold standard treatment, as it reliably targets the underlying problem of conditioned arousal and is effective even with co-existing conditions like chronic pain or sleep apnea.
2. Surrender Sleep Control
Learn to surrender control over sleep, especially when experiencing performance anxiety about not sleeping, because trying harder to sleep (effort) adds energy to the system and makes it more difficult to fall asleep.
3. Bed for Sleep & Sex Only
Implement stimulus control by strictly associating your bed with sleep (and sex), avoiding other activities like scrolling on your phone, working, or ruminating in bed, to strengthen the predictable link between bed and sleep.
4. Leave Bed During Night Awakenings
If you wake up in the middle of the night and cannot fall back asleep within a few minutes, get out of bed to break the negative association and prevent stress from escalating, returning only when you feel ready to sleep.
5. Practice Time-in-Bed Restriction
Practice ‘restriction of time in bed’ by initially limiting your time in bed to the actual amount of sleep you’re getting, then gradually increasing it as your sleep efficiency improves, to build natural sleep pressure.
6. Prioritize Morning Bright Light
Get 15-30 minutes of bright outdoor light exposure (e.g., a morning walk/run) early in the morning to set your circadian clock, strengthen your daytime rhythm, and inoculate yourself against the negative effects of light exposure at night.
7. Plan Sleep Backwards
Plan your sleep schedule by working backward from your desired wake-up time, considering how much sleep you need, the time required to wind down, and any morning activities, to ensure you budget sufficient time for sleep and preparation.
8. Screen for Sleep Apnea
Consider getting tested for sleep apnea if you frequently wake up suddenly for no reason, can’t get back to sleep, or feel like you can’t get enough quality sleep despite adequate time, as it’s surprisingly common and home tests are readily available.
9. Address Sleepiness for Injury Prevention
Prioritize addressing daytime sleepiness and insomnia, as these are stronger predictors of injury (e.g., concussions in athletes) than just sleep duration, indicating impaired focus and decision-making.
10. Practice Sleep Banking
Practice ‘sleep banking’ by consistently getting sufficient quality sleep for a week or two leading up to high-stakes events (e.g., competitions), as this builds resilience and minimizes the negative impact of one or two nights of poor sleep.
11. Insulate Sleep Environment
‘Bubble wrap’ your sleep by using simple tools like a cloth eye mask and earplugs to insulate yourself from minor environmental disturbances, which can consolidate sleep (especially deeper sleep) and lead to improved cognitive performance.
12. Sufficient Pre-Bed Wind Down
Dedicate at least 30 minutes before bed to a ‘wind down’ routine, dimming lights (preferably to orange tones) and metaphorically detaching from mentally activating tasks to allow your body and mind to slow down.
13. Mindful Phone Use Before Bed
When using your phone before bed, do so outside of bed, or if in the bedroom, stand or sit upright (not lying down) to maintain awareness of your body’s sleep signals and avoid associating the bed with wakefulness.
14. Curate Pre-Bed Media
Curate your pre-bed media consumption by choosing content that is not mentally activating and that you can easily disengage from if an ‘alarm’ went off, avoiding anything that makes you want to continue for ‘five more minutes’.
15. Strategic Melatonin Dosing
Use melatonin strategically: a 0.3-0.5 mg dose 5 hours before bedtime can shift your clock earlier, while the same dose in the morning can delay it. Be aware that over-the-counter doses (e.g., 5mg) are often higher than labeled due to manufacturing practices, so if you feel groggy, reduce your dose.
16. Limit Alcohol Before Bed
Limit alcohol consumption before bed, as while it may induce faster initial sleep, its rapid metabolism often leads to rebound activation and awakenings later in the night, disrupting overall sleep quality.
17. Avoid Late-Night Eating
Avoid late-night eating, especially calorie-dense or highly palatable foods, as it often stems from emotional reasons or being awake past your body’s natural sleep time, and can disrupt metabolic processes and sleep quality.
18. Caffeine Cut-off Time
Stop consuming caffeine at least four to six hours before your intended bedtime to avoid it interfering with your ability to settle down and fall asleep.
19. Delay Morning Caffeine
Wait at least an hour after waking before consuming caffeine, as your adenosine levels are lowest in the morning and your natural sleep inertia will dissipate, allowing you to leverage caffeine’s effects more effectively when adenosine has accumulated.
20. Avoid Long-Term THC for Sleep
Avoid using THC for long-term sleep aid, as its sleep-promoting effects fade, it can suppress REM sleep, and discontinuing use often leads to insomnia rebound and vivid, unpleasant dreams.
21. Melatonin Not for Insomnia
Avoid using melatonin to treat insomnia, as it is generally ineffective for conditioned arousal where the body already recognizes it’s nighttime but cannot sleep due to stress.
22. Ignore Wearable Sleep Scores
Largely ignore ‘sleep scores,’ ‘sleep quality,’ ‘readiness,’ or ‘recovery’ metrics from wearables, as they are often non-transparent, not scientifically vetted, and may not provide actionable or reliable information.
23. Avoid Sleep Data Obsession
Avoid ‘orthosomnia’ by not obsessing over wearable sleep data, as fixating on imperfect metrics can create performance anxiety, worsen sleep, and lead to insomnia. Remember that sleep doesn’t need to be perfect to be perfectly fine.
24. Trust Wearable Sleep/HR Data
Trust wearable device data primarily for tracking sleep versus wake times and heart rate, as these metrics are captured with high accuracy and have robust algorithms.
25. Caution with Sleep Stage Data
Interpret wearable sleep stage data with caution, understanding it’s a ballpark estimate (60-80% accurate) and not a precise measure; a low reading for deep sleep doesn’t necessarily mean you’re not getting enough, but rather that the algorithm may not be picking it up perfectly.
26. Focus on Sleep Data Trends
When using wearable data, focus on long-term trends (weekly or monthly) rather than obsessing over single-night readings, as trends provide more meaningful insights into your sleep patterns.
27. Identify Sleep Data Anomalies
Use wearable data to identify discrepancies between your perceived sleep and recorded sleep, or to spot anomalies like unusual heart rate fluctuations or misplaced sleep stages, which can signal underlying issues like sleep apnea, pain, or environmental disturbances.
28. Address High Nighttime Heart Rate
If your wearable shows a consistently high or rising heart rate during the night, investigate potential causes such as late-day caffeine/alcohol, medication timing, pain/inflammation, an uncomfortable mattress, or lack of pre-bed relaxation, and address them accordingly (e.g., breathing exercises, temperature modulation).
29. Reduce Nighttime Urination
If you frequently urinate at night, first investigate underlying causes like untreated sleep apnea. If no medical cause, try to fall back asleep without going to the bathroom, as you might be conditioned to urinate during natural awakenings.
30. Daytime Habits for Sleep Quality
Improve overall sleep quality by focusing on daytime habits: get regular physical activity and bright light exposure, eat a healthy diet (especially avoiding late-night unhealthy eating), and work to reduce systemic inflammation in your body.
31. Address Partner’s Sleep Issues
If your bed partner’s sleep issues (e.g., snoring, movement) are disrupting your sleep quality, encourage them to get tested and treated, or consider practical solutions like separate blankets or even separate mattresses pushed together to minimize disturbance.
32. Assess Sleep by Alertness
Assess if you’re getting enough sleep by observing your daytime alertness: if you can’t stay conscious in a quiet, dark room for 20 minutes, or if you fall asleep immediately when your head hits the pillow, you likely need more or better quality sleep.
33. Gradually Extend Sleep (Younger Adults)
If you are a younger adult or athlete, gradually extend your sleep duration by 15-minute increments (e.g., by going to bed earlier) to potentially improve physical performance, strength, and mental sharpness.
34. Read Paper Books Before Bed
Engage in reading physical books before bed, as it’s a self-paced activity that helps you connect with your body’s sleep signals without overstimulation, allowing you to recognize when you’re truly ready for sleep.
35. Magnesium & Glycine for Sleep
Consider magnesium and glycine supplements to help promote sleep, as both have shown evidence of aiding in falling asleep and staying asleep better.
36. Calming Supplements for Relaxation
If you primarily need calming and relaxation to prepare for sleep (and don’t have insomnia), consider supplements like L-theanine or chamomile, as they can be helpful for relaxation even if they don’t directly induce sleep.
37. Avoid Pre-Bed Glutamine
Avoid supplements containing glutamine before bed, as it can be activating and interfere with sleep, especially for those experiencing insomnia.
38. Take B12 in Morning
Take B12 supplements in the morning, not at night, because it helps boost light’s ability to suppress melatonin and can contribute to morning alertness.
39. CBD for Sleep (Low Hopes)
Approach CBD for sleep with low expectations, as research is murky, with some studies showing benefit, others no effect, and some even showing worsened sleep; its effects are likely secondary to anxiety reduction rather than direct sleep promotion.
40. Immediate Jet Lag Time Shift
For long-haul flights across many time zones, immediately adjust your mindset to the destination’s local time upon boarding the plane. Attempt to sleep during what would be nighttime at your destination, even if fragmented, and then power through the first day upon arrival with light exposure and activity.
41. No Naps for Jet Lag
Avoid napping while adjusting to a new time zone, as it can send mixed signals to your body and disrupt the adjustment process, especially if you drop into deep sleep.
42. Light & Melatonin for Jet Lag
Strategically use light and melatonin for jet lag: expose yourself to bright light during the destination’s daytime (no sunglasses in the morning) to signal wakefulness, and use melatonin at the destination’s evening to signal nighttime.
43. Exercise Upon Jet Lag Arrival
Exercise immediately upon arriving at your destination to send a strong daytime signal to your body, promoting alertness and helping to suppress any lingering melatonin from your original time zone.
44. Consistent Shift Work Schedule
For shift workers, aim for consistency in your shift schedule (e.g., permanently adapting to a night shift) to minimize the health damage caused by frequently shifting between different sleep-wake patterns.
45. Strategic Napping Techniques
Use strategic napping: for a ‘power nap,’ keep it short (15-20 minutes, or up to an hour earlier in the day) to avoid deep sleep; for a ‘sleep replacement nap,’ allow 2-3 hours to complete a full sleep cycle, beneficial for shift workers or athletes with disrupted nighttime sleep.
46. Treat Positional Sleep Apnea
If your sleep apnea is positional (worse when sleeping on your back), use a positional therapy device or a simple method like sewing a tennis ball onto the back of a t-shirt to encourage side sleeping.
47. Use Mandibular Advancement Devices
For mild to moderate sleep apnea, consider a mandibular advancement device (a dental retainer that pushes your jaw forward) to create muscle tone and keep your airway open.
48. Myofacial Therapy for Airway
Explore myofacial therapy or specific breathing exercises (like those used for didgeridoo playing) to strengthen upper airway muscles, which can help maintain muscle tone during sleep and alleviate mild apnea.
49. Mouth Taping Caution
Use mouth taping only if your issue is mild snoring or mouth-breathing without underlying sleep apnea; avoid it if you have sleep apnea and need to open your mouth to breathe, as it could worsen the condition.
50. Re-Test Sleep Apnea Treatment
If you’re using a sleep apnea treatment (like a mandibular device), get retested periodically (e.g., every couple of years) while using the treatment to confirm its continued effectiveness and ensure it’s properly adjusted.
51. Predictable Nighttime Routine (Irregular Schedule)
If your schedule is irregular (e.g., due to travel or shift work), establish a highly predictable nighttime routine, performing the same actions in the same order, and bringing familiar items (like a pillowcase) to create consistent sleep cues.
52. Find a CBTI Professional
Seek out a trained CBTI professional, either in-person or via telehealth, as specialized expertise can be crucial for effective treatment, though self-help resources can also be a starting point.
53. Overcome Bedtime Procrastination
Address ‘revenge bedtime procrastination’ by recognizing that improving sleep can lead to increased daytime efficiency and productivity, potentially freeing up more personal time during the day, rather than sacrificing sleep for late-night personal time.
54. Align with Chronotype
Align your daily schedule with your chronotype where possible; if you’re a night owl with early morning commitments, optimize your morning routine to be as short as possible to maximize late-night personal time, and maintain a consistent sleep-wake schedule seven days a week.
55. Understand Chronic Insomnia’s Root
Understand that chronic insomnia is often caused by ‘conditioned arousal,’ where the act of trying to sleep becomes predictably stressful, leading to a self-perpetuating cycle of activation and difficulty sleeping. This understanding is foundational for CBTI.
56. Self-Assess Chronic Insomnia
Self-diagnose chronic insomnia if you consistently take >30 mins to fall asleep or are awake >30 mins during the night, at least 3 nights/week for 3+ months, and it causes daytime problems, while giving yourself adequate sleep opportunity.
57. Consult Sleep Specialist for Problems
If you suspect a serious sleep problem based on wearable data or symptoms, consult a sleep specialist who can properly diagnose and treat the issue using established medical protocols, rather than relying solely on wearable metrics.
58. Sleep for Resilience & Performance
Prioritize improving your sleep to enhance overall resilience (physical, emotional) and boost cognitive and athletic performance, including reaction time, speed, and mental sharpness.
7 Key Quotes
The enemy of sleep is effort.
Dr. Michael Grandner
Sleep is not something that you do. Sleep is something that happens to you when the situation allows for this.
Dr. Michael Grandner
If I say bed sleep, bed sleep, bed sleep, bed sleep, I say bed, you say? Sleep. Correct. If I say bed sleep, bed wake, bed think, bed wake, bed sleep, bed wake, bed sleep, bed think, bed surf, maybe. Scroll. You have no idea. Right. You have no idea what's coming next. You can't predict the pattern.
Dr. Michael Grandner
People are not a good judge of how impaired they are due to sleep deprivation.
Dr. Michael Grandner
You cannot caffeinate away complex decision-making. You just make bad decisions faster.
Dr. Michael Grandner
A bathroom scale is not a weight loss program.
Amy Athey (attributed by Dr. Michael Grandner)
Sleep doesn't have to be perfect to be perfectly fine.
Dr. Michael Grandner
5 Protocols
CBT-I Stimulus Control for Insomnia
Dr. Michael Grandner- Reserve your bed strictly for sleep and sex; avoid other activities like scrolling, working, or ruminating in bed.
- If you cannot fall asleep within a reasonable time (e.g., 20-30 minutes) or wake up in the middle of the night and cannot fall back asleep, get out of bed.
- Go to another room or sit up in bed (not lying down) and engage in a non-stimulating activity until you feel sleepy again.
- Return to bed only when you feel genuinely sleepy.
- Repeat this process as many times as necessary throughout the night.
- Avoid adding stress or effort to falling asleep; surrender control and trust that sleep will come when your body is ready.
CBT-I Sleep Restriction (Restriction of Time in Bed)
Dr. Michael Grandner- Determine your current average actual sleep time (e.g., 6 hours of sleep in 8 hours in bed).
- Initially, restrict your time in bed to only the amount of time you are actually sleeping (e.g., 6 hours).
- Maintain this restricted time in bed consistently, even if it means feeling more tired initially, to build up strong sleep pressure.
- Once you are efficiently filling almost all of your allotted time in bed with sleep, gradually increase your time in bed (e.g., by 15-minute increments).
- Continue to expand your time in bed as long as you maintain high sleep efficiency, aiming for your optimal sleep duration.
Optimizing Morning Routine for Sleep and Alertness
Dr. Michael Grandner- Wake up at a consistent time each day, even on weekends, if possible, to anchor your circadian rhythm.
- Immediately upon waking, seek bright outdoor light for 15-30 minutes (e.g., a morning walk or run) to suppress melatonin and set your internal clock.
- Delay your first cup of caffeine for about an hour after waking to allow natural sleep inertia to dissipate and adenosine levels to rise, maximizing caffeine's later effects.
- Engage in physical activity or exercise early in the day, as movement is a powerful circadian phase shifter.
Jet Lag Adjustment Strategy
Dr. Michael Grandner- Before the flight, consider strategic, slight sleep deprivation to make it easier to sleep on the plane.
- As soon as you board the plane, mentally switch to the local time zone of your destination.
- If flying eastward (e.g., US to Europe), try to sleep on the plane, treating the flight duration as your nighttime, using eye masks, earplugs, and low-dose melatonin if needed.
- Upon arrival, immediately expose yourself to bright outdoor light and engage in physical activity to send a strong daytime signal, even if it's your biological night.
- Avoid napping during the adjustment period to prevent sending mixed signals to your body and to build up sleep pressure for local nighttime sleep.
- Use low-dose melatonin (0.5 mg) in the evening of the new time zone to help shift your internal clock earlier, if flying eastward.
Sleep Extension for Enhanced Performance (Younger Adults/Athletes)
Dr. Michael Grandner- Gradually increase your time in bed by 15-minute increments, aiming to go to bed 15 minutes earlier than usual.
- Ensure you are genuinely tired before attempting to go to bed earlier to maintain good stimulus control.
- Continue to increase bedtime by 15-minute increments as long as you are able to fill the extra time with sleep and feel benefits.
- Track objective performance metrics (e.g., speed, strength, cognitive sharpness) to observe improvements that may not be subjectively noticeable.
- Prioritize 'sleep banking' by consistently getting good sleep in the weeks leading up to important competitions or cognitively demanding periods, rather than solely focusing on the night before.