Ask Us Anything About… Insomnia

Description – The video begins inside a sleep research room at the Penn State Health Sleep Research and Treatment Center. Two people are standing next to each other. Standing from left to right is, Dr. Julio Fernandez-Mendoza and Scott Gilbert.

Scott Gilbert – This is, “Ask Us Anything About Insomnia.” I’m Scott Gilbert. At risk of sounding like a TV commercial, are you having trouble sleeping? And if so, you’re far from alone. Insomnia is one of the most commonly reported sleep problems. If you’re one of those thousands and thousands of people who suffer from it, that’s probably little consolation. But better for you, may be some information of the causes and treatment of it. And that’s why we’re calling in Dr. Julio Fernandez-Mendoza. He’s a clinical psychologist here at the Penn State Health Sleep Research and Treatment Center. Dr. Mendoza, thanks for being here today.

Dr. Julio Fernandez-Mendoza – Thank you for having me.

Scott Gilbert – Sure. Love to talk to you a bit about insomnia. And start with the basics. I mean, for example, we all have trouble sleeping sometimes. Where is that line? Where is that considered insomnia, versus just a little trouble getting to sleep?

Dr. Julio Fernandez-Mendoza – Like, the difference between poor sleep and insomnia as a disorder, right? So, as you mentioned, most people have difficulty sleeping, for example, in relationship with stressful events. And it may not be necessarily traumatic. But actual hassles that you have in a daily basis. Work related, like an important meeting the next day. Or, for example, going on a trip, right? We all have had the experience of having to go on a trip and the previous night, sleeping poorly. Well, that is not a disorder. That’s just normal. Poor sleep is part of life. But there is 10% of the population that actually would have chronic insomnia. And we have that very well identified. So, people with chronic insomnia are those who have difficulty falling asleep or staying asleep. Or something called early morning awakening. Which is when you wake up earlier than desired, way before you have to. And those sleep difficulties happen at least three nights per week. And they have to be associated with some form of daytime impairment. And that daytime impairment can be fatigue, which is very common. But also, mood disturbance or social discomfort. Or even poor work performance. And a very important one is daytime impairment in the form of being worried about your insomnia in itself, right? Apart from that, then we define it as chronic, when it has happened at least three months or more. Now, in my clinical experience, most people with an insomnia disorder, have had it for years.

Scott Gilbert – And so, that’s chronic insomnia. Acute insomnia is what? A more confined amount of time?

Dr. Julio Fernandez-Mendoza – Exactly. Acute insomnia would be that that happens within the first three months. And resolves by itself. Now, traditionally, we always use the cutoff of one month. Because technically, when you have acute insomnia, it is usually stress related. Or maybe actually insomnia symptoms. So, basically, poor sleep when you’re going through a stressful event. Or an acute medical condition. So, here I always bring up an example of when you have not so much a chronic pain problem, but an acute pain problem, you may sleep poorly that night, too. But it doesn’t mean that you have a disorder. So, it’s an acute phenomenon that resolves by itself.

Scott Gilbert – You’re watching “Ask us Anything About Insomnia,” from Penn State Health. I’m Scott Gilbert, alongside Dr. Julio-Fernandez-Mendoza, who welcomes your questions. Just put them in the comment field, below this Facebook post. Whether you’re watching this video live or on playback. And we’ll make sure we get you some answers. Either in this interview or in the comment field. Dr. Mendoza is a clinical psychologist here. Also, you’re part of the Behavioral Sleep Medicine Program, here at Penn State Health. I want to take a bit of a left-hand turn here and talk about that. Because it’s one of the few of its kind in the country, right?

Dr. Julio Fernandez-Mendoza – Right. So, there are very few board-certified behavioral sleep medicine specialists in the country. We are right now about 300 something. It’s kind of like the tip of a specialization for those of us who have the training in behavioral principles and practice. Meaning, usually clinical psychologists. But there are also medical doctors who are board certified in behavioral sleep medicine. Although, most of them would go through the pure sleep medicine route. And behavioral sleep medicine, just to put it very simple, it would be treating sleep disorders, without using medications. And relying on behavioral, evidence-based treatments.

Scott Gilbert – All right. We’ll be getting into some treatments for insomnia, here in just a little bit. First, I want to talk about who it occurs in most? Men versus women? Is there a disparity there?

Dr. Julio Fernandez-Mendoza – So, yeah, unfortunately, we’ve known for many decades that insomnia affects women disproportionately much more in a two to one ratio. In certain periods of life, actually, that goes up to four to one. The interesting thing and we have contributed to do this research, is that not only it affects women more often, but also earlier in life. So, we know that something important, right, happens in women during puberty. So, girls at the age of 11 to 12 years old, are also more likely to start to reporting insomnia symptoms early on. So, we know that in women, it is not just what’s traditionally believed in a very kind of like sexist way. That it was just because they were more likely to be anxious and depressed. We know that that is not a real scientific fact. In women, insomnia shows up earlier, associated already with early sprout and development of periods.

Scott Gilbert – And how about children? Do children experience insomnia the same way that adults do or differently?

Dr. Julio Fernandez-Mendoza – Good question. That is an excellent question because I’m very sure many parents out there are questioning well, I have insomnia, is my kid going to have insomnia? So, what we do know is that there is a specific, what we call phenotype. Or basically, a specific type of problem in children that we call behavioral insomnia of childhood. And this is what most parents experience. And it is the inability of the child to fall asleep by themselves, at a certain developmental age. Of course, early on, it’s important that a child may need their parents to fall asleep, right? But that is a different phenomenon. Now, as a mentioned before, in girls, we start to see those insomnia symptoms that are independent of those developmental problems. And at that point, we can start to see what we would say is adultlike insomnia. So, we know that in adolescence already, many kids, if you can call them that way. Already have the characteristics that I was mentioning before. The frequency of the insomnia symptoms at night, three times per week. And a duration of more than three months. Daytime impairment, you name it. Like, basically, at that age, clearly, they start to have the phenotype or the subtype that we usually see in adults. Now, do they require other diagnostic and treatment approaches? Yes. So, for example, myself, together with Dr. Calhoun, we overlap in seeing adolescents in this clinic. And many adolescents go through a developmental stage in which their body clocks shift. So, this is the complaint of many parents, right? Oh, my kid goes to — falls to sleep late and wakes up late. And it’s very difficult to wake them up. That is a different problem. It’s not necessarily insomnia. So, we’re — here, we’re talking about insomnia, even accounting for the fact that may be having a normal developmental shift in their body clock.

Scott Gilbert – And as we mentioned, we welcome your questions for Dr. Mendoza, here on “Ask Us Anything About Insomnia.” We have a question from Jen, now. She says, “She’s currently being treated for an autoimmune disorder.” And she says “She’s on Humira and 40 milligrams of prednisone.” “This is greatly affecting my sleep.” “Is there anything that can be done to help?”

Dr. Julio Fernandez-Mendoza – Yeah. That’s a great question. So, having an autoimmune disorder, I would highly recommend, Jen, to go to a sleep specialist. Not because they are going to give her the right answer. But because multidisciplinary care is essential, in this type of disorder. So, that’s number one. Second, obviously, medications, such as some of the ones that she’s taking, can disrupt significantly sleep. Especially things such as prednisone, can produce difficulty falling asleep. So, I would not, especially in this type of setting, ever recommend stopping any medication. What I would recommend is that you talk to your prescribing doctor. And request a referral to a sleep center. And get, first a consultation from a sleep doctor, like myself or any sleep — other sleep physicians. And also, get potentially a sleep study.

Scott Gilbert – That’s good advice there. And I’m wondering, is that a common thing? That is, do you see a lot of patients who have insomnia, secondary to a medication that they’re taking for an unrelated condition?

Dr. Julio Fernandez-Mendoza – Well, yes. And you’re right, it’s called — before we should have mentioned. That when we diagnose chronic insomnia as a disorder, we also always account for the fact that there may be potential medications that are causing the sleep disturbance. However, once it’s chronic, when it has lasted for ten years, it’s very likely that the medication may be worsening the problem. But not necessarily the cause. In those cases, usually they are resolved within our great family doctors. They are very good at figuring out oh, we put you on too much of a dose of this medication that is disrupting your sleep. And we can control you. And I see that at Penn State Health. That most of our internists and family community medicine doctors, are very good at managing coexisting medications.

Scott Gilbert – We have another question now from Rachael. She says, “I have insomnia and I can’t sleep without Trazodone.” I believe I’m saying that right. “Will I ever be able to get off of it?” Now, of course, we’re getting some rather specific questions. And the only cautionary note I’d throw out there, is obviously, Dr. Mendoza can’t diagnose you without seeing you. But just any general advice there for her?

Dr. Julio Fernandez-Mendoza – Right. So, we have good news. In fact, I was just telling Scott, before the interview, that about three years ago or so, there was a big — a very important event in the healthcare field. And it’s that an independent society. And when I say independent, means that it was not the American Academy for Sleep Medicine, the Sleep Research Society. Or more recently, the Society of Behavioral Sleep Medicine. Which are the societies that most of our sleep specialists belong to. But the American College of Physicians, came out — they did their own meta-analysis. Which means, their own study among many studies. And they put out guidelines, for us, for all practicing clinicians. And they said, cognitive behavioral treatment of insomnia, also called CBTI, is the first line treatment for insomnia. Now, we just mentioned that there are very few people in the country trained in that type of treatment. But it’s available here at Penn State, in other places. And it actually has a very effective treatment rate. Now, is that — does that mean that CBTI will get you off a sleep medication? In some patients it does. So, there are some patients that do remit with the — or in other words, that their insomnia resolves with CBTI. And they actually undergo with us, a discontinuation of their sleep medication. Because they have received the tools that CBTI provides you. Now, however, and this is important in a public setting like this. There are some subset of patients that may require long-term use of medications. Why? Because their remission rate with CBTI, although it’s large for a behavioral treatment. It’s about 45%. So, that means that you have, at the offset of treatment, 45% chance of your insomnia going away, okay? So, with the medication though, there is a subset of patients that may require it.

Scott Gilbert – So, really, what you’re saying is and this kind of speaks to the last question. Medicine may be presented sometimes as the only option. But it really is not.

Dr. Julio Fernandez-Mendoza – Absolutely. And we know now a days that CBTI should be the first way to go. And then based on treatment response, you may introduce a drug, a medicine.

Scott Gilbert – We’re coming to you live from the Penn State Health Research and Treatment Center. This is “Ask Us Anything About Insomnia,” from Penn State Health. Dr. Julio Fernandez-Mendoza, is a clinical psychologist here. And he welcomes your questions. It looks like we have one here from Brooke. She’s asking, “If there are tips for how to naturally get through insomnia.” She says, “She tries not to use medications.” “And she tries to avoid screens, right before bed.” So, are there any other options there that, I guess, behavioral would be a natural way. A good example.

Dr. Julio Fernandez-Mendoza – Right, right. So, she’s already doing sleep hygiene. So, I like to say that a sleep hygiene measures are like lifestyle, right? We all agree that having a good diet is good for you. Whether you’re obese or not. Whether — we all agree that enough physical activity is good for you. Whether you are obese or not. Whether you have diabetes or not or heart disease. So, sleep hygiene’s are almost like preventive measures, right? That we like to recommend to the public. And is one of the first things that people, who are suffering from persistent insomnia, first change. They stop drinking alcohol. They reduce the level of caffeine, or the things that she was talking about. Now, the problem is, if you’re making all those changes and you still see that you have a persistent insomnia problem. Then indeed, before medication, as we were just saying. There are specific behavioral tips that we can give to the general public. And one of them, for example, is get up every day at the same time, no matter how much you got. How much sleep you got. Which is something very difficult for people with insomnia to do.

Scott Gilbert – You can’t sleep in for three hours on the weekend?

Dr. Julio Fernandez-Mendoza – Right. Or laying in bed awake, you know, if you woke up at 4:00 a.m. And then staying there until 6:00. Second rule, don’t stay in bed awake, trying hard to sleep. Which is a very difficult mechanism of perpetuation of insomnia.

Scott Gilbert – So, instead get up and do what?

Dr. Julio Fernandez-Mendoza – Get out of bed. Go into another room, if you can. Read a book, like, an only at night book. Relaxing with dim lights or even no lights. I like to say, you know, the light that comes through the window. And remember that the goal is not to stay out there awake. It’s actually to go back to bed, when you actually feel sleepy enough to resume sleep. The same rule will apply if you simply are worrying in bed. So, for example, you don’t have to wait for 20 minutes, until you get out of bed. If that night you feel that you’re racing, your mind is racing. Just prevent it from going to bed. Wait until you’re calm and go to bed. Another important thing is never to compensate for a sleep loss. And therefore, never nap. But there is a very interesting story about napping and insomnia. That maybe you want to ask me about? But that would be for later.

Scott Gilbert – Well, it is interesting to know that many people with chronic insomnia actually don’t feel sleepy. They don’t nap. They don’t sleep in. And some of these people have only slept four or five hours.

Dr. Julio Fernandez-Mendoza – Exactly.

Scott Gilbert – Why is that the case? Why don’t they feel compelled to do those things?

Dr. Julio Fernandez-Mendoza – Right, right? So, that is one of the most fascinating things with chronic insomnia. Is that despite sleeping short, they don’t feel daytime sleepiness. Which is different than daytime fatigue. Fatigue is the physical and mental feeling of tiredness, without a sleep propensity. You know, many times popular expressions are very good. Many people have said, I was so tired that I could not fall asleep, right? So, many people with chronic insomnia, what happens to them is actually they don’t have the sleep propensity during the day. They feel exhausted. But they try to nap and they cannot nap. So, you were saying, why is that? Well, I like to explain to my patients that we see insomnia, not so much as a sleep disorder, but as awake disorder. That you’re too much time awake during the night. But also, that you are too awake. We call that hyper arousal. That insomnia is a disorder of too much activation.

Scott Gilbert – Well, we welcome your questions for Dr. Julio-Fernandez-Mendoza, as part of “Ask Us Anything About Insomnia,” from Penn State Health. As we’re here in the Sleep Research and Treatment Center on the Milton S. Hershey Medical Center on campus. We have a question or a comment now from Becky. She says, “Her husband stops breathing for ten seconds, then breathes heavy.” “He won’t go to sleep.” Any recommendations there?

Dr. Julio Fernandez-Mendoza – He needs to get a sleep study. That is a clear, not only a symptom. A symptom would be you hearing him snore. But when you observe a breathing pause like that, that is a clear sign of potentially sleep apnea. And I would strongly recommend that you convince him to go get a sleep study.

Scott Gilbert – Yeah. We can probably do a whole separate program on sleep apnea, sometime.

Dr. Julio Fernandez-Mendoza – Sure, sure.

Scott Gilbert – Because that’s a very important topic.

Dr. Julio Fernandez-Mendoza – Absolutely.

Scott Gilbert – And something people should be aware of. So, I very much appreciate that question. Now, when we talk about inability to sleep, when we try to sleep. I think about the time when I used to work third shift. And I’d try to get to sleep around 7:00 or 8:00 a.m. And sleep until at least 2:00 or 3:00, if possible. The body didn’t want to do it sometimes. So, are there other factors at play there? And any tips for third shift workers, who may feel like they have insomnia, for that reason?

Dr. Julio Fernandez-Mendoza – Okay, very good question. So, what — people who are shift workers or basically unconventional work schedules. Because we consider shift work, even if you are on a fixed early morning shift. Like, if you have to be at work at 4:00 a.m. in the morning, that for us a shift work. And we call that problem, a circadian rhythm disorder. Just to put it simple, the idea is that your work schedule is changing the way your brain regulates your body clock. And it is very well identified as shift work, sleep disorder. Not everyone who does shift work actually develops a sleep problem. But many people develop, as you said, inability to sleep. Which we would call insomnia, when they need to, right? In the morning, for example, if you do the third shift. But most people with that type of problem also have then excessive daytime sleepiness. In other words, because of the third shift, you cannot sleep, maybe during the morning. But then in the evening, before going to work, you actually feel very sleepy. And it’s more than fatigue. You really need to take a snooze. You really need to take a nap. So, for shift workers, I would recommend many things. It goes above and beyond chronic insomnia. It’s a very specific type of disorder. And now a days, in most multidisciplinary sleep centers, like ours, where we have different specialties behind. We usually treat these patients in a comprehensive manner. So, they sleep a sleep physician. They see a sleep physician with a psychiatry background. With a pulmonology background. They may see myself, as a clinical psychologist behavioral sleep medicine expert. Because it requires a multi approach. Not just medication or behavioral treatment.

Scott Gilbert – Well, it happens right here at the Sleep Research and Treatment Center at Penn State Health. Another good question here from Nicole. She’s asking, “If there’s a mindfulness app that you can recommend?” “Will this help,” she says, “For someone who is unable to fall back to sleep after waking in the middle of the night?” So, we might broaden that out, even just to talk about meditation as a tool, to try to fall back asleep.

Dr. Julio Fernandez-Mendoza – Well, Nicole, you’re asking a question right on target. In two weeks, we invited Jason Ong, who is also a clinical psychologist, like myself. Board certified in behavioral sleep medicine, who wrote a book on “Mindfulness Based Behavioral Treatment of Insomnia.” So…

Scott Gilbert – Good timing, Nicole.

Dr. Julio Fernandez-Mendoza – Right, it’s perfect. He’s coming in two weeks to give rounds here. I personally invited him. And the thing though, is that his type of treatment, which is also evidence based, incorporates CBTI. In other words, mindfulness meditation in itself, by itself, may result in some patients their — a little bit of their chronic insomnia. But not to the extent that it would be if it’s combined with CBTI. Which is cognitive behavioral treatment of insomnia. So, what I would recommend you, is that — and you can Google this. There is a lot of information out there that you have apps that are CBTI based. As well as some meditate — mindfulness meditation ones. What we do here, for example, we don’t use mindfulness meditation. So, my colleague Dr. Ong, is going to hit me when he comes. But we use relaxation therapy. Such as deep breathing relaxation. And progressive muscle relaxation, as an adjunct to the CBTI core components, okay? But yes, go ahead. Of course, if it’s going to help reduce your stress levels and so forth, it will help — it may help with your insomnia.

Scott Gilbert – Very good question. Another one now from Tracey. She’s asking, “Is Lunesta okay to take long-term?” And this is one of a few questions we’ve actually had about Lunesta.

Dr. Julio Fernandez-Mendoza – Right, yes. So, Lunesta has become a very popular medication. They mentioned before, the second most widely prescribed, which is Trazodone. The first one is Ambien, Zolpidem. Many of you are familiar with it. And actually, Lunesta I see it more and more prescribed. I don’t prescribe medication because I’m a behavioral sleep medicine doctor. But my colleagues use it. Especially for people who have difficulty staying asleep. Because it’s a medication that, as compared to Zolpidem, it helps you remain asleep a little bit longer. Now, most of my colleagues, sleep physicians, would say they don’t like people to stay on medications for a long period of time. The reality is that, as I mentioned before, the availability of behavioral treatment of insomnia, is not huge. I mean, we’re only 300 board certified. And we’re training other people now a days. But of course, I would recommend that you try to search for also behavioral therapy-based things. So, just to see whether you’re one of those patients who can basically taper off the medications.

Scott Gilbert – What are — and we touched on this a bit earlier. But what about when people try to self-medicate? They think, you know, I’ll relax after a glass of wine or a beer. And maybe that’s all I need to get a good night’s sleep?

Dr. Julio Fernandez-Mendoza – Big problems. So, alcohol has a huge — and here, without sounding moralistic. It has nothing to do with that. There is a — we know that actually those people who drink on a daily basis, just for example, one glass of wine. Have a better cardiovascular risk, okay? So, this is more related to sleeping itself. When you are a poor sleeper, drinking alcohol, at that time, to self-medicate, is the worst thing you can do. For two reasons. First, because of the impact that it has on the sleep itself. Most people who will do that, they will get much lighter a sleep in the early morning period. The second half of the night, their sleep is going to become very disrupted. Because your organism is getting rid of that alcohol, okay? But the second problem is the following. The frustration of not sleeping well and using alcohol as self-medication, can develop into a substance abuse problem. Especially in men. So, this is a huge issue of many individuals who were otherwise, I would say normal users of alcohol. Because of the suffering from insomnia and trying to self-medicate through that mean, actually developing, when they come to the clinic. You start to see that they drink way much more than they think. And they have developed actually a substance abuse problem.

Scott Gilbert – Oh, wow. Now, if people are out there thinking, well, you know, I have a bit of insomnia here or there. Okay, maybe it’s almost every night. But it’s something I can live with. Are there long-term health problems that can come about by people just to suppress their insomnia? But still not getting the night sleep they should?

Dr. Julio Fernandez-Mendoza – Oh, that’s a good question. Because you’re factoring in — two, basically. Is insomnia associated with adverse health consequences? But then you were saying, among those people who are, let’s say poor sleepers. But not necessarily have chronic insomnia. Well, we know that only a subset of those poor sleepers are at risk of significant health consequences. Such as high blood pressure or diabetes and the like. The group that is at risk is those with chronic insomnia. Now, the good news though, is that a whole lot of research, that actually we have contributed significantly at Penn State, together with Dr. Vgontzas here. Is that among those people with chronic insomnia, not everyone is at risk of things such as cardiovascular disease. So, this is kind of like a 50% message to the public. Is some of you guys with chronic insomnia, are not at risk of cardiovascular disease. Because your insomnia is mainly related to very specific mechanisms that are not putting you at risk of developing this problem. Bu there is another subset of people, about 50% of them. And those are the ones that have chronic insomnia. We studied them in the lab. And they are not able to get in the lab. Not at home, more than six hours of sleep. That subset is individuals that we start to see that, indeed, they may be at risk of developing health consequences. But as I said, it’s a combination of difficulties sleeping and the short sleep, as measured in the lab.

Scott Gilbert – You may not know which subset you fit into.

Dr. Julio Fernandez-Mendoza – Unless you have a study.

Scott Gilbert – Right, exactly. You’re watching “Ask Us Anything About Insomnia,” from Penn State Health. Some great questions. Keep them coming for Dr. Julio Fernandez-Mendoza. He is a clinical psychologist here at the Penn State Health Sleep Research and Treatment Center. A question now from Ann. She says, “Her husband went to the sleep clinic here at Hershey.” “He’s now on a CPAP machine and sleeps much better.” She says, “The machine is very quiet and gives us all better quality of sleep.” She says, “I strongly encourage your husband to encourage — to consider the appointment and the follow-up.” And she wishes good luck. That’s obviously in response to a previous comment, there. But good words from Ann. So, Ann, thank you very much for that. And we’re very glad to hear that your husband’s doing well on that treatment. So, and again, that sounds like — a CPAP, is usually a treatment for sleep apnea, correct?

Dr. Julio Fernandez-Mendoza – Correct, correct. CPAP, BiPAP, any type of mechanism like that is for sleep apnea. And is not a treatment for insomnia. However, some people with sleep apnea, even when they are put on CPAP. Because they have had a longer history of insomnia, actually end up needing treatment for their insomnia. Once their sleep apnea is under control. And this is a type of patient population that we see here often, combined disorders.

Scott Gilbert – Some great questions. And further proof, I think we’re going to have to come back here. Invite ourselves back to the Sleep Research Treatment Center for and “Ask Us Anything About Sleep Apnea,” sometime. Because those are really good questions. A very important topic. It really is a very important health problem, as well. So, Dr. Julio Fernandez-Mendoza, we appreciate your time today. Thanks so much. And we also appreciate you and all the great questions you’ve asked, as part of “Ask Us Anything About Insomnia,” from Penn State Health.