Lois Maharg is a writer and researcher who has lived with insomnia since her teens. In her well-researched book, “The Savvy Insomniac”, Lois takes an ‘in depth tour through the world of the sleepless’, visiting sleep clinics, researchers and talking to fellow insomniacs.
Covering the history of insomnia and the cultural attitudes toward it, insomnia treatments and the latest cutting edge research, The Savvy Insomniac is a comprehensive and accessible guide to the world of insomnia.
Jeff: Great to have you here. How are you doing today?
Lois: Oh, I’m just fine, just very interested in talking about insomnia and sleep.
Jeff: Yes, yes, me too, me too. I really enjoyed your book. It took me a long time to get through it because there’s so much stuff in there, the chapters are nicely spaced out into different subjects, so I was dipping in and out but it’s very dense, there’s loads of great information and research in there, so it’s taken a little while to come round to get to interview you but I’m really looking forward to the opportunity to talk to you about your book. I’ve got a few questions here, so can you tell us a bit about your background and what compelled you to write a book about insomnia?
Lois: Well sure. I have been sort of a shaky sleeper all my life, of course I can’t remember my sleep when I was a baby but my mother says that even as an infant I would wake up a lot if there were noise, so for example any dog barking or phone ringing or door shutting or anything like that. I think I’ve been a light sleeper even from the get-go and then my first memory is of being in 4 year old kindergarten and noticing at nap time I could never fall asleep, whereas the rest of my class mates were all just sort of sawing logs, you know that kind of deep breathing, that baby breathing and so from the get-go I think I was a short sleeper, a light sleeper and around college age was when I started to really feel like sleep was a struggle. I think in combination with the stresses of college life, you know, testing, performance, I was in a music program back then.
Jeff: For us UK fellows, college, that’s university age I guess, is that sort of 18?
Lois: Yeah right, right about that age it became a struggle and of course I’d looked out and you know what could be available for a person like me in terms of getting help and I read books and looked at magazine articles and even went to doctors but the recommendations there were fairly simplistic, you know, don’t drink coffee, don’t drink alcohol at night, you know, don’t read in bed and these were not things that seemed to help me very much, so I decided after years and years of suffering insomnia that I was going to go out and investigate the problem on my own and so that led to my book and also my website; The Savvy Insomniac.
Jeff: Okay. What was the journey to completing the book? Did it take you, was there a lot of research that went into there?
Lois: Oh gosh, yes, I’ve never quite done such an involved project in my life. I hate to confess this but it was 8 years that it took me. I did lots of book research at first to get myself up to speed in the field and then I went out to talk to other people with insomnia, quite a number of those because I felt that they would really embellish my story if I could include some testimonials from them. I also interviewed quite a few sleep experts. I went to conferences and seminars on sleep and sleep disorders, so it was a project for many years.
Jeff: Yeah, it really comes across the depth of research in the book. I’ve got to say I’ve read quite a few books in my own research for sleep junkies and a lot of them specially the insomnia books tend to come across as more general advise, less scientific, more let’s say self-helpy type books but you’ve obviously spent a lot of time talking to patients, doctors and health professionals as well.
Lois: That’s right. I think I aimed to do two things. One was to explore the topic in the fullness that I felt it deserved. Trouble with a lot of self help books is that they leave that part out but then I also wanted to provide some assistance to people who were looking for solutions. I mean one big motivating factor for me was looking for solutions for myself, so it’s kind of neither fish nor fowl but well sort of a little bit of both; informational but also self help.
Jeff: Now when people think they might have some symptoms of a medical problem they often turn to the internet before they’ll see a doctor and often this leads to conflicting advise, a lot of confusion, specially in the case of something like insomnia, so what’s your view on the type of information that you can get these days online and also could you explain the differences between some of these different categories of insomnia, chronic insomnia, acute insomnia, paradoxical insomnia, it can be pretty confusing at the best of times.
Lois: I think that there is quite a lot of information about insomnia on the internet and there are the trusted sources such as, you know the Mayo Clinic website, WebMD is a good website. The National Sleep Foundation is a good website, I mean all of those are going to give you the latest research, not in detail of course, but the latest recommendations in terms of how you can improve your sleep and I think those are good websites as far as they go but they don’t delve very far into the research and they certainly don’t, as you mentioned there are many different kinds of insomnia and one thing I found when I started interviewing people with insomnia is that we present with all kinds of different symptoms and so based on symptoms, the specialists, the researchers, have made these different categories for insomnia, which are good because some categories, for example idiopathic insomnia is the diagnosis given to people who had insomnia beginning in childhood and that’s assumed to have a rather large biological component and so that might be treated in one way whereas psychophysiologic insomnia, which is sort of the most common type of insomnia and it usually develops when we’re adults, you feel wound up and you have anxieties about sleep and you are prone to intrusive thoughts at night and so forth, that is another diagnosis and it might be treated in a different way than idiopathic insomnia would be treated, so it is hard to find information that’s very detailed on the web and so I usually suggest to people, especially if they have been to the doctor and are only getting advice about better sleep hygiene, you know, cut out the caffeine, don’t read in bed and so forth. I usually suggest that people go to sleep specialists, people who are specialists in behavioural sleep medicine or doctors who know something about sleep because they’re more likely to be able to really give a thorough diagnosis and the best course of treatment for you.
Jeff: I want to talk about what you discussed in chapter 5 of your book. Insomnia is one of those subjects where sometimes people might feel a bit ashamed or a bit embarrassed to discuss it because it’s just not really perceived as a, to a lot of people, as a real serious health condition and chapter 5 I found really interesting because you go through the last couple of centuries and there are different ways that doctors and society is basically viewed, insomnia, and it seems that those attitudes haven’t really changed very much up until very recently. Can you tell us a few of those old attitudes?
Lois: Sure, sure. The stigma of insomnia is something that I found that some people would say “Yes, yes I avoid talking about this because I’m just worry about how people are going to regard me.” But other people say “No, no, everybody can relate to not being able to sleep.” So I do think that this is a stigma, like a stigma attached to mental illness for many many years. I think this is a stigma that maybe slowly dying out but I always felt that I shouldn’t mention my insomnia to other people because it might have, they might think that I was neurotic or they might think I was making a mountain out of a mole hill or that I was overly emotional or they might think that I’m repressing my emotions and they’re coming out at night or I was doing something wrong like drinking too much coffee in the morning or in the evening or something like that, so it was always the idea of they would draw conclusions about me that I didn’t want them to draw. And so one of the things about that I wanted to investigate when I started my book was well where did these ideas come from? They had to come from somewhere, they didn’t just come out of thin air. And so I found that over the last couple of centuries, these ideas were prominent in the early 19th century, the idea was that in you were, in some way misbehaving. If you had insomnia that was indicative of the fact that you were going to too many parties at night or you had the bedroom all shut up at night, whereas then in the 20th century, it became more of a mental thing.
You had sort of a disease of mind, a mind disease and so it was all in your head, you were imagining this, you were sort of a hypochondriac, you were wanting attention from others, you were wanting to shirk your responsibilities and so forth, so I felt that before I got into the actual science of insomnia and science of sleep, I needed to sort of dispense with these attitudes because I think they keep us from talking about the problem and they keep us from reaching out for help and now there’s plenty of research suggesting that insomnia, chronic insomnia is associated with all kinds of health problems.
You’re twice as likely to develop clinical depression if you have chronic insomnia, it’s associated with anxiety, it’s associated with hypertension and heart disease and diabetes and obesity. So it’s not just a trivial problem, it really, really is something that needs to be, you need to go out and get some help for.
Jeff: I like the term that you use, Multifactorial.
Lois: Yes, yes. That word, that’s what they’re using these days. It’s assumed that there is some biological component, some genetic component and the exciting thing I think now is that they’re starting to identify candidate genes that might lead to, lead a person to be more vulnerable to developing chronic insomnia but also stress, the stress, environmental situational factors, play a very big role in the development of insomnia as well as some psychological factors and coping strategies and you know habits and behaviours that we adopt. So it is as I said before, a multifactorial disorder.
Jeff: I think it’s very interesting times at the moments. There seems to be a lot of advances in science with studies into the brain, biology, even psychology and a lot of these sciences tend to become together and hopefully over the next few years we’re going to be making a lot of breakthroughs into the way that we understand sleep.
Lois: Yes, yes, well I know that the 21st century is supposed to be the century of the brain and it looks like that’s the way we’re heading.
Jeff: Definitely, definitely. I wanted to talk a little about the current state of medical care and diagnosis for people with insomnia, another sleep issues. I was quite surprised when I came across a review where in 2005 and in a nut shell it basically revealed that most doctors receive very little specific training in sleep related health issues and I know that sleep clinics are becoming more common, also in the States then over here in the UK, the thing with sleep clinics is they’re expensive and obviously not everyone has access to them, so what are your views on the current state of health care for people with insomnia and sleep related health issues?
Lois: I think there are a couple of issues that you’re raising here, one is the issue of doctor training and I’ve looked at several sources that indicate that yes, in the field of sleep medicine and insomnia which is a part of that, general practitioners and internists receive a very little training, maybe up to 3 hours if that in the entire field of sleep medicine. So that’s the reason why I think a lot of people are not so happy when they go to see their family doctors about insomnia because as you point out, in this day and age of managed care, where maybe the appointment is going to last for 10 minutes, there’s just not enough time to delve into sleep issues in the way that there needs to be sufficient time, a series of question about how long has this lasted, you know, how severe is the problem and so forth and what are your symptoms. So that’s the reason why I suggest, especially if people been around the block with this issue for a while and haven’t gotten anywhere with their family physician that it might be time to go to a specialist. But the issue of sleep clinics is very interesting because it is true that sleep clinics are very expensive and I sort of see them as becoming less important rather than more, in terms of diagnosing sleep complaints. But one thing you can say is that they’ve worked fabulously for people who are suspected of having sleep apnoea, which is a very severe breathing problem. You can go in and then in half an hour or an hour’s time you can determine whether or not that person is suffering sleep apnoea and that’s a great thing.
Jeff: Because often people don’t even realise they’re suffering from sleep apnoea because obviously they think they’re asleep whereas…
Lois: That’s right, that’s right. Another thing that can be detected very quickly or at least in one night of a sleep study is Restless Leg Syndrome or things like Cardiac Arrhythmias or REM Sleep Behaviour disorder where people are acting out their dreams. The sleep study is very good at detecting those and based on the findings then the doctor can go ahead and prescribe a course of treatment. What I expect though, is because sleep clinics are as expensive as they are, is that whole monitoring devices will come into more frequent use now, just to cut the cost. I am aware that one of those has been developed now and so I would look to doctors using, relying more on those home monitoring devices to diagnose those problems that I’ve just mentioned but the issue is that with insomnia, there are two reason why looking at sleep as one would do in a sleep study isn’t the ideal way to diagnose it. One is that the sleep of people with insomnia tends to vary quite a lot from one night to the next and so if you’re just going in for a single night sleep study, that’s not going to be very indicative of the problem overall. But the second thing is that when people with insomnia go in for sleep studies, 50% of the time, their study, the results of their study look exactly like the results of normal sleepers so it just doesn’t discriminate very well, at least as it is conducted today. It doesn’t discriminate very well between normal sleepers and people with insomnia and so I also look for home monitoring devices to start to be used with insomnia sufferers more, but I suspect that they need to be more nuancedthey need to be more finely tuned, maybe to pick up the trouble that insomnia sufferers have at night
Jeff: You’re saying basically for insomnia is…. the one night in a sleep clinic isn’t really going to necessarily cut it.
Lois: Yes, yes, there wouldn’t be much helpful information that you could find after one night and quite frankly it wouldn’t lead to any particular course of treatment that wouldn’t also be determined by a good diagnostic interview at the doctor’s office.
Jeff: I wanted to talk a little about different types of treatments for insomnia. Now broadly speaking there are two approaches. There’s a drug approach or pharmacological approach and a behavioural approach. A lot of people are very anti sleeping pills, afraid of side effects, afraid of getting addicted to sleeping pills. Interestingly I found in your book you have much more of an open mind and you talk about how a lot of people can actually benefit from different types of medications for insomnia as well as the down sides. So could you just talk us through briefly these two different approaches to treating insomnia?
Lois: Oh sure, I do discuss this a lot I think in my book, on my book is very treatment oriented towards the end of the book. And there is a pharmacological approach to treating insomnia and then there is the behavioural approach as you mentioned and I think both are good in different scenarios. I think both have a place. With pills people like them because they’re quick and easy and there are many doctors who believe and I do too, that with acute insomnia, something has happens because of a major stress in your life, whether it’s a divorce or you know a major illness or something like that, that prescribed for the short term, that sleeping pills can help you get through that stressful period and they can prevent chronic insomnia from developing further down the line because what happens when you have an acute bout of insomnia that’s associated with stress is that you start sleeping poorly and the majority of people will come through this stressful period and then after that their sleep will resume as it always was but for about 25 to 40% of people going through a stressful event where they’re sleeping poorly, this is going to put them on the track to some form of persistent insomnia down the line.
And so there are some doctors and I agree with them, that prescribing sleeping pills in the short term for very serious and short in duration insomnia is a very good thing however with long term insomnia, with chronic insomnia, by the time it has gotten to this point you can really debate how good a strategy the use of sleeping pills is at this point because it does, even some of the more recent sleeping pills, they do change the nature of sleep and that’s still debated about how important is that, is that detrimental to health and there’s some suggestion that it is, that it does degrade the quality of your sleep and it may be associated with vulnerability to more illness as we age and even greater mortality. So long term use of sleeping pills is probably not a first choice strategy. The other strategy is of course the behavioural strategy that you mentioned. It’s called “Cognitive Behavioural Therapy for Insomnia.” And the upside there is that it is a strategy that can be used by people who don’t want to take drugs and the down side is that of course that it’s a little slower than sleeping pills, it will take you a couple of weeks of going through a stage where you feel a little bit sleep deprived and so you’re not at the top of your game and it does require some will power and that it’s a pretty exacting protocol. You are only allowed to be in bed a certain number of hours at night and you need to refrain from staying in the bed if your awake for beyond say, 10 or 15 minutes and so it requires some will power but the upside to that is that eventually using the strategy, many people, it’s about 70% to 80% of the people who try it, their sleep does improve, their sleep maybe a little bit longer, their sleep quality improves and their sleep efficiency improves.
More of the time they’re in bed. They’re actually sleeping as opposed to having frequent wake ups and so forth. So yeah, with chronic insomnia the behavioural strategies are certainly, I think what most people would prefer however I am not a purist, I feel that in many respects that these strategies are not mutually exclusive and the reason why I say that is because only about 25% of the people who go through cognitive behavioural therapy for insomnia, for long term insomnia are actually cured. That is to say they don’t experience insomnia ever again. It’s typically true that people, even people who learn to manage their sleep well and I would include myself in that category. I’ve found that cognitive behavioural therapy has really been a boom for my sleep; it’s much more reliable, much better quality of sleep and many fewer worries about sleep. However, people with insomnia, like me, the majority of us do have occasional bouts of recurring insomnia and at those times, I don’t think it’s necessarily true that we should be forced to go without sleeping pills because that opens the door again to those worries about sleep and anxieties about sleep getting re-established, those pathways in our brain coming open again. So I don’t think that we need to look at those different strategies as mutually exclusive necessarily.
Jeff: Yeah, it’s interesting. Therapy to a lot of people, maybe more so in the UK than the US, but a lot of people are sceptical of talking therapies in general and comparing a talking therapy to a pill, there is a perception a pill is medicine, a talking therapy is something else but as you said, CBT for insomnia, the studies that I’ve read and the research that in your book quotes that CBT is actually very effective for curing insomnia, maybe not curing insomnia for the rest of your life.
Lois: Well it’s as a management strategy and I think that’s what we need to sort of come around to accepting that many chronic problems cannot be cured at this point anyway but they can be well managed and just to clarify about cognitive behavioural therapy, it is a form of talk therapy but it’s mostly geared towards changing behaviour. Yes it’s also, you know it seems important also to change attitudes but I’ll give you just my personal opinion is that, I personally needed to see changes in my sleep before my attitude started changing. Now it may be true that others work differently than I do but I can say that based on the fact that my sleep has improved, my attitude towards sleep has now improved.
Jeff: Very interesting. Talked about sleeping pills, what about other non-prescription drugs? There’s lots of natural remedies you can Google for and you can buy in pharmacies and health shops, there’s over the counter treatments which are anti-histamines and things like that and Melatonin. Briefly what are your opinions on these non-prescription type of treatments?
Lois: They’re certainly not recommended by most doctors and why is that? When they’ve been subjected to clinical trials and stuff they haven’t really shown to be terribly effective, but they are, they do make you drowsy, the anti-histamines that are sold over the counter like the ZzzQuil and Tylenol PM and Benadryl and those kinds of things. They do make you sleepy, but they have a lot of downsides too. One is that they don’t work very quickly and so for people who have trouble falling asleep at night they may not do the trick. But they also have rather long half-lives and so when I tried them, I tried them when I was much younger, I found myself quite groggy in the morning and particularly for older people, I think probably a lot of older people do use them and yet when as we age, it takes our bodies longer to metabolise drugs and so they may be feeling groggy well on into the morning. But there’s also other things, dizziness, dry mouth, and so forth that are connected with these first generation anti-histamines, so I don’t know, I have spoken to people who swear by them and others do say “No they don’t work, they make me to groggy.”
One person I spoke to said, well he just simply cut the dosage in half and he found that that worked fine for him. With Melatonin, Melatonin is not a sleeping pill and despite what many people think, it’s something that’s termed a chronobiotic and so it’s much more effective at changing your sleep timing than it actually changing the quality or the duration of your sleep. So what I suggest is that people who are night owls, who typically don’t fall asleep until two or three in the morning and who would like to fall asleep sooner, then Melatonin might well be an effective drug for them. But you don’t take it right before you go to bed, you take it well in advance of your own Melatonin secretion beginning, which would be more like dinner time and what that will do is that shifts your sleep to an earlier hour.
Jeff: Yeah and also a lot of people taking Melatonin for jet lag as well which ties into what you were saying.
Lois: Oh yes, yes that is another good use of Melatonin, if you can start a Melatonin regimen, well it depends on the direction that you are travelling in and that’s a little more complicated than we want to go into here, but yes jet lag is definitely a time when Melatonin has a good possibility of helping you out.
Jeff: I’ve got one last question. I just want to talk about why the issues in society just regarding sleep in general, The Center for Disease Control, the CDC in the States recently described insufficient sleep as a public health epidemic, quite sort of scary language and it’s citing things like car crashes, industrial disasters, work related occupational errors and also the chronic health conditions, some of which you mentioned before. Do we have ourselves to blame in a sense that we live in a 24/7 society, a lot of work culture encourages working longer hours and of course we’ve got the internet which is always on, social media, people getting addicted to staying up late on Facebook or whatever, what do you think about the current state of how society views sleep? Are we battling this thing of respecting sleep in the face of all of these challenges?
Lois: I think I have my doubts as to whether or not we’re in an epidemic of sleeplessness. When I looked at the figures people have looked and see how long people are reporting sleeping, say 50 years ago as compared to today, I’m not so sure that that has changed all that much when I look at all the data. Some studies say yes, some studies say no, but it is true that life when you’re awake is more interesting than life asleep. There’s a lot of fun stuff out there to do and it might well be true that we’re shorting ourselves on sleep and that is leading to some health problems that we’d really like to avoid.
I’m actually excited about reading a new book, it’s called “Dangerously Sleepy” by Alan Derickson, he’s a Penn state professor and this book was just published this year, it’s coming out of the University of Pennsylvania Press and he’s talking about the wakeful work ethic that developed since the 19th century, I, certainly in my study of the history of insomnia, I did find evidence that there started to be the idea that it was the man, it was the human being and of course back then it was the man, who stayed awake long enough, who was going to make the biggest success of himself and I think ever since then, you know, ever since 24/7 lighting and so forth, that there’s been this myth that’s grown up I think about how to not sleep, to be able to say that you only slept 5 hours or something like that, it’s sort of a power, it’s a status thing or something like that and I’m sure that that works to our detriment. I would like to see more education about these issues coming out and I do see a lot of articles written online these days about the need for getting our, a certain amount of sleep every night and for focussing on that as just as we focus on the necessity of having a helpful diet and getting plenty of exercise and the right kind of exercise, we should also pay attention to our sleep. I personally, this is my main focus is on insomnia. I would like to see health education beginning really early and this is something that I don’t see with sleep community coming out and talking about. That it’s often times in adolescence when our circadian rhythms become delayed. It’s often times in adolescence and in college in the years say between 20 and 30 that sleep problems start to develop and so I would like to see education about sleep incorporated into high school health classes. I’d like to see it incorporated into the college curriculum. It so happens that they’re going to be using my book in a college class called the Science of Sleep and Circadian Rhythms. I think, “Wow, you know, this is a great thing to be studying in college”, back when I was in school there was nothing like that, but maybe you know, maybe more attention could be paid to sleep in college curricula.
And finally what I’d like to see is, I’d like to see doctors, you know they go through in a routine check-up, they ask you about you know, how’s your heart, how’s this, how’s your respiration, they go through checking systems, I’d like them also to check how is your sleep. I know that might open a can of worms but I think that just, the fact that they might inquire about it would signify to more people that sleep really is something that we need to pay attention to.
Jeff: Yeah, absolutely, even asking the question is a good thing. I’m optimistic as well. I do think we face a lot of challenges but I see movements like the start school later for teens, that’s going to help them in their studies. I think that’s a great movement. I think slowly we’re beginning to realize that we can’t take sleep for granted and education I think as you said is got to be the word for it. Well, that’s about all questions I’ve got today. It’s been really interesting.
Lois: Yes, well thanks so much for having me on the podcast and interviewing me. It’s been a very interesting conversation for me as well.
Jeff: It’s been great Lois and would you just like to give us your details and mention the book and your website, where people can find you.
Lois: Yes, yes, my book is “The Savvy Insomniac: A Personal Journey Through Science to Better Sleep.” And my website is www.thesavvyinsomniac.com and my book is available, I sell it off my website and it’s also being sold on Amazon.com as well as other online booksellers. It’s in both print and e-book formats.
Jeff: Fantastic. Thanks ever so much Lois! Alright, take care!