Question 1

What therapies do you recommend for Insomnia. How effective are sleep hygiene, paradoxical intent and CBT-I compared to sleeping pills?

Guy Leschziner · Accepted Answer

Before answering this, I would say that good sleepers often do not practise good sleep hygiene. They sleep well regardless. So while sleep hygiene may help the intermittently poor sleeper, it is not going to make a significant difference to people with chronic insomnia. Paradoxical intent may be helpful, but evidence really identifies CBTi as being the best approach. This multimodal therapy combines relaxation techniques, MBT, stimulus control and sleep compression, all with a view to breaking down the negative conditioned response to bed, and rebuild a positive conditioning. Evidence suggests that CBTi is non-inferior to medications, and may well achieve a longer-term positive outcome. Medications have a role in some individuals, particularly if there are co-morbidities, but concerns have been raised regarding the long-term adverse effects, including falls, accidents, habituation, dependency and cognitive dysfunction. There is a signal from the literature that long term hypnotics may be a risk factor for Alzheimer's/MCI, although there remain some unanswered questions in this area - these are detailed in my book.
In summary therefore, CBTi would be my first choice, delivered either face to face, via teleconferencing, or even using online platforms.

Question 2

What are the differences between a 'getting to sleep' problem and a 'staying asleep' problem? Are there different treatment implications for these two issues?

Guy Leschziner · Accepted Answer

The issue is more to do with the underlying cause. Psychophysiological insomnia can cause both initiation and maintenance difficulties, but it is more common for people to have difficulties with sleep initiation. The treatment strategies for both are the same. However, if people fall asleep readily during the day (which most people with insomnia cannot do), this raises the possibility of an underlying "biological" sleep disorder mimicking insomnia. For sleep initiation difficulties, these include RLS or delayed sleep phase syndrome. For sleep maintenance issues, conditions like OSA, RLS, or even narcolepsy. And obviously if there is an underlying cause, this needs to be addressed with the most appropriate treatment strategy.

Question 3

I work in a school setting and have contact with a number of teens being given melatonin as a sleep aid. Is this safe and appropriate?

Guy Leschziner · Accepted Answer

Melatonin in tablet form is a synthetic analogue of the melatonin released by our pineal gland, and acts both as a sleep promoter and Zeitgeber - a modulator of our circadian rhythm. Despite early concerns regarding its modulation of autoimmune conditions (not really subsequently borne out), it is held to be very safe. As you probably know, in the US and Canada, it is seen as a health supplement rather than medication, and in some European countries can be bought without a prescription.
Have said all that, it would always be best to avoid medication, especially in young people. We know teenagers tend to develop a delayed sleep phase, but there are certain drivers that will make this worse. Exposure to bright light at night, mental stimulation by the use of gadgets, distractions of social life, lack of exposure to sun early in the morning. So it would be preferable to address these issues first rather than reaching for the melatonin. Equally, if it is being given for insomnia, it is worth trying to address the insomnia first, using techniques like CBTi

Question 4

What can shift workers do to protect their health?

Guy Leschziner · Accepted Answer

There are two issues for shift workers. The first is that they are often sleep-deprived, as they are not able to achieve adequate sleep. The second is that their circadian rhythms are disrupted, with resulting negative effects on health.
Some of the solutions are structural, related to the nature of working patterns. It is difficult to shift your circadian clock by more that 1 hour per 24 hours, and so rapidly shifting rotas are difficult to cope with. Equally, rotas need to be mindful of giving people adequate sleep opportunity between shifts.
On a personal level, the most important thing is to be mindful of light exposure. Adequate bright light after waking, minimising bright light on the journey home (sometimes even resorting to sunglasses on the commute), maintaining a routine that provides opportunity for sleep, and utilising good sleep hygiene to ensure that sleep onset and sleep quality is affected as little as possible. However, it is important to accept if you as an individual are someone who can cope with shift work. If you have a tendency to insomnia or poor sleep anyway, then shift work is simply going to exacerbate that underlying trait.

Question 5

Hi Guy, what advice do you give partners of snorers who have ongoing disrupted sleep?

Guy Leschziner · Accepted Answer

Sadly, I think there are limited options. Best for both the snorer and the partner is to get the snorer's snoring dealt with! Options such as devices to keep the snorer off their back, dental devices called mandibular advancement devices, or for very carefully selected cases, surgery. Other options are earplugs or a separate bedroom!

Question 6

What's more important for neurological health - deep sleep or REM sleep?

Guy Leschziner · Accepted Answer

The answer is probably both, but there remain so many questions about this. Certainly NREM "deep" sleep is fundamentally important - perhaps one of the most important issues is that in deep sleep, the glymphatic system expands significantly, potentiating the removal of metabolites from the brain. This system has been implicated in the removal of tau and beta-amyloid, both of which have a role in the pathogenesis of Alzheimer's and other neurodegenerative diseases. REM sleep is also important, probably more so for learning, memory and emotional processing. But there are a number of paradoxes when it comes to REM. As we get older, the proportion of REM sleep diminishes, and we have not seen major ill effects from abolition of REM in adults. The likely explanation is that REM is more important and has slightly different roles in infants and children.

Question 7

I work as a psychologist predominantly with clients presenting with mood disorders. Would you recommend that I train in CBTi or ACTi to help them with their sleep disturbances?

Guy Leschziner · Accepted Answer

There is significantly more evidence for CBTi, in terms of its impact on sleep in anxiety and depression, but also its impact on the underlying mood/anxiety disorder. But the reality is that CBTi is hard to adhere to, so ACTi is a useful adjunct to reduce distress from sleep issues in those who cannot manage the CBTi protocol.

Question 8

With Veterans experiencing PTSD and sleep disturbance, would you recommend to address the trauma or sleep symptoms first?

Guy Leschziner · Accepted Answer

Undoubtedly, treating the trauma symptoms first, as it is the more holistic approach. Once this has been done, the sleep can be focussed on. As you know, PTSD-associated nightmares can remain despite other aspects of PTSD lessening, and in these cases, there are a variety of treatment options with varying levels of evidence - dream imagery rehearsal therapy, CBTi, EMDR, or medications. A popular medication is prazosin, a blood pressure med. A recent RCT showed no effect, but many of us seeing these patients have had some successes with this drug. The AASM recently published a consensus statement on PTSD-associated nightmare disorder, detailing the levels of evidence for these interventions.

Question 9

Can you comment on the anxiety disorders associated with insomnia?

Guy Leschziner · Accepted Answer

It is important to note that insomnia is associated with anxiety or depression in about 50% of individuals but can exist in the absence of anxiety in the other 50%. The nature of anxiety in the context of insomnia is hugely variable. For many people with insomnia, there is a single and isolated sleep-related anxiety - worry about the night ahead or the day after - and this causes hyperarousal or hypervigilance around bed time, or specifically in bed. However, any more generalised anxiety disorder results in a persistent state of hyperarousal which obviously then impacts on sleep initiation and maintenance. OCD may also lead to bed procrastination and repetitive intrusive thoughts, having much the same effect. 
It is also important to recognise that insomnia, and indeed sleep deprivation, causes physiological changes such as a hyperadrenergic state, which compounds anxiety, and there are probably neurophysiological changes that also lead to insomnia exacerbating anxiety states. Therefore, in the presence of both insomnia and anxiety, both need to be dealt with simultaneously for best outcome.

Question 10

What are the best methods for regulating circadian rhythm?

Guy Leschziner · Accepted Answer

The strongest influencers on the circadian rhythm are melatonin and light. However, there is something called the phase response curve, meaning that the effects of both on the circadian rhythm are dependent on WHEN they are given, so if you expose someone to light or melatonin at one point it may shift their clock forward, but at another time back. The size of the effect is also dependent on timing. That is why I do not recommend people try to manipulate their own rhythm with melatonin for jet lag. However, exposure to bright light in the day, especially the morning, and avoidance of bright light in the evenings helps anchor circadian rhythm.
It is important not to forget that lots of other factors also influence the clock. Eating, drinking, exercise temperature. The key thing with reinforcing the circadian rhythm is maintaining a regular pattern. But if you want to shift it, it is a little more complicated.

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