In today’s episode, Dr. James Flowers and Robin French chat with Dr. Mary Rose about her passion working with those suffering from behavioral sleep disorders. Dr. Rose discusses the different sleep disorders, her specialization in CBT for insomnia, working with your prescribing physician to titrate off sleep aids, and how just because a medication is “over the counter” doesn’t mean it’s safe.
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I Want To Sleep But My Brain Won’t Stop Talking To Itself With Dr. Mary Rose [Episode 56]
Welcome, everyone, to Understanding the Human Condition. I’m your host, Dr. James Flowers. I’m joined by my lovely co-host, Robin French. I’m so excited that this morning we have a wonderful guest, Dr. Mary Rose.
Good morning, everybody.
Great to see you.
Really honored that you would take time to do this. Thank you so much.
My pleasure.
We’re discussing a topic that seems to affect everyone at some point in their life, lack of sleep and how to know if it’s a sleep disorder or just poor sleep hygiene.
I think maybe I’m going to get help on this podcast.
I know. I worked that in here because I know that you need eight hours, you said, or otherwise, you just don’t function.
What happens with me is if I get five hours of sleep, I’m not good. At 1:00 in the afternoon the next day, my hands are shaking. I cannot function, maybe half a day. If I get six or more, I’m pretty darn good. Five, less than six, to me is not great. Why don’t you tell the audience a little bit about your background? I’m so interested in your practice, both for personal and then professional reasons for our patients.
Sleep Specialist
I am a sleep specialist, and that has really been my go-to. I’ve always gone back to sleep. Even when I was doing general health psychology during internship and during my training, I always came back to sleep. I started in college doing an undergraduate thesis on dreams, and that really moved and shifted. I went to Arizona, and when I went to the University of Arizona after I graduated, I worked in the lab there and learned the technical aspects of sleep. I thought it was fascinating.
I got to tell you, though, the thing I love about sleep the most is I think the people who do it are fascinating scientists and artists, and they are creative and interesting people. They really think about the science of it and the life of the patients and what they need eclectically. They understand the whole person. I stayed in that field, and then I did a fellowship at the VA in general sleep medicine. I’ve been in this field for about 25 years.
That’s amazing. Did you do the VA in Phoenix?
No, here. After I did my internship, I came up to Houston, and I did fellowship.
That’s fantastic. Good.
Sleep Disorder Vs. Poor Sleeping Hygiene
At what point do we know it’s just not poor sleeping habits or hygiene and that we might actually have a disorder?
There’s a lot of different types of sleep disorders. The one that is the most prevalent is insomnia. When people complain of insomnia, a lot of the time they go to their primary care doctor. As soon as they say, “I can’t sleep,” unfortunately, it’s assumed it’s insomnia. They’re often given medication. However, the standard of care for insomnia, if it is truly just insomnia or insomnia only, is cognitive behavioral therapy. It’s not even to just give medication because we know that that does not work for long-term use. It becomes ineffective. The medications are never really trialed on the kinds of patients who end up getting them. We only trial those medications on a very small, select group of people who come into those trials. When it goes to market, everybody gets the drug. That gets very confusing.
A lot of the time, patients come in, people come in, and they’re complaining, “I don’t sleep.” However, the reason why they don’t sleep becomes essential for the diagnosis. Are you snoring? Are you having a hard time breathing, which could be sleep apnea and often is obstructive sleep apnea? Apnea literally means without breath. That’s why it’s called apnea because you’re literally choking during the night. You’re suffocating. What we need to do is make sure that people don’t have obstructive sleep apnea or central sleep apnea, which is another type of apnea that people can have where they just stop breathing. Their brain just tells them to stop breathing for a myriad of reasons.
Insomnia, circadian rhythm disorder, a lot of shift workers have circadian rhythm disorder where they work at hours that don’t really jive with how they feel or how they perform. Night workers often have problems even if they’re dedicated night workers. Again, we don’t want to just treat it as insomnia only. We want to look at their shift. People can kick in their sleep, which can cause periodic limb movements that can cause a lot of arousal as well. We need to get a comprehensive evaluation of patients when they come in with their first statement, “I don’t sleep.” It should not stop there. We need to find out the myriad of reasons why they don’t sleep. Is it falling asleep, waking up at night, waking up too early? How much total sleep time are they getting? All of those things.
Is it true, you and I and Robin, we’ve all probably heard this from a lot of successful executives, men and women, both during an interview will say, “I just need two hours a day of sleep. I just sleep three hours a day.” Is that even possible, really?
No, it’s really not. It’s not. You were mentioning you need six hours. That makes sense to me because we know that if anyone sleeps less than six hours habitually, they’re considered a short sleeper. A very small percent of the population is a short sleeper. We really need 7 to 8 hours. There is zero correlation between achievement level or IQ and how much sleep people get.
There is zero correlation between achievement level or IQ and how much sleep people get.
Can you repeat that? What did you just say?
Zero correlation between IQ and achievement level and how much sleep? That is so important because Mary Carstein, who’s a very well-known researcher of adolescent sleep in Rhode Island, got a lot of the laws changed there to change the hours that kids were going to school. They at one point had a billboard that came up in front of one of the schools that said, “If you were sleeping more hours than your GPA, you’re sleeping too much.” I think she had that taken down because that’s outrageous.
We know that kids who do poorly in school are sleep-deprived. You know that. We know that sleep deprivation is responsible for many of the industrial accidents, transportation accidents, and medical accidents that we’ve had from physicians. It’s a huge factor. Unfortunately, in many Western cultures, it is just not prioritized. It fits with our fast-paced lifestyles, but it absolutely depletes everything about our health and our performance.
Many of the patients that we see at J. Flowers are performers, musicians, or entertainers that have come from Los Angeles, Nashville, New York, or wherever. They tend to go to sleep or they’ll come in and say, “I don’t go to sleep until 3:00 or 4:00 in the morning, and I sleep till 1:00 in the afternoon.” That can probably be compared to a shift worker, and then that upsets the circadian rhythm.
It does. A lot of people who do a lot of different industries are going to be nocturnal people to some degree. What you have to remember, though, is for millions of years as a species, our species has been diurnal. We’ve been day creatures. We’re really not intended, nothing about our physiology has set us up as a species, let alone individual differences, to be awake at night. It’s for the very good reason that, evolutionarily, we don’t see well in the dark. Our brains and bodies have developed so that we get the most bang for our buck in the daytime when we can see and have good physical activity and brain activity. At nighttime, it’s dangerous. If you’re out of the cave, so to speak, then you’re going to get eaten by something.
We also know that’s verified in many ways because when we look at what happens to our physiology at night, we know that the hours of 2:00 and 3:00 AM are called a witching hour for good reason. It’s because it is a bad time for us to be awake. It’s a bad time for our brains and our bodies. Our bodies, they’re not in sync with our brains. We are volatile. We don’t think well. In fact, there’s an extraordinarily abnormally high rate of suicides and suicide attempts between the hours of 2:00 and 3:00 AM. If you think about how many people are awake during that time, that is astronomical.
When those people, when you talk to them about it more, and those of us in the field of sleep really do love to ask people about those things, they say, “In the morning, I just didn’t want to do it anymore,” or they start to recognize, “I guess I am volatile. I guess I’m impulsive in those hours.” It’s not ideal for anybody.
I remember, probably like you, I’m not sure how you did your dissertation or when you did your dissertation. When I was working on my dissertation, I would go to sleep at a normal time. I loved to wake up at like 5:00 AM and start writing. That’s when I did my best writing on my dissertation, when my brain was just fresh and rested.
You were probably more of what’s called a lark, like someone who wakes early. There’s a lot of advantages to that. Some people are a little bit more of an owl, so to speak. That just means that they go to sleep a little bit later. Teenagers, for sure, start to phase shift. That’s totally natural. They go to bed later and they want to wake up later. That’s a natural developmental change. I actually did my dissertation on internal medicine residents and sleep deprivation and its effect on mood. That’s the data I was looking at when I was doing it.
Just briefly, what did you find?
After three days, because generally they would have all, like every third day, and after three days they had still not recovered. That deprivation, that you have, you don’t recover the next day. Sleep debt is very significant. You can’t just undo it by sleeping a long time the next day. It’s still sitting with you. It still has an impact on your mind and body.
Is poor sleep hygiene something that we’ve grown into, starting as far back as childhood?
It can be. It does go in families. Sometimes you find families where it’s like everybody’s wandering around the house, finding different places to sleep. You’ll say, “Sometimes I’m in my daughter’s room, and sometimes my husband is with my son, and sometimes we’re together.” People are wandering around the house trying to find a place that is going to let them sleep. There’s something in the air, it’s going in different rooms. We can teach kids that, which is not a great thing. We can learn bad habits. Hygiene is just habits. It’s the basics. It’s just making sure that you have a general routine, that you’re not drinking half-made beverages before bed, that you have wind-downs, those kinds of things. It’s the basics.
In fact, what we found is that people who have chronic insomnia actually don’t have bad sleep hygiene because they’ve read all about it. They know the habits that they should have. It’s more about deeper things, untreated sleep disorders. It’s not really recognizing what are the things that, what I call like the wolves, because I like that evolutionary concept, what are the wolves at your door? What are the things that are keeping you awake at night that are really scaring you? If you don’t deal with them in the daytime, they’re going to follow you into bed.
Behavioral Disorder
That brings me to asking you about mood disorders and sleep. Does one go with the other? How do you treat that?
It really does, but they’re also separate. We have found that it’s critical to treat anxiety and depression. It’s critical to treat, separately, their accompanying sleep disorder. We had research that was done at Menninger with Michelle Patriquin, which showed that really what they needed to do was treat both of those things. If we don’t, and people are admitted inpatient, then what happens is that they relapse with the mood disorder later. What we try to do, like we’re working with the patients with J. Flowers or anywhere in a private practice, is to make sure that we treat both of those disorders.
Generally, we’ll have one person who specializes in sleep treat the sleep disorder and make sure that we’re managing the insomnia symptoms or the circadian rhythm disorder. Someone else treats them in more individual therapy, more long-term, potentially with cognitive behavioral therapy or another type of therapy for the mood disorder. We’ve got to treat both. If we don’t treat both, then neither really fully recovers.
Do you treat people of all ages?
Yes, so I do. I treat pretty much six and up because there are different types of sleep disorders that affect different people. In children, it’s more insomnia of childhood. That’s when kids will start to do behavioral things like behavioral insomnia of childhood, where they’re not going to bed on time, they’re resisting bed, those kinds of things. They have nightmares. Sometimes they don’t even really talk much about their nightmares, but that’s what’s waking them up. There’s a different set of problems. When people become adolescents, adolescents have a phase delay. Parents often think they’re just lazy because they’re like, “Get up,” but the fact is that they just have a very hard time going to bed earlier.
We know that they produce melatonin, which is the drug that tells us that it’s dark, to be darkness and helps us sleep. They produce that later than adults do. Their system is set up two hours ahead of us, or, they’re two hours behind us. They’re just in a different phase than we are as adults. As people get older, they encounter a lot of other problems with their sleep. Sleep is more fragmented, it’s not as deep. They have difficulty, they go to sleep early, and then they wake up early. It’s all different problems that happen developmentally at different stages.
I remember twenty years ago at this point, probably, my mother was diagnosed with dementia. She came to live with me. When she moved in with me, my sleep started getting somewhat restless because I was worried about her. I’d get up in the middle of the night, or I couldn’t go to sleep. I wanted to make sure she was okay or wasn’t leaving the house. We didn’t have in-house help at that point. I know you share a little bit of the same situation with your mom. You’re open about talking about your mom with Alzheimer’s. How did that affect you?
I’m going to go back in a very similar way. I will say that one thing I’m guessing, Dr. Flowers, is that when your mother came to live with you too, there were a lot of things that you were changing for her. There could have been medical things where you’re like, “Now this, we’re going to change, we’re going to modify this.” There’s this transition of, how do I get help? At first, like you, the first three months that Mom was living with me, I had no night help. She had all the things that are very common, particularly for elderly women, like UTIs and things like that, which are very common when people are not caring for themselves as well. They’re up all night, and then you’re up all night because you can hear them.
You think, because of the way that you and I were raised and the way we think about our careers, like, “We can do it. We can do it,” and then, no, you can’t. We’re still human beings, and we need sleep, and we need rest. For me, it was a lot of transition and trying to figure out how to make this work for her and the overall goals for her. It’s identifying that. Her overall goals are not to be successful in a new career or any of that. Her goals are, “I want to be happy. I don’t want to be in pain. I want to feel safe.” Those are the main things, basic, good medical care. But when someone is getting older, they’re really thinking, “I want to be out of pain.”
Sleep is a big factor in people with dementia because, I’m sure, your mother went through this too. It goes up and down, and then it starts getting worse and worse. For us, what we needed to do was get full-time care. We’re very fortunate that we can do that. A lot of people cannot, but we have full-time care. We have to have someone there at night who helps her when she gets up. She will have sundowning. I don’t know if a lot of your audience may not be familiar with that. I know that you are, but it’s when the moment that sunset happens, almost just the moment.
It was on time, every time.
The person with the sundowning starts to get disoriented. They start to get a little paranoid. Sometimes they get more angry, they get confused. We really have to make sure that we have medications on board that help that but what’s really important is that the care provider be in good shape. We know that one of the best predictors for progression with dementia is the mental health of the care providers.
One of the best predictors for progression with dementia is the mental health of the care provider.
That’s right.
It really is. Neurologists will tell you, “We can give Aricept, Memantine, and all these medications, but what it really comes down to is the care provider and how they’re doing.” Because that patient, our mothers, needed to feel safe. They needed to feel happy. They needed to feel secure. But as they progress with that, sleep gets much more fragmented. We use melatonin. A lot of neurologists will recommend that, and physicians will recommend melatonin sometimes at night, particularly if people start having movement issues. Did your mom have movement?
Yeah, absolutely.
That actually falls in a category of what’s called REM behavior disorder. You don’t turn off the motor activity at night. That happens in Parkinson’s as well. We have to treat that, or else you get injured. They’re slamming things and hitting things and screaming.
It was an interesting, difficult time in my life, but more importantly in her life as well.
Was there anything different that you did?
No, I did the same. I was in therapy, taking care of my own mental health because I knew I needed to be healthy with my mom and for my mom. We brought in night help as well and then full-time help. Eventually, she transitioned from our home over to Seven Acres Jewish Community Home, which was just an amazing place for my mom. It was difficult. Sleep was a big part of that throughout her stay with me.
I think a lot of families struggle with that transition too, but it becomes very difficult and much safer often for people to go into someplace like that, knowing and recognizing that your mom or dad is okay. This is a good place for them, and they need you to get sleep. They need you to have your life as well.
That was probably the most difficult decision of my life, moving her from my home to Seven Acres. They helped me feel this amazing sense of comfort. I just can’t tell the audience enough that when it’s the right time for you, and you’re looking, Seven Acres Jewish Community Home is an absolutely amazing resource, and they take amazing care of their folks.
Very good to know.
Over-The-Counter Meds
I was reading your notes about, just because it’s over-the-counter doesn’t mean it’s safe. Can you educate the audience on this? Some over-the-counter meds can cause really great harm, and you also mentioned that melatonin isn’t found to be any better for you. Can you talk a little bit about all that?
I always tell people they need to review anything they’re taking, whether it’s over-the-counter or from another doctor, with their primary care doctor, the person who’s managing everything, and it’s absolutely essential. Medications, the FDA doesn’t rate medications based on safety, really. They base it on addiction potential. You could certainly overdose on many over-the-counter medications, and people have to be careful with that.
There are medications where, like if you have a seizure disorder, it’s not a good idea to take some of the ones like diphenhydramine, etc. Neurologists will tell you, “I’d rather you not do that.” You have to be very careful with it. Melatonin, you can get 10-milligram melatonin capsules, but we know that very large doses of melatonin over a long period of time can turn off those receptors potentially. That’s not good either, and you don’t get the bang for your buck. More than 1 or 1 to 3 milligrams of melatonin isn’t recommended. The other thing is, it’s not always very pure or very well-monitored when it’s over-the-counter. If the FDA isn’t monitoring it, you never know how much of the thing that’s supposed to be in it is in the thing that it’s supposed to be. That’s a risk.
Sleep Tips
How about some sleep tips to fall asleep quickly for the audience?
The basics are to make sure that, not necessarily having the same time to go to bed every night, but that you wait until you’re feeling that sleep drive. Not fatigued, but sleepy, like your eyes are heavy, and you’re falling asleep. Not, “I’m bored” or “just my legs hurt,” but sleepy. Getting up at the same time helps create that really regular schedule for you. Trying not to nap, if you can avoid it. Trying, obviously, not to use a lot of caffeinated products, etc., is really important, but having a day well spent, so to speak, so that you feel like, “This is a good day. I feel like I achieved a lot.” You’re not going to be carrying a lot with you into the bedroom. When it’s dark and quiet and there are no distractions, that’s when those things are really going to creep up and get you.
For those of us that do drink coffee in the morning and sometimes at lunch, do you typically recommend a cut-off time, or is that different for everyone?
I think it’s different for everyone. A lot of the time, we will tell people, “Don’t drink any caffeine after noon,” but that’s difficult for some people. Everybody’s metabolism with that is a little bit different. People do need to be careful with caffeine because caffeine is cardiotoxic to some degree. If you take it in large doses, that puts a lot of strain on your heart, and so it’s important not to do that. It can cause other medical issues. It vasodilates, and it can cause a lot of problems. It makes your blood flow more, and if you’re bruising or something like that, it’s not so great, or for inflammation. What you want to do is just try to reduce caffeine. Take a reasonable amount, and try to finish your caffeine dose, whatever you’re going to use, as soon as you can before bed.
Unfortunately, we see so many people in our practice that come to us on a fairly large dose, or sometimes even a small dose, of a benzodiazepine. People say, “I need it to sleep.” It went from, “I needed 0.5 milligrams at bedtime,” to “1 milligram,” and then, “I needed to take it twice a day,” and then, “three times a day.” Someone that’s detoxing off of a benzo is going to have sleep difficulties. What’s your thought process, and how do you work with patients when they’re fresh off of a benzo or even for the last ten years they’ve used a benzo to sleep?
I usually recommend that we try to do a slow downward titration for a lot of reasons. The physicians will say for medical reasons there’s a reason for that, but also because when you know you’re not taking something, you’re taking a lower dose, you expect a certain effect. You expect you won’t sleep. What can happen is that people go down and then they don’t sleep well. Then, the next night, they take the medication, and then they do sleep well, and they think, “See, it proves I need the medication,” instead of realizing, “You didn’t sleep the night before, so your sleep drive was building.” Recognizing expectation is a huge factor.
We can really see that we can give people a huge amount of sedatives, and they will stay wide awake. We have people who have a lot going on in their life, and they will sleep just fine. It really does suggest that our minds, we don’t give them enough credit, are very powerful. Don’t give the medication all of the credit for why this or that happens with how you feel, or how you sleep, or anything else.
We don’t give our minds enough credit. They are very powerful.
Couldn’t agree more.
It’s part of it, but going down slowly on those is so helpful so that people can see that transition and also have time to let other medications that I know your team puts on board to try and help with the mood disorder, etc., start to take a back.
Are there certain foods that can help you sleep?
My daughter, my seven-year-old, tells me warm milk. I think that things with tryptophan, like turkey, can really help for sure. Certainly, sugar, we know, is fast energy, and so if you ramp up on a lot of sugar, then you’re going to be in trouble trying to get to sleep. If you have reflux disorder and you eat a bunch of spaghetti or something right before bed, that’s not going to sit well.
Sleep And Menopause
My girlfriends are suffering with some sleep issues and menopause. Do you have any advice for those who are watching to help them out with that?
I will say that the worst sleepers in the world are women who are postmenopausal and perimenopausal. Sleep is fragmented. You can be a fabulous sleeper, and then you start going through those hormonal changes. Making sure that you’re seeing your provider to ensure that everything is working as properly as it can is critical. Women are more likely to certainly develop thyroid disease and things like that as they get older, and making sure that’s not at play is essential.
Many times, people will be hyperthyroid, and that’s going to keep them really awake, particularly women, who are more vulnerable to that. Then, making sure that you stay cool, because temperature in a room is very important for anyone for sleep. We really want to be cool, very cool, at night. A lot of us will keep our house warmer because, like, save energy, but we have hot flashes.
I keep mine like a meat locker. It’s 67.
Honestly, I think it was Candice Alfano at the University of Houston who found that you need to be closer to 63 to 64 degrees. That was one of her talks. I keep mine about 64, and it does help. It’s really helpful, particularly if you’re menopausal or you’re going to be very menopausal. You’re going to be sweating, and then it’s up, down, up, down, and our bodies regulate temperature, it goes all over the place at night. When we’re in REM sleep, we don’t regulate very well, and you’ll get cold, and then you’ll get hot. Keeping cool in the daytime, keeping cool with menopause symptoms, and treating those symptoms is important, but taking the pressure off overall is essential.
A lot of times, we wake up in the middle of the night, and we’re like, “I can’t believe it. Now I won’t be able to do this tomorrow, and I can’t go to work.” We really beat ourselves up as though it was a competitive sport that we failed at. We really need to reduce that pressure, and reducing that pressure in itself helps a lot to get sleep because our anxiety goes down. It’s just a lot easier if we can do that.
Snoring
That’s right. I have to ask a final question for all of the partners out there who have a loved one that snores. What is your recommendation when you have a couple or a partner that is having difficulty sleeping because their spouse or partner is snoring all night long?
It’s very important that they get that evaluated, and what I normally tell people is that if they’re going to go into the doctor’s office and get that evaluated, the spouse better go with them. When the doctor asks, “Do you snore?” they’re going to say, “No.” The spouse has to go with them, and they need to understand, too, that snoring is your airway resisting air. Often, that is apnea that gets to a point where your body just gives up, it stops breathing. Those are those pauses, which are actually what usually wake up the spouse, the pauses in the breathing, because there’s a part of our brain that says, “Wake up, there’s something bad happening.”
We are more likely to wake up if our partner stops breathing than if they’re snoring. Generally, what I say is, go with them so that you can report things. Recognize that you can be a very resilient person and do a lot, but it doesn’t mean that you’re breathing well at night and not suffocating. It is critical to get your airway open. There are a lot of different treatments, and don’t be scared of whatever you think you’re going to get for treatment, like positive airway pressure. Understand it so you can feel informed. People feel better when they get it treated. They are at lower risk for stroke, heart attack, diabetes, immune problems, so many things that impact you when you don’t breathe well, dietary issues, GI upset, everything.
I don’t know if this can be compared as a similar analogy or not, but you know how when someone lives near a railroad track and they hear a train whistle or a train going by, they adjust and they sleep through it? Or they live near a freeway, and they hear the noise, and it becomes an ocean sound, and they sleep? I wonder why we don’t wake up when we are loud snorers, it doesn’t wake ourselves up.
Some people, it does, but the other problem is that if you’re a very loud snorer, think about it. Those people are super sleep-deprived. People will often say to me, “I have insomnia, but I want to sleep like my spouse because my spouse falls asleep in 30 seconds,” and I’ll say, “That’s not normal.” Just falling asleep at the drop of a hat is not normal. It’s critical for people to understand that it takes a while, it’s natural, it’s normal. It takes us a few minutes to fall into sleep, and we should not be struggling with our airway at night. That’s definitely something that’s a red flag. It might be snoring, which we know, even if it’s just snoring, is resistance and not great for you, but if it’s apnea, it is suffocation. Get treated.
What a fascinating topic. I could keep going for hours on this. In our practice, we’re just full of this, and we hear it. I think everybody listening hears it as well. If someone wants to reach you as a sleep expert, what’s the best way to reach you?
They can contact me at RoseHealthPsychology.com. They can contact me through you, through J. Flowers certainly, but the best way to contact me is probably going through my website. In fact, I never remember my own contact.
I know. I don’t either.
It’s funny, I barely know my contact number. RoseHealthPsychology.com and RoseFamilyHealth@gmail.com.
Excellent. Everyone, reach out to Dr. Mary Rose if you’re experiencing some of these problems, or reach out to J. Flowers Health at JFlowersHealth.com. Again, what a fascinating topic. I work in chronic pain, obviously, and with a lot of chronic pain patients, and you work your expertise as sleep. I just think it’s so fascinating what you do. Thank you for your time.
I do too. I love it. I love this field, and I love our field, psychology. Sleep well, everybody, and thank you so much for having me on this podcast.
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We will. Thank you. We want to remind you that a clear diagnosis is the key to the most effective treatment possible.
Thanks, everybody.
See you next week. Thank you. Bye, Dr. Rose
Bye.
