I have people ask me how I get so much done in a day. I don’t think I’m Superman by any means, in fact I think I’m pretty spoiled in that I really enjoy all the different things that I do. But it is a fair point, that I am juggling a lot of stuff that requires mental exertion and relational presence. And my answer to that question is a pretty simple one.
I get sleep.
Seriously, I prioritize and protect my sleep like it is absolutely necessary for my survival because honestly? It is.
When clients are presenting a big bundle of symptoms related to depression, anxiety, stress, stomach issues, chronic pain, chronic fatigue, and all those other things that therapists hear about, the first thing I ask is, “How’s your sleep?”
And I usually get a double-take “WTF?” reaction. As in: “I just told you that running away from everything and living in a cave with the sasquatches in the Pacific Northwest seems like a good idea and you told me to have a juice box and a nap?” And it’s a fair question on the surface. What does sleep have to do with anxiety, depression, heart health, and inflammation? Probably a hell of a lot more than you realize.
If you have read anything else I have written ever, you have copped to the fact that I like functional definitions that set the tone for what we’re talking about. So here’s one for sleep.
Sleep is the brain’s own meditative state that happens about 8 hours out of every 24 (if we are doing it right) in accord with our circadian rhythm. During sleep, some parts of the brain become way less active and other parts of the brain become way more active.
When I say circadian rhythm, I’m referring to the natural cycle that defines a day for us. Circadian just means “around day,” after all. Every species on the planet (barring those that only live a very few days) has a circadian rhythm. It’s generated by our internal time clock but informed by the earth’s rotation. For my fellow science nerds, our internal time clock is an actual existing thing in the middle of the brain, called the suprachiasmatic nucleus.
Sleep occurs in four different stages that we cycle through during our time asleep. There are three stages of Non Rapid Eye Movement (NREM) sleep, moving from lighter to heavier and then there is Rapid Eye Movement (REM) sleep which is the time period where most of our dreaming occurs.
The cycling through REM and NREM stages is weird AF. There is no symmetry to how it happens, except we do know that the NREM sleep is more dominant early and the REM sleep is more dominant later (and closer to the time we wake up). So if we stay up too late we lose more NREM sleep, and if we have to get up too early we lose more REM sleep. Both are important. Equally so. Let’s get on with why that’s the case, eh?
Understanding why we sleep has actually been one of the final frontiers of how-the-body-works science. And only in recent years do we have a better idea of what’s actually going on.
When we are awake we are taking in all kinds of new information, right? NREM and REM sleep have different functions in terms of what our brains do with that information.
The brain is busy during the day, attending to all of our ongoing shenanigans. Sorting through those shenanigans takes time and energy we don’t have when we are active. NREM sleep is our time to store this new info, strengthen some connections, and prune away the unnecessary bullshit. It reinforces remembering what we need to remember and forgetting what we need to forget.
REM sleep is the time where we integrate all the info we brought in with the stuff we already knew to be true about the world. REM sleep is essentially our emotional processing time. It helps us recognize patterns and fuels our creativity. This is the likely purpose of the dreaming we do in this stage. It helps us make more intelligent and thoughtful decisions in future days. The brain is figuring out what things are important to remember and what things can be let go of. For those of us working through our old crap and creating new, healthier associations and coping skills, sleep is an important part of all of that happening.
The latest research shows that essentially, sleep time is housekeeping time. Research published by Dr Maiken Nedergaard in 2013 found that the brain’s toxin flushing system (the glymphatic system) is ten times more active when we are asleep than when we are awake. If the brain is a city, the glymphatic system DR334 is our sewer system (pleasant image, right?). During sleep, our neuroglial cells (the cells that support our neuron functioning; the word “glia” means “glue” in Greek) shrink up, allowing our sewer system to flush out. The toxins are pulled out of the brain and into the bloodstream so the liver and kidneys can process the waste out.
It takes a ton of energy to propel this process, and the brain doesn’t have the energy to spare when it’s busy processing information during our waking hours. Toxins build up continuously in our brains and bodies as the side effect of being alive on the planet. That’s not a cause for concern, as long as the body is equipped to do the cleaning outing part. For the brain, this process happens continuously as we move through different cycles of sleep.
You might be wondering what this has to do with the stuff we talked about in part one. Much of the toxins being flushed are neurodegenerative molecules so there is clean space between brain cells, allowing better intra-brain communication.
Additionally, adenosine, a chemical that exists throughout every cell in the body and is one of the neurotransmitters (chemical messengers) in the brain. Adenosine has an important proactive role in the body—it’s a nervous system depressant, meaning it suppresses arousal so we don’t have panic attacks 24/7. It builds up during our waking hours and plays a big role in our feeling sleepy at the end of the day. One of the things caffeine does is block the adenosine effect, which is why it makes us so jittery. Adenosine also builds up in areas of inflammation, trying to keep our inflammation responses from killing us. And we are now aware that inflammation occurs from emotional trauma, not just physical trauma and that neuroinflammation is wayyyy more common than scientists previously realized. So sleep is imperative in managing our body’s response to inflammation.
Every single one of these processes relate to trauma recovery. Dumping old ways of relating to the world and interacting in new and healthy ways? Reducing chronic inflammation and body toxicity? Flushing the built up crud that blocks the brain messaging correctly, and tamping down neuroinflammation so you can start the next day with a clean slate? Enhancing decision-making ability and creativity? Get some sleep!
You aren’t, are you? And you aren’t alone. Authors of a National Sleep Foundation report noted that two-thirds of all adults in the US do not get the minimum recommended amount of sleep (7 hours) at least on weeknights, and generally not at all. And it’s not like everyone is coming close but getting 6.5 hours or something. Most people are clocking way, way less on a regular basis. This isn’t just a US problem, however. The two-thirds number is exactly the same in Japan and nearly that in the UK. Other countries vary in their number count but it’s still way, way too high. Even in Germany, where it’s “only” 30% of the population who is sleep deprived.
Seven to nine hours: that’s what adults are supposed to get. I happen to be a nine-hour person, but seven is the minimum to ward off all the ills I’m going to discuss below. This isn’t a Dr. Faith number, this is a World Health Organization number.
“Bah!” a lot of people say. “I’m one of those people who don’t need much sleep.”
“Bah!” I say in return. Bullshit, alas. The number of people who actually are able to gain all the benefits discussed above on less sleep is minute. Like a fraction of 1%. And it seems to be related to a variant of a specific gene known as BHLHE41.
So why do so many people think they are just fucking fine? Several reasons, I’m guessing. The first is the cultural norm of sleep deprivation. We think we are supposed to push through things and be all tough and shit. Sleeping a full 7 hours is a cultural sign of weakness. Another reason is that it’s the norm for us personally. We don’t realize that this isn’t our optimal self. It’s just how it’s been for so long. Finally, research demonstrates that we greatly underestimate our level of impairment from sleep deprivation. The rate of mistakes we make when sleep deprived has been tested and quantified in studies, but ask us to estimate our level of impairment? We think we’ve got it under control.
Because sleep is inextricably tied to pretty much every function of the human body, it is not a shock that not enough sleep (or disruption of quality sleep) is associated with a multitude of problems.
Here’s a fun list of things we are far more likely to develop if we are sleep deprived:
• Reduced immune system function and immune deficiency
• Reduced motor function
• Cancer and the spread of cancer
• Depletion of our gut microbiome
• Cardiovascular disease
• High blood pressure
• Higher susceptibility to infections
• Higher susceptibility to infections
• Congestive heart failure
• Bipolar disorder
• Shorter life span
• Vehicle crashes and traffic deaths. Drowsy driving accounts for more of these than drugs and alcohol combined.
Now some of these things are causal. Accident rates due to drowsy driving? We make mistakes when impaired. Period. But it isn’t always a cause and effect situation. No one is saying (that I’m aware of) that sleep deprivation causes PTSD or any other emotional or physical illness. Correlation is not causality. But treating sleep can greatly reduce the symptoms of these other issues and help promote healing and recovery.
Okay, first of all, if you have the ability to get enough sleep (as in you can fall asleep just fucking fine) but you don’t let yourself get enough sleep (as in, you are binging on Netflix or some dumb shit instead of putting yourself to bed): stop that shit right now and get enough sleep.
There, easy fix.
Now, for the rest of you who are trying to get enough sleep but have trouble doing so and have for some time? Like you don’t sleep well for several nights a week for months on end? Or maybe you’re getting crappy sleep quality.
It’s possible you have a sleep disorder you’ll need to get medical intervention for. Talk to your medical doctor if you think this might be the case. But insomnia generally stems from worry, rumination, anxiety, and other types of emotional distress. It’s common. 1 out of 9 people meet the criteria for insomnia at any given moment. The rest of this section is for you. Let’s unfuck your sleep.
Set Yourself Up to Succeed
First, make sure you have appropriate sleep opportunity time. You need to give yourself a good 30 minutes to fall asleep. So if you need 7 hours, put yourself to bed 7.5 hours before wakey-uppy time. Have a regular going to bed and getting up time, even on your days off.
I know. The advice “have a bedtime routine” makes you want to throw up in your mouth every time you read it. But have a bedtime routine. If you didn’t fall asleep during your 30-minute opportunity window, don’t perseverate over it. Don’t look at the clock. Don’t toss and turn. Get up and go do something. Don’t turn on the Xbox or anything super stimulating, and nothing with blue lights in general (read: anything with a screen). Read something dry and boring like a Dr. Faith book. Do a load of laundry, empty the dishwasher, something like that. When you feel sleepy again, go back to bed.
Don’t take late naps. Naps in the early afternoon tend to be beneficial to us. Naps later in the afternoon or evening (I know a lot of after-work nappers) can disrupt your nighttime sleep.
Weighted blankets are superb for supporting individuals who live with anxiety, ADHD, ASD, and other issues. They have also been shown to support sleep. Weighted blankets provide deep touch pressure, which raises serotonin levels in the body, which as we know from above, promotes the generation and release of melatonin in the body. Weighted blankets used to be prohibitively expensive, but now can be found for under 100 dollars with some research. For adults, you generally want to get a weight that is 5-10% of your healthy body weight12. For kiddos, the general number is 10% of their body weight plus a pound of two.
Other weighting options can include “Korean mink” blankets (which I’ve seen available for up to 10 pounds for about 30 dollars, and no they are not actually real mink) or just piling on whatever blankets you have in the house. If you do the pile on trick, you will probably have to drop the temperature in the house some more because it will be significantly warmer. Weighted blankets use plastic pellets for the weight, therefore aren’t as hot to have over the body.
Bedrooms are for two things and watching TV isn’t one of them. It’s bad for your partnership if you have one and it’s really fucking bad for your sleep. A poll taken by a TV manufacturer (LG to be precise) found that 61% of people fall asleep with the TV on. Besides the blue light disruption, the cacophonous noise in the background is going to disrupt your sleep quality.
If you do better with noise at night, try a noise machine. Many of them offer different settings from white noise, like rain or heartbeats. A lot of people also use a fan or air purifier. Both make white noise while helping with air circulation and cleaning toxins out of your space.
Try to get natural sun exposure during the day and limit your blue light exposure in the evenings. Charles Czeisler of Harvard Medical School found that individuals who used electronic reading devices (like Kindles) before bedtime had a harder time falling asleep, had reduced levels of melatonin in the body, and were groggier the next morning. Like a 50% reduction in melatonin levels. That’s a big deal.
It’s the blue light coming from our screens, y’all. Whether it’s an e-reader, our phones, or the TV, our constant exposure to the blue light confuses our brain into thinking it’s daytime for longer than it actually is.
And if you’re thinking “Fuck off, Dr. Faith, watching Netflix in bed is my low key reason for living, I’m not giving that up”? Studies have demonstrated that people who used blue light devices and wore blue blocker glasses for three hours before bedtime produced just as much melatonin as people who were not exposed to blue lights. And the glasses are super inexpensive. A pair that is obviously yellow and looks like what Bono wears is about ten bucks. If you want a pair that does the trick without being so overtly weird, you can get them for twenty or so bucks. They are still yellow tinted to block the blue light but it isn’t obvious up close. You can also get them in different reading glass strengths. I think they’re actually kinda cute.
Another option is to download a program like f.lux on your computers. It will change your computer display’s light settings to match what the sun is doing outside. I’m currently typing on my laptop at 8PM and the light is a dimmer pink so I don’t need to wear my blue blockers of sassiness.
Temperature can help or hinder sleep. Your body temp needs to drop 2-3 degrees Fahrenheit (1 degree Celsius for anyone on the planet not in the US) in order to be able to sleep. Sleeping with a colder room can really help. Optimally, the room should be about 65 degrees. Most people keep their rooms warmer than that so 65 may be a big change. Try dropping the thermometer a couple of degrees from where you usually keep it and see if that helps. You can also take a hot bath since you will have a temperature drop when you get out of the warm water into the cooler air. And while exercise is helpful to sleep in general, exercising close to bedtime will raise your core body temperature and may disrupt your sleep.
For about five minutes, everyone and their dog was wearing a FitBit, smartwatch, or other tracking device. If you still do so, use it to track your sleep! If you don’t have one (or, like me, don’t want the continuous shaming about your level of inactivity) you can use a sleep tracking app instead. I’ve been using the SleepCycle app for about two years now and it’s been really helpful. It uses the mic on my phone to track my stages of sleep and quality of sleep. It also listens for distressed breathing and will record a small clip if you are snoring or if you’ve always wondered what you say when you talk in your sleep. It’s caught me having an asthma attack in the middle of the night, which was very helpful information. If you notice chronic breathing problems, you could have sleep apnea and you need to get a sleep study to find out. Even if you pay for the premium version, an app like this is waaaay cheaper than another tracking device.
You can also keep a notebook by your bed and jot down notes about sleep time and quality.
A lot of sleep disruption is due to stomach upset, needing to use the bathroom more, and breathing issues. Using other sleep hacks without treating the root causes may help a bit, but in the long term is more like changing deck chairs on the Titanic than anything else. For example, if you have blood sugar stress, you will likely be up peeing in the middle of the night a lot more than you would otherwise. I’m gonna tattle on Mr. Dr. Faith by pointing out how much better he sleeps after he got his blood sugar under control.
Remember the hierarchy of interventions? First, try looking at dietary changes, lifestyle changes, and supplements that can help manage underlying issues. For example, food sensitivities might be impacting your health and your sleep, so try an elimination diet to figure out what those are. Or maybe you sleep better when you’ve gotten a certain amount of exercise. Or meditating right before bed could clear out the anxiety that keeps you up. Anytime we can give our body what it needs to heal itself instead of treating symptoms, the better everything works.
If sleeping pills induced a natural sleep—meaning, appropriate cycling through NREM and REM sleep—that would be awesome. But they don’t. According to studies, sleeping pills (Ambien, Lunesta, and the like) only demonstrate a small improvement in the time it takes to fall asleep and they don’t create the brainwaves that we see in real sleep. And they have a fuck ton of side effects. You’ve probably heard about people doing crazy zombie shit on sleeping pills. There’s also the grogginess and forgetfulness that happens the next day. They are also
associated with higher rates of infection and higher rates of cancer. Also? Higher rates of death. All the things that are more likely to happen because of lack of sleep also happen on sleep induced by prescription sleep meds.
But that’s not to say that allopathic medicine can’t help with sleep. Some drugs can treat the underlying conditions that disrupt our sleep, like blood sugar and anxiety. Night terrors are something people with PTSD are often (understandably) seeking to medicate away, but even though sleep medications can lessen the night terrors, they also end up disrupting REM sleep and you also lose all the things REM sleep gives the body, so it’s not a good trade-off in the long run. There is a prescription option that may work better. Many individuals with PTSD have higher levels of norepinephrine (noradrenaline) released by the nervous systems. Meaning that the hormone/neurotransmitter that the body uses to engage the fight or flight response is swimming around in their heads, promoting alertness, even when they are supposed to be sleeping. Essentially, people with night terrors are trying to sleep through an activated sympathetic nervous system, they aren’t able to maintain a zone of tolerance even when they are conked out. So some docs are using a high blood pressure drug called Prazosin, which has the side benefit of suppressing the noradrenaline without suppressing REM sleep. Chat with your prescriber about it if this is something you struggle with.
Supplements can be an effective alternative, but we should always take into consideration possible side effects and interactions with other meds. As we will see in the last chapter when discussing aspirin and acetaminophen and the like, over the counter doesn’t equate to totally safe. Please read the Supplements chapter of this book and talk with your doctor before experimenting with supplements.
Melatonin is one supplement a lot of people find useful, especially those who have trouble falling asleep to begin with. Our body produces the hormone melatonin in the pineal gland. We generally have enough of it unless we are deficient in some way (as caused by the blue light usage, for example, which is everyone and their dog at this point). Melatonin works best if you take it 2-3 hours before you go to bed since it helps amp up the body’s own natural melatonin kicking in as part of your circadian cycle. If you take it like you would a sleeping pill (swallow pill and lie down) you’ll not get near the same effect.
For every person I’ve met who has tried melatonin and thought it was brilliant, I’ve talked to someone else who said it did nothing for them. There’s a good reason for that. Even if you are taking it exactly when you are supposed to, you may notice that you fall asleep pretty well but the staying asleep portion of the program is still problematic. You’re not the only one. Most melatonin supplements are fast-acting instead of continued release, so you get your little burst but then it wears off.
Melatonin is contraindicated with individuals with seizure disorders and with high blood pressure. It also shouldn’t be taken with a prescription sleep medicine. Like everything else, check with your doc and be safe.
One of the other supplements I often suggest (and I talk about it more in the Supplements chapter) is L-Tryptophan (yes, the stuff in turkey). It is one of the essential amino acids that the body doesn’t produce on its own (unlike melatonin). We have to get it from our foods or in supplementation. L-Tryptophan is used by the body to make niacin. Niacin makes, among other things, serotonin. And serotonin is instrumental in our melatonin production.
Now I know you’re thinking, wait, what? Serotonin? Does that make L-Tryptophan an antidepressant? Some research shows that L-Tryptophan does demonstrate some relief of depression-related symptoms. If you are able to add it in, you may be able to talk to your prescriber about reducing or discontinuing other medications you have been taking for depression. But let them in on what you’re doing before you start futzing with your dosages, mmmkay?
If you add L-Tryptophan, you may still use a little melatonin to help the falling asleep part but you won’t need nearly the dose because the L-Tryptophan will keep it producing throughout the night like a champ. And, yes, there are multiple studies that demonstrate that L-Tryptophan supplementation works like a boss for promoting sleep. And as I mentioned in a previous chapter, L-Tryptophan is contraindicated for people with eosinophilia myalgia syndrome and may have some level of interaction with other antidepressants since it is also involved in serotonin production. So all together now: Check with your physician!
Valerian root and the kava plant have both been used for their sedative effect for thousands of years and can therefore be beneficial for sleep. While I’m a fan of both, I am more cautious about the brands being used than I am with melatonin and L-Tryptophan. Both of these supplements are more expensive to produce, making it more likely that you end up buying something with a non-efficacious dose because the manufacturer is trying to amp their bottom line. I prefer the Mediherb brand because the quality is above and beyond and the manufacturing is so transparent. Annnnnnd because they water-extract their kava in order to eliminate many of the side effects associated with other extraction processes. If you’ve heard about kava being unsafe, you were reading about kava lactone toxicity. Essentially, some extraction methods used on the kava plant also extract glutathione, which can damage the liver. Clearly no bueno. Mediherb products are only available through professional treatment providers (as is another brand on my short list, Galen’s Way). For over the counter brands that are good quality, I lean toward Gaia Herbs and Mountain Rose Herbs. You may also find an herbalist in your area that makes their own extractions so you can see their process up close and personal.
Finally, here are a couple of teas to try sipping before bed. Grandma was right to give you chamomile. It’s generally really safe, per the FDA. Though if you have a ragweed allergy, you may react to chamomile—they are from the same family. You do need to make sure you brew it properly to get the sleepy-sleepy effect. Use two to three tea bags and put a cover over the pot or your cup so all of the good oils don’t escape in the steam.
Banana peels are not just brilliant in your compost pile (or fed directly to your rose bushes), you can make an amazing tea out of them—and bananas also contain L-Tryptophan. Cut off the stems and use them fresh, baggy them and freeze them to use frozen, or dehydrate them out to use later. One fresh peel is equal to about 2 tablespoons of dried peel, all of which is equal to one cup of tea. Boil water, throw in the peel, then cover and reduce heat to let it simmer for about ten minutes. You can add cinnamon and vanilla if you dig, as well. Bananas (including the peels) are a good source of magnesium and potassium, which are both things bodies need anyway and something many people tend to not have enough of.
Alcohol can help you pass out, but it’s not going to give you the sleep you need. A study just published in the medical journal The Lancet determined that any health benefits of alcohol (like the classic “red wine is good for your heart!”) are far outweighed by the risks. Essentially, the study authors found, there is no such thing as a safe amount of alcohol and it is the leading risk factor for death-and-disability-adjusted life years for those of us ages 15 to 49.
It also doesn’t help that drinking makes you have to get up and pee more (because alcohol is a diuretic). It over-relaxes your muscles, even in your throat, making it more likely that you will snore. It disrupts your circadian rhythm, it amps up your alpha brain waves which then compete with your delta brain waves making the restorative sleep less effective, and it blocks REM sleep like a motherfucker.
So seriously. No drankin’. Or at least reduce your amount of alcohol way down. You’re tracking your sleep now, so look at the differences on drinking and non-drinking nights. Even better, give it up for a month and track your sleep. If you aren’t sure if there is an improvement, add it back in and notice the difference, just like you would a food detox.
Also, avoid caffeine and nicotine before bedtime. Both are stimulants, right? We all have different rates of metabolism for these substances so pay attention to when you use either and how it affects your sleep. Some people can have coffee after dinner and be fine, while others of us need to cut out caffeine mid-afternoon or earlier.
Cannabis and kratom are two more substances that people often use to help them sleep, but that can have counterproductive effects. The research on both is limited, I realize. Most cannabis and sleep research comes from the 70s, though with it being legal in more states, we will see better studies and confirmatory studies over the next few years, I hope. Kratom (the tropical tree leaf that has stimulant and opioid properties) is legal in most states but new to the US in general so also has limited studies to back it up.
I know that a lot of people use cannabis (CBD or THC) or kratom to help them manage their symptoms of anxiety, depression, PTSD, and chronic pain. However, the research that is out there does show that both disrupt sleep quality, specifically reducing REM sleep (which we now know is kinda sorta really fucking important). Sleep problems on kratom are an oft-reported side effect. With cannabis, it’s slightly more complicated. Deep sleep is enhanced with initial use, but the cannabis-helping-you-sleep effect fades away pretty quickly the more often you use it. The “why” part of that is still unknown.
Because all of these fun herbs can disrupt REM sleep, it also lessens night terrors, and is used by folks with PTSD and the like. But then you also lose all the things REM sleep gives the human body, so not a good trade-off. There is a prescription option that may work better.
For those of you who are using cannabis and/or kratom to help you manage other symptoms, I feel you. I know many people consider them an absolute lifesaver. The lesser the dose, the less impact it has on your sleep. Monitor your dosing along with monitoring your sleep and work to figure out your sweet spot for the amount you take and time(s) of day you take it.
And if you smoke your THC? Consider using another method of ingestion. Smoking increases your risk of breathing issues (asthma, COPSD), which will also fuck with your sleep.
Therapy, or at least some forms of it, can also help you sleep. The Chronic Insomnia Task Force of the American Academy of Sleep Medicine has recommended CBT-I as the first professional intervention that someone should undertake for insomnia (assuming apnea, restless leg syndrome, and other medical conditions have been ruled out). CBT-I is a short-term therapy (4-8 sessions, generally) that pairs the principles of cognitive behavior therapy with specific sleep hygiene protocols and relaxation techniques to assist people in untethering the emotional distress that is the general root cause of insomnia.
If you are disrupted consistently by nightmares and night terrors, that means your brain is working hard to make sense of some traumatic shit you have dealt with in the past. CBT-I may be enough to help you through the process, or you may have to do some trauma-informed therapy to work through whatever it is that your brain is trying to figure out. All of the exercises that help you increase vagal tone and widen your window of tolerance will also absolutely help your sleep.