Parwy's Blog: Why You Can’t Sleep and How to Fix It - Dr Rhonda Patrick with Dr Michael Grandner

Insomnia complaints are shockingly common, affecting about one out of three people in the US.
Clinical Insomnia Disorder is defined as persistent difficulty initiating or maintaining sleep, or waking too early, occurring at least three nights per week for at least three months, and causing daytime impairment. A key indicator is taking at least 30 minutes to fall asleep or being awake for at least 30 minutes during the night.
The primary cause of chronic insomnia is conditioned arousal. This occurs when the brain associates the act of trying to sleep with stress and activation, leading to a self-perpetuating cycle where stress about not sleeping prevents sleep.
The fundamental principle regarding sleep is that the enemy of sleep is effort. Sleep happens to you when the situation allows, and trying harder will make the process slower.
Effective insomnia treatment, such as Cognitive Behavioral Therapy for Insomnia (CBTI), aims to reprogram the conditioned arousal cycle. CBTI is recommended as the first line of treatment by medical organizations and is effective even when other major medical conditions (like chronic pain or untreated sleep apnea) are present.

Stimulus Control: This principle dictates that the bed should be reserved exclusively for sleep (and sex). If one is awake in bed (ruminating, scrolling), they must get out of bed until they feel sleepy to break the negative association between the bed and wakefulness.
Restriction of Time in Bed (often mistakenly called Sleep Restriction): This method aims to increase natural sleep pressure (sleep drive) by limiting the amount of time an individual spends in bed to slightly more than the time they are currently sleeping. The goal is to move from being unable to fall asleep to being unable to stay awake when in bed.
Strategies for Arousal Management: If you wake up in the middle of the night, try to fall back asleep for a couple of minutes; if unsuccessful, get up, take a break, and wait until you are ready to try again without adding performance anxiety. Surrendering control often shortens awakenings.

Sleep apnea is shockingly common; estimates suggest about one in four or five men over 30 have some sleep-related breathing issues.
A non-obvious presentation of sleep apnea is waking up in the middle of the night due to perceived stress or for no reason, and then struggling to fall back asleep. The stress is often a secondary symptom superimposed on a physical event (like an adrenaline shot caused by the airway attempting to open).
Untreated sleep apnea disrupts sleep architecture by dramatically reducing slow wave (deep) sleep and REM sleep, and increasing shallow Stage 1 sleep.
Consequences of Untreated Apnea: It is a known risk factor for neurodegeneration (especially severe apnea) and causes oxidative stress due to intermittent drops in oxygen levels throughout the night. It impairs cognitive functions like vigilant attention, emotional regulation, executive function, and memory.
Non-CPAP Treatments: Mandibular Advancement Devices (dental retainers that push the jaw forward) are often used for mild to moderate cases. Myofascial therapy (muscle exercises) and implantable electrical devices (like Inspire) are also available. Positional therapy (preventing back sleeping) can help if apnea is purely positional.

Routines and Predictability: If consistent timing is difficult (e.g., due to travel), focus on building a highly predictable nighttime routine with the same actions in the same order, using things like a familiar pillowcase as a conditioned stimulus.
Timing Light Exposure: Getting 15 to 30 minutes of bright outdoor light in the morning at a consistent time sets the circadian clock. The light accelerates the natural drop in melatonin.
Light Inoculation: Getting plenty of outdoor light during the day inoculates the system against light at night, minimizing interference with the sleep cycle.
Caffeine Strategy: It is recommended to wait an hour after waking to ingest caffeine, as the natural sleep inertia is dissipating and adenosine levels are lowest upon waking. Caffeine reaches its peak effects about 30 minutes after ingestion. Caffeine intake should cease four to six hours before bedtime for most people.
Late-Night Eating: If you crave calorie-dense food late at night, your brain may be signaling that you should have already gone to bed. This vulnerability period, especially between 2 and 5 a.m., involves reward seeking but decreased reward processing, leading to poor choices.

Melatonin Function: Melatonin is a hormone signaling darkness, not a sedative. Low doses (0.3–0.5 mg) can be used strategically five hours before desired sleep time as a clock-shifting signal. Higher doses (3–5 mg) closer to bedtime boost the nighttime signal.
Other Supplements: While some supplements like Magnesium and Glycine promote sleep, no supplement has been proven to beat placebo for treating clinical insomnia. Calming agents (e.g., L-theanine) help relaxation but cannot override conditioned arousal.
THC and Sleep: THC helps people fall asleep but suppresses REM sleep and its effects often fade, leading to dose escalation. Withdrawal causes severe insomnia and REM rebound (vivid dreams/nightmares).
Alcohol and Sleep: Alcohol helps initial sleep onset but its metabolism creates activating neurostimulants (like acetaldehyde), resulting in middle-of-the-night awakenings and poor sleep quality.

Most Accurate Data: Wearable devices are best at estimating sleep versus wake time based on movement, achieving high accuracy. Heart rate data is also reliably good.
Sleep Staging Caution: Estimates of sleep stages (deep/REM) are a ballpark figure (60–80% accurate) and are not gold standard. Deep sleep detection is often the least accurate.
Scores and Metrics: Metrics like "sleep score," "readiness," or "recovery" should be interpreted with caution or ignored, as the proprietary algorithms are often not transparent or published, making informed decision-making difficult.
Orthosomnia: This term describes people who obsessively fixate on sleep data and metrics, leading to anxiety that worsens their sleep.
Actionable Use of Data: Use wearable data to identify long-term trends and flag deviations (e.g., fragmented sleep or high nighttime heart rate) that may indicate underlying issues like poor sleep hygiene, late caffeine/food intake, or an active physical condition.

Sleep Banking: For athletes and those needing cognitive performance, banking good sleep (getting extra sleep) in the weeks prior to an event is more beneficial than stressing over the night immediately before.
Extended Sleep: Younger individuals (adolescents/young adults, particularly athletes) benefit significantly from getting more sleep (potentially up to 9-10 hours) for physical strength, reaction time, and mental sharpness.
Injury Risk: Injury risk in athletes is better predicted by insomnia severity and daytime sleepiness than by sleep duration alone.
Simple Performance Hacks: Cheap technology like eye masks and earplugs acts as environmental bubble wrap to consolidate sleep, which can translate to better cognitive performance (e.g., test scores).
Caffeine Limitation: Caffeine can improve simple tasks (attention, speed) but cannot caffeinate away complex decision-making, leading to faster but poorer decisions in sleep-deprived individuals.