Peter Attia· MD
when you take those two parts then you start to add in some of the cognitive components that have been around also for decades the cognitive therapies part the Aaron Beck stuff with cognitive restructuring which is where we take a thought have you ever heard that phrase don't believe everything you think MH yeah so you take a thought and on the classic classic thought record tool you'll have patients write down the thought write down how they feel rate their feelings from say 0 to 90% And then we have them write down what's the evidence for this thought like if you had to go to court right now and there was a judge and a jury and what have you and you had to present evidence for your thought what would you be able to present evidence for a thought is not another thought it's not a belief it's evidence last time I slept 6 hours I got a worse grade on a test or something right that would be evidence you got worst SC test but then we we look at all the evidence for a thought we look at all the evidence against a thought like oh last time you didn't sleep so well you didn't get fired you still did fine in school whatever the thing and then we create a balanced thought which is okay even though I'm not going to be as well rested I'll still still get through this day right then we have people rate their emotions rate how much they believe this new thought this whole song and dance right this is the cognitive component and that's kind of the Bedrock of so much of cognitive therapy and so of course people have so many negative thoughts about sleep and and dysfunctional thoughts about sleep that aren't true or that are catastrophizing and whatnot that that is also Blended in to the treatment um and then we have relaxation techniques which are things like progressive muscle relaxation that came along as well and those are part of the treatment and that progressive muscle relaxation will be like where you squeeze your hands and let it go and squeeze your hands and let it go and then squeeze your arms and let them go and kind of move through your whole body to get out of your head and into your body and I don't know what or what order those actually were packaged into cbti um but I can tell you the first two the stimulus control and and the time and bed restriction those among the earliest earliest parts of cbti and what we know from dismantling studies is when you take either of those out of the treatment no dice yeah I I want to talk about both of those a little bit more um so I and I want to bracket sleep hygiene and come back to it because I think again the temperature and all that light stuff we we shouldn't we shouldn't gloss over that even though it's easy to take for granted and I I know that many people listening to this podcast will have heard other content where we talk about it but I'd love to have it all in one place sure um I think the the time in bed restriction is pretty interesting and and and in talking with sleep Physicians who also implement this it seems quite Draconian at the outset uh it can be remarkably difficult uh like you know they're giving people 5 hours in bed Max and and they're really trying to force sleep pressure right so how do you um uh how do you navigate that and how do you decide how to squeeze the the tube of toothpaste let me draw a line in the sand between what cbti says broadly as a treatment and then how I've actually implemented it in my clinich MH so what cbti will have you do is they will have you as a and I say you as the Royal you your patient they will have you f something called a sleep diary and this is a paper diary that covers seven days we have it love it because if I asked you how well you slept four nights ago you'd be like yeah yeah you have it's like a food frequency questioner in epidemiology totally total waste of time total so you have to do it every morning okay and of course I'm not obsessed with it being exact because I'm much more interested in the picture the pattern of it right if you asked someone to fill it out for just one day and then worked with that you'd have a totally distorted picture you wouldn't know what you're working with but what classic cbti does is they'll take that 7-Day sleep diary and then they will actually use it the time you got in bed time you fell asleep how many times you woke up um how long you you were awake what time you woke up it does a bunch of it has all of these different uh questions in it and you can use that to calculate how much time a person was sleeping on average over the course of the week and what cbti does is it says you patient why don't you pick what time you want to get up every day and then you you would off sensibly pick a time and then the cbti clinician would let's say your your sleep log said you were naturally s sleeping 6 hours a night right the clinician would add 30 minutes to that and make it 6 and 1 half hours and then work backwards from your chosen wake time so let's say you chose a wake time of I don't know 7 a.m. I would work back 6 and 1 half hours to get to a bedtime for you of 12:30 a.m. and of course that's the Bedtime of your childhood dreams right imagine going to a sleepover and your friend's mom saying all right kids you can't go to bed until after 12:30 a.m. right kids love it adults think this is this is torture right because it is so that's what classic cbti would do six hours being