Episode 27: Hyperarousal

Having trouble with sleep is not just about what you do at night. How you think and behave during the day impacts on sleep and can result in the brain being over stimulated or hyperaroused at night. In this episode Moira and David discuss how the brain works in insomnia, and talk with Professor Dieter Riemann from University of Freiburg about hyperarousal. What is it? How does it impact on sleep, and what can be done about it?

Dr Moira Junge (Health Psychologist) and Dr David Cunnington (Sleep Physician) host the monthly podcast, Sleep Talk, talking all things sleep.

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Audio Timeline:

  • 00:00 –  00:49 Introduction
  • 00:49 – 02:18 What’s news in sleep?
    • Getting back up to ‘work speed’
  • 02:18 – 23:30 Theme – Hyperarousal
    • 02:18 – 03:40 What is hyperarousal?
    • 03:40 – 13:01 Prof Dieter Riemann – Recognising and treating hyperarousal
    • 13:01 – 19:09 Hyperarousal, regional sleep and the Ebb Sleep device
    • 19:09 – 22:40 Ebb Sleep device for insomnia
    • 22:40 – 23:30 Take home messages around hyperarousal
  • 23:30 – 25:40 Clinical tip: Pay attention to arousal levels across the day
  • 25:40 – 28;02 Pick of the month:
    • 25:40 – 27:00 David – Thrive
    • 27:00 – 28:02 Moira – Smiling Mind app
  • 28:02 – 29:26 What’s coming up in sleep?

Next episode: Sleep and Cancer (Part 1) 

Links mentioned in the podcast: 

Presenters:

Guest interviews:

Prof Dieter RiemannProfessor Dieter Riemann is the Head of Department for Clinical Psychology and Psychophysiology at University Medical Center, Freiburg, Germany. Dieter is the Editor in Chief of the Journal of Sleep Research and very widely published with over 400 peer-reviewed articles. Prof Reimann’s research group aims to better understand the relationships between sleep, insomnia and mental disorders, especially depression. They combine expertise from psychology, psychiatry and physics to experimentally study sleep with a variety of methods in good sleepers and people suffering from mental disorders and insomnia. Besides striving to understand the pathopyhsiology/ etiology of disturbed sleep in psychiatry they hope to to improve current therapeutic avenues.

Regular hosts:

Dr Moira JungeDr Moira Junge is a health psychologist working in the sleep field, who has considerable experience working with people with sleeping difficulties in a multidisciplinary practice using a team-based approach. Moira has consulted at Melbourne Sleep Disorders Centre since 2008, and is actively involved with the Australasian Sleep Association (ASA). She has presented numerous workshops for psychologists wanting to learn more about sleep disorders, and is involved with Monash University with teaching and supervision commitments, as well as clinical involvement with the Monash University Healthy Sleep Clinic. She is one of the clinic directors at Yarraville Health Group which was established in 1998. In addition to her expertise in sleep disorders, her other areas of interest and expertise include smoking cessation, psychological adjustment to chronic illness, and grief and loss issues.

Dr David CunningtonDr David Cunnington is a sleep physician and director of Melbourne Sleep Disorders Centre, and co-founder and contributor to SleepHub. David trained in sleep medicine both in Australia and in the United States, at Harvard Medical School, and is certified as both an International Sleep Medicine Specialist and International Behavioural Sleep Medicine Specialist. David’s clinical practice covers all areas of sleep medicine and he is actively involved in training health professionals in sleep. David is a regular media commentator on sleep, both in traditional media and social media, and blogs for the Huffington Post on sleep. David’s recent research has been in the area of non-drug, psychologically-based treatments such as cognitive behavioral therapy and mindfulness in managing insomnia, restless legs syndrome and other sleep disorders.

Connect with David on Twitter or Facebook.

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Transcript:

Intro: Welcome to Sleep Talk, the podcast about all things sleep brought to you by SleepHub.com.au. Here are your hosts, Dr. David Cunnington and Dr. Moira Junge.

Dr. David Cunnington: So welcome to Episode #27 of Sleep Talk, the podcast talking about all things sleep. And welcome again, Moira.

Dr. Moira Junge: Hello, Dave. Hello, listeners.

Dr. David Cunnington: So this month’s theme is hyperarousal. And I know you’re asking, ‘what’s hyperarousal?’ Well, it’s something I see every day in people who have sleep difficulties, not just insomnia but sleep difficulties and it’s really, really common. But it is something that’s hard to explain exactly what it is.

Dr. Moira Junge: Yeah. Yeah.

Dr. David Cunnington: And thankfully, we have a couple of experts on that who will help explain that much more fluently so that we can give you a good understanding of what it is, why it’s important to insomnia and some things you can do about it.

So what has been happening this month, Moira? What has been happening in sleep?

Dr. Moira Junge: Well, speaking of hyperarousal, I think there was a lack of – there was probably underarousal in general, a really nice reset throughout the summer holidays in Australia. Yeah, things are back to normal now. And I think that even though I wouldn’t have thought that I have a lot of hyperarousal but I’m certainly at risk of hyperarousal myself. I feel that it’s something I have to work very hard at keeping a lid on things. Sometimes that racing mind and I’m just doing too much sometimes because I’ve had a sleep study relatively recently which shows quite a lot of evidence of hyperarousal which I’m taking steps to minimize. So it’s quite interesting that someone who has been in the sleep field, I do not intervise poor sleep. In fact, I’m always bragging about how well I sleep.

Dr. David Cunnington: Yeah.

Dr. Moira Junge: I think that it’s something – it’s really good. I think it’s something that all of us are not immune to.

Dr. David Cunnington: Yeah. And that’s a nice reflection. I certainly find too when I have some downtime like a foot off the accelerator a bit. I could easily nap in the afternoon or move a bit more slowly. Just my own personal pace is a bit slower than during the year, which just tells me that I’m doing something different during the working year to boost up that nervous energy.

Dr. Moira Junge: Yeah, absolutely.

Dr. David Cunnington: In essence, turning up the dial on arousal. And it’s a fine line between turning it up enough that you feel like you’re a bit more energetic and too much that it bubbles up and starts to cause an issue.

Dr. Moira Junge: Absolutely. So I’m glad we are talking about this month.

Dr. David Cunnington: It’s almost right into the theme given that we are already talking about it and we’ve introduced that sort of topic. So as I talked about, hyperarousal is really important because for many people we see with insomnia, it’s one of the key features that’s driving insomnia or it may have even precipitated some of the sleep disturbances in the first place and it’s not listed as a sleep disorder or other medical school training or advanced training even for sleep specialists. It’s often not something that people talk about. But what about in the psychology postgraduate education, Moira? Is it something …?

Dr. Moira Junge: Not termed in that way. I’m pretty sure I’ve used the terminology only since I’ve been working in the sleep field. It’s not a general term used much at all in the general psychology field.

Dr. David Cunnington: And it’s also when I’m seeing people, often people in the like community, they sort of get if I’m too buzzed or I’m too stressed out or too busy, it’s going to make me have trouble getting to sleep. But in actual fact, the more common presentation with hyperarousal is trouble waking up during the night.

Dr. Moira Junge: Yeah, the maintenance, yeah.

Dr. David Cunnington: Yeah, so waking during the night, having trouble getting back to sleep. So often, people don’t put that together. They say, “Look, it’s not being too busy, not being sort of over aroused was the issue because I can to get sleep.”

Dr. Moira Junge: Because I can get to sleep. They think that’s the outcome measure.

Dr. David Cunnington: Yeah.

Dr. Moira Junge: Yeah.

Dr. David Cunnington: And so that’s where hyperarousal is often the hidden thing that is a big contributing factor to lots of people with sleep problems. So to help us understand that a bit better, I’ve had the chance to talk to Professor Dieter Riemann. And Dieter write a really great article in 2010 in Sleep Medicine Reviews on hyperarousal and its role in insomnia and it was because he explained things so nicely in that article that was why I wanted to talk to him to be able to get that explanation from him about what it is and how does it relate to insomnia. Dieter is the Head of Psychology and Psychophysiology at the Centre for Mental Health Disorders at the University of Freiburg and he has also recently since the start of 2017 been the Editor-in-Chief of the Journal of Sleep Research.

So thanks a lot for joining us on the podcast. How would you define hyperarousal?

Dieter Riemann: Yeah, that’s a good question. Actually, if you look at the literature, there is not so much of definition but the implicit understanding is we have two systems governing sleeping and waking and one would be the arousal system or the ARAS as it’s called in the literature, the ascending reticular activating system. And the system will be a sleep system to put it very simply. And hyperarousal in that sense would be that the arousal system is somehow hyperactive either in relation to the sleep system or either in relation to good sleepers if we look at poor sleepers. And we can measure that on several levels. So we would conceptualize this as an overactivity on several axes, the autonomic system, the HPA system, the EEG, and stuff like that.

Dr. David Cunnington: It’s a sort of thing almost as a clinician you get the smell of it or you can sense it when you’re listening to somebody talk about their sleep. But what are some of those physiological measures? How can we measure it in either clinical practice or research?

Dieter Riemann: The simplest thing is if you look at the autonomous nervous system and if you look for at, for example, ECG, heart rate, heart rate variability, and there are now numerous that it’s showing that if you look at the heart rate, heart rate variability during the day, during sleep, the system is more active, is more variable in poor sleepers, in insomnia compared to good sleeper.

Dr. David Cunnington: And how much physiological hyperarousal contribute to the clinical disorder of insomnia? How do those two things interact?

Dieter Riemann: It’s probably insomnia, not just hyperarousal. There are definitely – there might be people with insomnia who don’t show very strong signs of hyperarousal. I’d guess at least 50, 60, 70% showed these signs and they do experience it subjectively because they try to get sleep and they would say, “I’m quite tired. I close my eyes and suddenly it’s like a switch turned around. I feel my heartbeat in my ear. I feel nervous and then cognitions start and all of that.”

So I guess it’s quite a major factor. It’s not the only factor in insomnia but it’s a major factor and many people with insomnia do not only show objective signs if we measure it by measuring the autonomous nervous system but measuring cortisol, by looking at EEG or stuff like that. But they also subjectively experienced it and they say, “This is something I’m – I’m not saying I’m aroused but just saying I’m nervous, I’m ruminating, I can’t stop this. So somebody in my body is going wrong at a time when I should rest.”

Dr. David Cunnington: Yeah. And the feeling can often then exacerbate or turn up the cognitive arousal that concerns sleep. We can turn and can drive the physiological arousal and it can become a bit self-perpetuating.

Dieter Riemann: Yeah. I think that’s really an important point that these systems are interacting. So if you have insomnia and not only if you have insomnia but everybody likes to sleep and you’re tired you want to sleep and suddenly, you realized it’s not working. And then the cognitions kick in. ‘What will happen tomorrow?’ And then you get more aroused. So it could also be some kind of conditioning taking place that people who are vulnerable to react to not being able to sleep with arousal and then they get into a vicious circle and the vicious circle between psychological aspect and emotional aspect hits the arousal, also the measurable arousal and physiological and cognition kick in as well. And then, in the end, you get the impression that you’re unable to sleep at all.

Dr. David Cunnington: And that change in thinking about sleep disturbance or insomnia with arousal being a more important focus, has that really changed how we approach treatment for insomnia?

Dieter Riemann: If you look at the main treatment approach for a long time, those were the benzodiazepines and the vet drugs, actually all of these drugs are strong inhibiting drugs. They inhibit arousal in the brain and also alcohol, for example, which too is unfortunately used frequently also by many people too. So actually, it is – suppression of arousal has something to do with the treatment of insomnia. I think that was known or is known for a long time. But there have been more specific ways if you look at now newer drugs like the orexin antagonist. Orexin is a major awake factor, arousing factor. And there is this new type of drug treatment, the orexin antagonist.

And on the other hand, I think also if you look at psychotherapeutic approaches, there are already, for a long time, people who use relaxation treatment like Jacobsen. People are using yoga now or other mindfulness things and all of these treatments are actually aimed at reducing arousal or controlling arousal.

Dr. David Cunnington: Sometimes the focus when people come to see me, their focus is on sleep but the blind spot often is how much they are aroused across the day, which in turn is driving a lot of difficulties with sleep.

Dieter Riemann: It’s a very important issue that we know that when we talk of hyperarousal, we think of a 24-hour hyperarousal. And it’s especially experienced by people at night and so they can’t sleep and this is what they say to their doctor, to their therapist, “I have a sleep problem.” But actually, if you look throughout their day, about their days with them, and you see many of these people are very active. They are totally under stressed most of the time. Mostly they don’t realize. They say, “This is normal. I have to cope with that.”

Dr. David Cunnington: Yes.

Dieter Riemann: So it’s really an important factor. Also naturally, we think in this insomnia more a 24-hour day terms and not focus so much on the sleep but really also focus on the day and find – these people should do – they should expose themselves to light. They should do some exercise. They should have real breaks in between, relaxing, stuff like that. That’s also very helpful.

Dr. David Cunnington: I agree with that. But it’s often not what people are looking for. People come and see us in a sleep clinic and say, “Right. I want to fix the sleep.” And not necessarily looking for us to tell them to restructure their lifestyle and learn to manage stress and how they manage energy across the day. So it can be a hard sell to get them on board with it.

Dieter Riemann: Yes, that’s absolutely true. I mean some people want the quick solution and they will always go – maybe they prefer sleeping pills in comparison to changing a lifestyle. But also, if you look at all the CBTI measures, I do a lot of sleep restriction stimulus control and this is something too which people don’t expect if you run the sleep restriction for a few weeks. That’s what people are surprised by saying, “Are you crazy? You prescribed me less sleep?” And it perfectly works and people are very surprised that afterward, they say, “Well, why didn’t I have myself the idea to do this?” Because usually, insomnia tends to prolong their time in bed in order to heighten the chance to get more sleep but just never works.

Dr. David Cunnington: Given this understanding of hyperarousal and its importance in sleep, what should we be doing in the future or how should we be looking at developing new treatments or new approaches?

Dieter Riemann: There are very interesting approaches concerning electrostimulation. There had been studies now just coming from basic research showing that we can influence our brainwaves by transcranial direct stimulation by these approaches. And people are really thinking about you would wear a device and this will give you certain electrical impulses and this could have an impact on brainwaves.

The interesting thing is that we also find an increased frequency of fast frequencies like the beta waves in the sleep of insomniacs. And people are thinking about and they are experimenting, could we do some electric stimulation suppressing these beta waves? Maybe this would stop the rumination. Maybe this would calm people down. This could be a very interesting approach I think to try this out.

Eric Nofzinger, if you’re going to talk to him, he has this new brain-cooling device. I think this is also basically something that acts on hyperarousal or reduces hyperarousal. So this has really to be tested and seen if we suppress signs of physiological hyperarousal, will people then get more sleep? Will this help them? I could imagine that and I think also biofeedback training during the day, learning to control your brainwaves to some extent to reduce heightened activity and all of that stuff. This could be very new, very different treatments to what we have now.

Dr. David Cunnington: Thanks a lot for those insights.

Dieter Riemann: Yup. Thank you.

Dr. David Cunnington: So, did you like Dieter’s explanation of hyperarousal?

Dr. Moira Junge: Yes. Yes. Thanks to you and thanks to Dieter. That was excellent. And yeah, what a great, nice, succinct way of defining it and just explaining in really simple terms what it actually is. Certainly, he is the man, isn’t he?

Dr. David Cunnington: Absolutely. You and I work in this area every single day and I’m always talking to people about hyperarousal but just listening to him talking like, “Oh yeah, I like that way of thinking about it. Oh, I could use that.”

Dr. Moira Junge: Yeah, very useful because obviously, he is a big name, lots of papers over many, many years so he is obviously a clinician as well.

Dr. David Cunnington: Absolutely. Now, when he finds some time because his research output is just …

Dr. Moira Junge: It’s huge.

Dr. David Cunnington: Yeah, very prolific and very high quality of work as well. So yeah, lovely to hear that perspective and really explained so clearly.

Dr. Moira Junge: What are the highlights in it for you?

Dr. David Cunnington: It also made me reflect on some things we are increasingly thinking about as well as if there is that heightened nervous energy or sense of hyperarousal and often, people will tell us, “Well, I’m not particularly busy or I don’t feel that I’m stressed.”

Dr. Moira Junge: Yeah.

Dr. David Cunnington: Well then, what is that? And so maybe for sometimes it boils down to personality factors and the sort of things people don’t think, “Well, it’s not different for me. This is just how I roll.” And so there are some personality types or traits we are sort of running on high nervous energy is almost the sort of modus operandi.

Dr. Moira Junge: Yeah.

Dr. David Cunnington: And that could offer a high risk for hyperarousal and therefore insomnia. So perfectionism, I can admit to a bit of that or sort of being a bit more obsessive about things because things have to be just so.

Dr. Moira Junge: Yes. And probably maybe less expressive type sometimes where we don’t want to – we don’t really rant or rave or not wanting to complain too much and we more internalize things. That’s also a big personality factor I think. In that way too, people say, “Oh, I’m not that stressed,” because they might be suppressing a lot of that or just internalizing it, not ranting and raving all over the shop and that can come out in the nighttime, in the wee hours that the nervous system can detect what your cognitive awareness isn’t detecting.

Dr. David Cunnington: And I think it also highlights why we’ve shifted the work you and I have done together over the last 5 or 10 years looking at mindfulness and sort of add-on treatments to cognitive behavioral therapy for insomnia that specifically addresses arousal over and above the CBT components.

Dr. Moira Junge: Yeah, that’s right because I mean we are big fans of CBTI and we know the importance of that but it doesn’t really specifically address arousal. Let’s talk to him again at another time because there’s so much more we could talk about.

Dr. David Cunnington: Oh, anytime. Yeah. He was one, very generous time. Thanks, Dieter, for giving up your time. And two, incredibly insightful and really helpful.

Dr. Moira Junge: Yeah.

Dr. David Cunnington: So one of the other concepts around hyperarousal is thinking about how the brain works during sleep. We’ve already heard that there’s a complex interplay between the wake-promoting systems and the sleep-promoting systems in the brain but it’s actually more complicated than that. The brain sleeps in different compartments. It doesn’t sleep as a single unit.

And there’s a term called regional sleep that sort of emerged and being used much more over the last few years which really reflects a lot of research that has been done looking at brain imaging both in people who are good sleepers and people with insomnia or poor sleepers. And some of that work has shown that in people who are poor sleepers, different parts of the brain don’t shut off as well as they do in people who are good sleepers. And maybe that’s part of the physiology of the hyperarousal and therefore maybe you could do something locally or do something to impact just on those parts of the brain and help with that switching off process.

Someone who has really driven research in that area over a number of years is Professor Eric Nofzinger. He is from the University of Pittsburgh and he has got a long history in brain imaging research in insomnia and based on some of that work has been involved in developing a treatment for insomnia called Ebb, the Ebb Insomnia Therapy Device that looks at cooling the forehead and trying to help with shutting off the prefrontal cortex.

So I did try to get an interview with Professor Eric Nofzinger but despite a number of attempts, we just couldn’t make it happen. So we will talk a little bit about some of his research just to give the background and that will give you an idea about why I was interested in talking to him.

So the reason I was interested in talking to Eric Nofzinger is he has done a lot of work on imaging to look at how functionally the brains of people with insomnia differ from the brains of people who are good sleepers during sleep. And really, you could summarize his findings in that there are some parts of the brain that remain active and behave in a more alert way even during sleep in people with insomnia compared to good sleepers. And those parts of the brain include areas or systems such as the default mode network and regions such as the prefrontal cortex.

In essence, it can lead to that feeling in insomnia of being partially awake or having some awareness of the environment despite being asleep which in turn can lead to that underestimation of how much sleep is actually occurring that we commonly see in people with insomnia, particularly with hyperarousal.

In a small case series that we looked at, we actually haven’t published that. We presented the results to one of the Australasian Sleep meetings. We showed that people with insomnia actually estimated that they were sleeping 2 hours less than they were when we looked at what was actually happening in the brain compared to sleep diaries. And that’s not everyone with insomnia but it is a particularly hard core group of people with quite challenging insomnia who were insisting they slept quite short periods, only around 3 hours per night. But in fact, were sleeping for around 5.5 hours per night when we measured what the brain is doing.

But if we were more sophisticated and used some of Professor Nofzinger’s techniques to look at imagine, we probably would have seen that there are parts of the brain behaving like they are awake and parts of the brain behaving like they are asleep. And this phenomenon has led to the term Regional Sleep, not thinking of the brain as a single unit during sleep but as multiple different regions that all behave differently during sleep, depending on different states and depending on different conditions.

So based on that research, Professor Nofzinger together, with some collaborators, has developed a device called the Ebb Device or the Ebb Sleep, they are now calling it, which look at cooling the forehead which is the region of the brain where the prefrontal cortex sits. And the theory is, if you cool the forehead, it will help to reduce that increased metabolism in the prefrontal cortex and then help with sleep onset.

They’ve done a number of clinical trials and in particular, a randomized controlled trial in around 100 patients showing that it got people into stage 1 sleep faster, into stage 2 sleep faster with a mean of just under around 40 minutes shortening the time taken to get into those two sleep stages. So that paper has been accepted and it’s going to be published in the Journal of Sleep later on in 2018.

The device still isn’t commercially available. It’s available in some limited centers in the US, about 19 centers that have been specifically selected as places you could go to trial the Ebb Sleep Device, and expected to be more widely available in the United States through 2019.

I’m really interested to see how that goes once it’s out sort of in the wild and people are using it more broadly. Our colleague, Simon Frankel, talked about in an earlier episode, he tried the device at one of the sleep meetings in the US and did find it very cold on his forehead. He was really sure how he was going to be able to go to sleep with that type of device. But the results showed that it did actually work in people with insomnia. So really, we’ve just got to see how it works once people are actually out using it in their homes and using it outside of a research setting. Is it something that’s practical that’s really going to work on a broader basis?

Dr. Moira Junge: It’s so interesting about the different regions of the brain and sleep can be different in different parts of the brain. I don’t think I was actually fully aware of that. What is your take-home from all of this?

Dr. David Cunnington: That the brain is a complex organ.

Dr. Moira Junge: Yeah. That’s new.

Dr. David Cunnington: Yeah. And I think it really does – with this increased understanding, the different parts of the brain behave differently like in different sleep stages and also between good sleepers and not-so-good sleepers or people with insomnia. It does open the door for lots of different potential therapies. Can you do something locally to just impact one part of the brain that makes it behave more like a good sleeper’s brain as compared to how the brain behaves in someone who has had poor sleep or who had insomnia?

Dr. Moira Junge: Yeah. I think there’s so much more. I’m excited by that. Couldn’t we be doing more already with perhaps with the EEG when we got such tiny little – we look at just the occipital and the central area of the brain, but really, already couldn’t we be doing a little bit more?

Dr. David Cunnington: And so the technology is sort of there. So the technology is there to collect that data. So a standard sleep study will do 6 EEG leads, occipital, central, frontal. And you can actually do EEG using 64 channels or even 256 channels to really try and regionalize where different brain activity is.

The trouble with bringing that to the clinic at the moment is the data processing. What do you do with that amount of data?

Dr. Moira Junge: Yeah. There’s so much of it. Yeah.

Dr. David Cunnington: There’s just so much of it. So to stage sleep with a 6-channel EEG is about a good hour to two hours’ worth of sleep.

Dr. Moira Junge: Yeah, that’s not practical, is it?

Dr. David Cunnington: Yeah, it’s not practical for everyday clinical practice.

Dr. Moira Junge: Yeah.

Dr. David Cunnington: It’s starting to be done in a research setting.

Dr. Moira Junge: Yeah.

Dr. David Cunnington: And hopefully, we will be able to, with changes in technology, use that more as a tool in the clinic to be able to map out how brain regional factors impact sleep in given individuals and use that better understanding of the physiology within a given individual to the target treatment and work on some specific treatment strategies.

Dr. Moira Junge: So watch this space I guess.

Dr. David Cunnington: So hopefully, that has given you a better understanding of hyperarousal and its role in insomnia. And for people who have seen me, you now understand why I keep banging on about it’s not all about what’s happening at night and don’t focus on the sleep so much, but actually got to think about what happens through the day.

If you’re looking for more information on the hyperarousal, I’ll put the link to Dieter Riemann’s paper in Sleep Medicine Reviews in the show notes. I’ll also put a link to a device, the Ebb Insomnia Treatment, which it looks at cooling the prefrontal cortex and has been approved by the FDA as an insomnia treatment. And there’s a video that I’ve done on SleepHub that looks at the stress performance curve and talks a bit about that as a model for nervous energy and hyperarousal and some of its role in insomnia and sleep disturbance.

So what’s your clinical tip, Moira?

Dr. Moira Junge: Well, my clinical tip of the month leads very nicely into exactly what you just said and I think it’s really picking what Dieter Riemann was talking about is that we’ve got to be aware as clinicians and directing our clients or patients to the fact that being aware of the 24-hour arousal issues, not just the sleep itself. It’s about that directing the patients to the hours well before they even go to bed when they get up for the day, what they do then too.

So all those – say, they’re a 6-hour sleeper, I’m much – I’m really interested in the 18 hours outside of that period they’re having trouble with. So they are coming to see you about this particular period but really redirect their focus and attention to the other parts of the day in which they’re hyperaroused and setting the scene I think if you like for why at night, there’s too much-circulating cortisol or adrenaline or the like.

So yeah, it’s really nice. It’s just nice. We’ve been talking about that for some time but just a reminder as a clinical tip for people, both the people who are clinicians or people who might be listening here who do have difficulty managing their hyperarousal to think about their day, not just the night.

Dr. David Cunnington: Yeah. It’s not about those supercharged switching off secret in the 5 minutes just before you go to bed.

Dr. Moira Junge: Yeah, that’s right.  You can’t go, go, go, go, go. Do a quick little something on your app, a 5-minute meditation or something, and then expect to be able to sleep well.

Dr. David Cunnington: So is that what you’re looking for in terms of the difference between sleep when you and I were kids some years ago?

Dr. Moira Junge: Forty years ago?

Dr. David Cunnington: But some years ago. Is that spice for the …

Dr. Moira Junge: Yeah, perhaps. Well, I think the daytime was very, very different, wasn’t it? The stimulation I would say to my kids we were just bored most of the day looking for something to do like roaming around with your bikes. So it wasn’t so much stimulation. We weren’t overwhelmed with information that’s for sure. Yeah, I think the stimulation, that was a very, very different that we need to really – we all know that but we forget that it’s a really obvious thing when we are thinking about sleep because people just focus on their evening. They think, “What do you mean – it doesn’t matter what I did this morning.” I say, “Yeah, it does. Tell me about your days. Tell me how you feel in your days at the time moment.” And that would tell us a lot about what’s happening at night.

So what about your pick of the month? Remember, it’s ‘game on’ this year. No, not really. I’m not that competitive. But I’m just jealous of your good picks of the month that you got. What have you come out with this month?

Dr. David Cunnington: Yeah. I’ve gone with a book again. And you’d be pleased to know I haven’t tried too hard so this is a very mainstream book. So the book that Arianna Huffington wrote some years ago is called Thrive, so not her latest one. That’s Sleep Revolution. This one is Thrive. And I actually think Thrive is a better book than the Sleep Revolution one. Sorry, Arianna. I had to say that.

The reason I like Thrive and it’s really relevant for our podcast this month is that one of the premises of Thrive is that Arianna Huffington was a busy, highly successful businesswoman and with that not sleeping much and essentially collapsed, hit her head on the bathroom sink and cut her head open, and that was the realization that you just can’t get away with both cutting corners and not allowing enough time for sleep and the impacts of being overly busy. And then based on that, wrote the book, Thrive and highlighted the importance of allowing space to sleep but also adequate nutrition, adequate physical fitness, adequate mental health, all those ingredients of thriving and being well.

Dr. Moira Junge: Yeah. So basically, reducing your hyperarousal and therefore thriving.

Dr. David Cunnington: That’s it. So that’s why it’s a good pick for this month. What about you, Moira?

Dr. Moira Junge: Well, similarly, I thought just keep with the theme and it’s not a new app. It has been around for several years but it’s just a really, really good one. And it’s one that is evidenced-based and it has been – it has shown that it does have efficacy that people who are using this app called Smiling Mind, which is actually helping people to meditate with mindfulness meditation and it’s a Melbourne-based group, set it up and it’s- but they’re international now. I think people who are listening to this all around the world should go there – wherever they get their apps and they will be able to find it and download it for free.

And what I like about it is it got different age groups. So you can think – I don’t know off the top of my head like say, under 7 or 7 to 16 and 17 to …

Dr. David Cunnington: Yeah, it does it really nicely.

Dr. Moira Junge: This has just a different thing because a child is going to be wanting a different thing for their meditation on how they are going to learn how to address their hyperarousal via meditation to an adult. So it’s really good. Different lengths and different pitches. I recommend people to get on board with that. Check out their website and I think they’re just a really good outfit at Smiling Mind.

Dr. David Cunnington: Nice pick. So things that are coming up in sleep now that we are back into the working year and getting off into a long, long time before our holidays and summer comes around again. Check-in on your own degree of hyperarousal and as we’ve been talking about, if you feel like those nervous energy levels are a bit too high, that may have an impact on sleep. So just checking in and putting in place some strategies to bring those things down.

Any other things coming up for you, Moira?

Dr. Moira Junge: No. Not that I can think of. I think looking forward to next month’s episode that we are going to be talking about sleep and cancer. So stay tuned for that. That’s going to be a great episode. We’ve got so many ideas all the time but we are really open to other suggestions so we would really love to hear from listeners. Please write to us with your suggestions. I think you all know, Podcast@SleepHub.com.au.

And certainly, leave us a review on the iTunes website if you do like us, talk about it, spread the word about this particular podcast. Yeah, that’s all from me for this month.

Dr. David Cunnington: Thanks very much, Moira. And healthy sleep for everybody.

Dr. Moira Junge: Yeah. Thanks for listening and we will catch you next month.

Outro: This podcast is not intended as a substitute for your own independent health professional’s advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider within your country or place of residency with any questions you may have regarding a medical condition.

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