Episode 57: Awake or Asleep?

At times it can be hard to tell whether you have gone to sleep or not, or how much you have slept. This can be a particular problem for people with insomnia who can be prone to under-estimating how much sleep they are actually getting. To understand how this happen we spoke to Dr Lieke Hermans from Eindhoven University of Technology, Netherlands.

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 / Chapters:

  • 00:00 – 25:28 Theme – Awake or Asleep?
  • 25:28 – 26:30 Clinical Tip
  • 26:30 – 29:53 Pick of the Month
  • 29:53 – 32:26 What’s Coming Up?

Next episode: Light

Links mentioned in the podcast:


Guest interview:

Dr Lieke Hermans was born in 1992 in Alphen a/d Rijn, the Netherlands. In 2016, she received her M.Sc. degree at the University of Twente in Technical Medicine, with the specialization Medical Sensing and Stimulation. During her master thesis she was involved in a project at the UMC Utrecht about EEG network analysis as a tool for detecting postoperative cognitive impairment in the elderly. In December 2020 she finished her PhD project at the Eindhoven University of Technology, titled ‘sleep structure and sleep perception in people with insomnia’. Currently she is working as a postdoctoral researcher at the Eindhoven University of Technology, where she continues to study how clinical relevant information can be extracted from sleep measurements.

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 is actively involved with the Australasian Sleep Association (ASA) and a board member of the Sleep Health Foundation. She has presented numerous workshops for psychologists and is involved with Monash University with teaching and supervision commitments. She is one of the founders and clinic directors at Yarraville Health Group which was established in 1998. 

Connect with Moira on Twitter – @MoiraJunge

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 an International Sleep Medicine Specialist, Diplomate Behavioral Sleep Medicine and Registered Polysomnographic Technologist. David’s clinical practice covers all areas of sleep medicine and he is actively involved in training health professionals in sleep.

Connect with David on Twitter – @DavidCunnington. David also regularly posts information on sleep to his Facebook page.

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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 57 of Sleep Talk, the podcast talking all things sleep. We are back, Moira.

Dr. Dr. Moira Junge: Yes! We are back! It has been way too long and it’s really nice to see you, albeit via Zoom. We haven’t seen each other for 12 months.

Dr. David Cunnington: Yeah, almost. Yeah, pretty much.

Dr. Moira Junge: Yeah. Except that we actually did one in the studio, we’ve been doing sort of phone and Zoom ever since.

Dr. David Cunnington: I know. We’ve both been pretty busy clinically, which has led to a bit of a hiatus in terms of the podcast but 2021, we’re back.

Dr. Moira Junge: We’re back and we are going to really dig deep and do it regular this year.

Dr. David Cunnington: All right. And just a slight change in format, rather than looking about what has been going on in sleep upfront, we are just going to get straight into the theme in each episode.

So the theme for this month’s episode is talking about a thing called sleep state misperception, which is when people think or perceive that they’re awake when in actual fact, they may be asleep. And it’s something that’s actually really common and something we commonly come across in clinical practice. And I find it challenging. It’s a challenging sort of thing to work with people.

What about you, Moira? Do you see much of this in your practice?

Dr. Moira Junge: Yeah, I do, of course. But then sometimes it’s hard to know upfront unless you’re working in a sleep disorder center and you got sleep study data like you never really know for sure, do you? You’re sort of working in the dark really. I strongly suspect a lot of the time particularly when someone might say, “I didn’t sleep at all for a week or I don’t get an ounce of sleep.” And they do know or you think to yourself, “I think there’s some degree of sleep state misperception.” But it’s a tricky area so I’m really glad we are covering this.

Dr. David Cunnington: Yeah, you’re right. It is a bit easier for me where I can access sleep studies to objectively measure sleep. But increasingly, people can access wearables now and they are reasonable in measuring sleep. But people with insomnia who are a bit restless, that’s one of the times the wearables will underestimate true sleep, which can actually feed into that belief that we are not getting much sleep or look how little deep sleep I’m getting. So it is a challenging area.

So although we talk about this sleep state misperception, it’s actually a normal part of sleep to take some time to realize you’ve actually been asleep. And it just seems that that’s a little bit exaggerated in people with insomnia but we’ve all had the experience of nodding off on the couch and our partners go, “What are you doing? You’re nodding off.” And we deny that we’ve actually been asleep. That’s the human experience. And it just is a bit more prominent in these conditions such as insomnia or anxiety or people who have had prior trauma.

Dr. Moira Junge: So to learn a bit more about it, we thought let’s go to an expert, someone who has just finished her PhD just in December 2020, so quite recently, so Dr Lieke Hermans from the Netherlands. And interestingly, she is from the Department of Electrical Engineering in The Hague University and we thought, “That’s really cool.”

Dr. David Cunnington: So thank you very much for taking the time to talk to us today.

Lieke Hermans: Yeah, thanks for inviting me.

Dr. David Cunnington: So tell us a bit about your current role and what’s the research you’re doing at the moment?

Lieke Hermans: Well, I finished my PhD in December 2020 at the University of Technology in Eindhoven and I’m working in the group that is doing sleep research with Sebastiaan Overeem who is a sleep professor there. And right now, I’m doing postdoctoral research in the same group. So I’m mainly organizing data collection but I’m also researching sleep architecture together with my colleagues.

Dr. David Cunnington: And you’re in the Engineering Department and have that sort of background. How did you actually get into sleep research?

Lieke Hermans: My background is in medical signal processing and I have always liked also psychology, so the behavior of people and the adults. So for me, studying the EEG, the brain signals, was a really nice way to combine those two things together so that I can have the technical parts and the psychological parts. So I started with research in epilepsy and delirium and then I could tell a vacancy for sleep research for insomnia so I felt that it will be really a good thing for me.

Dr. David Cunnington: Yeah. These are interesting fields in sleep. So in our clinical practice of doing a sleep study, we record so much data and it’s such a rich data set and we often, unfortunately, distill it down to a couple of indexes that really – you lose the richness of those raw signals and data that we record.

Lieke Hermans: And there’s really a lot of data in there that’s currently not used.

Dr. David Cunnington: Yeah, absolutely. And I’ve always thought that if people who are almost not in the sleep field can look at it and go, “Yeah, mathematically, I reckon I could tease out some waves or some variations or some patterns out of this dataset.”

Lieke Hermans: Yeah, and it’s also difficult because we started – well, we started wanting to do some set typing of insomnia with patients and looking at their journey to sleep recordings. But then we – and we want to find the new parameter for them but then we found out that you really can extract everything with this. You have a very long signal which is the whole night and it’s really a jungle of thousands of different parameters that you can find so it’s really difficult to know where to start.

Dr. David Cunnington: Come on. That’s where you’ve got to give the answers for the clinic. Hopefully, you can find the signal amongst all that noise using mathematics because in a clinical sense, often a lot of insomnia looks pretty similar so people start to think differently about sleep, get that hyperarousal type of phenotype and clinically it looks pretty similar. So yeah, I need your help to be able to tease some types out.

Lieke Hermans: We were thinking about this a lot and then we soon figured out that we need something to start with so that it will be a very good idea to combine the physiological parameters again with the psychological complaints so that we could maybe find what’s wrong with the sleep of people who are not experiencing a good quality sleep and maybe we can start from there and say, “OK, which night or which part of the night are experienced in a bad way?”And then can we find parameters that can fit the best quality of sleep? So that’s why we start looking at sleep misperception.

Dr. David Cunnington: And why sleep onset in particular?

Lieke Hermans: Well, this was a bit of a coincidence in the beginning because I had a dataset with 30 people with insomnia and we noticed that all of them had a pretty decent sleep time. So they were sleeping for about 7 or 8 hours. And most of them really had the impression that they had a very long sleep onset. Well, that was not really true. So this was just an observation that we made and that we really became intrigued by that and we wonder what the cause was. So that was – that left us wanting to investigate that.

And also, the sleep onset is easier because it is a localized event. So you can know that probably something is wrong with the beginning of the night and then you can specifically start to – for example, the first sleep cycle. So that was a good way to start.

Dr. David Cunnington: So that’s really interesting. I knew that we were going to be talking about this today and I saw someone in the clinic earlier today who swears that they are not asleep until 3:00 o’clock in the morning, yet, they go to sleep at 11 PM and their partner says, “You’re asleep before then.” But they swear they are not asleep. So I was trying to explain to them about this term, sleep state misperception. I don’t really like that as a term because it has got sort of a negative connotation to it.

Lieke Hermans: Yeah. Yeah, I agree.

Dr. David Cunnington: In the work that you’ve done, how do you try to sort of reconciling that? What did you find and what are some of the things we can help people understand that difference?

Lieke Hermans: So yeah, indeed, we found that it seems to be dependent on how long you sleep. So we saw that people who fall asleep and then ultimately awake a lot of times can influence their perception of falling sleep. It’s something that of course needs more research but I know already some clinicians in the Netherlands who are treating people with insomnia who are already using this also to put people a little bit at ease because they can say, “Well, it’s not – you’re not crazy. It can be that some parts of your sleep can lead you to have a feeling that you are awake. And then well, we can try sleep therapy to fix it.” And then, of course, we do not know exactly how that works. But it can already help people a lot to make them feel taken more seriously.

Dr. David Cunnington: Yeah. I really like that way of thinking about it. So not going back to the patient and saying, “Well, you’re wrong. You’re asleep.” But really recognizing that there need to be certain periods of undisturbed sleep to be able to make it feel like sleep and to be perceived or experienced sleep.

Lieke Hermans: Yeah, because we now really are focused on quality. So the amount of sleep that we do not really know if maybe you can sleep for a very long time but still not have good quality or the other way around.

Dr. David Cunnington: So then in looking at modeling sleep onset and the work that you did, what did you actually find in both good sleepers and those with insomnia?

Lieke Hermans: We started with exploratory analysis to see if we could find something in the first sleep cycle of people with insomnia, so if there will be a relationship between people with a lot of sleep misperception and their sleep will be different than people who do not get a lot of sleep onset misperception. And then we found that a team that the people with a lot of misperception have a lot of sleep fragmentation, so on the level of their sleep stages. So it seemed that they had to start over a couple of times and they kept awakening all the time.

So then we made the assumption that maybe you have to sleep without disturbances for a certain amount of time, which can be a little bit comparable to, for example, falling asleep on the couch. Sometimes people would nap for a couple of minutes and then their partner would say, “Oh, are you sleeping?” And they wouldn’t have known that.

And then I think that’s something that’s recognizable for a lot of people. So our hypothesis was that maybe you have to sleep for a short amount of time to know that you are sleeping. And then we started making a model and answering questions like OK, how long does short sleep has to be, and how long does the awakening has to be? It doesn’t matter if you were going to wake up for 30 seconds or for – it doesn’t have to be long to disturb sleep.

Dr. David Cunnington: And you used that term awakening. What do you actually mean by awakening? Do you mean the American Academy of Sleep Medicine Arousal? Do you mean behavioral eyes opening? Do you mean a self-reported, “I remember being awake?”

Lieke Hermans: We used awakening according to AASM definition so we did not use any of the arousals, only the 30-second awakening. So there was already some kind of threshold that they would like to look also at the arousals in the next research. Sleep recordings in the Netherlands we do not always have them scored so that makes it a little bit more difficult to research because it costs a lot of time.

Dr. David Cunnington: Yeah. And getting a bit technical but I think the tools that we are using in clinical practice the Rechtschaffen and Kales sort of sleep staging is a blunt tool. Arousal definitions are really blunt tools. I like cyclic alternating pattern as a way of conceptualizing unstable sleep within maybe transient breaks-in sleep that may actually then be perceived as awake or hourly multilevel stages for the transition between sleep and awake that it’s not just awake in one and two but many stages in that transition. I think we need to do better in terms of both, yeah, clinical practice of how we think about this.

Lieke Hermans: Yeah, that’s true. Yeah. And we are of course now looking at a very core measure of 30 seconds which can be far more detail than we currently know. At the same time, I think there is also a lot of information in those standard 30-second sleep stages that we are currently now using so – and those are the easiest to get and we know a lot about them because we have already done the research for years and years. So I think that will be a nice point to start. And then maybe from there, we can find the information that we need apart from that.

Dr. David Cunnington: Yeah. And I’ll come back and ask you a little bit about what I need to look for in my sleep studies. But when you looked at this sort of length of awakenings that people needed to perceive that they had achieved sleep onset, what did you actually find and how did that differ between normal and those with insomnia?

Lieke Hermans: We found that already 30-second awakening, so that was the shortest awakenings that we had recorded basically but they were already really important for the sleep perception, so already awakenings of 30 seconds can disturb the sleep. And we also found that people with insomnia seem to need longer, uninterrupted sleep fragments than people that are healthy sleepers. So it seemed like people with insomnia were a lot more sensitive to sleep fragmentation compared to healthy people.

Dr. David Cunnington: Did you have any sense of what underpins that sensitivity?

Lieke Hermans: Yeah, it’s difficult because there are of course a lot of different things that can contribute to sleep risk perception. What we tried was also finding other factors and linking them to the sensitivity of sleep fragmentation.

For example, we look at how well people are estimating time and then we saw that people who were more sensitive to sleep fragmentation also had more trouble with time as they call. So we asked them, “OK, can you press the button after 10 minutes?” So it seemed that maybe those two factors are separately or not separately both contributing to the sleep misperception.

Dr. David Cunnington: So if I’m looking at my sleep study that I’ve recorded on a patient with insomnia who is reporting that they have a long sleep onset, what do I look for? What would you suggest that I measure to try to get some insights into this sleep state misperception?

Lieke Hermans: Yeah. I think it will be easiest if you want to gather feelings for the sleep recording to look at how long it takes for a person who is reasonable – and they start sleeping for example, how long does it take before he has 20 or 30 minutes without waking up? And then if you see a level awakening at the beginning of the night and it takes a lot of time to reach consolidated sleep then it can be that he or she misperceives the sleep onset because of that.

Dr. David Cunnington: You talked in one of your papers about an index or sleep fragment perception index. Can I calculate that from my PSGs?

Lieke Hermans: Yeah, you can calculate it. It’s a little bit more difficult to calculate it from one night so I think that the other one is a bit easier. That’s also one that I use later. So I calculated the latency until consolidated for 20 minutes, that’s reasonable to calculate from one with sleep recording.

Dr. David Cunnington: I’ll pick a block, the first 20-minute block of sleep without a 30-second awakening and calculate the time from sleep onset to the commencement of that block.

Lieke Hermans: Yup. Yeah, I think that would help.

Dr. David Cunnington: And we’ve talked about insomnia, but what about other conditions with hyperarousal? Do you think this might be applicable to some other conditions that have similar physiology to insomnia?

Lieke Hermans: Yeah. I think it will be really interesting. I would particularly like to know what is the influence of hyperarousal on the sleep for example because one large question that I still have is, OK, people with insomnia seem to be more sensitive to those awakenings but is it also – can it also be that their sleep structure changes because of their hyperarousal or is hyperarousal maybe influencing the sensitivity? So I would really like to know about how can we exactly measure hyperarousal and does it influences sleep?

Dr. David Cunnington: Yeah. If you can come up with a measure for hyperarousal, please let me know because I’d really like that in clinical practice as well.

Lieke Hermans: Yeah. In the beginning, I thought OK, it was nice to look at the hyperarousal but it was more difficult than I thought to find the expression for that.

Dr. David Cunnington: I know. I try to kid myself that I can just look at the EEG and go, “Yeah, OK. That looks like hyperarousal.” But then my …

Lieke Hermans: Yeah, that will be great.

Dr. David Cunnington: … my fellows go, “Well, what are you looking at? What are you seeing?” Yeah, it looks like it. Just stop asking me questions. I can’t put my hands on exactly what it is that I see.

Lieke Hermans: Yeah. That’s another example that we know a lot of concepts about insomnia, and how it works psychologically but it’s really difficult to couple that to the objective measurement.

Dr. David Cunnington: It might help if we start to look at some of the measures like you are using in other conditions of hyperarousal like PTSD for example because there’s certainly the clinical sense. I have people with PTSD who have sleep state misperception, exactly the same as those who maybe have primary insomnia so there does seem to be some similarity in the clinical presentation and the EEG can often look pretty similar as well.

Lieke Hermans: Yeah. I think in the Netherlands that will be maybe also the group of people that often do not get a sleep recording so that makes it a little bit more difficult also often with insomnia. They often do not do a sleep recording because there’s not much to see on the sonography recording anyway. So that sometimes makes it a little bit more challenging.

Dr. David Cunnington: So then once you got together your data on the sleep onset and had a better understanding of that, what did you move on to? What sort of research questions did that then give rise to?

Lieke Hermans: I’m still hoping to extend the measure a little bit so I can also look at sleep fragmentation on the whole night and that only then do I have sleep onset. So we have the paper out in psychopharmacology where we try to do that. So we first look at people who are sleeping one night with sleep medication and one night without sleep medication. And we saw that when they use sleep medication, they have the impression that they feel asleep sooner and that seemed to be explainable because they have fewer awakenings at the beginning of the night.

And then more importantly, we tried to get that to a whole night measure. So we looked at the survival time of non-REM sleep and REM sleep and then we saw that people with insomnia when they use sleep medication, there seem to have more fragmented REM sleep. So it was not only sleep onset thing but through the whole night.

And right now, we have a paper out that is looking at the night fragmentation in a larger group of people, so the difference between insomnia and healthy people. And that we hope that’s going to be published soon.

Dr. David Cunnington: So do you think these markers will be able to be used as outcomes in some of the clinical trials in insomnia?

Lieke Hermans: I hope it can at least help maybe to find different types of people with insomnia. So that’s going back to the question that we started with four years ago because I can imagine that maybe not all people will have fragmentation of non-REM sleep and there are also a lot of researchers, they think that REM sleep is msierable. So I think if we can assess the fragmentation of those sleep stages separately then it may help to find what’s going on with the patients and why the patient has the impression that he is not sleeping well.

Dr. David Cunnington: Thank you very much for that explanation of your research and good luck with your ongoing work.

Lieke Hermans: Yup. Thank you.

Dr. Moira Junge: Well, thanks for that, Dave. Another great interview. She sounded really lovely and so enthusiastic too. She is at the very start of her career. What were the main things that just straight up, what kind of things were in the forefront of your mind?

Dr. David Cunnington: So one of the things I really liked about Lieke’s research which is why I wanted to interview her is I think her framework of the way she sorts of talks about sleep onset as you need these continuous periods of sleep without awakening to perceive it as sleep is just a simple message that really resonates with people I see in the clinic. You can talk to them in that sort of language and it’s not, “Well, you’re wrong. See, you actually slept this much.” It really can be that understanding of, yeah, I got bits of sleep but these little bits of awake in between meant that it felt like awake across that experience. And her research really fits with that framework. So I really like that.

Dr. Moira Junge: In fact, that was one of the things that really stuck out to me. I mean here I am, I consider myself an expert with insomnia and I’ve seen a lot of clinical patients over the years, I’ve never really had such a helpful framework to explain it to my patients because you’re right, sometimes it’s – it almost catches a bit of an argument that no, no, no, here’s the data, here’s a sleep study, here’s the 8 hours of really good quality or reasonable sleep. But you’re telling us you had nothing or half an hour.

And I’ve never really liked it. In fact, I don’t know if you remember this, this is an anecdote, back in 2008 when I very first started working at the Melbourne Sleep Disorder Centre, I was pretty fresh in a way and you had called me into the office to look at this polysomnogram what I would consider sleep and I was very skilled at sleep. Scientists I knew back then had a school of sleep, steps on how to go to sleep. But then you said to me, “This is so and so and this is – look, she said she got zero sleep. What are you going to tell her? She is next door.” like I had to sort of quickly pull myself together and think, “Oh, no! I don’t know what to do.”

So it’s going to be much, much easier 13 years later to have sort of a better framework than work in the dark of how to approach the patient who says, “I’m not sleeping.” And then you see the data that they are sleeping and insist. It’s really useful. It makes sense.

Dr. David Cunnington: Yeah, absolutely. And that is that nice framework. We did some other work looking at a perceived sleep in people with insomnia and there wasn’t often as big a discrepancy as 8 hours versus zero but not uncommon for someone to report 3 and be getting 5 for example, and that’s actually pretty consistently for a lot of people with insomnia.

Dr. Moira Junge: Yeah. And I remember as always, we used to have lots of clinical meetings and the psychology voice against the medical voice that we would have these team meetings and I would say, “Look, I don’t really care. That’s OK. I’m not moved by your data.” The person who she or he thinks is not sleeping and that’s why I’m happy to go with – I don’t know. I don’t think it’s that important that we’ve got this sleep study data. I don’t know. I can’t convince them because some of them would just actually think you’ve got the tapes mixed up and they didn’t – it wasn’t that helpful. In fact, it set up a bit of a conflict and a breaking of rapport anyway.

Dr. David Cunnington: Yeah. That’s a really nice point because if we do take that approach, “Well, look, here’s the data. You’re sleeping more.” It doesn’t acknowledge that it’s distressing. It’s distressing to feel not sleep and to feel tired during the day and feel not well. So that – you’re right, it really is important to acknowledge that distress and acknowledge that it doesn’t feel good.

Dr. Moira Junge: But nonetheless, in some people too, I would be really reassured to know, “Oh, good. I am getting sleep.” That’s how I thought it was always going to play out but I was surprised by the people who push back and didn’t really believe it or didn’t want to know that. This sort of research is too exciting and I mean, I don’t know if – correct me if I’m wrong, but in Australian sort of sleep centers, I don’t think anyone has really put a lot of attention on to sleep state misperception or am I wrong with that that we do have a bit of working group here locally?

Dr. David Cunnington: No, not really. And part of it is the scoring criteria. So the way we score sleep stages with the traditional REM, non-REM, and the stages of non-REM doesn’t take into account really the sleep fragmentation or the hyperarousal. It really doesn’t encompass that.

Dr. Moira Junge: Yeah.

Dr. David Cunnington: And so, we are mandated by Medicare in Australia to use certain criteria to score sleep studies. And so, we want to do the experts and then an add-on on top of that so it’s not something that is often done routinely. But as I talked about in the interview, there’s such a rich dataset that we record with sleep studies that hopefully we will get better biomarkers both of hyperarousal and this fragmentation over time.

Dr. Moira Junge: Yeah. I mean I’m thinking about now sort of our sleep centers, often they cash within the school of psychology for instance. And so, how wonderful to think, hang on a minute, maybe the school of electrical engineering might just have – they might have some better grants or some better ideas and we could really make something a bit …

Dr. David Cunnington: Yeah, and it’s interesting because sometimes you come to it with a fresh set of eyes. There’s not that preconceived notion that sleep fits in these boxes and please don’t disrupt my dogma or sort of challenge my sort of framework. If you have nothing to start with, you can actually look at it fresh and have a new approach.

Dr. Moira Junge: So how do you go about trying to manage these in clinical practice, Dave?

Dr. David Cunnington: So pretty similar to yourself. So particularly after looking at Lieke’s work, really trying to talk to patients, have people understand what’s going on at the brain level so they can – it’s not a mysterious thing that seems like it’s just not working. There’s an understanding of what it can feel the way they feel.

But the other thing for me at a purely clinical level is when I see someone who is often misperceiving sleep, often have been referred from a setting where there is not the ability to objectively measure sleep and the treating practitioners have been treating a symptom and the self-report of the symptom and often the referral guys will have tried this drug and this drug and this drug and this drug and this technique and nothing seems to be working, that’s the thing for me is like OK, what is it we are actually treating?

Dr. Moira Junge: Yes.

Dr. David Cunnington: And that’s often one of the settings that I see overprescribing because if a little bit doesn’t work, well, let’s go a bit more and let’s go a bit more and then that doesn’t seem to work.

Dr. Moira Junge: So if you are looking for more information, we will put Lieke’s papers into the show notes.

So what’s your clinical tip this month, Dave?

Dr. David Cunnington: So it goes along with what I was saying at the end of our discussion in medicine and lots of other sorts of practices, if something doesn’t seem right, we got to think, yeah, it maybe it isn’t right. And that really applies particularly to these particular issue we are talking about, is someone awake or asleep and how much are they actually sleeping, because again, if you are treating someone via the psychology-based strategies and they are not responding or if you’re treating them with pharmacotherapy, they’re not responding, you just go to think, what am I treating?

If I’m treating subjective sleep reports then maybe they’re off. Maybe there’s something about that person’s sleep which means they’re subjective sleep report is not quite right. That’s my tip. If something doesn’t add up, it may not be right. So take a step back. And rather than thinking, “Right, let’s add more medications or go harder on a particular line,” maybe we need to think about is the self-reported sleep experience a good reflection of the underlying physiology?

So what’s your pick of the month, Moira?

Dr. Moira Junge: So a tough pick of the month this time because we’ve had so much stuff, so much water under the bridge, I’m going for a non-sleep pick but I think it’s actually quite related in the end really to our interest in the sleep world, documentary series called Addicted Australia. It followed a sort of 8 or 10 different individuals over 6 months. So it’s about a 6 or 8-part series. It was absolutely excellent. There are a lot of interviews with professionals and the team at Turning Point who are based here in Melbourne, Victoria but other specialists too.

I just think it was really great. It just showed the struggle with addiction to drugs, alcohol, gambling, and the like. I found it really compelling. I think a lot of people I’ve spoken to really loved it too. So if you haven’t seen it, I think it’s very important for all of us health professionals and mostly I would answer health professionals. I think it’s good to get our head around the struggles with addiction particularly – they didn’t necessarily talk about sleep but I think that in our world as clinicians and researchers, we see a lot of struggles whether it’s alcohol, other drugs, or even prescription drugs, and the struggle with trying to or even over-the-counter so-called herbal things that just – people can actually just probably had too much of the wrong thing at the wrong time and just a need a lot of education, support, guidance, and understanding and less judgment, less stigma. So yeah, I thought that was great. It really struck a chord with me.

Dr. David Cunnington: Nice pick. I really enjoyed that series too. So yeah, thanks, Moira. So from my point of view, it’s a book I read over some of the lockdowns. I’ve been seeing a lot of people with fatigue syndromes in the last 12 months and I suspect I’m going to see a number more with long COVID being a common thing in people who have had COVID infections. So you know how I like my old books as well. So this one is called A Practical Treatise on Nervous Exhaustion and it’s written by George Beard in 1880.

Dr. Moira Junge: Wow!

Dr. David Cunnington: And describing what we think is this phenomenon in 2022, 2021 of burning out and feeling exhausted and having a sort of fatigue syndrome where we are just constantly tired. Well, you know what? It isn’t that new.

Dr. Moira Junge: It’s not new. Yeah.

Dr. David Cunnington: Amazing description of symptoms I’m seeing today and symptoms described in 1880 that are almost exactly the same and sort of progressed over time that really sorts of fits a lot of what I see today.

Dr. Moira Junge: And what did they think in 1880 were the causal pathways?

Dr. David Cunnington: Yeah, so they’re a little different. So they do talk – they use those lovely nonjudgmental terms like hysteria, particularly when referring to women.

Dr. Moira Junge: Yeah.

Dr. David Cunnington: Neurasthenia, neurosis, neuroticism, particularly where women were involved.

Dr. Moira Junge: Of course.

Dr. David Cunnington: So yes, certainly judgmental in terms of some of the causality but the common thing being that term nervous exhaustion. So that resonates because people still think of that sort of term now about too busy for too long has consequences and can cause a range of symptoms. So yes, you don’t have to buy the 1880 version. So I’m a collector of books so I do have one of those. There are modern reprints.

So things to look out for in our next episode, we hope to talk to Sean Cain from Monash University who has published some – yet more work on lights and the importance of that for just general health and sleep. So look forward to that.

And there’s a couple of research projects that we will be running across this year that – just to give you a flavor of the things that we are looking at, looking at people’s thinking styles and particularly, traits of perfectionism and risk of insomnia because you and I, Moira, recognize in our clinical practice. That’s something that we see. So we are trying to characterize that a bit better.

And also looking at a condition called REM behavior disorder and I hope to do an episode on that across this year at some point, which is something that happens during sleep when people act out their dreams, and that can be an early marker of neurological conditions like Parkinson’s disease. And we are doing some collaborative research with the University of Melbourne again looking at if we can find this as an early marker of Parkinson’s, could we potentially get someone on Parkinson’s treatment early and change the course of what might happen over the future? So it may be a way of trying to access people before it’s too late in terms of treatment of some of those neurological disorders.

Dr. Moira Junge: And in other news, it’s great to see a mindfulness paper get published and sees the light of day. It has been sort of on a shelf for a while. So well done to the team, well done to Allie Peters with the project that she did with all of us colleagues at the Melbourne Sleep Disorders Centre. So excellent. Well done. We will put a link to it in the show notes. We are really proud that it’s finally being published.

Dr. David Cunnington: So thanks for listening to this episode. And if you got suggestions for other episodes you’d like us to produce, send us an email at Podcast@SleepHub.com.au. We particularly love to feature early career researchers like in this episode just to get their work out there and help people understand and learn about their work. And if you like the podcast, review us on iTunes, subscribe, and tell your friends and work colleagues about us and they can listen as well. Thanks a lot.

Dr. Moira Junge: Talk to you next month.

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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