Episode 64: Borderline Personality Disorder

Sleep problems are a common symptom for people with borderline personality disorder. Symptoms include insomnia, excessive sleepiness and fatigue, vivid and distressing dreams. To better understand borderline personality disorder, how it impacts sleep and treatment approaches, we spoke with Ass Prof Blaise Aguirre, child and adolescent psychiatrist from McLean Hospital and Harvard Medical School, Boston.

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 – 27:04 Theme – Boderline Personality Disorder
  • 27:04 – 28:04 Clinical Tip
  • 28:04 – 31:59 Pick of the Month
  • 31:59 – 33:42 What’s Coming Up?

Next episode: 

  • Long COVID

Links mentioned in the podcast:


Guest interview:

Ass Prof Blaise Aguirre, MD, is a child and adolescent psychiatrist. He is a trainer in, and specializes in, dialectical behavior therapy (DBT) as well as other treatments such as mentalization-based treatment (MBT) for borderline personality disorder and associated conditions. He is the founding medical director of 3East continuum of care at McLean Hospital, Boston, an array of programs for teens that uses DBT to target self-endangering behaviors as well as the symptoms of borderline personality disorder (BPD) traits. Dr. Aguirre has been a staff psychiatrist at McLean Hospital since 2000 and is nationally and internationally recognized for his extensive work in the treatment of mood and personality disorders in adolescents. He lectures regularly throughout the world.

Dr. Aguirre is the author or co-author of many books including Borderline Personality Disorder in Adolescents, Mindfulness for Borderline Personality Disorder, Coping with BPD, and Fighting Back.

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.

Need more information about how you can sleep better?

At SleepHub we understand the struggle people endure with sleeping problems which is why we have created a comprehensive FAQs page and a range of resources with information for those seeking information about sleep disorders and potential solutions.


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 64 of Sleep Talk, the podcast talking all things sleep. And hi again, Moira.

Dr. Moira Junge: Hi, Dave.

Dr. David Cunnington: So the topic we’re going to talk about in this podcast is Borderline Personality Disorder. And really, one of the triggers for that, in part, is because I’ve been doing some professional development myself around this area because it is something we commonly see. And the other reason to talk about it is exactly that. This is something that has sleep problems associated with it pretty commonly. And so people with borderline personality disorder are overrepresented in people coming to sleep clinics. And you know, it’s something we will often see in clinical practice, Moira.

Dr. Moira Junge: Yeah, for sure. But then I think it’s important to say upfront, is that we, they won’t necessarily have that on the history. Like, they won’t necessarily say they have that label. The GP hasn’t talked about it. So they might, sometimes they don’t know that they were being given that diagnosis, although it’s clear to people working with them, it might be clear to you.

So that’s a bit of a problem, it was an ethical dilemma for me, and sometimes perplexing that I wonder, because I feel like I can pick, I certainly have done a lot of reading and certainly no diagnostic criteria, et cetera. But I would say in all of my long clinical years, like, over 20 years, there will be less than a handful of people who have actually overtly talked about it. Like, they’ve told me that that’s their label. They’ve been given that diagnosis.

What about you? Do you find that it’s… I mean, how what’s the percentage-wise of people who you think might have borderline personality disorder and those that you overtly talk about it?

Dr. David Cunnington: Very similar experience to yourself, Moira. So quite common that it’s not a label that someone’s been given. But when I think about, does this individual has issues with emotion regulation, might have been exposed to early life trauma? Or do they have problems with establishing stable relationships? And it’s often pretty common because those features go with difficulty turning off at night, and having insomnia.

So yeah, it is actually pretty common. There’s not great research in this area, interestingly. But some series have shown that it’s about 20 odd percent of people presenting to sleep clinics have a personality disorder, be it borderline, or narcissistic personality disorder is also common in people presenting with insomnia. So having an understanding of this, I think it’s really important for us as clinicians.

Dr. Moira Junge: Sometimes it’s diagnostic, insofar as you have done all your general treatments like standard sort of things, and in standard hours, in standard timeframes, but then they can be just, things are a bit tricky. This is just not responding, or they’re not available– but or chaotic in their attendance, or they’re sort of desperate, and they end up seeing them after five and you normally wouldn’t. That sort of a pattern sometimes I find, clues me into thinking, oh, I think there’s something more at play here than what I was told from the GP, or from the sleep physician.

Dr. David Cunnington: Yeah. And I find myself doing that as well. I’m always thinking if I do something that’s not in my ordinary practice, then I’m going, why did I do that? Why have I done something differently in this case compared to how I’ve managed other cases? And it’s usually that’s informative, that reflection

Dr. Moira Junge: And the access to sort of things going on, just alert you, too.

Dr. David Cunnington: Yeah. And in terms of sort of diagnosis, there is an emerging sort of diagnosis not yet in the DSM of complex PTSD, which is early life trauma, features of PTSD, but also personality changes, similar to borderline personality disorder. And I have seen a number of people coming with that label, rather than a label of borderline personality disorder.

Dr. Moira Junge: Yeah. And so, someone I recently sent to a psychiatrist because I thought it might have been borderline personality disorder came back with and said no, I don’t think it’s a complex PTSD. So it’s interesting to note that.

Dr. David Cunnington: Yeah. And that particular group, actually, it’s common in borderline as well, not only can have trouble with sleep itself, but trouble with sleepiness during the day, and distressing dreams and nightmares at night. So often have a number of different sleep manifestations.

So to help us understand the area of borderline personality disorder, some treatment approaches are a bit better. We’re fortunate enough to be able to talk to Blaise Aguirre, who’s Assistant Professor of Psychiatry at Harvard Medical School, and a child and adolescent psychiatrist. And Blaise works at McLean Hospital in Boston and has produced a number of resources on borderline personality disorder, including a book on mindfulness that I’ve talked about in previous episodes and a YouTube series, including what is borderline personality disorder, and how you use mindfulness.

So thanks very much, Blaise, for helping us out with the podcast.

Ass. Prof. Blaise Aguirre: Yeah, you’re welcome. It’s nice to come to you from Boston.

Dr. David Cunnington: And just to kick-off, what is borderline personality disorder?

Ass. Prof. Blaise Aguirre: Yeah, borderline personality disorder is a confusing disorder because it seems to present in different ways for different people. But at its core, there are two predominant and prominent features. And one is a tremendous difficulty in regulating day-to-day, moment-to-moment emotions. Different from something like bipolar disorder, where the mood state seemed to last for weeks, maybe even months.

In borderline personality disorder, it’s controlling highs and lows, typically secondary to something that’s happened between the person and somebody else, feeling rejected, feeling abandoned. And that’s the second big feature, which is difficulty in regulating relationships. So these relationships tend to be characterized by feeling very intensely about someone, idealizing them at times, devaluing them at other times, and then a terrible fear that that person might actually leave their lives.

So what we tend to see and certainly in the clinical practice that I have is this combination of difficulty in controlling emotions and difficulty in controlling relationships.

Dr. David Cunnington: And what do you think are some of the factors that might lead to someone developing some of those characteristics of borderline personality disorder?

Ass. Prof. Blaise Aguirre: I practice a therapy known as Dialectical Behavior Therapy, which is these days considered the gold standard for treating borderline personality disorder. And the theory that kind of underpins Dialectical Behavior Therapy, or DBT is that a highly sensitive person, meaning a person that has very big reactions to seemingly small provocations, feels things more intensely, more deeply than other people. And when they feel an emotion, it takes them longer to return to baseline.

So somebody with that degree of sensitivity is brought up in what the developer, Marsha Linehan, the developer of DBT, called the invalidating environment. And that is an environment that told the person that their inner experiences were not real, that a person was making a big deal out of it that they should just get over it.

So if you think about a child being really sad about something, and the parent is saying, “Look, that’s nothing. You should just get over it.” Of course, for people who can’t get over it, they typically do. But for people who go on to develop borderline personality disorder, it’s much harder for them to actually control those experiences.

So that degree of invalidation over time, often well-meaning by parents, it’s not that they want to damage their children, obviously, in a highly sensitive person, that that combination of transactions over time is thought to lead to borderline personality disorder. And then there’s a genetic factor, which about 60%, which is that temperament appears to be about, you know, inherited to a certain extent. So things like sensitivity, and irritability. And so, we have some biological factors and environmental factors.

Dr. David Cunnington: So I see people with borderline personality disorder presenting to me often with these two different polls of sleep symptoms. So at one extreme, it’s the can’t sleep, just cannot switch off, and can’t achieve sleep. And the other extent, it’s the constant feeling of exhaustion, or tiredness through the day and almost a dissatisfaction with the waking experience. And a lot of that I can sort of understand how that might go with that inability to regulate emotions and difficulty with self-soothing. What are some other examples of things that can occur or issues that can occur for people in their life as a consequence of those emotion regulation problems?

Ass. Prof. Blaise Aguirre: In particular, for sleep, you know, in the early days, so I opened a program in 2007, just to treat people with a borderline personality disorder. And I was, you know, it’s interesting that you’re talking about sleep, because one of the early findings was that many of the people with borderline personality disorder had great difficulties with sleep in the way that you described.

At first, I thought, OK, these people need to sleep study. So what was really interesting is that the second we put them in a sleep lab, it appeared that they’re actually sleeping fine. But that their experience of sleep was that they hadn’t slept at all. And then, presenting them with the data was very confusing to them, because they would experience not having slept, but then they would have slept.

And then, and cert– there were certainly some people whose sleep architecture was very poor that they didn’t seem to get into REM sleep and that. So it was possible that the sleep states were very, very pretty shallow. And certainly, if someone hasn’t slept well, like with many psychiatric conditions, without having slept well, it’s very difficult to regulate emotions and regulate the self and regulate relationships. That’s for sure.

One of the other things that we find, particularly pertaining to sleep is that many people that have borderline personality disorder have experienced trauma in their lives; physical, sexual, and other traumas. And so many of the people that we had met have comorbid, PTSD, and they are either terrified of going to sleep because bad things happened at night. Or that they’ll have nightmares, or when they do go to sleep, they actually experience nightmares. And the nightmares can be trauma-related or not.

Dr. David Cunnington: And that’s really interesting, your observation that you saw when you put people in the sleep laboratory. I see exactly that as well, and I think it’s partly a failure of our sleep classification system, the REM non-REM. It’s almost blind to sympathetic activation, or the monoaminergic system, which is really the system that’s an issue.

And if we look at surrogate features for that, like arousals, for example, alpha activity, or fast-wave activity in the EEG, it’s there. But just that conventional sleep staging system doesn’t see it. And that can lead to this paradox of you telling someone who already is not feeling well-grounded, that what you believe is actually not true. And in fact, and that, you know, it doesn’t go well. In terms of therapy, I haven’t found that works well with people.

Ass. Prof. Blaise Aguirre: Yeah, that’s exactly right. Well, because you’re having then to explain the contradiction that presents with, on the one hand, telling someone that they’ve actually slept according to the sleep study, and on the other hand, that they feel so exhausted in that they haven’t slept.

So, you know, and then how do you do that? And I think that this is where some of our patients are very interested in brain biology, and all sleep. And if you target some of the neurotransmitter systems, and you look at arousal, and even using behavioral skills target some of that hyperarousal that you can actually start to get to improve.

The other side is I definitely have patients who would tell me that they spent the entire day in bed, in and out of sleep. In many cases, that has to do with avoidance and avoiding certain situations. But they, you know, certainly when we speak to their parents, they often say that child has spent all day in bed sleeping. And it’s hard to imagine but you know, some of them will insist that they do.

You know, with hypersomnolence, you… we have found a host of patients, I mean a small percentage, but they’re there nevertheless that have presented with sleep apnea. As to they’re exhausted all the time, the environment then tells them “You shouldn’t be exhausted.” “You got enough sleep, you shouldn’t be tired.” But you know their O2 sats have dropped overnight. And you know, dealing with that has actually improved their lives quite dramatically.

But that’s invalid. You know, we talked, I talked earlier about invalidation from the system, but that’s when we get invalidation from our medical system. You know, we tell people, you should feel rested because you’ve slept. Or, you tell me you’re not sleeping, but the studies show that you are sleeping. And so there’s work, there can be some invalidation because there’s very little in it for the patient subjectively to get a good night’s rest, and say that they haven’t gotten one.

Dr. David Cunnington: I certainly agree with that. And part, a sleep study is part of my workup when I’m working with people with a borderline personality disorder. Because here, we sometimes find other sleep disorders. And I do think that being able to sort of unpacking what’s going on with sleep and out make it tangible, something that someone can actually look at, and I can look at the EEG with them, for example, on the screen, and talk through.

Yeah, you know what, yes, you’re getting the right type of non-REM, REM distribution. But hey, look at all these arousals and look at these sort of bursts in heart rate that shows that sympathetic systems really activated. It can actually help them get a bit more engaged in that long-term approach that we need to help turn down some of that sympathetic activation.

Ass. Prof. Blaise Aguirre: It’s interesting that you’re saying that because I very much agree with you. I have I tell my patients that the body doesn’t lie. What do I mean by that? That, you know, often they’ll say, “Well, I’m not upset with you.” “I’m not angry at you.” And so for some of them, I started getting them to wear a pulse oximeter.

And you can see during interactions that, so say their resting heart rate is 75, and all of a sudden you see something that is really upsetting to them. Although you might not pick it up and maybe they’ve learned over time to mask their experience, all of a sudden you see a spike in pulse. And I would probably imagine that it was paired with a concomitant rise in blood pressure. But they tell you that they’re not aroused or that they’re not agitated, but then their pulse oximeter says your blood– your pulse rate has just gone up.

And that, I mean, we know that there’s a lot of evidence in this actually, we know that people with borderline personality disorder have poor vagal tone. You know, there’s some controversy about the polyvagal theory and stuff like that, but I definitely see that the ability to regulate for my patients with borderline personality disorder is very poor. And I do think that the adrenaline, noradrenaline system is, it’s overstimulated.

Dr. David Cunnington: And so what’re some of the psychologically-based strategies that you can use to help turn down some of that overstimulation?

Ass. Prof. Blaise Aguirre: One of the things that I’m very proud of I suppose, I’m not proud of it for myself, but I’m very happy about it for our patients is that many of our patients come on multiple medications because they’re so exhausted. So what happens is that our psychiatrists continue to add medication. So they come in on very big doses of mood stabilizers and antipsychotics, and stuff like that.

So I mean, eventually, you get some degree of behavioral control, because you’ve shut down the brain so much, and maybe they’re sleeping, or maybe they’re not. And so our task has been to remove a lot of the psychopharmacology that really hasn’t been all that effective, and teach some of the behavioral skills that are needed to regulate.

And the core of Dialectical Behavior Therapy is mindfulness practice and meditation.  So we get our patients to practice mindfulness and meditation. It’s a little bit too out there for some of our patients who think that they don’t want to necessarily go down that path. And, but then, you know, we get to some basic stuff and we say, “Listen, if you eat well and you exercise regularly, and you have a good bedtime routine, you start to feel a lot better.

So even if it’s a little bit of daily exercise, whether it’s yoga or walking or jogging, you know, making sure that they pay attention to the impact of food on sleep. I mean, we used to see a lot of people who would do binge eating, especially at nighttime, especially high carb diets, which would be very activating. So paying attention to what food does with sleep, what exercise does with sleep, what mood-altering substances do to sleep.

Now, I have a student population mostly and some of them want to pull all-nighters, as they call them, in order to get papers done and study for exams. So they’ll use a lot of caffeine at night, stimulants, and other things like that. So yeah, I mean, there are some obvious mood-altering substances that can actually impact sleep pretty adversely.

And then anything that would lead to a certain degree of dependence, whether it’s benzodiazepines, THC, marijuana, where maybe they do get some sleep, but at a great psychological cost over time. Again, here’s where the mindfulness piece comes in is a very careful paying attention to the impact of various things on what happens to sleep.

Dr. David Cunnington: And when we’ve used mindfulness in insomnia, in some respects, that allows people a window into some of the emotions and thoughts that sleep and their sleep experiences may give rise to. And partly, what we’re trying to do is change people’s relationship with sleep.

Ass. Prof. Blaise Aguirre: So for instance, if there’s been trauma, and they’re terrified of going to sleep, but the trauma happened in a certain context, I mean, we want context-dependent learning to take place to say, look, you’re not in that context. You’re safe at home, you’re safe in your room, you’re not in that other situation where something maybe awful happened. And we want you to start noticing that your body is, it’s almost, it’s sending alarm bells. Like it’s sending a fire alarm when there isn’t a fire, actually.

So fire alarms are really important when there’s a fire. And fire alarms might be important if there’s a fire drill. But they’re certainly not that important if there isn’t a fire. And actually, it can give you false information. So to start to make that distinction between that hyperarousal that we were just talking about in the context of safety versus hyperarousal in the context of danger, and to be able to make that distinction, I think is very important. And you know, for patients who can do that, they definitely have tremendous benefit method to that.

Dr. David Cunnington: How do you bring that in as part of DBT? Or how does the mindfulness interdigitate with that?

Ass. Prof. Blaise Aguirre: Yeah, although DBT seems to be a very simple treatment because there are four skill sets. There’s mindfulness, there’s emotion regulation, there’s distress tolerance, and there’s interpersonal effectiveness, which is, which targets all of the deficits of people with a borderline personality disorder or the skills deficit.

So for instance, if what you notice is that, I don’t know, drinking red wine gives you headaches and a bad night’s sleep, and not drinking red wine or having a beer doesn’t do so, then paying very, very careful attention.  So we get actually people to track their experience on something called diary cards, which is really a sort of a daily register of functioning.

Maybe they’re tracking emotions or tracking relationships or tracking substance use or self-injury, or suicidal thoughts. But if they’re tracking sleep, it’s OK, you’re tracking sleep. What happens to sleep after exercise? What happens to sleep if you start having caffeinated coffee at 2:00 in the afternoon versus 12:00 in the morning? What happens if you go to bed at 10:00 versus at midnight? What happens when you have your TV on late at night versus not? What happens if there’s somebody in the house versus not?

So we get people, to do a kind of a map of their sleep habits, things that enhance sleep and things that work some sleep. And this is where mindful attention is really important that without doing that, you know, it’s a guess, really.

Dr. David Cunnington: So that’s the sort of DBT mindfulness, sort of package. Moving forward, you know, what are you looking as sort of add-ons or the next types of strategies to add into some of the psychologically-based therapies?

Ass. Prof. Blaise Aguirre: As I say, there are some people who don’t necessarily like mindfulness as a modality either because they feel that it’s too tied to ancient religious ideas, or it’s too new agey for them. So the other, some of the other ideas that I think are important, other ways of monitoring that hyperaroused state, so are their wearables that will tell you, look, your pulse rate is up. Your O2 sats are down. Your blood pressure is up.

So that by paying attention to that, then you can work on even breathing exercises, or maybe going for a walk, or starting to turn down the TV, maybe an hour ahead of time, and then monitoring and then seeing what happens to your body’s sort of arousal systems and your thoughts. So maybe body monitoring devices.

And then you know, I mean, certainly that there are people who do have a primary or secondary sleep disorder that might actually benefit from, you know, somebody has sleep apnea. If somebody has other physical illnesses, say diabetes, when their blood sugars are dropping maybe in the middle of the night, or other breathing problems, you definitely want to rule those things out.

You know, certainly, tracking sleep and sleep hygiene is very, very important, treating comorbidities. We definitely get mood disorders and other psychotic disorders, substance use disorders, treating those comorbidities is important. You know, it’d be great to find some rescue medications for the occasion when a person really hasn’t slept and they’re just exhausted, and maybe could benefit from a little bit of something.

You know, we commonly see diphenhydramine, atrazine and Desyrel, benzodiazepines used, some of the other sleep aids. People use a lot of atypical antipsychotics. We try to stay away from them and use them as a medication of last resort if nothing else is working. And for some people, they actually do benefit quite a bit from them, and without necessarily developing tolerance or dependence on them.

Dr. David Cunnington: So thanks very much for those really great insights, Blaise.

Ass. Prof. Blaise Aguirre: Yeah, you’re welcome. And thanks to you David for reaching out and certainly to all your patients, especially the ones with borderline personality disorder, sending them a lot of compassion from here in Boston. And I hope that they’re able to get a good night’s rest.

Dr. Moira Junge: Great interview, Dave. You must be a true fanboy, really of Blaise, as you now have many books and things you’ve read of his.

Dr. David Cunnington: Exactly. So having…

Dr. Moira Junge: Have you declared your fan status?

Dr. David Cunnington: I did. So having read the workbook about mindfulness and watched some of the YouTube videos, I thought Blaise would be really good. And of course, you know, he’s great. You know, really, from that clinical experience and his passion for trying to improve education and people’s understanding, which really fits with your– where you and I are coming from, because we’re very passionate about those same things as well. It was just a real privilege.

Dr. Moira Junge: Oh, he was great, wasn’t he? He’s, I mean, clearly a very good clinician, very kind. You know that whole… when we said something about… he was just there to support and educate, not blame and shame. Something like that, that was one of the lines sorts of I remember, thinking that resonated with me.

And that sometimes, particularly people with borderline personality disorder, they do… People don’t necessarily treat them necessarily nicely. There’s a lot of judgment or harsh language around how difficult they are and how manipulative they might be, and those sorts of things. So it was nice to hear his balanced approach to this group of people and his passion for it.

Dr. David Cunnington: And interestingly, you know, as you and I discussed offline, the treatment approach is actually not dissimilar to the treatment approach we take with anybody else. So we use sort of a challenge thinking and behavior around sleep with a CBT type approach, look at helping…

Dr. Moira Junge: Reducing arousal.

Dr. David Cunnington: Reducing arousal with either a mindfulness or ACT type approach. And that’s really a very similar approach.

Again, I’d highly recommend the resources that Blaise has generated with books on DBT, and a recent book DBT for Dummies, which he told me was actually a bestseller on Amazon for a couple of days, which really shows you the need for this sort of communication, and the series of videos on YouTube that McLean Hospital and their Borderline Personality Disorder treatment service have developed. It was around 2017, 2018, a really good education series both for people with borderline personality disorder, but also clinicians, and their families to be able to help understand.

So we’ll take advantage of your expertise, Blaise. What’s that clinical tip for people working with people with a borderline personality disorder?

Ass. Prof. Blaise Aguirre: Well, I’ll tell you the one that changed my mind about how experienced people with borderline personality disorder, and that was the idea that they were doing the very best that they could.

And that’s because historically, I have been told that these were very manipulative attention-seeking people. And so the idea that when somebody is suffering from conditions like borderline personality disorder, they’re doing the best that they can, given their condition was really a very benign way of seeing people. Because then, what it allowed me to do is to teach and help rather than blame and judge.

So when you see somebody who is struggling with whatever that they’re doing, that is the best that they can do, given their present circumstances.

Dr. David Cunnington: So Moira, what’s your pick of the month?

Dr. Moira Junge: Well, there’s a book that’s about to be released. I think it’s released online, but I saw a date that it’s coming out at the end of the 29th of December 2021. And it’s by Colin Espie, and it’s called Overcoming Insomnia, Second Edition. It’s a self-help guide using CBT techniques.

And Colin Espie is a Professor based in the UK, affiliations with Oxford and many other Institutes. Probably, I would consider him the grandfather or one of Insomnia Treatment, particularly in non-drug approaches, and has a psychology background. And I’m just so excited. I think this is something I want for Christmas.

The first edition was in 2012, so I’m very keen to see how it’s different. And he is someone who, him and Charles Moran, I use everything I know about insomnia back in the ’90s. I just learned from their books. So I can highly… And the good thing about this is that it’s self-help. So it’s not– the books used to be for clinicians, and now, his books are more, or some of them, at least, for people who are struggling, and they can step themselves through.

Well, I think it’s a good idea for perhaps sleep clinicians, GPs, people who want to send their clients to perhaps a psychologist to do some CBTI but can’t get them in anywhere. I’d recommend getting half a dozen of these books, for instance, and lending them out to people because they can step themselves through some just really important evidence-based simple things that will make all the difference actually, they will turn them around. Then they may still need to see a sleep psychologist but maybe not. So it’s certainly in the meantime, so I highly recommend it. We’ll put the link in the show notes.

Dr. David Cunnington: Yeah. And it really fits with Colin Espie’s step care approach in insomnia management from his sort of paper in 2009. All of it is the best. We’ve got the sort of self-help guides, and then you step it up to maybe more an online CBT that may be supported online CBT. And then you step it up to one-on-one sort of work with a therapist. So having something to cover all those bases is really important.

Dr. Moira Junge: Absolutely. Particularly with maybe minimal comorbidity, I guess that’s where the self-help book would be really, really great. But even in really complex presentations, it’ll help a little bit, I’m sure. What’s your pick of the month, Dave?

Dr. David Cunnington: Well, it’s really been a saga that’s been going on for the last six months. It’s the gift that keeps on giving. And that’s a CPAP Recall from Philips. So in June of this year, Philips announced they were recalling CPAP devices, most of them were manufactured in the last 10 years because of an issue with acoustic foam.

And that’s created a whole lot of logistic challenges because there are hundreds of thousands of people in Australia, and millions of people around the world whose CPAP machines have now had to be replaced. And that’s created issues with the supply chain and you know, a whole lot of other things and better access to CPAP treatments.

And then recently, the FDA has been looking at the foam Philips have used to repair and replace the old machines. And there are questions about that foam. So this is just an ongoing saga that’s really kept both physicians working with people with CPAP in the last six months on our toes, trying to keep abreast of what’s going on and keep people on treatment. But it’s also been a bigger saga for people who’ve had the Philips CPAP devices trying to work out how to find advice, how to look at getting their device repaired, or replaced.

So it’s not a pick in terms of something I really love, but it’s something that’s really been sort of forefront in the field of sort of clinical sleep medicine, particularly in the sleep apnea space in the last six months. And important for people to know that that’s an issue that is having a broader impact on accessibility to sleep apnea treatments.

Dr. Moira Junge: What can we look out for, Dave, in coming episodes?

Dr. David Cunnington: So in addition to looking at impacts of sleep deprivation, and potentially long COVID, I’m still trying to find the right person to talk to about some of the pathophysiology of fatigue and the underpinning mechanisms of fatigue. Tied up in that is another brain system called the glymphatic system that’s important in sleep. So I’m just trying to get my head around, do we get someone about glymphatic on feeding with fatigue? Or do we do glymphatic as a separate topic? And we may actually end up doing that as a separate topic.

Dr. Moira Junge: Awesome. That sounds good. We haven’t done glymphatic, I don’t think, have we on our… as an episode in all the years?

Dr. David Cunnington: No, we’ve tended to be… Yeah, yeah, we’ve tended to be more on the sort of clinical outcomes rather than some of the physiological changes that happened in the brain during sleep. So yeah, I think that’d be a good topic to talk about.

So thanks, everyone, for listening to this episode. We’re always keen to feature early career researchers. So if you are a researcher and you’ve published a paper, let us know because we’d love to look at that paper, look at the area, talk to you about it. And if you’ve got any suggestions for topics for the podcast, email us at podcasts@sleephub.com.au.

Dr. Moira Junge: Of course, remember if you like the podcast, review us on iTunes, subscribe, tell your friends and colleagues about it. I’d be really grateful.

Dr. David Cunnington: Thanks a lot.

Dr. Moira Junge: Bye!

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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