Timestamps

 

(7:00) Why do we need sleep?

(11:15) Sleep cycles & sleep trackers

(22:00) How to fall asleep (sleep initiation) 

(34:50) Circadian rhythm & clock genes 

(40:00) How to stay asleep (sleep continuation) 

(45:25) Melatonin 

(57:40) How sleep medications work

 

Transcript 

 

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Recurring Guest Dr. Robert Kachko

Michelle Shapiro:

Do you know that you are the first guest who’s coming back every single season and who has made their second appearance so far in only the second season?

Dr. Robert Kachko:

So you’re predicting future seasons. You’re saying I’m gonna wanna be back.

Michelle Shapiro:

Let’s be honest about the situation. Let’s be real about what’s going on here. When I was conceiving of making a podcast, I said, Rob, Dr. Kachko, you need to co-host this thing with me. And then you went on this whole thing about how you were too busy seeing patients all day and helping people to do this podcast with me. So I would say that the bare minimum of what you can do is come on seasonally to this podcast.

Dr. Robert Kachko:

I mean, I’m looking at like I’m talking about season four and people are listening and looking back. This is the biggest podcast everywhere and I regret it already. So it’s just the beginning of season two, I guess. And I already regret it

Michelle Shapiro:

You’ve been sending me messages, like occasionally being like, Hey, how’s it going? Wow. Maybe I should have done it. You know what? Yeah, you should have done it for the listeners.

Dr. Robert Kachko:

Yeah, that’s okay

Michelle Shapiro:

I am very, very happy you’re here. I’m going to reintroduce you and ask you to reintroduce yourself. If anyone didn’t catch you in season one, talking about trauma, which was an amazing episode. So funny. A lot of the feedback I got on that episode was just about our dynamic where people felt like again, why you would have been amazing co-hosts. Shame on you. Where instilling trauma onto you.

A lot of people were saying that we felt very like, obviously natural friendship and connection and that brought out a lot of really juicy and good info. So I’m glad to have you back for that reason too. From a professional perspective, I’m obviously happy to have you back because you’re my favorite practitioner ever. Tell us what is your license? What is your, what do you practice? Who do you serve? Talk to us.

What is Integrative Medicine?

Dr. Robert Kachko:

So I am a Naturopathic Physician. We can spend a lot of time talking about naturopathic medicine and licensure and all that. I’ve been fortunate enough to do a lot of advocacy work in this realm. And so again, we can maybe do a whole other podcast all about the whole world of integrative medicine and the different parts and all of that.

But I’m also a licensed acupuncturist. We’ve got two integrative medical centers, one in Manhattan, New York, one in Stamford, Connecticut. We serve everyone, honestly. The only thing we don’t treat in our clinic is cancer, but we support people with cancer.

I personally do a lot of mental health related work, a lot of trauma work, a lot of work in the chronic pain space and sort of by virtue of that, a lot of GI stuff, cause then we can talk all about how gastrointestinal issues are so deeply correlated, actually with sleep as well, so we can talk about that today.

But we see everything that comes in because we treat whole people. And it’s our philosophy on how we view the body that I think sets us apart, as opposed to the modalities that we use, right? Not the treatments that we use, it’s about why we use them and how we use them.

But the very idea is that what we always want to do is support the physiology, support the biochemistry, and that the body is always working to heal itself. And our job is not to force that, but to support that process and make that possible by resolving root causes, by removing obstacles secure. that kind of stuff.

Michelle Shapiro:

You’re healing facilitators, which is instead of, as we think of a lot of practitioners who are more, I don’t know, like illegitimate or something, or they’re not practitioners and they’re salespeople. And they say, I kind of can give you the cure and this is the cure. You’re talking about facilitating the body’s own ability to heal and giving whatever that push or support looks like.

Dr. Robert Kachko:

Yeah, yeah, that’s a good way to put it.

An Integrative Approach to Sleep

Michelle Shapiro:

Thanks. So we are talking about sleep today. And as we were texting this morning at, I’m sure like 5 a.m. when we usually like catch up, we both did not sleep well, which I feel like is a good omen because I did an acid reflux episode and had tremendous reflux. So did Erin Holt, our amazing guest on that episode.

So I feel like we have to experience what the listener is going through ourselves. So I’m glad that we both got really crap sleep last night.

Dr. Robert Kachko:

But the degree to which you function on really crap sleep is impressive because your sleep was worse than mine based on what we were texting this

Michelle Shapiro

For sure, yeah. But I think we all have our things that we’re sensitized to or desensitized to. It’s interesting because I guess can function very well on little sleep, which I don’t recommend. And certainly not in this episode I’m going to recommend. But if I was a little bit nauseous, I would be texting you like, I can’t deal with this specific symptom.

Dr. Robert Kachko:

I just hope it doesn’t delegitimize us. But I think what we’re gonna talk about today or what we should talk about today is just how common sleep challenges are and how, I think the statistic is something like 98% of adults at some point go through some protracted period of difficulty sleeping.

Michelle Shapiro:

Which is a fun statistic too, because many cases of insomnia do correct themselves, which is really good too. And I know of that statistic, many of them are spontaneous and do correct if it’s more of a long-term issue. We’re gonna address kind of both of those things.

And I’m kicking us off with, there was this Jerry Seinfeld stand up bit that he did. And he said, it’s so weird that I’m standing up here and trying to make people do something involuntary. Like I’m trying to force you all to laugh and laughter is like an involuntary body mechanism. It’s not like you can make yourself laugh through thinking.

I think of sleep in that same way too, where it’s, we, we can exert conscious and voluntary control over it, but it ultimately is kind of like something you need to surrender to at some point. Um, and something that feels, I know that feeling of not being able to sleep, how frustrating and scary it is for people. talking about what literally is happening during sleep, what sleep literally is at the highest level, take us through that.

Why We Need Sleep

Dr. Robert Kachko:

Yeah. Well, I think we have to go back and look at the sort of the evolutionary basis for why we need to sleep in the first place. And that’s very poorly understood. You would think that over time we would have evolved away the need to sleep. There’s I think there’s one species that has been able to do that. It just they don’t it doesn’t sleep. I forget the name. It’s a little rodent of some kind.

Michelle Shapiro

Probably, it’s like a cockroach in New York City. It’s gotta be something like that.

Dr. Robert Kachko:

It’s the New York City pizza rat. Everyone else needs to sleep. Every other animal in the kingdom needs to sleep. We’re still trying to figure out why I think that what I’ve read, I kind of put four plausible theories out there that what I’ve seen, the first is the most obvious that sleep is restorative.

We need sleep to repair fascia, repair connective tissue, repair muscles, reduce inflammation, all that. We’ll talk about, we should talk about stages of sleep.

Michelle Shapiro:

We’re definitely going to talk about stages of sleep!

Dr. Robert Kachko:

So we’ll talk about when that happens. The second theory is more of a cognitive one, that’s how we make sense of the world, that’s how we prune out memories, that’s how we do memory reconsolidation and reprocessing, it’s how we allow ourselves to function day to day with all this information overload that comes in.

Then there’s sort of the group of researchers who seem to say, nope, it’s really just about energy conservation, we could not survive in these bodies. if we didn’t power down and metabolism does decrease and all of that by 10 or 20%. So there’s some plausibility to that.

And then I think one of the more interesting theories around why we sleep is more related to the importance of inactivity at night for survival. In the sense that when it’s dark outside, we were more likely to get picked up by some kind of animal that wanted to eat us if we weren’t sleeping in a cave as opposed to walking through the bush, right? And so the bears we love talking about bears and so from the perspective again of It doesn’t make sense to sleep because we are prey. We are vulnerable. We are prey.

We should have evolved it away when we sleep for seven to nine hours, which is sort of the happy range. Anything’s possible and in our deeper stages of sleep that sort of the deepest stages of non-rem sleep and in REM sleep It’s very hard to arouse us. Obviously there are sleep disorders that make that difficult, but there are certain people who, you know, you can be playing a corn concert right in their ear and they’re not going to wake up from it. That’s sort of the other side of sleep goals. So it doesn’t fully make sense.

It’s also obviously necessary because otherwise we would have evolved it away. We need sleep more than we need food. We cannot go 40 days of not sleeping like we can not eating. Not necessarily suggesting that, but sleep is essential. In terms of how and the mechanisms of sleep, I think that’s also something that we’re just still learning a lot about.

What Happens When We Sleep

There’s five to seven neurotransmitters that are involved. Everyone thinks about serotonin and GABA, but there’s a lot of histamine that goes on, the H1 receptor on histamine, which I’m sure you’d love to talk about a little bit. There are effects of dopamine, of course, there are effects of norepinephrine, which are more, you know, you think of norepinephrine as noradrenaline more arousing, but there’s this complex interplay GABA, our most important inhibitory neurotransmitter starts that whole process. That process mostly starts in the hypothalamus.

There’s sort of a posterior anterior hypothalamus is the part of the brain that really then regulates a lot of our hormones. People know the HPA axis, the hypothalamic pituitary adrenal axis, But the hypothalamus starts a lot of the, are we awake? Are we asleep? Should we be awake? Should we be asleep? Processes in the brain.

And then other brain areas kick in, we think about especially during dreaming areas like the hippocampus, which is responsible for memory areas like the amygdala, which is responsible for our emotional response. And so that’s why dreaming is so important because it allows those parts of the brain to kind of prune out. and do their work. So we’ll talk about REM sleep, which importantly is the only period during which we actually dream.

Why You Might Struggle With Sleep

Michelle Shapiro:

Can you actually just take us through the sleep cycles briefly and kind of what’s happening during each and what’s, we’ll talk about how, what percentage of your sleep you should be in that, hours, recommendations. I mean, it’s not really a recommendation because again, it’s hard for people to force themselves to sleep, so we’ll actually tell you what can, you can do to support sleep.

One thing before we do that, actually, I just want to backtrack on is, we both know if you are experiencing insomnia, hearing the phrase, you sleep is essential and you’re gonna die without sleep can increase your stress and that is not the goal. We will also just, if that instigated a little nervous system response for you, just know we’re going to give you some tangible strategies and talk about why that might be happening. But that it is, but it’s okay if you haven’t slept and we’ll talk about that feeling of being fearful of not sleeping too.

Take us through the sleep cycles and I just wanted to give that little note to people who might’ve felt scared by that.

Dr. Robert Kachko:

It’s an important point too, because everything that we’ll talk about in terms of statistics, they’re all correlative, right? The body is multifactorial, things are complex here. And one of the things we’ll talk about is, so let’s just say the example that people who don’t sleep are at higher risk of something like blood sugar dysregulation and diabetes. Fully 50% of sleep disorders, if we look at the whole population, about 15% of sleep issues are what we call primary insomnia. So that’s, you’re not sleeping just because you’re not sleeping.

Another 25 or 30% is a result of some sort of psychological strain or stress, right? Anxiety, depression, bipolar disorder, whatever. And then there’s a whole other category of just other medical conditions that can cause that point being: Yes, they’re correlative, but if we can address the medical cause, if we can address the reason why someone’s not sleeping or the psychological or psychological emotional however you want to describe it, that also contributes.

So it is a little bit of a vicious cycle if you look at it as something that goes in the wrong direction, but the other way to think about it is if we address the root cause, we can work it back.

Michelle Shapiro:

I also will say, you know, I have confidence and competence and it varies with different conditions. When it comes to sleep issues, I feel like both of us feel very competent and confident. And I’ve seen like, I can’t say with, you know, certainty, every single one of my clients made, made it to like perfect sleep, but I’ve never had someone not make any improvements whatsoever. So there’s always hope.

There’s always something you can do when you’re exploring the root cause. Like that feeling of insomnia is really scary for people. And just know that there is, there’s always a direction to go and there’s always a way to look. And I thank you for bringing that up too. Okay, take us back to sleep cycles and walk us through them.

Sleep Cycles (HINT: It’s More than REM)

Dr. Robert Kachko:

So people are familiar with REM sleep and then I think most people are familiar with there’s another part of sleep that’s non REM sleep. And it’s funny you’re talking about percentages. I have not gotten that question prior to five years ago. No, no, no one asked that. The reason people are asking about percentages is because of all these sleep trackers. People are interested in that because these devices report percentages.

First of all, most important to say is that these percentages are population-based and you can do just fine getting 10% REM sleep. We’ll compare that to what the sort of the average or the norms are, but you can do just fine. What matters is your normal. And then let’s just talk about these devices because we brought them up or I brought them up. What’s important is learning and developing appropriate pattern recognition around what affects you, right?

Let’s just take the two most common things that people use, in my opinion, inappropriately to help them sleep: alcohol and benzodiazepines, Xanax and all those sorts of things. Those are going to reduce the most important stages of sleep. You’re going to feel like you’re sleeping, right?

I’ll run you through the stages in a moment, but you’re going to be more on what we’ll describe as N2 level sleep, non-REM stage two. You won’t be getting very much non-REM stage three, which is most important, and REM sleep at all. And so it’s important to understand that even though there are norms, knowing what’s normal for you and then most importantly what you can do about it. Again, we’re trying to be empowering here. What you can do about it, we’ll talk about sleep hygiene and things you should avoid. I think that’s the key.

If I had to give you percentages, the typical avatar of a person spend about five minutes in a more wakeful stage. That’s more of a beta brainwave kind of stage, more active thought.

We start transitioning from there into more of a calming alpha brainwave state, which starts to bring us into the first stage of non-REM sleep, N1. People tend to spend a couple of minutes in that stage. Interestingly, men spend a little bit more time in the N1 stage of sleep.

The next most common area, somewhere between, from what I can tell in the research, is about 40 and 50 percent. of sleep stages. Again, we didn’t know about this stuff.

What Sleep Trackers Don’t Tell You

Whoop and Oura don’t report the non-N3.So most of what they’re reporting, if you look at your app, there’s a percentage on there that is not slow-wave sleep or deep sleep, and it’s not REM sleep, it’s this N2 stage of sleep. We’re spending about 40% or 50% of our time in this N2 sleep. More in the early part of the night and then we do more REM sleep later on in the night.

When we get into the deepest, most restorative layer of non-REM sleep, that’s N3, most people should be spending around 20 to 25% in that stage of sleep. And then we transition finally to REM sleep. Usually it’s the same thing, 20 or 25%.

And importantly, it’s not that we start with N1 and then we, you know, an hour later we go to N2 and N3 and N4, we cycle through this. Most people go through about four to five cycles of somewhere between 70 minutes to like 120 minutes. You tend to have longer cycles as you go later because REM sleep expands. We spent about 30% of our sort of last couple of hours in REM sleep.

Another important question people often ask if they don’t want to buy, you know, these fancy tools, how do I know if I’m getting REM sleep? How do I know if I’m not? We have to sort of broadly break it down into physical, and this is an oversimplification, but into physical and sort of mental-emotional processing.

Most of our physical recovery, I mentioned that sort of restorative theory of why we need to sleep. Most of that is happening in that N3, deep sleep or slow-wave sleep. Those are all the… names for the same thing. REM sleep is, and then there’s some sort of memory consolidation stuff that happens in N2, which is the state before that, and then in REM sleep, it’s this just fascinating thing that happens where our bodies are actually as active as when we’re awake.

Whereas, if you look at a sleep study in the N3 stage, we have these slow and steady kind of up and down waves. We have a very active brain in REM sleep. That’s when we’re dreaming, but so that we don’t act it out, our physical body kind of goes into a bit of a paralysis.

Michelle Shapiro:

All right, don’t say that word, but I knew you were going to say that, but like, say it, but don’t say it. Okay. Go ahead.

Dr. Robert Kachko:

In a very healthy way. We want that because we need this, you know, if we’re going to start walking around while we’re dreaming… it’s a protective mechanism for a necessary part of the sleep zone.

Michelle Shapiro:

When people get into that. It’s when people wake up in that stage that they feel like that there is that distinct, what’s it called? When you’re awake, but you’re asleep at the same time and you feel like you can’t move your limbs. They’re probably waking up in the wrong sleep stage, I’m assuming?

Dr. Robert Kachko:

Correct.

How to Know if You’re Getting Enough REM Sleep

But so to answer the question of how do we know if we’re getting REM sleep, if you’re not dreaming, you’re not getting as much REM sleep as you need, because, or if you’re not waking up from a dream, because really the way the cycle goes is normally because we’re spending most of our time in REM sleep towards the end, you should be waking up from REM sleep. That’s kind of the last thing before you.

Michelle Shapiro:

Does that mean that you have to remember your dreams to know that you were dreaming?

Dr. Robert Kachko:

Generally speaking, if you never remember your dreams, you’re probably not getting enough REM sleep. It’s kind of the role of them.

Michelle Shapiro:

Got it. And then that’s one kind of psychological symptom, let’s say, what are some physical symptoms? Just feeling like not getting muscle recovery, things like that, like soreness, things like that.

Dr. Robert Kachko:

I mean, so again, we can talk about all the correlated conditions, named conditions, but by definition, if you know, we can define insomnia. So what does it mean to not get enough sleep? But by definition, one of the components of insomnia is that you just don’t feel physically rested and recovered. And that’s different for every person, right?

First of all, there’s no good diagnostic tool for insomnia. It’s a good clinical history. But I can talk to 10 people and they’re all going to have a very different experience of what it means to get enough sleep and feel rested.

Michelle Shapiro:

Yeah, this is interesting too. Is it actually true that different people just need different amounts of sleep? I’m a person who, since I was like five, I sleep seven hours. I’m at my like brink of like, that’s way too much. Like seven hours is my most complete amount of sleep. I’ve probably gotten eight hours of sleep like very few times in my life, but I do feel truly rested on seven hours.

How Much Sleep Do We Need

Dr. Robert Kachko:

Yeah, it’s a pretty big range. It’s, you know, the classic range is seven to nine hours in terms of health outcomes and all that. So some people need nine. More than nine, you would think more sleep is better. More than nine is also not indicative of sleep. Now, it’s really hard to distinguish why is that person needing 10 hours of sleep or 11 hours? Is there depression going on? You know, are there other factors that might be contributing? But generally speaking, the range is about seven to nine hours is what the- what’s established by the Sleep Association.

Michelle Shapiro:

What’s your sleep schedule? Because we’re always talking at like 5 a.m., 6 a.m. So are you, do you sleep the same hours as me? Are you like a nine to fiver?

Dr. Robert Kachko:

No, no, I can’t, I can’t quite do nine. Um, depends on how late I get home. If I get home at eight 30, it’s a little bit hard. I tried generally speaking. It’s helpful that my wife, um, prefers to go to bed earlier, but I try to do, I try to do like 10 to six is kind of my target. Give or take 30 minutes. Um, let’s talk about sleep hygiene and the importance of sleep consistency. Um, but, but 10 to six. Um, and so Shannon, but then, the dog wakes us up pretty early in the morning as well. So there’s, there’s bookends on that.

Why We Can Have Trouble Falling Asleep

Michelle Shapiro:

I feel like what we need to also talk about is that for some people, there’s sleep initiation issues and then there’s sleep like continuation issues basically, where some people can’t just cannot fall asleep and some people can’t stay asleep. Give me some examples of why someone wouldn’t be able to fall asleep. And we’re gonna talk about, of course, sleep hygiene and all of that too, but why wouldn’t someone be able to fall asleep?

The specific sensation I’m thinking of is someone is, Maybe their minds racing a little bit and they really wanna sleep really bad and they’re telling their brain like, please be asleep and their brain is not letting them do that. Why would that be happening?

Dr. Robert Kachko:

Hmm. So remember I mentioned those brainwave states and sort of more calming and more active. If our body doesn’t feel like you know, for lack of a more complex way to describe it, that it’s safe to sleep it, we won’t. And so if our brain is buzzing and we’re active, it’s important to distinguish also for people the difference between being tired and being sleepy.

There’s physical fatigue and then there’s, my eyes are shutting. And so I often, you know, we’ll have people talk about this idea of feeling wired and tired. You know, I’m physically tired all day, but I’m anxious, I’m nervous. to a degree that’s what happens in those moments at the very beginning of a sleep issue. For most people, once it becomes chronic, and if we define acute versus chronic, it’s about a month.

So once you’ve been dealing with an acute sleep issue, it’s about a month to transition into a chronic sleep issue. For most people, what they’re dealing with after the fact is, again, unless there’s some kind of sleep disorder, which is pretty rare. 10 or 15% of the time that that’s what’s going on. Unless there’s a sleep disorder, now it’s an expectancy around sleep. And so now the person’s laying in bed and saying, oh, I’m not gonna be able to sleep tonight. And that becomes a true fulfilled prophecy.

Michelle Shapiro:

And something you said that I need to reiterate on this episode is that, like you’ve said, our nervous system learns by example. So it’s kind of like your body’s like, this is what I do now. I sleep this many hours and at this time. So your body just adapts to what it thinks is the correct thing. This happens with weight as we know too, with set point theory, like our body kind of figures out or believes this is the way things should be and then stays in that cycle.

What is Sleep Debt

Dr. Robert Kachko:

Yeah, yeah, and it’s obviously a little bit more complicated than what either of us are saying here, but generally speaking, there are two factors that contribute to that over time. Like this expectancy around we don’t know how to sleep. Broadly speaking, there is the, what I would describe as sort of sleep debt, where you wake up in the morning and over time, let’s sort of create an analogy for this.

You have a bucket that’s full of water and as the day goes, your bucket depletes. And in a perfect world, when your bucket is fully empty, you are ready to get in bed and fall asleep. That bucket depletes at different rates for different people. Some people start with the bucket only a quarter full, right? That’s how we feel throughout the day. So that’s the homeostatic basis around sleep and timing. We have to sort of deplete our reserves in order to be ready for sleep for the next day, because that’s how our body learned to function.

Michelle Shapiro:

I have to add onto you really quick. That’s one of the, what I would call conditions that we need to meet is that we need to be like depleted enough to need that recharging. Can you tell us about what other conditions need to be met for sleep to happen?

How to Fall Asleep Easier

Dr. Robert Kachko:

So we talked about the neurochemistry around it a little bit, the GABA mechanisms and all that. There are hormonal cascades that play a role. The two most common that people think about are melatonin and cortisol.

Michelle Shapiro:

Oh, we’re definitely gonna talk about melatonin too.

Dr. Robert Kachko:

Let’s talk about both of those. And then there’s sort of a physiologic basis for feeling like you’re safe enough to sleep. And so that’s where a lot of the sleep hygiene stuff comes in. That’s where it has to be. pitch black in the room, that’s where it needs to be completely quiet, that’s where it needs to be cool. In order to fall asleep, in order for our body to transition into restful sleep, our core body temperature has to drop around one or two degrees Celsius.

Michelle Shapiro:

Yeah, and which is bigger than Fahrenheit too. There’s a decent drop that has to happen.

Dr. Robert Kachko:

The goal is to sleep in a cool room. It’s also the reason why people do really well with hot showers before bed or even like drinking a hot herbal tea. Maybe they’re doing something if it’s a high quality formulation. But what we’re doing with the hot shower and the tea is bringing our core body temperature up and then hopefully we sleep in a cool ambient environment. That’s what allows our core body temperature to drop, to transition into that process.

Michelle Shapiro:

it’s not actually the degree of temperature that matters, it’s the drop that matters. That’s the condition is basically you need to have that one to two degrees Celsius drop in order, and that condition needs to be met too.

You know how like there’s people though who can just like literally sleep anywhere, like they can sleep on a plane in any temperature, in any condition. Do they have less conditions that need to be met in order to initiate sleep? Like if, does everyone’s body temperature need to drop for sleep to happen? or is that their body’s better at making that temperature drop?

Dr. Robert Kachko:

Yeah, I think it’s more the latter that they have all, we have all the same sort of physiologic and biochemical needs around this. It’s just easier for some people to do that. So that’s one category, right? Sleep, death, homeostatic sleep mechanisms around that.

How to Reset Your Circadian Rhythm

The second is our circadian rhythm, which people are more familiar with. And the way to tie these things in together is to say, hopefully when that bucket hits 0% full, it’s also the right time of day for your, what we describe as chronotype, that is sort of your sleep type, to be able to make that transition. And there’s a lot of… genetics that are deeply tied into this and it’s complicated.

The circadian piece is why it’s so important to have consistency in our routine. It’s why it’s so important to wake up at the same time every day if possible. And it’s why it’s so important to try to go to bed early enough. If you’re chronotype, there’s about 10 or 15% of people who truly are like, you know, the night owl type.

If your chronotype is such that you’re in the general part of the population, getting your midpoint of sleep to happen before 3 a.m. which would also coincide with your melatonin spiking. Usually the melatonin peaks are on somewhere between two and four AM. So three AM having that midpoint of sleep, which for most people means going to bed before midnight, certainly before 11 and before 10. So a lot of people, that the goal around getting people to sleep is slowly to start retraining their brain that is, that is when we sleep and to match that circadian piece.

Michelle Shapiro:

And you also taught me you can’t really change your circadian rhythm by more than, what did you say, 15 minutes a week? Like you can’t actually titrate like, all right, I’m gonna sleep at 2 a.m. and next week I’m gonna sleep at 9 p.m. Like the body will not adapt to that.

Dr. Robert Kachko:

Yeah, practically speaking, what I’ll ask people to do is 15 minutes every three or four days to kind of wind it back. And even that might be too fast for some people and some people have to go very slowly.

Why We Have Difficulty Falling Asleep

Michelle Shapiro:

Why does it feel like in that moment where you can’t sleep? I wanna talk about the emotions behind that and what we can give people just in that literal moment where they feel like I’m up for five hours, I’m staring at a wall, I can’t sleep. What, why is it that in your head, the conditions for sleep aren’t being met?

Again, it could be this cortisol response that’s happening and ultimately an adrenaline response after a long period of time. What advice can we give people in that moment and what is happening? Why is it that when we want to sleep the most, sometimes we can’t?

Dr. Robert Kachko:

Hmm. Well, I think it’s similar. And you and I have spoken a lot of time, spent a lot of time talking about anxiety and sort of how that alarm signal kicks in. It’s very similar. Wishing away anxiety and wishing away insomnia are both as equally ineffective. the mechanisms I think are poorly understood. Maybe there’s, you know, researchers who understand it better, but the idea that we start telling ourselves this is going to be impossible becomes a fulfilling prophecy, for sure.

And it’s, you know, the downstream effect is all the things that we need for sedation and somnolence. The flip side turns on for wakefulness. So the GABA system does not turn We produce actually more serotonin and more norepinephrine in those moments. We think of serotonin as purely improving sleep. It’s sleep regulator much like anything else.

Melatonin is very similar. So all the same mechanisms kick in, but in reverse in those moments. And in terms of what we can do about it, unfortunately counting sheep doesn’t really work. It doesn’t accomplish what we’re hoping to do. In terms of what we can do about it, There are multiple approaches that really come from like cognitive behavioral therapy perspectives. And the first idea again is going to bed at the same time every day. And importantly as an add-on to that, if you don’t fall asleep within 15 minutes or if we say later in the night you wake up, get out of bed.

Michelle Shapiro:

Yep, I love that recommendation. I find that so helpful for my clients too. It’s like changing your, we get like caught in the loop of that and changing your environment can like open those new neural pathways for you and like let you know that you’re not stuck in that head space and it can just change the entire perspective.

The other piece I’m gonna add on too is just like immediately flow into acceptance and just, you know, if I have a night where I can’t sleep, which will happen, I’m very trigger happy for not sleeping, which is why like, my family and friends know like you gotta catch me before nine because if I don’t go to bed, the reason I go to bed so early is not so that I can never see my husband or my friends is because they’ll be around forever anyway, but hopefully, but is because if I don’t my brain will start wanting to do stuff and get like excited again.

I’ll get the total second wind where I’m like hyperproductive ready to rock and I need to kind of defeat that by going to sleep early. It’s just like. That’s part of my rhythm and part of my HP access activations. So I think that the first thing I would tell people to do when they feel like they can’t sleep is just like immediately accept it and just be like, yep, this totally stinks. I don’t know how long this is gonna last. There’s nothing physically happening to my body right now. I’m not under attack. Nothing is going on. It’s just, my eyes are open and I have a little more time today.

I think rolling with that and just immediately going into acceptance, we’ll start to shift those hormones around a little bit. What I think you’re saying too, Rob, is that you’re not guaranteeing that you can get someone to sleep in those moments. But what we’re both saying is you can make it more tolerable and you also can do things that will initiate sleep. Even if it’s a little later, there’s things you can put into motion.

What to Do When You Can’t Fall Asleep

Dr. Robert Kachko:

And that over time is possible to unlearn all of that. So that’s where the idea of that 15 minute rule is, okay, go do something else for 15 minutes. Don’t watch TV. Don’t, you know, watch politics or anything like that, but do something that’s under kind of low light. Um, read a book, listen to a podcast, for example. But after 15-30 minutes of that, you go back and you try again for about minutes.

Michelle Shapiro:

It’s a number we want people to keep an eye on. I’ll tell you something just straight up, because I again had terrible sleep yesterday. I know what got me. I’ll tell you right now what got me. I watched the new Avatar and I got so like overly emotional watching it. And it just like totally set me off. I was crying. It was like, it was beautiful.

Dr. Robert Kachko:

So you started watching that at like 5 p.m. and then got in bed by nine. Ha ha.

Michelle Shapiro:

That’s what happened. And it’s exactly what just three and a half hours later, however long the movie is. Yeah, it’s just that you know what, we have to also know when it comes to sleep our own stuff. And like, you know, Jeremy came in the room yesterday and was like, watching that at 5pm a little risky, you know, because I get so attached to the characters, I’m emoting into the movie, we have to just know ourselves and know what our patterns are.

Because that’s also, I think a really important part of sleep too, is that everyone’s it’s so individual. what’s gonna impact someone, but understanding more of like, you know what, I really didn’t sleep well that night. Let me evaluate what I ate that day. Let me evaluate who I spoke to that day. Let me start to get an understanding to know what’s hyping our system up or bringing our system down too.

Dr. Robert Kachko:

Yeah, yeah, no, I agree. That makes perfect sense. And it comes back again to what we started with that evolutionary mechanism. If we don’t feel safe, sleep is the silliest thing we can do in the world. And so, yes, absolutely.

Michelle Shapiro:

Right, because it’s like sleeping with one eye open. You’re not sleeping with one eye open, exactly. If you think something is going to attack you. So let’s talk also, this idea of circadian rhythm. I wanna talk about what it means even in the beginning of the day.

Genes That Impact Our Sleep

I also wanna talk about clock genes, because I think they’re so freaking cool. And I think you can give us a really cool deep dive into them. So let’s talk about both of those things in whatever way you wanna flow and talk about sunlight, all that fun stuff.

Dr. Robert Kachko:

Well, so generally we all have our own circadian rhythm. We all have our own set point. There are multiple genes. Clock is the most common one. There’s one called PER2. There’s another called WINT16 that actually correlates a lot to bone health, believe it or not, but somehow seems to play a big role in sleep. And then there’s a, there’s a fourth gene called ARNTL, I call it ARNTL, A-R-N-T-L all in caps.

These are all measurable. You can do your 23andMe ancestry and kind of pull those. They are, first of all, importantly, they’re interrelated, right? And so they, you know, just looking at, you know, what does your clock mutation look like and all of that isn’t gonna tell you that much. And we’re learning so much more every couple of years about these sorts of things. But generally speaking, what we know now is that they create a set point. How to augment those?

Keys for Sleep Hygiene

None of the prescription medications are targeting anything in that category. I think the most important thing that we can do is set our rhythm and our sleep hygiene and all of that. And we could talk about medications for sleep and sort of how those all work and don’t work and what they do and don’t do, but the cues that our body receives, you mentioned sunlight, are what stimulate that.

The temperature, the cues, the timing, the consistency, our relationships, our social connections, all of that turn on genes that promote sleep and help us feel safe and turn off genes that don’t. I think the most critical one is our exposure to sunlight. The melatonin production happens when there’s less exposure to light.

But generally speaking, we talked about that idea of homeostasis or sleep debt, that is initiated in the morning. Our degree of bucket filling is initiated in the morning based on our exposure to and the timing by which we wake up in all of it. And so that’s where the best thing to do is get early morning sun.

The next best thing, especially if you don’t live in a climate where that’s always feasible or a time of year where that’s always feasible. is to do things like light boxes and all that. And so for some people who have really, truly difficult sleep issues, we do use light therapies for sleep retraining.

In addition to just telling people to wind back the clock, we have to use red light in the evening, 10,000 lumen bright light to mimic the sun in the morning to slowly, gradually work back that circadian rhythm.

And then we could talk a little bit about cortisol, which is the body’s main stress hormone that does correlate, right? So our body’s cortisol should be highest in the, sort of within an hour of waking, it comes up and then comes gradually down throughout the day and it should be lowest when we’re ready for bed.

That also is the concept, that’s the closest, and aside from melatonin, the closest physiological correlate to when we should actually be falling asleep. And that’s something we can measure, which is nice. There’s saliva tests and urine tests and all that.

Feeling “Wired and Tired”

Michelle Shapiro:

I remember also seeing a lot of DUTCH tests that it’s interesting. Like obviously we know we want that slope with cortisol where it rises when you were waking up and within that hour and then it comes down. What can happen with a lot of people is when they are exceedingly wired and tired, like you said, for a very long period of time, is that sleep cycle can kind of flip and you can start feeling really awake at night and then really tired during the day.

So is there a progression to that point? Does that happen spontaneously? Where people feel like I’m up all night, but I wanna sleep all day, and their circadian rhythm has kind of flipped on its head.

Dr. Robert Kachko:

Yeah, generally speaking, what you’ll find, and it’s hard because you catch that moment in time and you don’t know where someone is in their stress cycle, their trauma cycle, wherever they are, but generally speaking, our cortisol will rise to meet the moment, and then over time, it’ll flip the pattern, and then over more time, it’ll just be low all day.

Depending on where we catch it, first of all, it always has to be correlated to their actual life and how they feel. Right, so just looking at a DUTCH test is not that helpful if they, have no symptomatology, usually speaking, there’s something that we can pinpoint that says, okay, based on this time, X, Y, or Z are happening, including blood sugar drops that will raise your cortisol, not because of stress-related mechanisms, not because your circadian rhythm is misaligned.

But as a general rule, yes, if the cortisol is too high, that flipped pattern that you’re talking about, it’s going to be very hard for people to fall asleep. And then what I’ll often do is give people an extra sort of sample salivary or otherwise. to take right when they wake up in the middle of the night. And that’s usually really high as well.

Dr. Robert Kachko:

Well, just a little bit of chicken or egg there, right? Is it now that they expect that they won’t sleep so their cortisol is rising or that’s the primary cause? Hard to say. For both scenarios lowering, it is helpful because it’s there at that moment.

Michelle Shapiro:

Exactly. Well, this is the very interesting thing about all of this too, where, you know, I think the phrase like, test don’t guess, we hear a lot of functional medicine where it’s like, you always want to see what’s going on with the test. You and I are like, let’s really understand what someone’s experiencing first before doing, we love lab testing, but before doing all that lab testing, because you’re going to learn more about it from them speaking.

Why We Wake Up in the Middle of the Night

For instance, if I hear a client who says, I wake up every day between two and 4am and I’m feeling really hungry and really anxious. My thought is, oh, that cortisol might be firing off a little bit early. Let’s talk about that specific pattern.

And if you see that in your practice too, I’m rolling my eyes because I know that we have seen that with mutual patients, clients. So tell us about that specific pattern where you’re waking up in that like one to four-ish kind of window and you are kind of woken up like that. Less of a sleep initiation issue, more of a sleep continuation issue.

Dr. Robert Kachko:

Yeah, yeah, sleep maintenance, I actually see more of that than sleep initiation. Broadly speaking, sleep initiation is mostly illumination, you know, difficulty powering down, mind is racing, that kind of stuff, anxiety, etc. The sleep maintenance issue tends to be more likely hormonal.

In my practice, I’d say about 50 to 60 percent of the time, it’s the cortisol piece, or again, at least we find it and then we treat it and then that resolves whatever else caused it. The most common cause of that is a blood sugar drop, honestly, for a lot of people. And what a lot of people do is just like keep a half a cup of blueberries on their nightstand.

Michelle Shapiro:

So you, you know, if you would have heard the trauma episode from season one with Dr. Kachko, you all would know that Dr. Kachko became my business partner, you know, close colleague and BFF. After I was his literal patient and it was in one of my initial plans, you put blueberries and sunflower seeds before sleeping to stabilize blood sugar and create tryptophan.

And it is definitely one of the things that I just absolutely… jacked from you and using so many of my client plans to this day, like almost 10 years later, it is so supportive to get blood sugar down. All right, this is, I’m so juiced up about this and have to talk about it. So there’s like a lot, a lot of doctors on Instagram.

You don’t use the social medias, but on the net, Rob, a lot of doctors are saying eating before sleep interrupts sleep. And it can, if eating, like I’m assuming yes, eating a very heavy meal, drinking alcohol, those things can, but it’s so funny because in practice, I’ve worked with over a thousand clients. You’ve definitely worked with over a thousand patients over the years.

How Blood Sugar Impacts Sleep

I’ve never seen someone who has blood sugar dysregulation and cortisol issues do well with like an intermittent fasting because the first thing I see is that exact cortisol window when they wake up in that like one to four, two to four kind of range. Why is everyone saying that you should never eat before sleep, even blueberries, and that it won’t stabilize blood sugar? Why, and why are they wrong? Because I just don’t, I just, I don’t agree. to be honest with you.

Dr. Robert Kachko:

Well, I think to your point, it depends on what you’re eating. Actually, blueberries before bed isn’t a good idea because that’s not that quicker carb fix isn’t going to do it for you. The quicker carb is more helpful in the middle of the night if you wake up. And by the way, you mentioned, I think sunflower seeds, my new jam is pumpkin seeds. They work way better.

And you don’t need a lot. Like two tablespoons. You don’t need a lot. And so. To whoever’s point, there is a volume question here in terms of if you’re eating a heavy meal right before bed or within two, three hours of bed, totally not gonna help.

Michelle Shapiro:

Of course. Well your body still initiating digestion then, which is one of the conditions that would not promote sleep, right? Because your body’s working and we want it to be at a time of exhaustion, essentially.

Dr. Robert Kachko:

Correct. Because it might work for a little while and then all of a sudden, when that process is nearing completion, then your sugar drops and you go back to that vicious cycle. Whereas if you eat something that just has the right amount of a little bit of healthy fat, a little bit of protein to stabilize you, that is far more effective.

Michelle Shapiro:

But I do have to say, it’s just in practice, I really even, that’s what you’ll see in my client plans. Like this is a spoiler alert basically, but blueberries, sunflower, pumpkin seeds, combined together. Some people, if you don’t have good blood sugar control or your blood sugar tends to drop low, you might need some carbs before sleep. And it’s okay if it helps you. And it might not be forever, but I have seen it be really helpful for people.

I think that again, with those. If your cortisol is irregular, your blood sugar is going to be irregular too. So in the time where you’re trying to regulate cortisol, one of the things you can do is stabilize your blood sugar. And if you already don’t have stable blood sugar, you might actually need carbs because your blood sugar might be dipping too low. So it’s really gonna depend on the person.

But what I can say is broad strokes, one of the main reasons I see for that wake up is when people initiate intermittent fasting, and then from a nutritional perspective, and then I see them waking up at 2 a.m. and I’m like, They’re like, I think intermittent fasting’s working really well for me. I’m like, how do you know? They’re like, well, I’m not losing weight and I’m not sleeping. And I’m like, well, that would indicate it’s actually not working well for you. Essentially.

So, just had to thank you for rolling with me on that. And I knew we were going to talk blueberries and sunflower seeds. One thing that we keep promising to come back to that we haven’t also is melatonin. Tell us about the hormone melatonin. Tell us about people taking melatonin. Do you like it? Do you recommend it? What do you think?

Melatonin May Not be the Best Sleep Supplement

Dr. Robert Kachko:

Yeah, it’s useful sometimes. It’s useful if there’s a true melatonin deficiency more often than when there isn’t. And people who are taking mega 10 to 20 milligram doses, there’s not much benefit, both clinically but also in the research, one to three, sometimes six milligrams of melatonin. If it’s gonna work, it’s gonna work there.

The thing about melatonin though is people think about… as a sleep initiator, I’m gonna take melatonin, it’s gonna help me fall asleep. It’s not, it’s a hormone, it’s a sleep regulator. Naturally what happens, and I think the most likely reason why taking serotonin support, tryptophan, 5-HTP, which are very commonly used, naturally what ends up happening is our bodies, when it’s the right time, convert serotonin into melatonin, and that’s what tells our brain, okay, start producing the GABA pathways, go into that more… sedative, somnolent type of biochemical pattern, it initiates that process, that cascade.

What we also know is that people who don’t produce melatonin appropriately, a lot of the night shift workers and things like that, do have correlates to all kinds of things. Let’s just start with, it’s almost impossible to lose weight if you don’t sleep correctly, and just to go back to what you just said earlier.

So forget about restrictive dieting and all that kind of stuff, which I know you’re very get yourself sleeping, get yourself feeling healthy and strong enough and then the rest follows. Melatonin is a key player in that, but you don’t need mega doses. We’ll use mega doses of melatonin in cancer patients. You don’t need it for sleep. That’s not the mechanism that it’s useful.

Michelle Shapiro:

Yes, this is by the way, I have two clients who have sleep apnea. One of them is a mutual client. Shout out to him. He knows exactly who he is. And we found that before we could get, because he has sleep apnea, before we could get him sleeping, his weight loss efforts stalled so much.

Sleep Can Help Weight Loss

Why can’t we lose weight when we can’t sleep? And then when he got sleeping, by the way, we started rocking and rolling again. It was really exciting, but why is it impossible to lose weight if we can’t sleep?

Dr. Robert Kachko:

Let’s combine two sort of factors that we talked about earlier, this idea of you need to feel safe enough to sleep, and this idea that we have fully spoken about it, but if you don’t feel safe enough, our body goes into conservation mode. Right? We quite literally lower our basal metabolic rate to say, okay, if I’m not sleeping, it means that I need to conserve… as much as possible for some future event, for some future experience, whether that be a famine that’s coming or needing to run away from a tiger and we need to conserve our glycogen stores, etc.

The challenge is if we’re getting four or five hours of sleep, aside from the fact that our body goes into conservation mode, there’s also a lot of metabolic changes that happen. People who tend to get four or five hours of sleep for about a week go into a pre-diabetic state. And so that impacts leptin, which is that hormone we need to understand that we have the right to tie it in, ghrelin and adiponectin and all these insulin, of course.

There are two mechanisms. One is the, we don’t feel safe enough, our body’s smart enough to say something bad’s about to happen. And there’s a metabolic effect. And there’s really interesting research that shows, especially for people who like to exercise in the mornings, you make almost no gains if you don’t get enough sleep the night before.

A long time ago, I wrote an article, something around, it was for like some bodybuilding magazine, I think, something around like honestly give up on that early morning exercise if you’re not sleeping. It’s just not, it’s hard, it’s not worth doing. And so because your body doesn’t feel safe enough to focus on sort of that anabolic growth that we need.

Morning Routine To Improve Your Sleep

Michelle Shapiro:

The, we’re definitely gonna come back to melatonin because I have a question about it too, but what we’re seeing as a pattern in this conversation is also what we do earlier in the day influences what happens at sleep. So getting enough sunlight in the morning.

I think stabilizing your blood sugar in the morning is almost more important than stabilizing your blood sugar at night. So I like to say to people have 30 grams of carbs and 30 grams of protein within 30 minutes of waking up, really easy to remember 30, because that will set the pace for a stable. blood sugar for the rest of the day, and a stable cortisol for the rest of the day, which are very interrelated too.

So what we do earlier influences sleep just as much. And again, if you watch Avatar a couple hours before bed and you’re like an HSP, you might have a problem because that’s gonna influence you too. So it’s not what we do immediately before, it’s what we do all day also. Melatonin, oh,

Dr. Robert Kachko:

Bring it back to that bucket that I was talking about, that homeostatic basis for sleep, that sleep dead idea. Your avatar just filled you back up, right? Or getting the right sunlight, set the mechanism in place to deplete it appropriately. Same thing with your blood sugars going up and down.

Your body wants to, again, oversimplification, but your body wants to have predictability. And so if it can predict, okay, we can deplete 5% every sort of time interval, that’s what’s important. All those things play a role to set that up.

Michelle Shapiro:

Regarding weight loss and sleep too, we think of, I think of like a bomb calorimeter, like something that determines how many calories you’re burning as being like oxygen consumed over CO2 expelled, right? If you’re having something like sleep apnea and you’re not breathing, it’s also really hard to just lose weight by nature of not having enough oxygen and not having enough of that balance.

So that’s just something, again, sleep apnea is a whole other episode and a whole other conversation, but to whatever way possible, getting the mask on in whatever way possible, engaging in those treatments. It also can help with weight loss efforts too. So it might not seem like a big deal if you’re trying to lose those like little last 10 pounds, but you’re like viciously counting calories and nothing seems to work.

A direction I really have people look in is sleep, but it is not something that’s like a bang for your buck kind of remedy where you’re gonna immediately start losing weight when you start sleeping. Same thing with trauma therapy. I think people seek trauma therapy because they feel like they’re holding on to weight and they wanna release.

These are like really intricate mechanisms, really hardwired from that evolutionary perspective. They don’t change overnight and they take a lot of time, but setting up those foundations of having a balanced nervous system, having good sleep, is what’s gonna be important for people weight loss wise, which is always important to acknowledge on something like this.

Last thing about melatonin really quick too, is much like how the myth of cholesterol has always been like you eat cholesterol, cholesterol go up in blood, is taking exogenous melatonin the same as the melatonin you produce in the body? Is it that simple to just take a hormone and then it gets integrated as it exists in the body?

Dr. Robert Kachko:

Well, no, it’s not a one-to-one for sure. But it works, right? So we know from the data that it works. Much like the example that comes to mind is how taking probiotics in your digestive tract changes vaginal flora, right? How does that happen? The mechanism, the body’s, you know, pretty miraculous in that way. Melatonin is, you know, made up of… amino acids and those are broken down in the gut.

There are better absorbed forms, liposomal forms and things like that, that do absorb more effectively. I don’t know that we fully understand why it works because there is first pass and second pass metabolism before it actually gets to your central nervous system. But it works. There’s solid enough data on melatonin that it works. But no, nothing will replace your body’s own rhythm.

Natural Supplements to Support Sleep

CBD

Michelle Shapiro:

What about, this is a huge thing, right? CBD, I wanna know how you feel about it, and L-theanine. I feel like L-theanine was because Huberman said it on his podcast, and now everyone’s really into L-theanine. I know a third one that we barely have to discuss, because I’ve probably mentioned so many times in the podcast is both of us recommend magnesium glycinate as a supportive supplement. What do you think about CBD and L-theanine? Two different things, obviously, but both of them separately.

Dr. Robert Kachko:

Yeah, CBD is effective. It’s expensive. And so I honestly, I save it for, you know, as one of the last resorts because you’re on it for a long time if it’s gonna be effective. But CBD can be quite helpful, but it’s, I rarely get to CBD because usually there’s other things that work, you know, just as well.

L-THEANINE

L-theanine is interesting. I think L-theanine… Really what it does is that, remember I was mentioning as we went to the sleep stages, the different brainwave activities and all that, L-theanine helps us transition from that beta to that alpha, which is what helps us go from wakefulness towards that N1 transitioning into N2 non-REM sleep. Not a lot of really good research on L-theanine. L-theanine also is an amino acid. How is it absorbed? Why does that happen? Why does it work?

But clinically speaking, I have seen it work well. There’s some small studies that are interesting. It combines best with GABA because if L-theanine does the transition of the brain waves, the GABA helps to initiate that mechanism and sort of attach to GABA-A receptors and all that. It also combines very well with Valerian for very similar reasons, mostly because A, it works, and B, if we look at the research, it’s probably the best studied.

It’s probably the only one that’s well studied, probably secondary to primary, and then secondary would be lavender extracts. have some pretty solid research for, again, sleep initiation, sleep maintenance, quality of sleep, sleep duration, all these mechanisms that we look for. Which brings up the other point that these supplements won’t do anything if all the other factors aren’t in place.

Michelle Shapiro:

Thank you for saying that.

VALERIAN ROOT

Dr. Robert Kachko:

They’re not sedatives, they’re regulators. Valerian seems to be, again, we think, a GABA reuptake inhibitor, so it keeps GABA in the cellular cleft a little bit longer. That’s not gonna do much if the mechanisms are not coming from hypothalamus to the rest of your… neurocircuitry to initiate sleep. Right? And so it all has to be done at once.

Sleep Hygiene is Essential

And that’s probably one of the frustrations for people is they say, well, actually, one of the most common phrases that I get is, I swear, if you tell me to do sleep hygiene, I’m going to walk up, you know, don’t tell me just to do sleep hygiene, because I’ve tried that. You have to do it all at once. And you have to do it based on your individual challenge.

Sometimes that’s based on testing. Sometimes it’s just based on a good, thorough clinical history. and you need to give it time because it’s retraining of sleep that matters.

So all those supplements are helpful, but you have to kind of do it all at the same time, inclusive of blood sugar and moving right during the day and working on your trauma and your relationships and all these sorts of factors. That’s what makes it hard.

Michelle Shapiro:

With sleep, you have to know your “things.” You have to know what is going to activate you and what is not. And we’re very disconnected from our bodies. We’re very disconnected from understanding what we need. And I think part of that sleep piece is understanding that. And I also want to say there are supplements that really do help to understand which ones work for you, either work with an amazing practitioner, I think you are the best.

I think that that’s one option or you can of course self experiment and play within the, you know, the recommendations of a health care provider or, you know, within your own research, but at your own risk, this is not medical or nutritional advice. But again, the one thing I wanna reiterate about sleep that’s so important is there is like definitely a pathway forward always, there’s always something you can do.

And just when you think the pieces aren’t gonna come together, like you said with the sleep hygiene, with the retraining, Just when you think they won’t is exactly when they will. So just keep at it and doing the things that we know work, even if we don’t know why they work for ourselves, even if we don’t feel them working in the short term, because when things come together, it will be a lot more effortless.

How Sleep Medications Work

The one other thing I wanna ask you about is those actual medications. Like, why does Ambien or Trasadone, why do they work? What are they doing?

Dr. Robert Kachko:

Hmm. So broadly speaking, two categories. There’s like the benzo, diazepine, state medications. They attach to the GABA-A receptor, which is the most sort of important component of GABA. Then there are non-benzo medications, ambien, sulfadam, you know, fall in that category.

They seem to not, they don’t attach to the receptor. They seem to make the receptor more sensitive to. GABA, which is a little bit different. They attach to a different subunit of the receptor. It’s all in the end GABA related, but it’s not benzo specific. And then there are medications that are melatonin agonists that are remelting, and it’s one of the more common ones on the market that are kind of newer on the block.

To me, a little scary because we don’t exactly know what happens to the hormone and all that because it does so many other things. I mentioned, you know, we use it as an antioxidant in cancer and things like that. And then there are sort of non-classic uses, antidepressants. We don’t really know why the trazodones work.

It basically wasn’t intended for that. People were given that for depression, they started sleeping better. Certainly some of the serotonin mechanisms play a role, but I don’t think we fully understand that. And that’s the scary part is when we don’t understand and we’re messing with sleep, it’s tough.

And then there’s sort of the over-the-counter H1 antagonist histamine type work. you know, your Benadryl, your diaphent, hydramines, and things like that. So, none of those are meant to be a long-term solution. I think that’s important. And that’s not coming from me, that’s coming from every sleep academy that’s out there.

What they basically say is, use these as a tool, do your cognitive behavioral therapy, use your relaxation techniques, do the other things that are gonna fix the problem. But sometimes you have to break the cycle. And I’m not… provider to tell people don’t use these medications. They have a role to play because that expectancy sometimes we have to break the cycle and then work backwards. Just know that it’s not the only solution that is the long-term fix.

How Histamines Can Affect Sleep

Michelle Shapiro:

The histamine piece, by the way, as I’ve seen with my clients an explosion of histamine intolerance, now that’s our new fun game that we play, Rob, where I’m like, test this person for histamines and their plasma now. Is, I have seen a lot more since just the COVID virus itself just because as we know, it’s creating a very, this always fascinated me that there was that study that showed that cure, not cure, the abatement of symptoms for long haul COVID was people taking Pepsid.

And I was always so fascinated by that. And one of the main symptoms that was helped in that study was not acid reflux or anything like that, but actually insomnia. Because histamine excess or intolerance, if you can’t break it down, can lead to insomnia symptoms. So again, it’s really important, and I’ve certainly seen this in my clients, where they were taking things like Ambien to sleep, and then they just switched to like a Zyrtec, and they were like sleeping again.

It really depends on what your root cause is, which is why it is obviously beneficial to work with a practitioner, but also really beneficial to understand what works for you and what doesn’t. Whether it be a medication, a supplement, or anything like that, you’ll learn more about what’s going on inside of your body from those reactions themselves too.

And I also have clients who take things that are very like relaxing, like nervous system supporty kind of herbs and supplements. as recommended by me. And sometimes when you take them and they’re like, if anything, I was more nervous. I’m like, that’s because your nervous system didn’t like being more relaxed basically.

So you have to understand also where you’re at and then push yourself tiny, tiny bits forward as opposed to trying to just always totally sedate yourself. Because I think that it’s an urgency. I understand people really have, but also trying to, I think move the needle might be a better strategy for sleep overall. Do you agree with that?

How to Retrain Your Sleep

Dr. Robert Kachko:

Well, I think the most direct way to say that is it’s never a quick fix. Right. And so that retraining, that reprocessing that has to happen, um, is generally better done incrementally. I tend to agree in terms of what’s sustainable. You can take Xanax and sleep tonight, whoever’s listening, but it’s not going to be the long-term solution, right? They’re both valid approaches. They have to be done within the context of the big picture.

Michelle Shapiro:

And sleep is always available to you. Don’t worry if you feel like you can’t sleep, you will sleep again. There’s always a way to find sleep. Something that I found really interesting that I wanted to bring up too is that my amazing, brilliant cousin Amy is a social worker and just understands a lot about medication interactions and things like that too. She’s a guidance counselor now, school guidance counselor now, she’s amazing.

And she was talking to me about how patients with, because she’s worked in a lot of mental health facilities too, patients with bipolar disorder, the reason that a lot of the medications have like a sedative nature in them is because the manic, like the way she described it was she was like, the best way to heal someone’s episodes is to get them to sleep because sleep is so essential.

So that’s why a lot of those medications do a lot of amazing things, but a lot of them do, mostly just making people get to sleep essentially. So it’s just re-emphasizing how important sleep is for our mental health and also for people who are just kind of like sleep in five hours a night and are like, you know what, I work really hard, capitalism, baby, I’m good, you know, no problem.

Understanding that even that little tiny extra amount of sleep that you might not realize you’re missing could be altering your weight loss efforts, your anxiety efforts, all of those things. So just making sleep a top priority and is I think essential for people’s health. And I do not mean to say that to scare people by saying, if you don’t sleep, you’re gonna have a mood disorder or anything like that or it’s gonna make things worse.

Sleep Issues are Temporary

I’m saying that A, there’s always something you can do, B, not sleeping is temporary for almost everyone throughout life. And if you’re in it right now and you’re feeling like I can’t sleep right now, accept it, roll with it, change positions, come back to it, and understand that nothing bad is happening to you when you can’t sleep in that moment and that there’s always a path forward and always a way to find out what you can do.

Dr. Robert Kachko:

I want to underline that because I wanted to end on something like that as well. The vast majority of people who are going, even through a chronic insomnia episode, get back to regular sleep.

Michelle Shapiro:

Totally. So it’s temporary. We just did a bloating episode that I think is gonna come out before this. And it was the same experience. I was like, bloating and insomnia make you feel, their bark is so much worse than their bite. Like they really make you feel so, so scared. And the one, the most important thing, I can’t believe we didn’t mention this.

This is the most important thing that we can do to affect sleep, to affect your, and instigate your parasympathetic activity is, of course, breathing. Give us a one-liner about breathing and what people can do in that moment if they feel like they can’t sleep.

Dr. Robert Kachko:

Well, you mentioned this idea in the beginning of sort of what’s voluntary, what’s involuntary and all of that. Our breathing is the only tool that we have that’s under both voluntary and involuntary control. You don’t have to think about breathing, but using your breath, you could send signals of safety.

We talked about this in our, in our trauma episode, you can send signals of safety to your nervous system through your respiratory system, through your heart that, okay, actually I am safe. You’re not going to sleep. You’re not going to breathe your way into, into perfect sleep, but it can help. pull back a little bit of the intensity a little bit.

Michelle Shapiro:

And it certainly can turn the symptom of fear around. It certainly can, which is, I think, kind of the worst part of sleep. It’s just feeling scared about sleep. Thank you so freaking much for coming on. Another banger, like I really feel like the trauma episode, I got so many messages that people were so moved and I want to know where, obviously you’ll be back next season.

We’ll probably do like a pain episode or something juicy like that. Not that pain’s juicy, but helping people with pain is juicy. How can people find you? We’re of course gonna link everything in the show notes. What patients are you seeing? Where are you seeing them? Thank you.

How to Work with Dr. Kachko

Dr. Robert Kachko:

Yeah, I think the most direct thing, as you said, I’m not a big social media guy, but you can always go to our websites though, our New York practice is nycintegrative.com, New York Center for Integrative Health, and then our Connecticut practice, of course, our sister practice, you can find us at is ctcintegrative.com. Connecticut Center for Integrative Medicine. So happy to work with you. We’ve got a great team of providers and we kind of see everything. So we’re there for you.

Michelle Shapiro:

And you see everything with a bunch of different modalities too, which is, I think, really exciting for people. In your centers, they’re not just, you’re not just working with, you know, potentially acupuncture. You’re not just working with supplements. You’re not just working with medications even. There’s a whole kind of support system and a whole different team that people can work with, which I think is really powerful too.

Dr. Robert Kachko:

The right medicine for the right person at the right time. That’s what integrative medicine is.

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