Please note that Walker does not discuss chronic fatigue syndrome or fibromyalgia in his book, and this blog does not specifically pertain to either disease: it is not meant to be a prescription for sleep for either disease. (That will come later in the sleep series.) Rather, it’s a general overview of sleep topics from a leader in the field as Health Rising starts its Sleep Series.
This is the second part of a two-part series reviewing Matthew Walker’s book “Why We Sleep: Unlocking the Power of Sleep and Dreams” . Walker PhD, is a Professor of Neuroscience and Psychology at the UC Berkeley, and the founder and director of the Center for Human Sleep Science. He’s co-authored over a 100 sleep studies. A self-proclaimed “Sleep Diplomat“, Walker has been on a mission to convince the world to take sleep more seriously.
The most controversial chapter in Walker’s book is undoubtedly the one on sleeping pills. During an interview he said the publisher assiduously fact-checked that chapter, in particular, to avoid being sued by the pharmaceutical companies.
Approximately 10 million people take some sleep aid every month and the numbers rise as we get older. One estimate suggests that 20% of older Americans regularly take sleep drugs. People in the U.S. spend $30 billion dollars a year on prescription drug and over-the-counter sleep remedies.
Walker isn’t having it, though. If he had his way, one gets the feeling all sleeping pills would be removed from the market. Sleeping pills, he bluntly states, at the beginning of the chapter, “do not provide natural sleep, can damage health, and increase the risk of life-threatening diseases”. Ouch.
In fact, Walker doesn’t believe these are “sleeping pills” at all. They’re basically sedating agents or knock-out drugs. The older sleep drugs, such as diazepam, basically did knock you out, but Walker doesn’t believe the newer sleep drugs are much better. They don’t improve sleep – they simply shut down the higher regions of our brains’ cortexes.
(This is not quite true. Some studies suggest that Ambien, for instance, improves spindle activation and short-term memory. Studies suggest that sleep drugs do improve total time asleep, reduce time to fall asleep, etc., and that people may feel better using them; i.e. they experience more restorative sleep.)
Putting sleep in parentheses, Walker reports that the type of “sleep” drugs like Ambien or Lunesta promotes lacks the large, deep brainwaves produced during normal NREM (non-rapid eye movement) sleep.
Walker’s assertion that these drugs can’t reproduce natural sleep is borne out in the grogginess, forgetfulness and slowed reaction times during the day that some people experience with them.
There’s also the potential problem of “rebound insomnia” in which insomnia worsens when one stops the drugs, as well as possible problems with drug withdrawal.
Walker goes further, suggesting that the drugs don’t do a great job of inducing real sleep, though. He asserts that they’re actually dangerous.
Walker reached back to a very large (n=10,500 patients) 2012 study by University of California at San Diego which found that over a 2 1/2 year period that people taking hypnotic sleep drugs (zolpidem (Ambien), temazepam (Restoril), eszopiclone (Lunesta), zaleplon (Sonata), other benzodiazepines, barbiturates and sedative antihistamines (ketotifen) were almost 5 times more likely to die. Even people using sleeping pills 1 1/2 times a month showed an 3.6 fold increase in mortality.
(The participants were age and gender, smoking, body mass index, ethnicity, marital status, alcohol use and prior cancer matched people; i.e. none of these other factors could have caused the increase in death rates.)
Possible reasons for the increased death rates included increased rates of drug-induced depression or suicide (several sleep drugs come with suicide warnings), car accidents from impaired motor skills, increased falls due to reduced coordination, increased rates of sleep apnea and increased rates of cancer.
Given the important immunological boosts, which occur during natural sleep, but which Walker implies don’t take place with sleep drugs, he suggests that higher rates of infection may contribute as well.
The UCSD study is just one of 24 studies which have found that using hypnotic sleep drugs increased mortality rates. No studies have found that using them has improved mortality rates – as one would expect from a helpful drug. A 2018 500,000-person, 13-year study found that Ambien carried the highest mortality risk. Two recent studies found that using hypnotics for sleep was associated with an increased risk of coming down with Alzheimer’s Disease.
But doesn’t having a sleep disorder, by itself, increase one’s risk of mortality or of coming down with a disease? Throughout his book, after all, Walker has harped on the dangers of not getting a good night’s sleep. Maybe it’s the poor sleep, not the drugs, which is causing the increased mortality and other issues.
A meta-review of 17 studies which including a total of 36 million people over 11 years, however, found no increase in mortality in people with symptoms of insomnia compared with those who didn’t have those symptoms. It did, however, find an increase in mortality for people with insomnia who were taking hypnotic-type sleep aids.
A large (n=158,000) Women’s Health Initiative sleep study also found no association between insomnia and mortality but did find an association between hypnotic sleep drugs and insomnia. It also found a “small but robust” association between amount of sleep (either too much (9 hours or too little (<5 hours) and mortality. Sleep abundance, rather than insomnia, is the contributor to increased mortality.
Walker’s Prescription for Good Sleep
“Eighty percent of my patients make their sleep worse.” Dr. Lucinda Bateman
So what to do about insomnia and/or poor sleep? Walker has spent hundreds of pages attempting to convince everyone how important sleep is. He’s just skewered the most common sleep remedy – sleep drugs. After all that, Walker’s prescription for good sleep comes as something of a letdown. It’s called sleep hygiene, and if that doesn’t work, there’s CBT-I (cognitive behavioral therapy for insomnia).
Many people have heard of sleep hygiene which involves preparing a good environment for sleep – the consistent sleep times, the darkened, cooled room, turning off digital media (avoiding blue light), using the bed only for sleep, avoiding napping after 3 pm, avoiding caffeine and alcohol, taking a warm bath before bed (to cool down your core), relaxing before sleeping, getting out of bed if you’re not sleeping.
That’s all good, but there is a more powerful approach. Virtually every sleep drug mortality study suggested that insomniacs turn to a therapy – the name of which will likely to raise the hackles of many people with ME/CFS – cognitive behavioral therapy for insomnia (CBT-I) instead of drugs. In 2016, in fact, the American College of Physicians recommended that CBT-I, not sleep drugs, be used as a “first-line” treatment for insomnia.
CBT-I is more effective and produces less side effects. Plus, you don’t have to worry about kicking off early or developing Alzheimer’s or other diseases. It is, however, more difficult than taking a pill.
- Matthew Walker, a neuroscientist at UC Berkeley and the author of Why We Sleep: Unlocking the Power of Sleep and Dreams” argues that while sleep drugs do knock one out, that they don’t provide natural sleep, and can even be harmful. (Sleep drugs can increase sleep time, reduce awakenings, etc. and may help some people achieve more refreshing sleep.)
- Walker reports that most sleep studies report that taking sleep drugs is associated with an increased risk of mortality, as well as some cancers and diseases like Alzheimer’s disease.
- Studies that have tracked people with symptoms of insomnia do not find that insomnia, itself, increases the risk of death – but have found that taking insomnia drugs may.
- Noting the many ways that sympathetic nervous system activation (which is prevalent in ME/CFS and FM) impairs one’s ability to enter into sleep and then to enter into deep sleep, Walker promotes practices like sleep hygiene and CBT for Insomnia.
- CBT for Insomnia or CBT-I is now recommended as a first line treatment for insomnia (over sleep drugs.).
Sleep drugs are generally recommended only for short-term use.
Insomnia and Sympathetic Nervous System Activation
Walker showed that activation of the “fight or flight” system (sympathetic nervous system (SNS) activation), a common problem in both ME/CFS and FM, has multiple impacts on insomnia and sleep. SNS activation makes it more difficult to transition from light to deep sleep. By keeping the core body temperature higher SNS activation also makes it more difficult to get into light sleep.
(A drop in core body temperature is associated with entering into sleep. The benefit of a warm bath occurs not while you’re in the bath but when you step out of the bath into the colder air, spilling body heat into the air, and sending your core body temperature down.)
Not only do the vigilance centers of the brain remain on guard in insomnia, but the sensory gates that usually stop the flow of stimuli to the brain remain open. When people with insomnia do get to sleep, their sleep tends to be shallower and is more punctuated by awakenings, and they tend to wake up feeling unrefreshed – a common experience in FM and ME/CFS.
CBT-I studies have not, to my knowledge, been done in ME/CFS but in general (2 positive, 1 negative study) have had positive results in fibromyalgia.
CBT-I uses a variety of behavioral techniques and practices to, among other things, calm the fight-or-flight response down. They include sleep hygiene and go well beyond it. The practices can include such things as:
Aspects of CBT-I
Keeping a Sleep Diary – check out an example from the National Sleep Foundation.
Sleep Restriction Therapy (SRT) – SRT has been called the “most effective sleep hygiene technique” available. That’s the good news. The bad news is that it’s also the toughest one and can in the short term (weeks!) actually make your sleep temporarily worse. Still, many swear by it.
In sleep restriction therapy, you determine how much sleep you’ve been getting (a minimum of 5.8 hours), set a wake time and a bedtime that will allow you to get that much sleep, and then stick to it through thick and thin. No napping is allowed. Over time, sleep will hopefully even out, your circadian rhythms will return to normal, and you will experience more refreshing sleep.
- Check out the National Sleep Foundation’s Bedtime Calculator to get good times to go to bed and wake up.
Stimulus Control Instructions – A sleep behaviorist identifies factors that may be inhibiting good sleep (doing things other than sleeping in your bedroom, avoiding caffeine, etc.).
Relaxation training. In his experience, Dr. Friedberg has found that 30 minutes or more of relaxation exercises (focused breathing, progressive muscle relaxation, visualization exercises) help ME/CFS and FM patients sleep better and have more energy the next day.
Cognitive training aims to reduce thoughts that interfere with sleep. These include catastrophic thoughts around not getting a good night’s sleep, attempts to stop trying to get to sleep, practices to stop worrying about sleep.
Acceptance and Commitment Therapy– this rather Buddhist approach of non-judgmental acceptance of what life brings us has been called the “third wave of cognitive behavioral therapy”. It’s different from CBT-I in that it doesn’t attempt to change thoughts. Rather, the goal is to “just notice,” accept, and embrace your thoughts and feelings – especially negative ones – leaving one at peace and ready to take the appropriate actions. It can be summed up with this acronym: ACT. Accept your reactions and be present; Choose a valued direction; Take action.
Remaining passively awake. This practice involves actively letting go of fears and worries about going to sleep, as worrying about going to sleep will actually keep you up.
Paradoxical Intention – involves staying awake as long as you can (!), thereby removing the anxiety that keeps you awake.
Biofeedback – a biofeedback device can help reduce muscle tension and heart rate, and help you relax.
Walker’s goal was to wake up the general population about the importance of sleep, and the downsides of sleep drugs. (He does not acknowledge that sleep drugs can increase sleep time, etc. and have some other benefits. Nor does he address more severe sleep disorders.)
Where one feels an almost inevitable letdown are in his prescriptions for better sleep. His general recommendations for better sleep are just that – general recommendations. (Besides recommending CBT-I, he says little about it.)
On the other hand, Dr. Bateman has said that 80% of her patients do things that hurt their sleep, and any technique which ramps down the “fight-or-flight” response could be helpful for sleep. There’s clearly opportunity for improvement for some.
The many, many other things people try for sleep – from raising the head of one’s bed, to supplements, to cannabanoid products, to bio-rhythm devices, Walker leaves untouched. In short, Walker plays it safe and sticks to the information found in scientific journals.
Nor does he speculate about future drugs. He’s more interested in digital advances that could pinpoint optimum temperatures for sleep or light bulbs which could optimize wave-lengths for sleep. Rather surprisingly, he doesn’t hold sway on the efficacy of sleep tracking devices.
Still, Walker’s main point – that getting good sleep is an important part of health – is well made.
Health Rising’s ME/CFS and FM Sleep Series
- Sleep Pt. I: Why We Sleep (and What Happens When We Don’t)
- Why We Sleep Pt II: Walker on the Dark Side of Sleeping Pills and a CBT That Works?