#37: Getting Better Sleep, with Behavioral Psychologist Dr Hylton Molzof, PhD

In this conversation, Stanford psychologist and behavioral sleep specialist Dr. Hylton Molzof joins Dr Khan to discuss the complexities of sleep. They focus particularly on insomnia in chronic illness, and the role of Cognitive Behavioral Therapy for Insomnia (CBTI). They discuss the physiological stages of sleep, the impact of chronic illness on sleep patterns, and practical strategies for managing sleep-related anxiety. Dr. Molzof emphasizes the importance of adapting CBTI techniques for individuals with chronic conditions, especially in the context of long COVID. The conversation also covers the significance of sleep evaluation and the nuances of sleep restriction as a treatment method.

Find printable worksheets and resources Dr Molzof has shared at https://substack.com/home/post/p-154561158?source=queue&autoPlay=false

Chapters

• 0:00 Introduction
• 4:00 Role of Behavioral Sleep Medicine
• 6:24 Defining Healthy Sleep
• 10:00 Physiology of Sleep
• 16:00 Sleep Tracking
• 24:10 Bed Use and Stimulus Control
• 31:52 Acute and Chronic Insomnia
• 42:12 Sleep Consolidation and Compression
• 46:09 Managing Sleep Anxiety
• 52:53 Resources and Final Reflections

Transcript

Zeest Khan (00:00)
welcome or welcome back to Long COVID MD. I'm Dr. Zeest Khan, your doctor friend who has long COVID. Today we are starting the conversation about sleep. We're starting it because this is a very complex and nuanced topic and it's gonna require more than one episode to cover thoroughly.

But today we're gonna talk about a lot. We're gonna cover the physiologic stages of sleep. We're gonna talk about what healthy, sleep looks like, what could disrupt your sleep, and ways to start approaching chronic insomnia. I can't think of a better guest to start this conversation with than my guest today, Dr. Hylton Molzof

Dr. Molzof is a clinical assistant professor and a licensed clinical psychologist in the Department of Psychiatry and Behavioral Sciences at Stanford School of Medicine. She's board certified in behavioral sleep medicine and she specializes in the assessment and treatment of sleep disorders via behavioral sleep medicine interventions, including ding, ding, ding, cognitive behavioral therapy for insomnia or CBTI.

You may have heard the term cognitive behavioral therapy as a treatment for long COVID. That's really controversial and I quite frankly don't believe that CBT is an ultimate cure for long COVID

But we're talking specifically about CBT for insomnia today. Cognitive behavioral therapy is a behavioral science that centers on the idea that interrupting dysfunctional thought processes can help improve our health. CBT for insomnia specifically,

is the gold standard to treat chronic insomnia and has been shown to be more effective than any other medical intervention in the treatment of chronic insomnia. Because of that alone, it is important that we don't overlook

this huge medical resource that already exists in our healthcare system.

The problem is implementing CBT techniques for insomnia is not really accessible or practical for people who have chronic illnesses like long COVID, particularly those of us who are anchored to our beds in ways that someone who doesn't have long COVID experiences. So how then do we access?

reliable, established science to benefit those of us with long COVID. That's where Dr. Molzof comes in and why I'm so excited to have her on the podcast today. She has a background in public health and she is passionate about making sleep medicine accessible to people with chronic illness.

In our conversation she offers really concrete ways for us to utilize CBT for insomnia methods in ways that work for us.

we also talk very openly about the limitations of CBT for insomnia, in particular the benefit or the possible harm that techniques like sleep consolidation might have

on people with long COVID.

Dr. Molzof is a wealth of information and I'm so excited to introduce her to you. So without further ado, here is my conversation with Dr. Hylton Molzof.

Zeest Khan (03:45)
Dr. Hylton Molzof thank you so much for joining me. Welcome to Long COVID MD.

Hylton Molzof (03:51)
Thank you so much for having me. It's really my pleasure to be with you here today talking about one of my favorite topics.

Zeest Khan (04:01)
This is not the first time we've met. We spent weeks and weeks together when I got to enroll in your CBTI course at Stanford, Cognitive Behavioral Therapy for Insomnia. And we'll talk about that. But first, can you tell us what you do as a psychologist who specializes in sleep

Hylton Molzof (04:22)
Absolutely. Well, my area of training within psychology fits under this umbrella that we refer to as clinical health psychology, which is really focused on supporting health behavior change, often among individuals who are experiencing chronic illness. And we really have an appreciation within that context.

of not only the role of an individual in their health, but also the broader context that health exists in. So we're thinking not just about the biology, but also the psychology and the social factors and cultural factors and environment and the medical system within all of that that exists as well. And under that broader umbrella, we have further specialty within my area of interest, which is

behavioral sleep medicine, which is really focused on helping educate patients and the public about understanding their sleep health, again, from all of those different perspectives, biological, social, cultural, environmental, and then helping also teach strategies that will build self-efficacy and enable individuals

individuals

in improving their sleep in various domains. And when we think about sleep disorders, one of the most common and one that we'll be talking, I'm sure, about today quite a bit is insomnia, particularly chronic insomnia, this unwanted wakefulness at night, whether it's trouble falling asleep or staying asleep or waking too early. And I think that condition can be challenging for so many.

It's also very common in the context of chronic medical conditions and chronic illness. And it often takes a multifactorial approach to really set people on a path to sleep as well as they possibly can.

Zeest Khan (06:24)
close to 40 % if not more of people with long COVID complain of difficulty sleeping, whether that's difficulty falling asleep, waking up too much or having unrefreshing sleep, which was

one of my very first symptoms. Can you tell us what healthy sleep looks like?

Hylton Molzof (06:47)
Yeah, such a good question and I think such a complicated question that often gets overly simplified. And you know, I think we've all come across those media headlines where they have these very anxiety inducing messages of, you have to get eight hours of sleep, that sleep has to look this certain way or else we are wrecking our health, which then creates

maybe feelings of guilt that aren't, you know, well placed or appropriate. And I think within that context too, even medical providers can be well intentioned of giving this message of sleep is so important, you need to do X, Y, or Z, which then only compounds that anxiety for those who aren't sleeping well. But to come back to your question of like, what does it mean to have

Healthy sleep. I think we often want to recognize that people differ in terms of what healthy sleep may look like.

And there are several dimensions of this context of sleep health. think a lot of times quantity of sleep is emphasized, but I would say even more important than quantity of sleep is really the quality of the sleep that is being had, the regularity of the sleep, like how reliable is it night to night, and how restorative it is, which can sometimes be independent of the

the quantity of the sleep itself. And in terms of that question of quantity, even that is a pretty complex thing to parse apart. You know, I think this message of eight hours of sleep often gets perpetuated because our need for sleep, our sleep duration does exist on a bell curve. And so I like to use the analogy of, you know, if we take different heights of individuals, there are going to be some individuals that are very tall.

maybe over six feet, there are going to be some individuals who are short. There's a lot of the population that's in the middle of that bell curve. And the same can be said for sleep duration, that many people are going to fall in the middle of maybe getting and needing seven to eight hours of sleep to support their energy during the day. However, there are going to be others that exists on the boundaries or the edges of that bell curve.

I really like to give the reassurance that people vary and whenever I'm working with

in improving their sleep, I really ask them, you know, what does it mean to you to have healthy sleep? Does it mean that you are minimizing your wakefulness at night? Or does it mean that you're going to bed or waking up at a certain time? Or does it mean that you have certain expectations for your energy? And once we understand how someone defines what their sleep goals are, then we can work in that direction.

Zeest Khan (10:01)
Can you talk to us briefly about what does your body physiologically do during a typical night's sleep?

Hylton Molzof (10:10)
Absolutely. I think it's such a helpful question because, you know, I think it's such an interesting aspect in that sleep, if it's going well, we don't remember it. And even if it isn't going so well, we really can't capture it, you know, well or really fully understand what's happening behind the scenes. But if we kind of look at, you know, different experiences of

We

sleep is a very dynamic process across the night and

The first thing that's really helpful to know is our sleep cycles. Sleep cycles vary from cycle to cycle in duration. They vary within a person and across people. On average, we can think about a sleep cycle as perhaps somewhere around 90 minutes. What a sleep cycle is, is that we're kind of going through different stages of lighter versus deeper sleep. If we get a little bit more granular,

about

what are those kinds of sleep stages. we have REM sleep, stands for rapid eye movement sleep. And what's really notable about this stage of sleep is it's our dreaming state of sleep. And our brain activity is very similar to wakefulness in this state. It's a very active state of sleep for our brain. We are consolidating our memories. It also has implications

for our emotion regulation. And our body is very relaxed as a way to be, you know, protective so that we don't act out our dreams during the night. And we tend to get most of our REM sleep in the second part of our sleep period. And this is notable because it's an active state of sleep for our brain. And we tend to have a bit of a lightening of our sleep that happens in the second part of the night.

And so it can be very common that we might perceive the second part of our night towards the early morning as just a little bit lighter in quality, maybe a little more restless. We may notice that we're a bit more vulnerable to waking up briefly during that time. And we can contrast that with the first part of the night where we're getting more of our deep sleep. So we refer to this as our non-REM, so non-dreaming state sleep and our deep

Deepest sleep is specifically non-REM stage three. And this is a time of sleep where our brain activity has these really slow waves, our body is very relaxed, there's an emphasis on our physical recovery and restoration associated with our deepest sleep. We also have other non-REM sleep stages that I'll mention briefly. We have non-REM stage one, which is a very

light transition state of sleep, I like to highlight that non-REM stage one is unique or interesting because you can be a non-REM stage one and we can see that based on your brain activity if you were to have like an overnight sleep study. And yet if I were to wake you up during non-REM stage one, you might actually say that you had been awake or had had awareness in that moment. And I think especially when we're having very fragmented sleep,

it can be common that there's like this blurring of edges between sleep and wakefulness and part of that may be because of this stage one sleep experience. We also have non-REM stage two, which is our kind of moderate level of sleep. We actually spend the majority of our sleep period in non-REM stage two. And then we have our non-REM.

stage three, which is our deepest level of sleep. because we have that non-REM stage three predominating in the first part of the sleep period, we may sometimes have the perception that we sleep more deeply for those few initial hours. And then again, there's a lightening of sleep that can happen later on. So I share all of this to say that there is a lot happening when we go to sleep. It can

helpful to have some of this awareness of how and why our sleep may feel or look certain ways based on these dynamics. It is also very normal to wake up briefly during the night. This is always a bit astonishing for me to share and remember that when we look at research articles we actually see that even healthy normal sleepers wake up somewhere between 8 to 12 times in a given night if we're looking

looking

at arousal of brain activity. And fortunately, most of those awakenings are not remembered. If they're a few minutes, you roll back over, you transition back into sleep, and you're good to go. But I share that to say that wakefulness at night can be normal.

And often what wakes us up isn't what keeps us awake. And so learning strategies to cope when we find ourselves awake at night can be really helpful. And certainly in the context of chronic medical conditions, there can be many experiences that cause more wakefulness than that baseline in terms of body pain and discomfort or autonomic, you know, dysregulation and things of that nature. But all of that is

to say there's a lot that happens when we're sleeping and so it can just be helpful to have some of this awareness and then see how it maps on to each of our unique sleep experiences.

Zeest Khan (16:11)
I did a group course with you,

I remember when, even before our course started, you asked all of us to start tracking our sleep I remember you asking us to document when we got in bed.

when we fell asleep, how often we woke up in the middle of the night and for how long.

Can you talk a little bit more about the benefit of tracking sleep and what specifically can be helpful to track when there's so many things that we could be focusing on? I ask in particular because those of us with long COVID, some of us are like tracking every single thing like that we can to try to make sense of it. What do you suggest that we pay attention to when we're trying to

make sense of our sleeping patterns.

Hylton Molzof (17:12)
It's such a good question and I think that sleep tracking is such a good place to start. I would also recommend using kind of old-school pen and paper trackers and these can be found online. A very common one that's used is what's called the Consensus Sleep Diary and that's publicly available. But I emphasize this because I know that

wearable devices have made it so that sleep tracking is ubiquitous and yet the technology that we have to monitor sleep with these wearable devices while it has come a long way and has its advantages, I think it often really can't capture more of the subjective components that are so valuable to individuals and we know that a lot of the sleep tracking and the

wearable devices tend to be normed on quote unquote normal sleepers, whatever that may mean, which means that they can be less accurate for the people who perhaps are most invested in using them, those who do have sleep challenges. So I first just like to give that nuance that these wearable devices can be valuable and also to kind of hold that data with a grain of salt.

especially if it's causing more anxiety rather than providing information that feels useful or actionable.

And when we think about kind of using these paper trackers, or there are also Excel versions that can be accessed as well, what we're really wanting to capture is our perception of sleep. And when we think about kind of objective measures of sleep, there's just a lot that we really can't fully capture these days. And so there's still a very large role of subjective perception in making informed decisions around sleep and improving sleep.

And so to your point of like there's so much we could track. How do we make sense of what is useful so that we're not spending, you know, untoward time on this endeavor? I think that the things you outline are usually what I would recommend of kind of distinguishing what time are you getting into bed? Also, what time are you turning out the lights and intending to sleep since sometimes people may come to bed

to rest or to do a bit of a wind down activity. Once the lights are turned out, how long does it take to fall into sleep?

And after you fall asleep, how many times are you aware of waking up and how long does that wakeful time feel for you? And then what time are you waking up in the morning and what time are you getting out of bed? Those tend to be the collection of questions that really can help us capture a bit more of what sleep is looking like night to night. There are a couple of nuances I like to mention that

I think whenever we ask people to track something, we can become a little particular about the details. If it was sleep tracking in particular, we really encourage people to not look at the clock or check the time for the sake of accuracy. Instead, it can be helpful to have your sleep log that you fill out in the morning.

maybe you're having your breakfast or coffee, you sit down for a few minutes and then you think back of what did the night look like based on my rough recollection? And again, this is really valuable information. You know, as a clinician, I'm most interested in how long did it feel like it took you to fall asleep? And if that felt like a long time, then that is what we would want to act on. And so really just having this broad retrospective impression

of the past night. I often like to say, you know, treat it more of like an art project than a science project. We don't have to have really granular specifics of five minutes versus 10 minutes, but we want this sense of, it about 30 minutes? Did it feel like an hour or a couple of hours? And that is informative data, that kind of quality. And then what we do with that is just try

trying to have some curiosity and openness to see what the data show. We can see what a particular night looks like. We can see what a particular week looks like. We may be able to notice patterns that sometimes certain events or symptoms are linked to worse nights of sleep. Or we may also be surprised to notice that there's a lack of correlation. That sometimes people do this tracking and they notice, you know what,

used to think that my sleep always predicted my fatigue, for example, but as I tracked my sleep, I had some recognition that perhaps that correlation was not as strong as I had imagined it would be. And so I think that those insights can be really valuable. It also equips people with a baseline where you can then start to experiment and make changes and then see if those changes are moving things.

in a forward direction or in a backward direction.

Zeest Khan (23:02)
There's so much fantastic suggestions and information in what you just said and I wanted to emphasize a few things. One, this idea of trusting yourself

more than something digital or someone else.

trust yourself and use your judgment. The other thing as you were giving examples of how

a sort of typical person's nightly and daytime routine is looks kind of different for someone with a chronic illness. It actually can look dramatically different when we are spending so much time in bed during the day

Can you talk a little bit about the ways people who spend a fair amount of time in bed can sort of initiate sleep? I'm thinking it must confuse our body.

I know that it does, it confuses my body to be in bed because we make associations with the bed. Do you have any advice or insight for us?

Hylton Molzof (24:10)
Absolutely, I'm really glad that you raised this because I think that this can be such a difficult thing to navigate for individuals, but even for clinicians. I know that later we'll talk a bit about cognitive behavioral therapy for insomnia or CBTI, which is the first-line treatment for chronic insomnia, this wakefulness at night.

and one of the main components of the treatment, the technical term that you may come across is what's known as stimulus control, which really emphasizes the importance of creating a strong association in the brain that the bed is a place for sleep. And so the core tenets of stimulus control as it's written, and we'll talk about nuances that we can build into that,

it's written that says, you know, don't do anything in bed other than sleep or, you know, sex or intimacy with a partner is an exception. And number two, if you're in bed and sleep isn't happening, get out of bed until you're feeling sleepy. And if we take those guidelines at face value,

That requires quite a lot of people that is often not accessible, especially in the context of chronic illness. And as you said, Zeest it really disregards the need for rest as separate from sleep and the reality that oftentimes the bed...

is the most comfortable place to have that rest or to engage in other activities. And so we really do need to be mindful of adapting these interventions. And I think whenever we can take a very robust and evidence-based recommendation like stimulus control, we can ask the question, what is the intentionality behind these recommendations? And the heart of it is we want to

our brain. As you said, don't want our brain to get confused of why we're in bed. One way that we can do this, perhaps in a way that is more accessible to individuals who do need to be in their bed for other purposes, is there is this alternative approach. And because we're in science, everything has a technical term. The technical term is counter control, which is, okay, maybe we are accepting the reality that we need.

to be in bed, can't just be a place for sleep. How else can we signal our brain about our intent around sleep? And so this opens the door for a lot of creativity and things that may be more accessible to individuals. Some examples of that could be, okay, when I'm in bed resting, could I be on the opposite side of the bed from which I usually sleep? Or the opposite end of the bed.

Could I set an intention to be on top of my blankets if I'm in bed resting versus under my blankets when I'm wanting to sleep? Perhaps when I'm in bed resting, I'm a little bit more at an incline or have a different change of body position compared to when I'm intending to sleep. Perhaps when I'm resting, I will have the light on versus when I'm intending to sleep, I'll have the light off. So kind of thinking about what other

contextual cues can we use that will inform our brain of when we're wanting to sleep versus when we're wanting to be awake while still making allowances for other things can be happening in the bed.

Zeest Khan (28:07)
yeah

learning that was so important for me. Once again, it does help to feel a little empowered when there are some things I can do. There are ways that I can modify some of the science that we know outside of how it looks for most people. How does it look for me?

I remember learning from someone on social media that she switched her blankets.

just switched her blankets when it was time for bed and she was already in sort of the sensory deprived state with limited energy and just doing that was the trigger to her that it was time for bed and that was her habit and that was her wind down.

when I was initially learning about...

CBT for insomnia, I was really turned off by this notion of so many physicians telling me get out of bed or rest somewhere else. Like we only have so much home space to use. We only have so much furniture and for many of us our bedroom becomes our home and becomes our only thing. So thank you for those insights and ways that we can personalize.

this approach.

I would love to talk about this topic a little bit more, what you mentioned about what wakes us up isn't always what keeps us up.

for people who have had COVID. We know that things like sleep apnea is increased after a COVID infection. During a COVID infection, like with any respiratory infection, you can have a period of time where you have apneic spells because of airway inflammation and nasal congestion. And there are pretty accessible and easy

ways to test for sleep apnea even at home.

So please, if you're listening, be evaluated for sleep apnea if you are concerned about your sleep being disrupted. Restless leg syndrome is something that can startle people awake. And we know that people with long COVID complain of neurologic sensations that are new and disruptive, pain, as you said, as well.

there has been a period of time in my long COVID journey where I was waking up for reasons I did not understand.

And then there were multiple things preventing me from falling asleep quickly. And a lot of that was grief and worry about my health, why I was awake, kind of being angry for getting woken up again, and then worry about what is this gonna mean for my next day.

What is this going to mean for the long run? So there are acute issues that trigger insomnia. And then there is this response that our bodies and our minds do that sort of reinforces bad habits. Can you talk about

the difference between acute and chronic insomnia and the role that CBTI and psychological science plays in helping those of us who might have physiologic issues that trigger the sleep problems, but need help with maybe approaching the wakefulness and difficulty going back to sleep at night.

Hylton Molzof (31:52)
Yes, there are so many things that you mentioned that I think are... No, it's... No, it's... I think so much of it is so important. So I'm so glad that you did mention. First, I just want to echo your recommendation of sleep evaluation. I think especially for all the reasons you mentioned, when there has been a COVID infection, what we do know about changes in sleep, which is limited, and yet we do see increased

Zeest Khan (31:55)
I talked a lot there.

Hylton Molzof (32:22)
prevalence, as you said, of sleep apnea, of restless leg syndrome, sometimes hypersomnia. So other reasons that sleep may be non-restorative even if you're sleeping for quite long durations. And when we think about diagnosing these conditions, being evaluated by a sleep medicine physician and often having an overnight sleep study in the comfort of your home or by coming into a sleep

can be incredibly valuable. And I also recognize that sleep medicine is not always accessible to everyone. And so also knowing that there are direct to consumer companies online that do provide home sleep tests, especially for those who may have a suspicion of sleep apnea. And usually that testing is somewhere in the $150 to $200 range.

So not cheap, but perhaps not prohibitive for many. But that's one way that if there is any suspicion and it's difficult to get connected with a sleep medicine provider, something that could be looked into.

But to your question that you brought up, Zeest about differentiating a bit between acute and chronic insomnia, this is something that we talk quite a bit about to people who come through our clinic. They think having some awareness of the progression of insomnia can really help provide context for how and why interventions can be helpful. And so oftentimes the framework that we

introduced

to people is a framework called the 3P model, which stands for predisposing factors, precipitating factors, and perpetuating factors. And we'll kind of briefly break those down. We can think about that first P of the 3P model, predisposing factors. So these are really risk factors that we all have that may increase our risk of developing

a sleep issue at some point in our lives. It's not deterministic, but just increases some of that vulnerability perhaps. And these are things like increased age, female sex, gender.

family history of sleep disorders, there might be a bit of a genetic component, having certain medical conditions and mental health conditions. And so it's helpful to kind of know what we're bringing to the table that might increase that risk. And yet, it's not usually until we're encountering a stressful moment of our lives that we start to notice the acute onset.

onset

of insomnia, of sleep suddenly becoming an issue, which is what we refer to as this precipitating event. And so certainly medical conditions can fall under that umbrella. Stressful circumstances in terms of job loss or loss of a loved one.

stress in various forms. We often think about stress in more of a negative context, but I also like to emphasize that even positive life changes can precipitate sleep difficulties. perhaps someone gets a job promotion and there's a lot of excitement built around that, but there's also a lot of expectation. Perhaps someone welcomes a new addition to their family, a baby, a puppy. So we're really thinking just about any deviation from our baseline.

that brings about the sleep issue and this is somewhat by design. I know we often, you know, think about like more sleep is better sleep, but our sleep system is designed that it can be overridden in the context of stress and acutely that can be adaptive at times and meaning that, for example, if we've ever had to pull an all-nighter, it's adaptive that we can.

override our sleep system when circumstances warrant or if we've ever had to wake up and respond to a fire alarm, for example. And yet, it of course isn't sustainable in the long term. And what we often see as we move from acute insomnia into chronic insomnia is that that precipitating factor, that acute stress has either resolved or we've

habituated to that new context in whatever way that we can and the immediacy of that stress perhaps is somewhat lessened. And yet the sleep problem often persists for individuals. And when we think about moving into chronic insomnia, we often have this awareness of what we call perpetuating factors. And we can think about this as, you know, before we have a sleep problem,

We probably don't think about our sleep. We just take it for granted it happens. And then as suddenly when sleep is not working, we start to overthink it and we can become a bit superstitious even if I need to do X, Y, or Z in a certain way or sleep won't happen. We no longer are trustful of our sleep system because it feels like it's very unpredictable and unreliable. And so then there can be a lot of anxiety, understandably, that develops.

about our sleep specifically, and then we start to change our behaviors in well-intentioned efforts to protect our sleep that maybe inadvertently backfire and can make our sleep worse because of the way that our sleep biology works. One example is that if sleep is feeling really unpredictable, our gut instinct is, I better give myself more time in bed to catch sleep whenever it happens to come.

And yet we know that having too much time in bed intending to sleep relative to the amount of sleep our body is producing can diminish our body's appetite and hunger for sleep in the long term. So that is just one example. And a big focus of CBT for insomnia is understanding our biology, working with our biology to repair a trusting relationship.

in our sleep again and to reduce some of our sleep-related anxiety as well.

And part of this, I think to the second part of your question, is about what do we do when we're awake at night that might shape our experience and increase or decrease the probability of returning back to sleep? One example could be if we wake up and we check the time and we start to worry about how we're going to feel tomorrow or about things from the

the

past that have been difficult, all of that really can reactivate our stress response, which again overrides our sleep and makes it that much harder to sleep successfully. And so if we can identify some of these things that perhaps are not helpful for sleep in the moment, we can then try out different responses. So perhaps maybe I don't need to look at the clock because I notice that whenever I do, it causes me to feel a lot more stressed or frustrated.

And maybe if I notice that I'm worrying a lot, maybe my sleep time has become my worry time. So could I reallocate some time during the day to process or recognize some of those concerns to see if that helps kind of turn down the volume a little bit on that mental activity.

Zeest Khan (40:46)
I think those are a couple of the parts of CBTI that were helpful for me. It took me a really long time to get connected with you. And also, I didn't want to try CBTI prematurely because there was a period of time that my sleep was so...

I mean, it was horrific. It was clearly pathologic that behavior modifications were not going to necessarily help. And I was quite frankly concerned about working with someone who was going to emphasize sleep restriction.

but when I worked with you, I was at a period where my sleep was a little bit more manageable but still not refreshing. And you were very open with me about...

just being easy and not pressuring me to try sleep restriction. I wanted to talk about sleep restriction because I don't quite frankly think it's right for everyone, particularly those of us with long COVID.

So can you tell us a little bit about the sleep restriction technique in CBTI?

Hylton Molzof (42:12)
Absolutely. I have to say that as far as branding goes, feel like sleep restriction is a pretty bad term, and yet it's the one that we ourselves as behavioral sleep providers thought was a good idea for whatever reason. I often like to kind of reframe it as bed restriction or even better, consolidation. And again, we can kind of think about first, what is the guideline as it's written?

Zeest Khan (42:20)
You

Hylton Molzof (42:42)
and what is the spirit of that guideline? And so as it's written, sleep consolidation is really about taking inventory of how much sleep is happening on average and then reducing the amount of time in bed intending to sleep to that amount plus a bit of a buffer. So for example, perhaps someone is getting six hours of sleep, but they're in bed for

for nine hours and are wanting to sleep those nine hours, but it isn't really happening right now. With sleep consolidation, we would perhaps make a recommendation if we were being very ambitious to limit someone's time in bed intending to sleep to maybe six and a half hours. So the amount of sleeping they're having, but a little bit extra. And the intent with that is that we're wanting to build up what we refer to as

sleep hunger or sleep drive. These are interchangeable concepts, which is just this reality that our body becomes sleepier the more hours that we're spending awake and also the more variety that we have to our day during those wakeful hours, whether we're talking about physical, social or cognitive activity or daylight exposure, which again is going to look very different for different people and what feels accessible.

to them. And you know, that restriction, sleep consolidation, is a very effective technique, which is why it's often recommended in CBTI. It's one of our most robust tools. And yet, it isn't the right thing for everyone at that moment, given their context. And I think this is where we can think about the intentionality, which is that we are wanting to build that sleep

hunger stronger to facilitate more quality sleep. We're also trying to spend less time in bed trying hard to sleep and maybe feeling stressed and anxious and frustrated in the process. And there are more gentle ways to do that. One alternative to sleep consolidation is a concept of sleep compression, where instead of, you know,

cutting out all that extra wakeful time in one go, we would instead say, okay, can we trim off 30 minutes of your time in bed intending to sleep, for example? And with that, would that correlate to 30 minutes less of unwanted wakefulness during the night? So I just offered this because I think a lot of people get turned off, and rightfully so, by sleep consolidation or stimulus control that are

applied too rigidly and not perhaps collaboratively, but that for every one of these recommendations there is a discussion and conversation to be had about how can we preserve the integrity and intentionality and the benefit of this practice in a way that will be appropriately adapted and accessible given someone's goal ultimately.

Zeest Khan (46:09)
Thank you for explaining that.

there were two exercises that you guided us through over the eight weeks that we spent together that have helped me and that I continue to do. One was, as you alluded to, taking time a few hours before bed to, I call it a brain dump. You had a much more elegant name for it, but to write.

down those thoughts that tend to pop

up in your head the moment you put your head on the pillow intending to sleep. So the things that typically worry me, I give time to and I say, this is your time. And I write the problem that I generally worry about and one, as you put it, one action I can take. Is this in my control? Is there something I can do about this? If so, what's one thing I can do about this? If it is not in my control, how can I become okay?

with this being in my control. And then the second thing I would love for you to talk about a little bit more is this concept of separating ourselves from our thoughts. First, did I nail the brained up exercise well? And second, can you talk to us about this concept of sort of separating ourselves and not getting looped into a worry spiral?

Hylton Molzof (47:35)
Yeah, I think that you did a beautiful job. you said exactly what I would have said in terms of actually like the idea of a brain dump or, you know, scheduled worry time, whatever resonates with that experience. It has a lot of different names. But the spirit of it is just wanting to allocate a time during the day away from our sleep time where we're listening to what our mind is telling us. I think a lot of times we spend a lot

of energy pushing things away and then it always comes back and we really don't have control over that. We do have some control at least of when it's going to come back and it's the difference of whether it comes back intruding into our sleep or whether it comes back because we sit down and kind of invite some of that reflection at a time that hopefully is a bit more opportune. So I love the way that you walked through those steps.

And think that we also have a worksheet for those who may be interested in building a similar practice for themselves. The other topic that you raised though is this concept of like working with our thoughts differently. And I think, you know, these techniques are complementary in many ways that in sitting down and listening to what our mind is worried about, the first step is cultivating some awareness.

of what's coming up for us. And in that awareness, we may notice that there are certain thoughts that I like to say are like really sticky. They hold onto us and they bring up some pretty strong emotions and it's hard to appease those thoughts. They may feel like they're very urgent or threatening or bring up a lot of worries for us. And so if in our reflection we're noticing those kinds of thoughts

coming up, we have different options in terms of what we do with that. You know, one route that we can take falls under this terminology of cognitive restructuring of, you know, is there a way that we can modify that thought in a way that still feels authentic, but is perhaps a bit more balanced or helpful? Since a lot of times what our mind tells us is not particularly helpful or compassionate, especially when we're awake.

in the middle of the night, perhaps. So that's kind of one route we can take. kind of, think Dev tells nicely with this question of what's within our control versus not. If we have a thought that we have some control in changing, and if that helps lessen some of the emotional intensity, then that's wonderful. Let's do that. And we also want to normalize that sometimes we do that and we're still stuck with this really sticky thought. And then it becomes a question

can we create some space from that thought so we're not necessarily trying to change it but we're letting it be there but perhaps have a little less influence over us and that kind of approach is something that we borrow from a therapy known as acceptance and commitment therapy and the kind of technical term for this practice is something that we might refer to as diffusion. How do we diffuse

from that thought, how do we unstick from it? And there are a lot of kind of quirky tips and tricks for how to do that. There can be this practice of just acknowledging to ourselves that this thought is a thought and I'm noticing that I'm having this thought and it's here. And just that acknowledgement can sometimes lessen some of that emotional intensity. There are also things that at face value maybe sound a little silly but can be helpful.

which is repeating the thought over and over until it loses meaning or singing the thought or saying it in a bit of a silly voice. And the intention here is not to invalidate that thought because again, if it's bringing up strong emotions, it's perhaps something that's very important to us and it's there maybe for a reason. And yet we're trying to just remind our mind.

that that doesn't have to be anything in this moment. It doesn't have to threaten us. It doesn't have to require urgent attention. Again, especially when we're awake at night where we are not in a place to do our best problem solving. We're in a place to really be able to respond effectively.

Zeest Khan (52:25)
I like to use that practice when I am up at night and notice that I'm getting caught up in a worrisome thought. It is at face value very simple and practically very powerful.

Thank you so much Hylton for taking time with us today and sharing all of your knowledge. Is there anything that we didn't cover that you want the listener to know?

Hylton Molzof (52:53)
I just want to thank you, Zeest This has been such an enjoyable experience. really love being able to speak about sleep and share information that I hope will empower people and reassure people and open that door towards better sleep. think everyone deserves good sleep and there are many things that can be done to help with that improvement. I would just encourage, you know, for people

who are interested in behavioral sleep medicine or cognitive behavioral therapy for insomnia. There are many very talented clinicians. The Society for Behavioral Sleep Medicine has a clinician directory for those who might be interested. There are also some good self-management resources in terms of books as well, which I would be happy to share.

the names of and if people have experienced CBTI and it wasn't as good of an experience the first time around, also hopefully connecting with a clinician who will have this more flexible and adapted approach can also be really useful.

Zeest Khan (54:17)
I that adaptive approach was very helpful to me. I was very pleased to work with you because I was worried that it was going to be really rigid. And I do want listeners to know that many CBTI instructors are consolidated in urban settings and can be difficult to travel to, but...

like I did with you, many are available through telehealth and that might be a good option for you as it was for me. Thank you so much.

Hylton Molzof (54:48)
Such a point.

Yes, thank you as well.

Zeest Khan (54:52)
Hope you have a great day and hope we all have sweet dreams.

Hylton Molzof (54:56)
Yes, I agree

Zeest Khan (55:00)
What a phenomenal person. I have learned so much from Dr. Molzof and it doesn't end here. Dr. Molzof is kind enough to share some tools that she actually uses in her own CBT for insomnia course that she teaches at Stanford. You can find links to the sleep tracker that she mentioned, to the Consensus Sleep Diary that she was talking about.

and the other resources that she mentioned here at the end in the show notes and at my sub stack, longcovidmd.substack.com. Let me know what you think. Let me know if you have sleep issues with your long COVID, what has helped, what hasn't. Have you tried CBT for insomnia? Did it work as well for you as it did for me? Did your instructor adapt the approach to you?

And if not, were some of the techniques and ideas that Dr. Molzof brought up helpful in trying to access those techniques now? we're gonna talk in a future episode about medications that can help with sleep and the stigma around using those medications. But for now, dive into this wealth of information that Dr. Molzof has shared.

and let me know how it sits with you. You can email me at longcovidmd at gmail.com, like, follow, and share this podcast to get more eyes on it and bring more awareness about long COVID. I hope you're feeling well today. I'm looking forward to talking to you again. Until next time, bye for now.