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Episode 105 - Dr. Sarah Silverman - Behavioral Sleep Medicine to Help Adjustment to CPAP Therapy


Hey there, it's Emma Cooksey here, and I'm your host, so I'm recording this, of course, at the last minute because I always do the intro at the last minute.

And I just got back from vacation.

So we've been gone for four days and we were just here in Florida.


We we went about four hours from our house and rented a house with a pool.

And we had an actually relaxing time.

Like, I can't remember being on a relaxing, you know, holiday or vacation.



Since I had my kids, I feel like it's always trips where we're on and off planes and I always had the extra thing of, you know, lugging my Cpaps through airports and all that kind of thing.

But we just drove there and same time zone and I really had a relaxing time.


I read my book, I went swimming, really can't complain.

So wherever you are, whether it's summer or not with you, I hope you get a break.

Like that because it just really does you so much good.

I think that you forget when you're just in the same routine for a long time, how much we need breaks.


And just a break from your normal routine seems to do wonders.

Or it does for me.

So today's episode is my conversation with Doctor Sarah Silverman.

Sarah is a behavioral Sleep Medicine specialist.


So I think oftentimes we think about clinical psychologists and sleep as being all to do with CBTI, so cognitive behavior therapy for insomnia.

And certainly we've had doctor Shelby Harris was on the podcast a while ago talking about CBTI and how people with obstructive sleep apnea oftentimes also have cooccurring insomnia and how.


That can be treated with CBTI along with whatever treatment you're doing for sleep apnea.

So I was really interested to talk to Doctor Silverman because she also uses behavioral Sleep Medicine in helping people to adapt to their CPAP mask.


So a lot of people have.

Trouble with that initial getting used to having something on their face.

And she uses behavioral Sleep Medicine techniques to help people adjust to that.

So I thought that was super interesting.


That was really why I was excited to interview her.

So a little.

Bit about Doctor Silverman.

She trained initially at the University of Miami and.

She's a licensed psychologist in Florida and New York, and she's a former Stanford Sleep Medicine clinical fellow.


She's also the former director of the behavioral Sleep Medicine program at Montefiore Medical Center and which is in New York City.

And she's also the former director of behavioral Sleep Medicine at Tampa General Hospital.


If you're interested in the upcoming course that Doctor Sarah talked about on this episode using behavioral Sleep Medicine to help you adjust to CPAP, and there is a link in the show notes where you can sign up for the wait list for that course, so you might want to do that.


There's also a PDF that Doctor Silverman shared with me.

I'm going to be sending it out to my e-mail list.

It goes over.

Sort of the process of how to move through these steps to help you adapt to your CPAP mask.


So if you're not already on my e-mail list, that will be going out to my e-mail list shortly.

So go to sleep and you can scroll to the very bottom and pop your e-mail in there and you can get that PDF.


So without further ado, here's my conversation with Dr. Sarah Silver.



So nice to meet you, Doctor Sarah Silverman in person.

So, so good to meet you, Emma.

Thank you.

My pleasure.


So I'm going to start for the audience because they're going to be like, why isn't she asking if you're related to Sarah Silverman, the comedian?

And I'm not going to ask that because I know that you're not because I follow you on Instagram and you already addressed it, so.


That's kind of hilarious, though.

You must get that all the time.

All the time.

And people actually, they asked to see my idea as well, they don't believe me.

Oh my gosh, not related.

Did you want to just start by telling everybody a little bit about your background and a bit about how you got into the whole sleep thing?




I love to so.

I am a clinical health psychologist by training, but I specialize in behavioral Sleep Medicine, which is kind of an umbrella term for really intervening in terms of sleep disorders from a non medication perspective.


So kind of bridging the gap between psychological factors, behavioral factors, really this kind of.

Combination of areas in someone's life that may be impacting their sleep and I've seen in a nutshell what I try to do, you know, if folks are on board is to get people off of their sleep medications.


That's one of the biggest things that I do.

But I also these days really see pretty much any sleep disorder where there's something that can be.

Cleaned up or if there's something that somebody wants to improve from more of a nonmedication side.


So I'm always looking for things, whether it's behavioral or if changing mindset, changing thoughts about sleep, looking for nonmedications of drugfree approaches to really help someone sleep better.

So is the main thing you do the kind of behavior therapy or is it outside of that as well?


Because I I hear a lot about CBTI and I don't know whether that's exactly what you do or if it's more than that or.

Yeah, so, So cognitive behavior therapy for insomnia or CBTI is my primary specialty.

So I do see a lot of folks who have chronic insomnia, but I also see folks who have sleep apnea and that is also often times coinciding with insomnia.


There are a lot of folks who have both.

I also see folks who have chronic nightmares and restless leg syndrome, periodic limb movement disorder, or you know, some of other rare sleep disorders or other parasomnias like sleepwalking and sleep eating and things like that.


I think persomnia as well.

And even though CBTI is the first time treatment for insomnia, we actually.

Now you use CBT for other sleep disorders as well because it's been shown to be so effective for insomnia.


So for a lot of other sleep disorders, I use the principles of CBT to really help improve sleep quality.

And really just, you know, for folks with sleep apnea, often times it's getting them feeling more comfortable using their CPAP.


Or sometimes it's getting more comfortable with our oral appliance, you know we're.

Going to get all into that in a minute.

And so for people, like I did a constant behavior therapy course way back in the day, mainly for anxiety as a way to kind of manage anxious thoughts.


But for people who have never heard of this before, like, can you just kind of explain what kind of things you're doing?

What do people learn?

Like, what are the skills that you teach them?

Specifically around like insomnia or a sleep disorder.

Like I think sometimes people have a difficult time like understanding what kind of behavior therapy is at all.


Yeah, it's a fantastic question and I and I love this because there are a lot of misconceptions about CBT or I'll often get asked like what is CBTI keep hearing this act and it what does it actually mean?

So cognitive behavior therapy is also this umbrella term and.


In a nutshell, CBT is this idea that the mind and body are connected, so your thoughts influence your behaviors and they influence your emotions.

Everything is connected, which is very different from say kind of traditional western medicine where you go to a different doctor for every different body part and.


That's part of our problem.

And so this thinks of you as this whole person, everything being connected.

So your thoughts are going to influence your behaviors, also going to influence how your body responds and then in turn influences your emotions.


So essentially what you think can do affects the way that you feel.

So CBT as kind of a foundation treatment explores all of these different areas and how they influence each other.

So there are CBT for anxiety specialists or CBT for depression specialists.


And in my case, CBT for insomnia, CBT for CPAP adherence and so it's applying the foundation of CBT and exploring that mind body connection and really applying it towards the presenting concern, a presenting problem.


I think that before I did CBT course like I had never considered that.

Like your thoughts?

Aren't necessarily are usually not facts right.


Like I think that it's the first time that I ever really had any space between I just thought that thing the Super catastrophizing like oh what all these things happen and but it gave me kind of this space to be able to actually evaluate and say that's what I just thought I don't necessarily have to accept what I just thought as being true.


So it's a really helpful tool, I think, for a lot of people.

And so let's get on to the CPAP.

Like, this is brand new to me.

So we had Shelby Harris come on a while ago and we talked a lot about the fact that insomnia and sleep apnea can coexist together.


We didn't have a chance to get into this whole thing about like using CBT almost to like.

I don't know if you'd say desensitize people to their mask and the problems they're having.

So do you want to maybe get into a little bit about that and how you work with people around that?


That's fascinating.

Yeah, yeah.

It's actually one of my favorite things to do because I think a lot of folks get prescribed a CPAP and they're told here you go, now go use it.

And they're not really given much else.


Or sometimes sleep doctors will.

Leave it up to the DME companies and then they might not even really provide much education about how to use their CPAP.

There's often this thing where I think everybody thinks that the other person's doing it, like educating your patient and actually oftentimes nobody is.


Yeah, yes.

And so often times when folks come to me, you know, they're they're usually referred by their doctors because they haven't been wearing their CPAP.

And they need to be in order for insurance to keep paying for it.

So that's often a big motivator.


But in general, you know, my goal is to really help folks get desensitized to their mask and to be able to use their machine so that they can keep their machine for insurance requirements and really of course for for optimal health.


So I would say there there's also a misconception about.

Say, sleep psychologist or insomnia specialist, that maybe that's all they do is CBT for insomnia.

For someone who is, say, a behavioral Sleep Medicine specialist or a BSM psychologist, they often do provide this treatment as well.


It's just not as widely talked about.

And sometimes I even have to remind the sleep doctors like, hey, you know, I can help your patients who are struggling with their machines.

They often just think about insomnia, which of course is still incredibly important.


You know, this is something that I think so many folks can benefit from.


It's learning a new set of skills.

But ultimately, you know, if we think about using CVT for CPAP use, it involves that underlying foundation so that there's the mind and body is connected and it also involves an exposure hierarchy.


So I'll get into that a little bit more.

So it actually stems from kind of this fear avoidance model where you actually gradually expose yourself to the mask to wearing the headgear and then you know plugging in the machine and being able to tolerate the pressure over time.


And that's done in very incremental steps.

So it's a step by step process that I walk folks through and.

You can think about this in the same way that you might think about like someone who has a phobia, like they're afraid of flying or they're afraid of being in an elevator.


This type of exposure therapy actually stems from some of that work.

So instead of of course being exposed to those types of phobias, the goal is to be exposed to the mask, the machine, which becomes a fear for a lot of.


I think, I think a lot of people put a lot of pressure on themselves.

And I mean, I've, I've certainly heard from a lot of people who they have, you know, like anxious feelings around having their mask on their face, which is quite normal to begin with.


If you haven't been used to having something on your face, it's quite a lot to get used to.

And then also, I think a lot of people, there's the like some sort of claustrophobia, feelings, all of that.

But then there's also this thing of, like you were saying, compliance and insurance where people put pressure on themselves.


I've got to sleep with this for this many hours, you know, at least, because otherwise my sleep will be taken away and I will have failed it, you know, and like, it's important for my health.

And so I think that that can be a big part of it.

It's just.

You know, so much pressure surrounding it.


I absolutely.

I completely agree with you.

And there is so much pressure to have to use this machine right away when you know it's almost for for a lot of folks.

It's this foreign device that you have to get used to wearing.


It's not as easy as just putting it on and sleeping with it.

And sure, there are a handful of folks where that might be the case.

But I'd say the vast majority of people it is not that way.

It actually does take quite a bit of an adjustment process and at least for the folks that I work with, usually that adjustment process like on average is 3 to six months, give or take, sometimes much longer than that.


You know I.

Think for anybody listening who.

Is starting out on this whole CPAP thing.

They're surprised to hear that.

Like, I think, I think people are sitting at home thinking I'm the only person dealing with this.

And you know, people will say to me, I've had my CPAP for a week and I'm still taking my mask on and off at night.


Like, is that normal?

And I I'm like.

Yeah, that's really, really normal.

Like, it definitely took me a couple of months to find the right mask for my face to get used to that whole thing.

So I think there is perseverance involved with it for sure. 100% a 100%.


And I think it's so important to normalize the adjustment process because it isn't something that most doctors are talking about.

It takes time to get used to CPAP.

And sometimes having the realistic expectation of how long.

You know, a lot of people in the same situation take to adapt like is actually really helpful.


Yeah, yeah.

The adjustment process is, I think for most people, incredibly frustrating.

And so having someone that can kind of help guide you along the way can be really helpful.

I would say, just like any other skill, consistent practice is key.


And everyone's adjustment process is different.

So again, I'd say like the length of time to feel comfortable with using the mask on average is at least a couple months.

But I work with folks where maybe it's been much longer than that, you know, a year to really feel comfortable with it.


And you know, I, you may have heard of this analogy, but I like to think about it like just like we put on clothes in the morning, you know, we know that we're wearing clothes, but we're not actively thinking about the clothes that we're.

So you want your mask and using your machine to be this thing that just becomes part of your normal routine and you can get there.


It just takes some time to slowly build up to tolerating the mask.

And so when you work with people, is it normally online or are you working one-on-one with people in person or how do you do it?


I am working one-on-one with folks virtually.

So my practice is in.


In Florida and New York.

And New York.

That's right.


So, so and so people are looking like, I feel like there aren't as many of like the kind of professionals like you around.


So what's the best way for people listening to find somebody in their area?

You're right, it is less likely to find someone who really provides.

This PAP exposure therapy, I would say the best place to start would be the Society of Behavioral Sleep Medicine which is behavioral


There's a link to that in the show notes as well.

Yeah, yeah, that'd be awesome.

There's a directory where you can actually search based on your location and you can look and see who has behavioral Sleep Medicine training.

And then within those people, I would say you'll likely have to ask if they provide the service, hopefully, you know, list that on their website and their information.


That's really, I would say the best place to start.

Certainly it's also worth worth asking your sleep doctor or sleep specialist if they know of anyone.

But you're right, especially in Florida here I don't know of.

You're it, I'm pretty sure.


Yeah, I mean, of those that are, you know, doing sleep behavior, Sleep Medicine, I think they're primarily just insomnia, So very hard to come by.

So are there so for people who can't find somebody like you to work with.


So, so the people that haven't hit the jackpot and don't live in Florida and New York.

Are there like particular, like you talked about desensitization?

So are there particular things in general people can do to help them get used to them?


I know it's not as good as working one-on-one, but are there particular tips like do you advise people kind of starting slowly and building up, Like what?

What's the best way for people to go about it?


I would love to kind of walk you through the hierarchy of steps because I think that that would be incredibly helpful for your listeners because you're.


Yeah, I get emails all the time from people saying that's all great for people in New York and California.

But I live in, you know, fill in the dots.

It's like Wisconsin or, you know, like just another state.

That doesn't happen to have some of the specialists we're talking about, so.


I have no idea what Wisconsin has.

They might have a bunch.

I just thought that.

Yeah, it's just it it does take a little bit of research and you know, really trying to find these specialists.

You know, that's maybe something that we should create is a directory of providers who actually do this so that it's.


Easy to do that.

Yeah, so that it's easier to find because yeah, it's really hard to to come by so.

So yeah, I would say I'm happy to kind of walk you through that.

So, so really I should say the kind of overarching term here is this exposure hierarchy.


You can think about it as a ladder of steps that you work through in order, you know, in this case, in order to tolerate using your CPAP for every sleep episode.

So that would include your night time and then.

If you take naps during the day, so everyone's a little bit different, of course.


But the idea is, as you you know, as you've mentioned, for the folks who feel fear, anxiety, claustrophobia, any type of negative emotion around wearing their cpap, instead of the mask equaling this frustration, this anxiety, we want the mask to actually become a cue.


For relaxation.

So this hierarchy actually does involve quite a bit of relaxation training, and specifically I'm talking diaphragmatic breathing or belly breathing, which is very different from.


Breathing that you and I are probably doing right now, which is often short, shallow, chest breathing.

We all do it.

You should see me when I'm interviewing people who do breath work, like I was when I was interviewing, like James Nasser and Patrick McEwan.

I was like a nervous wreck because I was breathing like, I'm like my clothes, like breathe.



But I was like breathing through my chest the whole time.

It's crazy.

So, but yeah, normally we should be breathing using.

Our diaphragm, breathing from the diaphragm, which is that big muscle that sits underneath our lungs.

You know breathing from the diaphragm that the belly breathing is really what promotes more rest and digest, so promotes A parasympathetic response, which is what we want within our nerve system, so part of.


This therapy, so using CBT, but also there's a motivation component, so really trying to increase motivation to change.

And I think for a lot of people, you know, in terms of getting used to their mask, there could be a couple things in the picture.


One, it could be actually feeling that anxiety or claustrophobia with the mask itself, like the headgear is eliciting that response.

Or for some people, it's actually when they turn it on and the pressure, what's causing those negative emotions.


Or sometimes it's a combination of both.

So first I really like to like dive into what's actually going on.

You know what, what are the barriers to being able to use your mask and being able to use your machine and once we kind of figure out those barriers.


You know, then it's like, okay.

Well, what are the benefits of changing these barriers and kind of troubleshooting ways to really help get to that point in addition to learning some of these relaxation techniques.

So I always like to start off really simple.


Diaphragmatic breathing can be an incredible tool for anyone, not just for folks who are struggling with their machine.

It truly is something that I wish every humid can learn because.

It's it's so, so vital for our nervous system to feel regulated not only from a sleep perspective but just for day-to-day life and being able to manage stress.


So in terms of the treatment and kind of this hierarchy typically you know the first step of course is to kind of figure out what's actually going on.

I think it can be helpful to.

Set up your machine and everything earlier in the day so that it's ready to go before bedtime.


You know as best as you can.

And I think another big area here is actually getting your partner involved because oftentimes.

I think that's huge.


I think oftentimes like.

Partners maybe don't find the treatment to be important.


They don't quite understand why it's important to use and so I think.

Really, or the other thing you have is partners who are the ones driving the bus, who made made their partner go and get tested and all the stuff.


And they know it's really important for their health.

So sometimes that can actually be another stress stressor.

You know, putting pressure on the person to make it all work out.

You're so right about that.

And so that I think that's such a that's a huge factor in why someone may or may not, you know, choose to to wear their CPAP or even give it a try.


And you know as part of enhancing motivation to change.

One of the the two areas that I like to start with is, you know how important is this?

For you to change, how important is it for your partner for you to change this or kind of exploring how important for overall health that might be?


And then of course as also like as a relationship as a kind of couple issue as well.

And then the other area is like how confident are you that you can make these changes?

How confident is your partner that you can make these changes and work together as a team to really ensure that.


You can get to the point where you're able to tolerate and use it on a regular basis.

So there's so many variables involved.

But I think engaging your partner in these efforts is huge and often times I am working with the bed partner as well and I actually, I invite them into the sessions because I think that's such a huge part of this.


So I.

Love that you do that.

Like, I think that there's there's so many things that seem really.

Common sense that I talk to so many people all the time who haven't really, really broached the subject of the fact that they're going to start wearing this, you know, apparatus to bed every night and that and what kind of impact that's going to have on a relationship and that you might want to talk about that.



It is a conversation to have and you know, I always joke about it and like, we have to make your CPAP sexy.

So how can we, you know, what can we do to get you to that point?

And so yes, involving the partner is.

That seems like a tall order.


I feel like something like.

I mean, I've talked about it on the podcast before, but we have Tucken cuddles before the CPAP goes on.

So by the time my Cpap's on, it's sleeping time, but which isn't very spontaneous.


But I think that whatever works for.

You know the couple involved is is a good way to go.

Exactly and sometimes you have to get creative with it, but that is a huge piece of this.

And then in terms of the actual steps to work towards and to be able to get used to your your mask.


I always start off like and this may seem silly, but start off by suggesting to just where your headgear.

Without the tubing, without it plugged in, just wear the headgear around the house as much as you can.


So just getting comfortable with wearing the headgear.

Again, nothing, nothing plugged in, just getting used to that.

And then once that becomes comfortable then you can work towards plugging in the tube.

And that's even more silly, walking around with the headgear and the right.


You have to get created with that.

But you know, again it goes back to you really.

Want your brain to essentially forget that you're even wearing it.

So just kind of become one with you.

And if you do that for a couple days, most people end up forgetting that they even have it on.

So just kind of wearing it around the house, wearing it, you know, after work, around dinner time, wearing it as much as you can tolerate.


And then once you build up to wearing the mask with the tubing, the next step would be to actually.

Plug it in, turn it on, But now maybe just sit and watch TV with it on or.

Don't put pressure on yourself to actually sleep.


Yeah, yeah.

So even before we take it to the bedroom and take it to your actual sleep time, it's actually just getting comfortable with it during the day and you just having it on with things that you're doing during the day.

So something said and Terry like watching a good show or reading a good book.


Just doing something where you can sit, relax with it on, and as you said, no pressure to sleep with it, no pressure to really, you know, have to use it more than just getting comfortable with it.

And the next step would be introducing some relaxation techniques.


So just really practicing some deep breathing while it's turned on.

And again, you can kind of do this with that sedentary activity.

Rather, it is watching TVI think that's probably the easiest for for most folks, is very distracted.

And then you just find like, Oh yeah, I've been wearing this for a while.


So sometimes it's starting off 5 or 10 minutes while watching TV and then working yourself up to say 20-30 minutes.

Sometimes I'll have folks sit there for an hour with it on.

So you know, as much as you can tolerate and as much as you feel comfortable before you then.


Proceed to the next step, which would be to try it out during a nap episode.

So actually schedule a nap time during the day if you have the opportunity to then use your CPAP and so that could be even if you don't fall asleep, maybe just resting time to 5 or 10 minutes while lying down using your mask, working yourself up to say a full nap time and.


You know, by the way, this isn't something that's happening like every single day.

This is probably over the course of several months.

Here we're splitting up these steps, so really incrementally building up the time that you're tolerating at each of these levels and so.


They One of the things people never realize is that for the insurance part of it, they don't.

Their requirements are usually like over a 24 hour period, so naps kind of towards that.


So I think sometimes it's helpful if people, you know, get used to wearing their masks, like outside of the sleeping time and they can rack up like even a few hours doing that.

Then night time becomes less of a stress.


Like I'm I must sleep the whole night, you know?

Yeah, that's such a great point.

You're you're right about that.

It it all counts.

So you know, building up that time especially for insurance purposes can be helpful while you're working through these steps and just learning how to get used to it and taking that pressure off of having to use it for your full nighttime sleep.


So, so yeah, I think that that's such a fantastic point and then as soon as you are feeling comfortable wearing your CPAP during nap time.

And then the next step would be to introduce it to your actual nighttime sleep.


And I think that is often like a big leap for for folks.

So sometimes it's maybe just starting off with an hour and, you know, using it for an hour or working yourself up to, you know, 3-4 hours, working yourself up to a full night.


That does take time, but ultimately it's just really starting off.

Just getting used to the headgear, then working yourself to plugging it in, sitting with it, then working yourself up to a nap, and then ultimately introducing it into your sleep time.



You have such a nice voice.

I like I'm kind of like want a nap so I can see that you're in the right job.

Was your your kind of success rate like like there's not going to be every single person is going to be able to.


Adapt to CPAP, right?

I just think that would be unrealistic.

It just is quite a difficult therapy to get used to.

And I just think sometimes, like after people have given it a really thorough try, like they've really tried everything for a few months.


Like at what point do people go back to their doctor and say this isn't working?

Yeah, of course it it it does vary on an individual basis, but.

I would have to say probably in terms of my success rate, probably about half of folks will be successful and the other half.


That's actually kind of amazing to me because by the time somebody's coming to you that they already have the problem.

So it's not like you're treating like, you know, the full range of people.

You're only, you know, dealing with people who are having a problem with it.


So I think that's kind of amazing.

Yeah, Well, thank you.

I mean certainly that that's like what I estimate because you know I do see folks where they, they really stick with the steps, they're really motivated, they make it happen And then you know I see folks where sure they got some benefit and they learned some relaxation techniques they, you know they didn't leave empty handed so to speak, but they still.


Really struggle with feeling comfortable with tolerating the mess and sometimes we find like maybe they didn't have the right mask all along.

You know there's so many other factors that go into being able to use your machine.

So it's exploring all of these different areas and.


I think for most people they do benefit, but of course there are gonna be some folks who.

I think, I think I love the idea of going through something like that, where you feel like you can say I gave this everything.

I've tried everything right?

I thought I think sometimes, well a lot of the time I feel like with CPAP.


People tend to just kind of give up too early without really feeling like they gave it a good shot just because they don't like the idea of it or it just seems too hard.

But I feel like once you've been through a program like that and you, you can really say I've tried all these things, you know, like I've given it my absolute best shot.


And then the next thing would be to go back to the doctor and be like, what else have you got?

What are your?


Yeah, because sometimes CPAP is also prescribed without talking about the options.

So while of course CPAP is the first line treatment, it isn't the only treatment and sometimes it isn't the best option for you.


So, well, I mean, I could talk about that for three hours, but yeah, that's that's really, I think a really big.

Part of it is communication between doctors and patients and there are some excellent sleep physicians partly the way that the health system is where if a doctor only really has like 10 minutes or something with a patient, you know, it really does hamper having a lot of communication back and forth.


And so, yeah, there there are definitely some issues around that for sure people are still.

Going to the doctor with insomnia and being prescribed drugs as a first line treatment and so maybe speak a little bit to that.


And then also just how do people know so if someone has sleep apnea, they absolutely can have.

Still occurring insomnia at the same time, I think often times we think I've been diagnosed with sleep apnea, so that's why I'm not sleeping well.


So do you want to just go over what to look for?

Like what?

How would somebody know they had insomnia and should seek some treatment for it?

Great question and I would say.

That was about four questions.

It's a lot of, definitely a lot to unpack there, but I think it's it's so, so important to know and sometimes it's hard to know.


I think for a lot of folks it's kind of a chicken or the egg question, you know, having sleep apnea.

And I find this to be the case for a lot of women they've likely had.

Undiagnosed sleep apnea for many years and now their their symptoms look very much like insomnia.


But we find that, you know, one of the causal reasons for insomnia was due to sleep apnea.

So I would say one of the biggest signs in terms of recognizing insomnia is worry around sleep.


Sleep anxiety to me is its own beast.

It's very different from kind of generalized anxiety.

So it's very specific about how well you might sleep, how many hours of sleep you might get, how well you might function the next day.


So there's a lot of distress not only about how you sleep at night, but also how you feel during the daytime, so.

That's a huge piece, and I would say that for most people, that's probably the telltale sign that there's some form of insomnia in the picture is when you start to really worry about being awake, to worry about your sleep, when you start to worry about how you feel during the day.


And ultimately, a lot of the symptoms do actually overlap, like not getting restful or restrictive sleep.

That's common in both.

It could also be both difficulty falling and staying asleep If they for sleep apnea, it's mostly that sleep maintenance that's more pervasive.


But they can absolutely overlap and cooccur, so sometimes it's really hard to tease them apart.

But I'd say they're truly for most folks, that often Is that anxiety, that stress component when it comes to sleep?

That can often give us a sign that insomnia may be in the picture, right?


On and so then.

Talk a little bit about because I think most people don't know still the CBTI is the first line treatment, right?

Tell us about that.

I'd love to.


CBTI is the first line of treatment for chronic insomnia in adults.

It is considered the gold standard, so it really should be the first step when you go to your doctor and you tell them, hey, I'm having trouble sleeping.

It should be the first step, but unfortunately there is a shortage of leaders who specialize in this, so that becomes a big problem.


A lot of doctors don't know who to refer to, or they don't have someone nearby that they can send you to.

So for a lot of folks, they do end up getting prescribed sleep medication as a first line option.

But what we know about CBTI, and in a nutshell, it's changing thoughts and behaviors around sleep.


What we know about CBTI and medication is that CBTI is just as effective as medication in the short term, but even more effective than medication in the long term.

Because you're learning skills.

You're learning very specific skills that are evidence based that go far beyond sleep hygiene or general sleep advice, and you ultimately learn how to.


Achieve quality sleep without needing to rely on medication.

So it actually builds up confidence in your natural sleep ability.

So of course I'm biased that, you know, I think really anyone can benefit from some of the techniques because there's so much misinformation about sleep out there.


And people will read all those sleep hygiene tips and they'll think, oh, I, you know, I already know all that stuff or I'm doing all that stuff.

But if you have insomnia.

Or if you have sleep apnea or another sleep disorder, sometimes those sleep hygiene tips are not going to be enough.


So yeah, like sleep hygiene, that's, I mean, not that there's anything bad about that, but I think for a lot of people who have undiagnosed sleep disorders, like sleep apnea, like you can do sleep hygiene.

All the time.

And you're still not gonna feel better because you have a sleep disorder.


So I think that sometimes that's a great place to start for a few weeks and then go and see your doctor if you don't, if you don't feel better, you know.

Yeah, I completely agree with you.

Starting with sleep hygiene is important because those behaviors are important for maintaining good sleep, but they you can think about it as maintenance.


They help to maintain good sleep if you already have good sleep.

But if you have insomnia, if you have sleep apnea, if you have another sleep disorder, you could be doing all of those things and it's likely not going to be enough to really change things or improve things.

So yeah, if you try those those sleep hygiene tips for a couple weeks and you're not noticing any difference, please speak with your doctor and talk about your options because there are evidence based techniques that can be.


Incredibly helpful and much more helpful than just sleep hygiene alone.

I could not nod more.

I'm just like, let's keep saying that a lot.

So tell people about, so I follow you on Instagram and I've been seeing about you have a course.


Do you want to tell us about that?

Sure, sure.

So, yes, I just recently launched A holistic sleep improvement course called the Holistic Sleep Academy.

And it is designed for folks who have chronic insomnia or chronic sleep struggles, who really want to learn CBTI techniques.


So it's a DIY selfguided course.

And it it's honestly, I would say it involves pretty much everything that I do in my Oneonone visits, but in a.

Simplified way so it's easy to follow and do on your own.


And one of the main reasons for why I created this is because there's just not many sleep psychologists or behavioral Sleep Medicine specialists to go around.

In fact, I recently checked there is less than 500 in the world.

So to me that that's mind blowing to me.


So this is, you know, out of my desire to really make CDTI more accessible.

To more people.

And so that because you're not working one-on-one, people can do this anywhere.

Like it doesn't have to be far to New York.


Doesn't have to be far to New York, it is worldwide.

Anyone can do this.

Anyone can go at their own pace.

It's designed to be set up in an 8 week format, but you can take your time and go through it so you learn all of the CBTI techniques and it truly is.


You know, another way to work with me, so to speak, but you know, kind of a work around.

I love that.

And so tell everybody where they can find that and where they can find you.

Yes, yes.


So you can find more about the Holistic Sleep Academy on my Instagram.

I'm at.

Dr. Sarah Sleep I'm also at Dr. Sarah Sleep on most social platforms so you can feel free to connect with me.

I'm most active on Instagram, but you can take your pic in terms of.


Are you on TikTok?

I am.

I'm less active on there.

It's like it's a whole nother world, but yes.

It's a whole nother world that I made it through about like a week and then I was like, I don't know about this, so my 15 year olds like.


So much better than Instagram.

And I'm like, I'm gonna go back to Instagram, but good for you.

That's good.

We'll reach more people.

Yeah, that's the goal.

To really make evidence based sleep treatments more accessible and just.

Make them.

That's what we need.


Yeah, and actually I'm working on a self-guided course.

For folks who are having trouble adjusting to their seat path.

That was gonna be my next suggestion for you.

Yeah, yeah, I'm so pleased.



So that is definitely something to stay tuned about.

I'll be hopefully launching that maybe it's summer.


Step by step way to really learn this exposure hierarchy, learn some relaxation techniques and.


Just to really get folks feeling more comfortable with using their machine.

I love that.

Well, let me know however I can help.

Thank you.

Thank you.

Was there anything else that we don't cover that you wanted to talk about?

We covered a lot of ground.


I would say.

Just to reiterate, one of the best places to find a behavioral Sleep Medicine specialist would be the Society of Behavioral Sleep Medicine.

That's behavioral

Also, the American Academy of Sleep Medicine is also a great place.


They do also have a directory that you can search for a sleep center near you.

American Sleep Apnea Association.

I know there are a lot of really great organizations project sleep, doing a lot of advocacy work for sleep apnea.


All of those resources are amazing and just know that there are other ways to really.

Be able to get used to your CPAP.

There are, and you're not.

Alone is the main thing.

Not alone.

Yeah, you're not alone.

There's definitely folks out there who are rooting for you like me.


You know?

It really is.

Just know that you have options and that you're not alone.

And there are people who are here to support you.


Well, thank you so much.

I really appreciate you coming on.

Thank you for having me.

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