Dr. Greg Sazima: “Take Control of Place and Time”

Dr. Greg Sazima (author of Practical Mindfulness) says bodies and brains like stability and predictability in the where and when.

… Take control of place and time. Bodies and brains like stability and predictability in the where and when. Besides a comfortable bed, opt for a sleep place that is cool and has a minimum of additional sensory stimuli to pull on attention, whether that’s noise leaking from other rooms or a laptop nearby calling you to check emails. In terms of time a regular, bedtime and wake time and hold to it most of the time to reinforce circadian rhythms. It’s not uncommon for people who get more rigid with this to not need an alarm clock, just waking naturally. There’s a reason there are now rules that limit doctors in training from the old call night gauntlet that old geezer docs like me had to endure (and still carry on about.)

Getting a good night’s sleep has so many physical, emotional, and mental benefits. Yet with all of the distractions that demand our attention, going to sleep on time and getting enough rest has become extremely elusive to many of us. Why is sleep so important and how can we make it a priority?

In this interview series called “Sleep: Why You Should Make Getting A Good Night’s Sleep A Major Priority In Your Life, And How You Can Make That Happen” we are talking to medical and wellness professionals, sleep specialists, and business leaders who sell sleep accessories to share insights from their knowledge and experience about how to make getting a good night’s sleep a priority in your life.

As part of this interview series, we had the pleasure to interview Greg Sazima, MD.

Greg Sazima, MD is a psychiatrist, educator, and author, based in Northern California. He teaches physicians-in-training at Stanford’s Family Medicine Residency Program. His new book, Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners, is available now. www.practicalmindfulnessbook.com

Thank you so much for doing this with us! Before we dig in, our readers would like to ‘get to know you’. Can you tell us a bit about your background and your backstory?

I grew up in Cleveland, from a family of dentists and oral surgeons (the worn-out family gag is that I chose to work slightly north.) School and training has taken me to Baltimore (Johns Hopkins), Cincinnati (med school), Hartford (psychiatry residency at UConn), and finally to the Northern California Bay Area (more training and research at Stanford, then practice and teaching). My lovely bride is a family doc; we relocated with our three sons to the Sacramento area about 20 years ago, shouting distance from extended family and my teaching work with Stanford’s Family Medicine residency program.

I love my career(s); always some gratitude, learning, and growth in helping people with their own suffering, and in the craft of teaching. Meditation was for me at first a mere tactic I learned about for my patients’ benefit, then became a passion for me as my own spiritual path developed in Buddhism.

I’ve had an exciting last decade that I’ve needed that balance for. I was diagnosed with an aggressive cancer, chondrosarcoma, in my cervical spine in 2010. Three recurrences and multiple surgeries from 2010 to 2015 made life pretty challenging — raising a family, keeping my practice afloat and my head on straight (the hardware in my neck helped). Managing sleep disruptions and chronic pain became a personal challenge, not just a professional skill set. I’m blessedly in remission for five years now, following some whiz-bang radiation treatment that stopped the tumor from replicating but left me with some health challenges to manage going forward. Not complaining, considering the alternative.

The whole “life’s getting short” drama lit a fire under me to complete a book I’d been planning, Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners. It’s an accessible, informal, kind of irreverent guide to meditation. The aim is to demystify it and to appeal to folks curious about meditating but perhaps turned off by a mystical/New Age-y approach. Lots of my fellow docs are in that camp, too. I intend the book to be a resource for folks in health care and education to embrace mindfulness and spread the goodness. Meditators tend to be more chill, less prone to anxiety-driven insomnia, too.

Can you share a story with us about what brought you to this particular career path?

I guess there’s not a particular “story” to share but certainly some aspects of my life. There have been struggles with mental illness in my family of origin, and me in the archetypal “rescuer” role in the family — a pretty common streak in psychotherapists (and not always a healthy one.) I’ve pursued a parallel, creative path in terms of music and writing. In psychotherapy work, there’s a creative, non-linear aspect in terms of ways of working with a wide variety of individuals and getting flexible and creative in finding the best way to help them. I’ve also had the good fortune of having a strong sense of compassion and ethics engrained in me by my family — helping others, being of service. That’s found its way into my work, writing, volunteering, and parenting. It feels right and good to live and work that way.

Can you share with our readers a bit about why you are an authority in the sleep and wellness fields? In your opinion, what is your unique contribution to the world of wellness?

“Authority” (excuse me while I straighten my ascot)… sounds a bit grand. But yeah, I’m confident in giving effective information and tactics on wellness in general and sleep in particular. Shrinks learn (or should) from early on that the job of treating almost every illness, from depression to anxiety, to substance dependence and the rest, is infinitely harder if the foundation of adequate rest is not solid. So attending to the whole trajectory of sleep is an essential component of good mental healthcare. And it’s not about prescribing a sedative and moving on. Collaborating with patients is key, from how we properly prep for it, to what interferes with that, to how to manage breaks in healthy sleep, to adapting to some inevitable or poorly controllable obstacles, like pain syndromes, sleep apnea, or PTSD.

I think the idea of “honoring sleep” is a useful one — reinforcing sleep as essential self-care and maintenance, not to be short-sold or borrowed from.

Is there a particular book that made a significant impact on you? Can you share a story or explain why it resonated with you so much?

Well, I’ve pitched mine already, so… (I kid). In this arena, a book that I’ve loved in terms of its deep knowledge base and also the no-nonsense style is Dr. Robert Sapolsky’s Why Zebras Don’t Get Ulcers. His main theme, which really drives our current understanding of human stress, is that we’re still built, physiologically speaking, for the occasional big stress event — like our animal “relatives.” But contemporary human life is instead more of a “simmering” of persistent stress. The neuro- and immuno-chemistry our response to that kind of stress has not yet evolved so well to meet this moment. If zebras had mortgages to pay, powerpoints to present, let alone political unrest, racial inequity, and viral dread, they might be reaching for the anti-acids, too. (And sleeping poorly.) It’s a great, accessible book about the biology of stress.

Do you have a favorite “Life Lesson Quote”? Do you have a story about how that was relevant in your life or your work?

Hmmm… my impulse here would be to go a little meta and say, “life needs fewer ‘life lesson quotes’.” (Sorry, that was snarky.)

Ok, here are two: “pay more attention,” and “get over yourself.” Both are informed, I suppose, by my dance with cancer, which truly pushed my face up against the window of a shortened life and not taking for granted of the privilege of being conscious, of having a day after day as a default expectation.

One tale to illustrate both quotes: in residency, I took care of a dementing old soul who was considered psychotic, as he talked endlessly about his “dog and pony show.” Over and over, in response to most any query about his history, his family, what was upsetting him… “so, with my whole dog and pony show, I…” “Perseverative speech — must be manic and psychotic”, we smarty-pants shrinks diagnosed; powerful medications did not dent his belaboring this old phrase. I decided to take a different tack one day and find out more about said show if only to gain some clarity about why the phrase was so important to him. He excused himself to his room and returned with a VHS tape. Into a conference room, we went; I pressed play. There was an enrapt Jane Pauley, reporting from some county fair in Vermont, interviewing my (somewhat younger-looking) patient about his being the “last dog and pony show in the Northeast.” And then well-trained, tiny canines scampering up and down the back of a bored-looking pony.

So, pay more attention. And get over yourself (and your fixed certainties about folks and their lives.)

Ok, thank you for all that. Now let’s move to the main focus of our interview. Let’s start with the basics. How much sleep should an adult get? Is there a difference between people who are young, middle-aged, or elderly?

The “official” National Sleep Foundation line is somewhere between 7–9 hours nightly. But your mileage may differ, normally so, entrained by one’s own interior circadian rhythm “sleep clock.” We all know some folks that swear by their twelve hours and others who seem to do just fine with five. The concern in terms of sleep disorders, or sleep impacts from other medical problems, is in a persistent change from that personal “norm” both in terms of the length of sleep but also the quality of the sleep. Ten hours of shallow, restless sleep — which can be illustrated on EEG, for instance — is still a problem.

As to the other question: there are variations in need through the life cycle. Obviously, infants need more sleep. More recently, it’s become clear that adolescents do best with more sleep. That hasn’t been terribly well-addressed yet by most school systems. We often have middle- and high-schoolers tacking on extra-curricular activities requiring very early rising, and tackling mounds of homework into the night.

At the other end of the life cycle, ironically most elderly adults find their sleep needs reduce a bit from the 7–9 hour per night norm, heading toward around 6–7 hours. This can be complicated in some by daytime somnolence and long-stretch napping. I’ve found that many elders that experience a shortening of their nighttime sleep try to compensate by turning in earlier, hoping that giving more “time to sleep” will rectify the situation. Unfortunately, it often worsens it — turning in at 7 pm results in waking up (normally) at 1–2 AM, and even more frustrated. Encouraging them to try to stay up a little later to push their waking time closer to daybreak seems unusual, but it often helps.

Is the amount of hours the main criteria, or the time that you go to bed? For example, if there was a hypothetical choice between getting to bed at 10 PM and getting up at 4 AM, for a total of 6 hours, or going to bed at 2 AM and getting up at 10 AM for a total of 8 hours, is one a better choice for your health? Can you explain?

In my experience, it’s more about “how much” (and “how good”) rather than “when.” But it’s a little tricky. Some recent studies out of Northwestern University suggested shorter longevity for “night owls” (staying up late and rising late), regardless of sleep length. But teasing out timing as its own risk factor from struggling to initiate sleep due to pain, depression, anxiety, substance use. All of them are confusers in terms of contributing to a shorter life span. So, it’s complicated.

In terms of mood disorders, early light (even via lightbox treatment) does confer some benefit, especially in fall and winter. But “extending” the daylight at the sunset end does not so score one there for early risers. My own recommendations in honoring sleep include respect for one’s very own sleep clock. Sticking most of the time with a regular bedtime and wake time helps reinforce one’s own individual cycle of the alternating “rest the body” non-REM phases and dream-laden REM phases. Radical changes from day to day in sleep patterning erode that. Bodies and minds like predictability and routine that way.

As an expert, this might be obvious to you, but I think it would be instructive to articulate this for our readers. Let’s imagine a hypothetical 35-year-old adult who was not getting enough sleep. After working diligently at it for 6 months he or she began to sleep well and got the requisite hours of sleep. How will this person’s life improve? Can you help articulate some of the benefits this person will see after starting to get enough sleep? Can you explain?

That’s a good question, framing the optimal benefits. It’s actually an effective tip for doctors in promoting sleep hygiene to patients who may be enamored with the supposed bonus of more awake time.

So the hypothetical 35-year-old… we’ll call him, uh, “Tyler” (heh)… Tyler can expect some benefits in both content and process, in the “product” of the day and the “ride.” As we all tend to adapt somewhat to the states we’re in, we can get used to tolerating and pushing through fatigue, minimizing the impact on our concentration, attention, and sequential rule-following. Work function goes slowly south, but we can rationalize it away, or just adapt. When sleep improves in a sustained way, it’s like the windshield gets cleaned. Mental activity gets clearer and sharper, and Tyler wonders how he was driving half-blind for so long. Besides the improvement in mental functioning, there’s the perhaps more obvious physical benefits: more energy, easier out of the gate in the morning, less likely to have daytime lulls in energy. Emotionally, better sleep has a direct positive effect on Tyler’s overall mood and in less reactivity to stresses. There’s an indirect effect, too — reducing the dread and demoralization about how the day will go that often accompanies chronic fatigue for insufficient sleep.

Many things provide benefits but they aren’t necessarily a priority. Should we make getting a good night’s sleep a major priority in our life? Can you explain what you mean?

Every individual has one’s own priorities, and many of us also may be forced by our work or caretaking into sleep patterns that are great for us. As a medical resident on call every third night for a few years, and as the parent of three kids, I can attest to the lack of regular control over the sleep schedule. That said, proper sleep is a foundational aspect of healthy living — physically, emotionally, and mentally. It’s when we recharge when we heal when we’re ill.

While it’s harder to prove in a measurable way, there’s a likely functional purpose for REM/dream phases of the sleep cycle. While the non-REM phases of sleep rests the body, the dreaming phases (usually about 4–6 per night) appear to be when we mixmaster our experiences of the conscious day. That interior sausage-making is how we develop wisdom, how we evolve our responses to and in the world.

When sleep is impacted regularly by, say, regular substance abuse like with alcohol or high THC cannabis, you can witness over time the stasis in emotional and social development. I happen to think it’s a big reason why a subset of young adults “using” daily in their teens and twenties seem stuck developmentally and behaviorally in a persistent “adolescence.” So we need both aspects of the sleep experience — recharging the body, and giving the mind some peace to do its thing.

The truth is that most of us know that it’s important to get better sleep. But while we know it intellectually, it’s often difficult to put it into practice and make it a part of our daily habits. In your opinion what are the three main blockages that prevent us from taking the information that we all know, and integrating it into our lives? How should we remove those obstacles?

Broadly, we’re a society that is conditioned on doing more than being. Performance, outcomes, acquisition, and achievement are the coin of the realm, even as, ironically, the huge growth in the self-help industry suggests that our “go-go-go” approach is burning lots of people out. Sleep hygiene isn’t monetized (yet?).

On an individual level, healthy sleep habits, like meditation, represent an intentional unplugging from doing. Sleep is an easy, sometimes inevitable or necessary segment of life to “borrow from.” The interest rate on that borrowing isn’t that apparent at the moment but becomes an incremental burden when it’s not addressed.

One other obstacle is the wide availability of artificial ways to momentarily “cheat” poor sleep. We’re an increasingly caffeinated society, pharmacologically masking the lack of rest. It’s no accident that there’s a Starbucks on every corner and cans of Red Bull in every corner market.

Do you think getting “good sleep” is more difficult today than it was in the past?

I do, for some reasons I’ve elaborated on earlier. One other huge factor now is technology. We all love our cell phones, and social media is obviously evolving to keep us swiping and scrolling more than ever. The quick-twitch stimulus/response action is a common activity at bedtime.

Ok. Here is the main question of our discussion. Can you please share “5 things you need to know to get the sleep you need and wake up refreshed and energized”? If you can, kindly share a story or example for each.

Five? The Covey folks always want seven of everything. Ok, five ways to honor sleep:

One: take control of place and time. Bodies and brains like stability and predictability in the where and when. Besides a comfortable bed, opt for a sleep place that is cool and has a minimum of additional sensory stimuli to pull on attention, whether that’s noise leaking from other rooms or a laptop nearby calling you to check emails. In terms of time a regular, bedtime and wake time and hold to it most of the time to reinforce circadian rhythms. It’s not uncommon for people who get more rigid with this to not need an alarm clock, just waking naturally. There’s a reason there are now rules that limit doctors in training from the old call night gauntlet that old geezer docs like me had to endure (and still carry on about.)

Two: set yourself up to succeed physically prior to sleep. Avoid stimulants after dinner — coffee and tea are obvious, but dark chocolate can do it too. Sugar can do that too — so take care with the evening snacking. If you have some alcohol, be aware that the intoxication/withdrawal timing for alcohol is such that the withdrawal effects, which can be activating and make sleep more shallow, are a possible impact three to five hours later — so can pop you up in the early hours. Light exercise in the evening is helpful, but not right before bed; that forces the body to “jam on the brakes” from activation to stillness. That leads to

Three: create a wind-down routine to “land the plane” without a nosedive. Reduce stimuli in the last 30–60 minutes of your conscious day. Television and social media are invested in your continuing vigilance; better to shut them down for the night. Any music should be soothing, not activating. Consider some stretching, relaxation breathing, or basic breath or body scan meditation to set the intention that it’s time to rest. For those who tend ruminate on problems when the light goes out, consider some brief journaling — not a novella, unless that’s your thing, but just some brief notes on what’s pinging around upstairs, to return or attend to in the morning. When in bed, the best wind-down is longer-form reading — not scrolling or other quick stimulus-response actions. There’s a little effort needed in following an article or book, and a “tell” when you’ve stopped following the story. One other thing: if using a device to read from, use backlit or “dark” mode. Most phones and computers emit light wavelengths that actually mimic, of all things, sunrise. That can confuse and disrupt circadian rhythms.

Four: don’t just lay there whether in an initial struggle to fall asleep or in getting back to sleep if you wake up during the night. If it’s been 10–15 minutes with no sliding into somnolence, it’s usually better to sit up in bed, or even to a chair, and read a little, then try again. The main issue here is not reinforcing the bed as a place of struggle and failure, which can happen if it’s nightly siege of tossing and turning.

Five: don’t freak out if you are having a bad night’s sleep. It’s not great, but not the end of the world; no one dies of insomnia. I bring this up because some individuals become more activated in grievance or dread as they stay awake, which only impairs their ability to relax. I usually advise not tacking on more hours in the morning to make up for it unless it’s essential; a regular routine of “to bed late, then wake up late” just shifts the sleep cycle later or even inverts it into a “night shift” schedule.

What would you advise someone who wakes up in the middle of the night and can’t fall back to sleep?

Besides the other advice you asked about (avoid the wrestling match with sleep and the secondary tension of the moment), here are a couple of other points. I urge patients to resist the urge to take a sedative after 1–2 AM; whatever momentary benefit usually is paired some “overhang” of the medication in the morning. Even if one can fall back to sleep, resting peacefully but awake still has its benefits.

What are your thoughts about taking a nap during the day? Is that a good idea, or can it affect the ability to sleep well at night?

Naps can be very helpful; obviously, whole cultures across the planet consider them normal, beneficial. With my own post-radiation dysautonomia condition, a lunchtime power nap on long workdays is essential for me. The main issue with napping is to limit its length so as not to start to mess with the overall sleep cycle. I saw some studies purport that the optimum length was 26 minutes. Not clear how they nailed that exact amount down. My advice is to keep it under 45 minutes, based on my experience over time with my patients. For me, that’s my cellphone timer set and placed on my chest. (And you thought those funny couches were just for psychoanalysis…)

Wonderful. We are nearly done. Is there a person in the world, or in the US, with whom you would like to have a private breakfast or lunch, and why? He or she might just see this, especially if we tag them. 🙂

Actually, two come to mind. It would be an unbelievable honor to meet His Holiness the Dalai Lama, who just radiates kindness and peace. And if it’s a meal, it would be a kick to sit down with Jacques Pepin. I’ve been hooked forever on his cooking techniques and his wonderful spirit. So, yes, omelettes with Jacques!

How can our readers further follow your work online?

Thanks for asking; information on my book, as well as my blog and podcast work, is available at my writing website: www.practicalmindfulnessbook.com. I also write a mindfulness blog directed toward caregivers at Psychology Today’s website: www.psychologytoday.com/us/blog/your-mindfulness-toolkit

This was very meaningful, thank you so much. We wish you only continued success on your great work!

Glad to be of help!

Practical Mindfulness

A Physician’s No-Nonsense Guide to Meditation for Beginners

Training exercises that work. Practical Mindfulness approaches mindfulness and meditation from a hands-on, how-to, irreverent perspective–appealing directly to smart readers curious about meditation. By applying Dr. Sazima’s training routines, learn to spend more time in real engagement with the world. Cultivate a deeper appreciation of experiences, from the everyday to the extraordinary, and live your life more fully, wisely, and joyfully.

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