Episode 71: Chronic Health (Part 2): Patrick’s Biopsychosocial Assessment
Sep 12, 2024
Show Notes
A lot can be learned about our nervous system and needs by looking at biopsychosocial aspects of life.
In this episode, Patrick Casale and Dr. Megan Anna Neff, two AuDHD mental health professionals, explore the biopsychosocial aspects of sleep and how they intersect with mental health through the lens of Patrick’s experiences.
Top 3 reasons to listen to the entire episode:
- Gain insight into Patrick Casale's ongoing battle with sleep issues, from his childhood to the present day, and learn how various factors—like sleep environment, hydration habits, and caffeine intake—impact his nights.
- Hear Dr. Neff's expert advice on practical strategies for better sleep, including the use of cognitive behavioral therapy for insomnia (CBTI) and small, manageable changes that can make a big difference over time.
- Understand the biopsychosocial dimensions of sleep disturbances, including how stress, rumination, and hypervigilance can disrupt your rest, and discover methods to counter these challenges through visualization and grounding exercises.
If you struggle with sleep, consider doing a biopsychosocial assessment for yourself, and find the small changes you can implement to improve your sleep quality and overall well-being.
DISCLAIMER: This episode is not intended as medical advice.
Resources:
- Patrick’s Biopsychosocial Venn Diagram Download: drive.google.com/file/d/1W5SwQ1x3gmEc6fnpVyMjhPUfzFwI2A07/view?usp=sharing
- Biopsychosocial Venn Diagram Download: drive.google.com/file/d/1W8zJvBOcokPqW2OIi70hIhlqmJcowdKA/view?usp=sharing
- Sleep Resource (Neurodivergent Article): neurodivergentinsights.com/blog/autism-adhd-and-sleep
- Sleep Workbook (Neurodivergent Insights): neurodivergentinsights.com/neurodivergentstore/sleep (Use Code: DCPOD for 25% off)
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Transcript
PATRICK CASALE: Hey, everyone. You are listening to the Divergent Conversations podcast. We are two neurodivergent mental health professionals in a neurotypical world. I'm Patrick Casale.
MEGAN NEFF: And I'm Dr. Neff.
PATRICK CASALE: And during these episodes, we do talk about sensitive subjects, mental health, and there are some conversations that can certainly feel a bit overwhelming. So, we do just want to use that disclosure and disclaimer before jumping in. And thanks for listening.
Okay, welcome back to Divergent Conversations. Today, Megan and I are going to do some biopsychosocial work that we talked about last week on last week's episode when we were talking about medical conditions and struggles. And we hope you can follow along with us and create your own version of this so that you can fill it in, and that way it helps you track all the information that we're adding to this.
MEGAN NEFF: Okay, so you're the first one in the hot seat today, Patrick.
PATRICK CASALE: Okie dokie.
MEGAN NEFF: So, also, it's been like seven years since I've done a biopsychosocial, so I might be a little bit rusty. But I'm going to ask questions. And I've got a diagram pulled up. I'll make notes as I listen. And then, we'll use it as an anchor for our conversation.
So, as we mentioned in our last episode, this is a great one to catch on YouTube if the visual aid is helpful. But sleep is your main thing.
PATRICK CASALE: Yep.
MEGAN NEFF: So, first, just like open-ended question, tell me about your sleep. I'm just going to be listening.
PATRICK CASALE: Yeah, sure. So, sleep has been really challenging since as long as I can remember. Even as a child, I remember really struggling to fall asleep. My mind would be racing at night. If I did fall asleep, it was not until late into the night, then I would, ultimately, sleep all day as a young adult and teenager.
Now, it's more of I will fall asleep probably around like 10 o'clock at night, but I wake up constantly. I typically wake up around 2:00 AM. I cannot fall back asleep once I wake up. I might wake up because I have to pee. I might wake up because the dog needed to go outside. I just might wake up because I've woken up. This, ultimately, just leads to feeling exhausted all the time. And I have tried all the things like put technology outside of the bedroom, keep your room dark and cool, no distractions, no screen time, read before bed, tried mindfulness. Yeah, I've tried a lot of things. I've tried different prescription medications.
Around once or twice a month, I will have a night where I do not sleep a single minute. That actually happened to me two days ago. I just could not fall asleep. I was tired. I was exhausted. I was mentally and physically exhausted, and I could not fall asleep. And it didn't matter what I did, it didn't matter if I switched the environment, it didn't matter if I went into a different room. Nothing worked. And those days are really, really challenging, especially, the next day because you kind of feel delirious.
MEGAN NEFF: Okay, so you've tried a lot of things. You tried [INDISCERNIBLE 00:05:11] mindfulness, prescriptions. Like, tell me about, like, what worked, what didn't work with those.
PATRICK CASALE: Yep. So, when I have tried, like, keeping the room cool and dark, that's essential. I cannot sleep if it's hot. I cannot sleep if there's not, like, a fan or an air conditioning going on. I need to hear the noise and I need to have the air ventilation, circulation. That's an absolute must. So, sleeping in other environments, hotels, Airbnbs, other people's houses, really, really challenging.
Mindfulness before bed, we've talked about mindfulness on this podcast before, but it's something that I just often really struggle with. I can't get my mind to slow down. And it's just constantly racing, whether it's thoughts of the day, new ideas, something that I may have said in conversation that I'm now, like, playing back in my head over and over and over again, something really nonsensical, like, that doesn't even make sense. That stuff's happening a lot.
Prescription meds, I've tried them all, from like Ambien, Ambien and Lunesta, Lunestra, I don't know, one of those, the ones that are like, typically, recommended for sleep. I've tried Trazodone, I've tried Restoril/Temazepam. And honestly, none of them work. Ambien and Trazodone made me feel like zombie-like whether I just was like in a daze, laying in my bed awake, unable to fall asleep. Or if I fell asleep, it was really broken sleep, not REM, not deep sleep. And I would wake up feeling unbelievably disoriented, unbelievably lethargic.
And Temazepam is one that I currently take. It doesn't really have any physical effect. I don't notice it after I take it, but I do think it helps me actually fall asleep. It does not do anything to keep you asleep, though. So, that is really where the big struggle is these days.
MEGAN NEFF: Yeah, I mean, that's something that struck me, was you said you wake up consistently, and then, struggle to fall back to sleep.
PATRICK CASALE: Yeah.
MEGAN NEFF: And it sounds like different things are waking you up. So, like, the dog might wake you up, needing to use the bathroom. What else wakes you up?
PATRICK CASALE: Yeah, so I've been experiencing this, like, chronic restless leg pain or restless leg syndrome-esque symptoms. So, it's almost like this tensing and this intense pressure in my calves and my ankles. And I will have to, like, compulsively constrict them over and over and over again. And they're so painful. And I will end up, like, circulating or twisting my ankles over and over and again to crack them and to alleviate the pressure. And that is something that I'm doing not only subconsciously throughout the day, but it intensifies at night, and that is really challenging.
MEGAN NEFF: Yep, and have you tried anything for that?
PATRICK CASALE: So, I reached out to my doctor. They did a ferritin level test, specifically, to see if I had whatever the levels needed to be. Of course, they came back within normal limits. So, it offers no solution. I've tried, like, medicated creams and like things that are prescribed specifically for restless leg syndrome. Nothing has worked on that regard.
I did tear my calf muscle a couple of months ago playing soccer. I'm sure that plays a role. So, it's hard to identify that specific issue.
MEGAN NEFF: Yeah, yeah. Okay, so, yeah, that's a huge thing that would be waking you up at night. And I've got that in the bio section. And then, how much are you waking up to use the bathroom at night?
PATRICK CASALE: Probably two to three times.
MEGAN NEFF: Okay, tell me about, like, your hydration throughout the day. So, like both, in regards to like water, you mentioned seltzer, but also, caffeine and alcohol.
PATRICK CASALE: Yep, so I drink a lot of water, whether it's regular water or carbonated water. Just because of my vocal cord damage that I experienced from surgery, my throat always feels dry. I always feel dehydrated. So, constantly drinking water. If I had to guesstimate how many ounces I would say at least 96 ounces of water a day, then adding probably in the morning and early afternoon I, typically, will drink one to two iced coffees ranging in size of 20 ounces to 30 ounces at a time.
MEGAN NEFF: Oh, shit. Okay. Let's start there.
PATRICK CASALE: [CROSSTALK 00:10:02]-
MEGAN NEFF: Wait, wait, wait, wait.
PATRICK CASALE: I'm kidding.
MEGAN NEFF: Okay, caffeine… Well, and again, you're, like, so tired. We're not judging here, but like, so it makes sense. I've done that too.
PATRICK CASALE: I totally get it.
MEGAN NEFF: So, did you say two iced coffees in the afternoon?
PATRICK CASALE: Usually, I'll start at like eight in the morning, and I'll have a second one around like noon.
MEGAN NEFF: Okay, okay.
PATRICK CASALE: I don't usually drink caffeine past noon. Like, on the days where it's one of those nights where I didn't sleep a single second, that might become a three-coffee day, but that's not typical.
MEGAN NEFF: And it's like a 20 ounce iced coffee.
PATRICK CASALE: Yep.
MEGAN NEFF: Okay, but if you're drinking it at noon and you're sipping on it, like, how long are you…?
PATRICK CASALE: So, I don't sip anything, I think that's a problem. But, so everything is drunk very quickly. I probably will drink an iced coffee or a water of that size in about five minutes.
MEGAN NEFF: So, your drink frequency, is that where we're going to put this? I actually just, so, wait, all of a sudden I'm blanking, Huberman Lab, is that someone you follow?
PATRICK CASALE: Mm-mmh (negative).
MEGAN NEFF: He's a neuroscientist. He's got some really interesting podcasts, but there's like a two-minute clip we can link to it in our show notes about urination at night. And there's several strategies like hydrating well during the day, reducing liquids in the last few hours of the night.
But then, this was what was new information to me, how you drink also matters how it comes out of the system. So, if you sip on a drink versus gulp it down, it will also come through the system more slowly. So, he also recommends, in addition to drinking less the last few hours of the night, like, if you have maybe five to eight ounces in the last few hours to sip it instead of gulp it, that will also impact how it comes out. So, your drinking, like your style of drinking, I'm going to also put that as a biological.
PATRICK CASALE: Yeah, that makes sense. Because you're, like, shocking your system. Essentially, you're like, by gulping something down, you know? All of a sudden, you're introducing 20 ounces of fluid into your bladder, like, that probably didn't need to be introduced in five minutes.
MEGAN NEFF: Okay, so you do follow the, like, no caffeine after 2:00 rule.
PATRICK CASALE: Yeah.
MEGAN NEFF: Seltzer water, when do you stop that?
PATRICK CASALE: I probably stop that earlier in the day as well, before, like, two o'clock.
MEGAN NEFF: Okay. And then-
PATRICK CASALE: [CROSSTALK 00:12:46]-
MEGAN NEFF: And then, any alcohol at night, typically.
PATRICK CASALE: Yeah, probably two to three nights a week I'll drink socially with friends, and that can look like two to four beers.
MEGAN NEFF: Okay. And any difference in your sleep those nights.
PATRICK CASALE: Usually, I'll fall asleep easier, but my sleep will be very broken.
MEGAN NEFF: Yeah, yeah, that makes sense. What about food? What's your, like, food look like?
PATRICK CASALE: Yeah, I don't eat a ton throughout the day. If I'm being honest, I'll have like something very light. In the morning, usually, I'll do like a smoothie because liquids are just easier. And then, lunch I, typically, do a lot of delivery because I don't leave my house very often. And so, I'm usually doing like Indian food or I'm doing Asian food. A lot of the time I do put a lot of hot sauce on my food. I know that is a bladder irritant. I know caffeine is a bladder irritant. When you're saying this stuff out loud, you're like, "I know what to do and-"
MEGAN NEFF: I know these things. Of course, we do.
PATRICK CASALE: Right.
MEGAN NEFF: But also, like, food is so comforting. Like, so I'm trying and failing to do a juice cleanse right now. And I'm realizing, like, food is one of the few things that I, like, look forward to in a day. Like food and drink, partly, the sensory experience. For me, also it's spice, it's sweet, and it's like one of the soothing things. And when you're like, tired and in pain we go to these things, so…
PATRICK CASALE: Absolutely, absolutely.
MEGAN NEFF: Yeah. So, spicy foods, okay. And when's your kind of, like, last meal of the day, typically.
PATRICK CASALE: So, I was joking with my friend the other day that I really enjoy going out to restaurants for dinner around 5:00 PM because nobody's in them.
MEGAN NEFF: Same, yeah.
PATRICK CASALE: And I really think that's like my true personality. So, usually, I'm eating dinner around like 5:00, 5:30.
MEGAN NEFF: And then, do you have any snack before bed?
PATRICK CASALE: Not typically. Sometimes, like you mentioned sugar last episode, I do love ice cream. It's a soft spot for me. But, I mean, that's like a once-a-week thing, but so usually not stacking before bed.
MEGAN NEFF: This is outside my scope, so totally remember that. But I was just in a book I'm reading on CFS. One of the things he was talking about is how sometimes, especially, for those of us, because hormonal stuff can absolutely play into sleep, and for those of us with, like, adrenal fatigue, or I think, I have to go back and read, I think he was also talking about restless leg syndrome, but sometimes having, like, a high protein snack before bed, it'll keep your blood sugar from dropping. And sometimes it's that drop that wakes us. So, I don't know. That could be on your experiment list, is trying a high protein snack to see if that does anything. Ooh, I'm going to start an, maybe, experimental list.
PATRICK CASALE: Right. Start an experiment list, for sure, yep.
MEGAN NEFF: But again, that's, like, I'm not sharing medical information there, that's just something I've read that maybe you should try if you want to experiment.
PATRICK CASALE: We'll use a disclaimer again in this episode, this episode is not designed to give you medical or mental health advice. So, everything do at your own discretion. I'm willing to try anything. That's basically what I tell my PCP anytime she suggests something at this stage. I'm like, "This has gotten so bad that I don't care. I will try anything that someone suggests at this point."
MEGAN NEFF: Okay, do you nap during the day?
PATRICK CASALE: Nope. Never have, never will.
MEGAN NEFF: Like you can't nap?
PATRICK CASALE: No, I just can't. Can't fall asleep.
MEGAN NEFF: Okay. Yeah, and then movement right now. I know you used to do a lot of soccer, but you're have an injury right now. Are you able to walk? Are you able to walk on it? Like, what does-
PATRICK CASALE: [CROSSTALK 00:17:00]-
MEGAN NEFF: …movement look like?
PATRICK CASALE: My wife and I have an agreement that I leave the house once a day. Usually, it means that I walk to a neighborhood nearby, which is like a 15-minute walk each way to go meet a friend for dinner, or to go get a coffee, or whatever. I basically walk everywhere I go in Asheville, it's a small city. I don't need to drive very often. So, that's helpful. But I'm not moving like high energy or high intensity the way that my body used to. And that used to look like three days of soccer a week, 90-minute games, like super high intensity. So, it's a big shift to not really have that.
MEGAN NEFF: And was there a sleep difference when you were doing that?
PATRICK CASALE: I think there was probably a little bit of a difference. I know like after games you're kind of amped up, you have a ton of adrenaline. But, like, I definitely would sleep longer.
I did tear my calf muscle a couple months ago playing soccer, so that impacts everything as well. But I've been trying to play pickleball with my friend twice a week now, and that helps get into some movement as well despite my physical therapist telling me not to do that.
MEGAN NEFF: Oh, interesting.
PATRICK CASALE: She's like, "You know, you have a torn calf, like lateral movement back and forth is going to make it worse."
MEGAN NEFF: Does that create pain on days you play pickleball?
PATRICK CASALE: Oh, yeah, a little bit.
MEGAN NEFF: Okay, so pain is part of your experience as well?
PATRICK CASALE: Yeah.
MEGAN NEFF: Okay.
PATRICK CASALE: Yeah.
MEGAN NEFF: Leg pain, back pain.
PATRICK CASALE: Leg pain. I have chronic back pain because I have two herniated discs and I also have a torn hip labrum. So, my entire right side of the body is probably being overcompensated for by my left side of my body.
MEGAN NEFF: Okay, yeah, does pain also wake you up at night?
PATRICK CASALE: Only this, like, weird leg sensation, but not pain, typically.
MEGAN NEFF: Okay, okay. So, often, like, when doing a biopsychosocial, like, I often start with, like, "Walk me through your day." That's an open-ended question, so I've asked you more specifics, specifically, around the biological pieces. But is there anything else, if it was like, "Walk me through your day." That I haven't asked about, whether it's food, sleep, socializing, work, things that feel significant?
PATRICK CASALE: Work is a lot of sitting.
MEGAN NEFF: Okay.
PATRICK CASALE: There's a lot of, like, sitting. I know I have a standing desk and I never use it.
MEGAN NEFF: Work involves a lot of sitting, okay. And why don't you use the standing desk, like, in your opinion?
PATRICK CASALE: My opinion is because I'm lazy.
MEGAN NEFF: Well, you're tired. You're like waking up tired, and so…
PATRICK CASALE: Yeah, yeah. It's exactly what I said last episode. It's like you're so tired that all these little things that should be easy to do just become one extra thing to do.
MEGAN NEFF: Right, right. No, I 1,000% feel that. Okay, so work involves a lot of sitting. Anything else about work we haven't really talked about?
PATRICK CASALE: Not really. I mean, you know, if it's not podcasting, it's managing a group practice, but that's all virtual, retreats, obviously, but that's only, like, when those events are happening, I'm on my feet a lot, and I'm moving a lot, and I'm obviously, much more social in those environments. But like, that's not my typical day.
MEGAN NEFF: Okay, and work stress. Like, how stressful would you say your work is?
PATRICK CASALE: Well, good thing we just finished our entrepreneurial series where we talked about all the glamorous sides of being an entrepreneur. It's stressful. I mean, it's definitely stressful. I put internal stress on myself, internal pressure. There's stress of owning a group practice that has 20-plus people working for it. I am stressed just about the creation process of my other job. I get stressed about, like, having to market things like we've talked about because I just don't enjoy that. I have RSD-related stress to all of these things.
MEGAN NEFF: You mentioned, like, mind racing, that you've always been that way, and that's part of your sleep issue. Does work stress show up at night?
MEGAN NEFF: It does, yeah, whether it comes in, like, the form of an idea that I feel like I should jump on immediately or I think of something I need to tell someone so I have to get up and, like, schedule send the email or the text message so I don't forget. And then, if it's in, like, you know, retreat season, and I'm thinking about an event, and all the things that could go wrong, yeah, it comes up at night.
MEGAN NEFF: Okay. Does that both make it hard to fall asleep, and when you wake up, do you also do the work rumination stuff?
PATRICK CASALE: Yep.
MEGAN NEFF: Okay, outside of work rumination, is there other rumination that's… So, one thing I love, I heard this once, I love, it's like the mind loves to have an audience, and when you're trying to fall asleep it's like, the mind's like, "Oh, I've got you all to my attention right now, let's go."
PATRICK CASALE: Yep, oh, yeah, yeah. I can ruminate about anything. It could be childhood stuff. It could be something I've been watching or reading. It could be something nonsensical that has no importance. I could be ruminating about, like, phone numbers that I remember from back when I was a kid or about… I'm just trying to think about the things I think before bed. Sometimes I'm ruminating about not being able to fall asleep.
MEGAN NEFF: How often is that?
PATRICK CASALE: It's not as much anymore. It's almost like an expected situation of not being able to but I used to ruminate, and look at the clock, and, like, count down the minutes. I used to do this mental math where it would be like, "If I fall asleep by this time, I will get four hours, or I will get three hours, or I will get two hours." I no longer do that because I've given up on that and it's not helpful.
MEGAN NEFF: Yeah, those sleep-stress thoughts, though, are really, really common.
PATRICK CASALE: I love this, by the way. Like, this is so visually soothing to me.
MEGAN NEFF: Is it? Yeah-
PATRICK CASALE: Yeah.
MEGAN NEFF: What's this like for you?
PATRICK CASALE: Oh, it's great. I feel like I'm in therapy.
MEGAN NEFF: Okay, well, I was like, "I hope it doesn't feel like therapy or feel like I'm interrogating you."
PATRICK CASALE: No, it's great.
MEGAN NEFF: Okay. Oh, I know, when you start thinking about sleep at some point in the night do you start stressing out about it?
PATRICK CASALE: Yeah.
MEGAN NEFF: Okay, well, is there a point in the day where you start, you're like, "Oh no, it's going to be bedtime."
PATRICK CASALE: Yeah. I'm physically and mentally exhausted all the time. So, by the time I decide to go into bed, I try to, like, prolong going into the bed because sleep hygiene stuff. And I'm like, "Okay, it's eight o'clock, I can finally get off the couch and go into the bed." Or whatever time it is, usually eight, 8:00, 8:30. And I will lay down. Sometimes I'll put a show on that is just mindless, and I'll put it on in the background. I'll probably be asleep in like, an hour to an hour and a half because I'm so tired. I start stressing the second I wake up. So, if I wake up at 1:30 or 2:00, my mind immediately goes to, "I am so exhausted and I am so worried that I'm not going to be able to fall asleep." And that's what happens every single day.
And I don't even check the clock anymore, like when I wake up. I think I've told you, I've now woken up at around 2:00 AM and for about 45 straight days.
MEGAN NEFF: Yeah, which is terrible.
PATRICK CASALE: [CROSSTALK 00:25:00] clock, I know going out into the living room, because I'll shift sleeping spaces so I don't wake my wife up by tossing and turning. And I'll look at the clock and be like, "Yeah, it's 2:01, it's 1:48." And I would have felt like I slept for eight hours.
MEGAN NEFF: So, when you were texting me about that I noticed that it seems like you're waking up after like, a sleep cycle. So, a sleep cycle's usually like three and a half to four hours.
PATRICK CASALE: Yeah.
MEGAN NEFF: Well, and I know you just went to the sleep doctor, and it was utterly unhelpful. But like, have you done any medical workups for, like, sleep apnea, hormone testing to see if, like, what testosterone, like, have you done any of the [CROSSTALK 00:25:41]-
PATRICK CASALE: So, I've never done [CROSSTALK 00:25:42]-
MEGAN NEFF: [CROSSTALK 00:25:42].
PATRICK CASALE: …hormone testing but I have done a sleep study which didn't discover any apnea.
MEGAN NEFF: So, no sleep apnea, okay. And no other significant findings.
PATRICK CASALE: Right, yeah. [CROSSTALK 00:25:55] I don't know where this should go in the social component, I assume, but all the jet lag, that has to play a role, too.
MEGAN NEFF: Yep, absolutely.
PATRICK CASALE: All the time zones, all the new environments, like all the Airbnbs or uncomfortable hotel room pillows, and all the things that comes with traveling, and running retreats, and, yeah.
MEGAN NEFF: Yeah. So, yeah, running retreats, yeah. Yeah, I mean that, like, throws off your cycles on, like, and actually, I'm going to put that over here. Your bio's social combo is good impact, the things that exist in the intersection of both biological and social. So, yeah, the jetlag.
And I would also add, actually, I'm going to put that in the biopsychosocial psycho because I think, here's my guess is that the jetlag, obviously, there's a biological component, there's the social component because retreats, but then I'm going to guess that you also have a narrative in your mind around, like, "Oh no, I'm coming home. I have jet lag. I'm not going to sleep well." Like, is that fair?
PATRICK CASALE: Oh, yeah, for sure.
MEGAN NEFF: So, I would put that right in the middle of all three.
PATRICK CASALE: This is going to sound really weird, but the one moment that I look forward to during all of those travels is the day that I come home because I'm going to be so exhausted from being up early in Europe, coming home, landing at like 10:00, 11:00 PM that I will get so knocked out, that I will actually sleep until like 7:00 or 8:00 AM.
MEGAN NEFF: So, you're like, excited for that, like, one good night sleep. That's so sad, Patrick.
PATRICK CASALE: I know, I know. It's so sad to even say that out loud.
MEGAN NEFF: Yeah. Okay, tell me a little bit more about your sleep environment. I know it sounds like you sleep in a cold, dark room, but the dogs are with you, right?
PATRICK CASALE: Yeah. So, my wife has a sleep [PH 00:28:05] app. It doesn't make a ton of noise, but it does make noise. The dogs sleep in there. So, we have a Shih Tzu who is unbelievably neurotic, who sleeps in the bed, and he wakes up often. Sometimes he's barking, sometimes he's just scratching, sometimes he's moving around. We have a larger dog that sleeps on the floor. There are nights where they are having sleep issues and they're up and out of the room constantly because they either need to go out to the bathroom. Our little dog likes to jump off of the bed so he can go into the kitchen and you can watch him drink water. You assume he needs to go to the bathroom, but he just drinks water, and then he goes back into the bed. But he needs an audience to do it. Thankfully, that's only like two to three times a month, but when that happens, it does really suck.
MEGAN NEFF: Yeah, you've got a lot of external factors that wake you. Any other, like, sensory stuff that wakes you?
PATRICK CASALE: Not really. When I'm having really bad bouts of sleep, struggle, I will remove myself and try to sleep in our spare bedroom upstairs by myself. But even that has not worked recently. Usually, that's like a pretty safe bet that that will help me.
MEGAN NEFF: So, like, when you're in a bad spot you'll go to this… I'm going to call that the sterile room because, like-
PATRICK CASALE: Yeah, [CROSSTALK 00:29:32]-
MEGAN NEFF: There's less, yeah. But that sometimes helps, but it's not been helping lately?
PATRICK CASALE: Right, yeah.
MEGAN NEFF: Okay, because you're still waking up at 2:00.
PATRICK CASALE: Yeah, yep.
MEGAN NEFF: Okay. Let's see, so you watch a show in your room. Is there anything else you do in your bed?
PATRICK CASALE: I'll read before bed sometimes, and that will almost instantaneously make me fall asleep.
MEGAN NEFF: Okay, so reading helps.
PATRICK CASALE: Yeah.
MEGAN NEFF: How's your phone used in bed?
PATRICK CASALE: So, I put my phone in a different room. I put it in a living room every night starting around like 6:00 PM.
MEGAN NEFF: Oh my gosh, that's so, like, impressive.
PATRICK CASALE: I have to because, like, there are nights where I can tell that I'm feeling more obsessive about checking it and those are nights where I feel increasingly more anxious. So, I really have to create as much separation as possible.
MEGAN NEFF: Okay, so, yeah, your phone is away.
PATRICK CASALE: Yep.
MEGAN NEFF: Starting at 6:00.
PATRICK CASALE: Yeah.
MEGAN NEFF: Nice, okay. Let's see. Are there other things I haven't asked about that you're thinking of or you're associating to as this Venn diagram is unfolding?
PATRICK CASALE: I'm having like childhood realizations as a kid and like teenager, I used to have this rational fear of someone breaking into our house constantly. And that would keep me up at night. But that no longer impacts me, so I don't think that feels presently relevant. But that was a constant fear and that never happened. So, you know [CROSSTALK 00:31:25]-
MEGAN NEFF: There's like a hypervigilance around, like, going to sleep and like, will the world stay safe while I go to sleep?
PATRICK CASALE: I've had rational fears where, like, if I fall asleep, I'm going to die in my sleep, yeah.
MEGAN NEFF: Yeah, and like, given health stuff. And I actually hear that I feel like a lot, especially, with autistic people. I mean, if you think about sleep, it's like the ultimate releasing of control. We're, like, releasing up our conscious awareness, which-
PATRICK CASALE: Yeah.
MEGAN NEFF: And, like, I think that's hard for a lot of us.
PATRICK CASALE: That's spot on. It is that releasing of control. Oh, you asked me what else I've tried, I've had a friend who's a therapist in town offer hypnotherapy that did not work. And she mentioned that exact statement. She's like, "It really looks like you're not able to allow your body to relax enough to go into this state."
MEGAN NEFF: So, that makes me also wonder, kind of, like nervous system stuff. Do you have a sense either just from, like, knowing your own body, or from some of the bio, like markers that are available or not biomarkers, but like biofeedback things? Like, do you tend to be sympathetic dominant?
PATRICK CASALE: Yeah, absolutely, 100%.
MEGAN NEFF: Okay. So, I know you've tried, like, meditation, all those things. Like, what have you done with, like, relaxation-type exercises to get you into parasympathetic?
PATRICK CASALE: I've done some mindfulness work. I've done some, like, breathing and relaxation techniques. I used to use, like, apps like the Calm app or Mindset Timer, things like that, or Insight Timer, I mean.
MEGAN NEFF: Do those just stress you out more?
PATRICK CASALE: Yeah.
MEGAN NEFF: So, okay, this is something I've sometimes noticed, and here's how I conceptualize it. Curious if this will resonate or not, that for some folks, especially, with complex trauma who are SNS dominant, dipping into the parasympathetic nervous system actually feels really scary because it's like I'm letting my guard down. But because the hypervigilance is my protector, and so, then using relaxation exercises can feel really scary. Does that resonate?
PATRICK CASALE: Yep. That resonates 100%.
MEGAN NEFF: Okay. So, that, like, again, like, from a body being protective, that makes sense. It's like your body wants to get into parasympathetic relaxation mode, but there's part of your body that's saying that it's not safe to do this?
PATRICK CASALE: Yeah.
MEGAN NEFF: What I would historically pair when that's the case is doing not relaxation exercises on your own, but doing it with grounding exercises, like impairing the two because the grounding exercises, and the grounding exercises for listeners, are exercises that kind of bring us back to this present moment. So, like the 5, 4, 3, 2, 1, like five things you can see, four things you can touch, those sorts of exercises, pairing that with relaxation, so that there's one to anchor you, remind you you're safe while you're also, like, practicing tolerating the more relaxed state.
PATRICK CASALE: Right.
MEGAN NEFF: Our social part is not very… our social part of our sleep Venn diagram, we've got sleep apnea, [INDISCERNIBLE 00:35:00] dogs, you're running retreats, dog needs. But are there other social things we haven't talked about that seem important?
PATRICK CASALE: No. I mean, we have, like, drinking alcohol in the social and bio piece, but that is a social component. So, I would say, but I don't think, like, I can think of anything that feels that I would include in there.
My wife used to have horrific night terrors where she would stand up on the bed and start screaming at the top of her lungs, which was really enjoyable to experience because then she would immediately go back to sleep as if nothing happened. I would be checking under the bed, in the closet, but that hasn't happened in years, thankfully, but that was happening and it was horrible.
MEGAN NEFF: [CROSSTALK 00:35:48]. So, yeah, like her night terrors would activate, probably, your existential anxiety about the world isn't safe when I fall asleep.
PATRICK CASALE: Exactly.
MEGAN NEFF: Yeah.
PATRICK CASALE: And then she would just go back to sleep like nothing had happened, and I would just be lying there like, "What the hell just happened?"
MEGAN NEFF: Yeah, yeah.
PATRICK CASALE: That has not happened in years, but that was a horrifying experience.
MEGAN NEFF: Yeah, I've had sleep tears, and like, it's true. Like, you often don't remember them unless you get woken up. But, yeah, sleep tears are terrifying. I mean, they have a good name.
PATRICK CASALE: Yep.
MEGAN NEFF: Yeah, I sometimes get those. And I do think I agree, because my mom had sleep tears. And it's often like, more terrifying for the spouse or the partner, especially, if the person's not waking up.
Okay. Well, how do you feel about this little diagram we've created? First of all, does this feel like this captures?
PATRICK CASALE: This feels like it captures, yeah.
MEGAN NEFF: Okay, so then right, the next part is, like, we talked about last week. Like we want to look at where couldn't we intervene? So, obviously, there's a lot of biological components. I think the ones that stand out to me is I didn't realize, like with your throat condition how much… it sounds like you're drinking a lot more liquid, and it's easier to drink liquid than to eat food. And then, you know, you're getting up to use the bathroom two to three times a night, and then, falling back asleep is huge. So, that to me, like, that's a huge in the biopsychosocial. I'm like, well, that throat condition really feels significant in your sleep.
PATRICK CASALE: For sure.
MEGAN NEFF: So, okay, there's a lot in the psycho compartment, psychological compartment psycho. There's a lot in the psychological compartment that I think you could like, push a needle on, is that the phrase?
PATRICK CASALE: Yeah.
MEGAN NEFF: But I don't know, where would you want to start looking at this? Because I feel like there's a few anchor points where it's like, okay, I could start working on some of the hydration stuff to see if I'm waking up to use the bathroom less, and then there's less of that.
PATRICK CASALE: Yep.
MEGAN NEFF: I think some of the mind-racing stuff you could start with.
PATRICK CASALE: I'm definitely think the most tangible feels like the amount of hydration and the timing of hydration. Like, that's a big one. So, if that's going to be a variable in waking up in the middle of the night when you're already asleep to have to use the bathroom, that's a big deal. So, that feels like something I can truly anchor into, and manage, and actually, have some control over.
The next part would probably be, I don't know. Something that's going to have to be more therapeutic, I assume. I am doing consultations with two CBTI therapists tomorrow for sleep, cognitive behavioral therapy for insomnia, for those of you who don't know what that means. I am not a huge proponent of CBTI, not CBTI, CBT, but for this specific issue, I am totally willing to give it a shot.
MEGAN NEFF: I like CBTI. Like, I say that in my sleep workbook. I'm like, I don't typically like CBT for us, but I like CBTI.
PATRICK CASALE: Yeah.
MEGAN NEFF: I'm glad. That's great that you're going to be working with a CBTI person. I think, yeah, given how much rumination, and stress, and just even, like, your relationship to sleep, given how stress that is, like, I think that will be huge. I'll love hearing your, like, updates on that.
PATRICK CASALE: For sure.
MEGAN NEFF: So, hydration. And then, the other one, like, if you're messing with hydration, like, changing the 20 ounce afternoon iced coffee to like a 12-ounce, is that something…
PATRICK CASALE: Yeah, a reduction and moderation management. So, that feels better than saying, like, just cut it out completely, which feels unrealistic.
MEGAN NEFF: Yeah, totally. A lot of behavioral health, it's about creating realistic goals. Because a lot of people, it's like, well, I'm going to change this, this, and this, and this. And it's like, no, it's like, small changes over time, small tweaks over time.
PATRICK CASALE: For sure.
MEGAN NEFF: So, if we were to make a goal list for you to experiment with and let everyone know how it works, afternoon coffee, 12 ounce, how many ounces of liquid do you think you're having in the last, like, five hours? Four or five…
PATRICK CASALE: 36 ounces.
MEGAN NEFF: 36 ounces in the last like five hours?
PATRICK CASALE: Yeah.
MEGAN NEFF: Okay. Does your throat start hurting if you…
PATRICK CASALE: Yeah, that's a causation because by the time the day is getting over with my voice is now basically used up, so then it takes even more liquid to lubricate my throat to be able to speak.
MEGAN NEFF: And, like, are liquids equal? Like, in the sense of like, does tea versus water versus seltzer water? Like, do some of them soothe more than others? Or is it all equal?
PATRICK CASALE: [INDISCERNIBLE 00:41:00] for cold tea, throat cold tea is helpful, so I'll drink that. But yeah, I can certainly start, like, trying to minimize going from like 36 ounces to 24 or something like that.
MEGAN NEFF: Well, and that's where I was, because that's the complicated factor with your throat. Like, you've got those competing needs there where, like, if tea is a more effective liquid per an ounce. So, switching to something that's, like, more impactful per an ounce? Does that make sense?
PATRICK CASALE: Absolutely.
MEGAN NEFF: So, shifting the hydration toward earlier in the day. And then, the sipping, like I would experiment with the sipping versus the gulping. And I think tea also would make it easier to sip versus gulp.
PATRICK CASALE: For sure. Like, that's [CROSSTALK 00:41:52]-
MEGAN NEFF: So, what he said in his podcast on it was five to eight ounces like 10 hours after you wake up, at that point. Then you should just have five to eight ounces before night, if you've hydrated well during the day. But with your throat thing, I think you'd want to adjust that.
PATRICK CASALE: Right, absolutely.
MEGAN NEFF: Okay, I like concrete goals. So, what would be your, like, ounce of liquid 10 hours after you wake? Well, I guess after you get up because if it's 10 hours after 2:00 AM that's…
PATRICK CASALE: Right, yeah, yeah. I don't know, I would just like to reduce it a little bit so that it feels manageable. I think that it can go from 96 ounces during the day to like maybe 60.
MEGAN NEFF: Well, I would keep your hydration. I don't think you have to decrease your hydration for the day. It's more about those last several hours. So, you could go from like 36-
PATRICK CASALE: [CROSSTALK 00:42:56]-
MEGAN NEFF: …to like 24.
PATRICK CASALE: Yeah.
MEGAN NEFF: And partly, see how your throat deals with that. And then, the sipping it versus the gulping.
PATRICK CASALE: Right.
MEGAN NEFF: And then, have you tried cognitive shuffling?
PATRICK CASALE: I have, yeah. I did it after we did our sleep episode that one day.
MEGAN NEFF: What was your experience of that?
PATRICK CASALE: It didn't really have any impact. I played around with it for like five days in a row, and then I was like, "No, I've given up."
MEGAN NEFF: Was your mind wandering, or was it like you were doing it for a long time and not falling asleep?
PATRICK CASALE: A little bit of both. Happy to revisit.
MEGAN NEFF: Yeah, it's so interesting because I have this same thing where I wake up and I start stressing. And it's like every time I actually do cognitive shuffling and actually, pull myself back when my mind gets distracted, back to the cognitive shuffling, it always works. But it's hard because it's like, I have to train my brain to not go on that divergent thought and to come back to…
PATRICK CASALE: For sure.
MEGAN NEFF: …the word I'm shuffling. But, well, how do these goals feel?
PATRICK CASALE: These goals feel good, and they feel manageable, and they feel like things I can actually do, which is what we want to highlight, for those of you who are listening, is like things we can actually start to implement into our day-to-day that don't take us an enormous amount of restructuring, or effort, or energy.
MEGAN NEFF: Yeah, exactly. Like, looking at this diagram, like it's overwhelming, right? Like, there's a lot of factors contributing to your sleep stuff.
PATRICK CASALE: Yeah.
MEGAN NEFF: And it might be like, what all you're doing is cutting down your caffeine by eight ounces and your water by10 ounces. That's all you're doing. But it's like, that's how we have to start with these things. It's one… What is it like? Like, I hate the metaphor how do you eat an elephant one bite at a time? Like, that's a terrible metaphor, but that's what's popping in my head.
PATRICK CASALE: I mean, yeah. I-
MEGAN NEFF: I don't eat animals.
PATRICK CASALE: For sure, but yeah, it is about like small, manageable little steps that can build momentum too, because otherwise, it can feel significantly way too overwhelming to do.
MEGAN NEFF: Yep. Okay, so here's what we're going to do, Patrick. Every afternoon, maybe not every afternoon, unless you want to, you're going to take a picture of your iced coffee and send it to me. And it should be like 12 ounces.
PATRICK CASALE: I can do that.
MEGAN NEFF: Okay, cool.
PATRICK CASALE: [CROSSTALK 00:45:36]-
MEGAN NEFF: Well, I'm excited for my week-
PATRICK CASALE: [CROSSTALK 00:45:37] therapy payment for this last hour of my life because [INDISCERNIBLE 00:45:41] it felt like a therapy session, which was really good.
MEGAN NEFF: Sorry. No, like that actually makes me feel kind of like awkward. I'm like, "Oh, I hope you didn't feel too [INDISCERNIBLE 00:45:49]."
PATRICK CASALE: Oh, you did such a good job. Yeah, that was really helpful to lay it out that way and to visualize it this way, and to be able to compartmentalize and conceptualize. So, this is what we want, for those of you watching at home, especially, if you're watching on YouTube, to be able to create something visually, and then, to break down these experiments step by step, like little, tiny tweaks that you can introduce into your life so it does not feel like you have to look at the whole Venn diagram, get overwhelmed, and just say, "Nothing is ever going to change?"
MEGAN NEFF: Yeah, exactly. It's all about, like, self-experimenting and becoming a, you know, detective and starting with the little concrete things, yeah.
PATRICK CASALE: For sure.
MEGAN NEFF: Yeah.
PATRICK CASALE: Okay.
PATRICK CASALE: Okay, we will figure out a way for you all to have access to this, aside from the YouTube channel. Maybe we'll put it in a show note as a downloadable, but nevertheless, thanks for following along and just taking the journey on this experiment with us because we know this is a different type of podcast episode today. Next time, we're going to do Megan's and then we will keep you all posted on the progress.
Thanks, Megan, that was actually super helpful.
And to everyone listening to the Divergent Conversations podcast, new episodes are out on Fridays on all major channels and YouTube. Like, download, subscribe, and share. And we will see you next week.
