Live Discussion with Dr Dimitri Gavriloff - 27th February 2019

Dr Gavriloff will be hosting a live online discussion here on Wednesday 27th February, from 7:30pm to 9:00pm British Time or 2:30pm to 4:00pm US Eastern Time.

He will discuss as many topics as possible in the hour and a half and, as always, you are welcome to ask any questions at all about sleep or the Sleepio program. If there are a lot of questions, he may not be able to answer all in the time available, but will try to answer as many as he can.

Please do note that, as per our guidelines, Dr Gavriloff will not be able to give personal medical advice including those about medication. His replies to questions will be made in such a way as to help as many people as possible who might have similar issues.

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Posted 25 Feb 2019 at 12:47 PM
  • 17 comments
  • 10 helped

Comments

  • Sleepio Member

    • 30 comments
    • 3 helped
    Graduate

    I'd appreciate your help in a few areas.

    My sleep score is fair and quite often I sleep well. However, if there's a 'trigger', like for example coming back from my first workout in the gym for a while last week and feeling overtired, this can result in a run of bad sleep. This can last several days. I should add that my workout was early evening and not late on, however that particular evening found myself nodding off involuntarily. What is the best way to deal with this?

    I have resisted sleep restriction as I still have a degree of sleep anxiety, (especially when such things happen) and am nervous that this will make it only worse. My average sleep is currently five hours per night and the thought of going to bed at 1am and getting up at 6am (as suggested by this site) seems like my worse nightmare. I've had two days off work in the last week through this and want to avoid taking any more time off.

    Thanks, John.

  • Sleepio Member

    • 7 comments
    • 2 helped
    Graduate

    Hello Dr – I have been on the course and graduated sometimes back. I do have the occasional flip but use the tools to bounce back.

    However, for the past week, I have the insomnia return and I have been suffering from it. I have tried all the techniques including relaxation , quarter hourly etc.

    My problem now is that the second I hit the pillow even after I’m very sleepy, I wake up and kind of have hot feeling in the stomach. Then I really struggle to sleep.

    Feeling very dejected after I thought I nearly overcame my insomnia. Thanks for your feedback I.

  • Sleepio Member

    • 3 comments
    • 0 helped
    Graduate

    I've graduated from the course and put most of the techniques into use, but I've been having problems with sleep lately. I admit I've been lax with the sleep restriction. Initially I didn't pay it much mind because it seemed it was meant for people who get very fragmented sleep, but my main issue is falling asleep in the first place – if I can get over that wall, I can sleep for hours. I've been hesitating to commit fully to it because I fear not falling asleep at all, and then not being allowed back to bed past the time SR dictates. I figured it's better to let myself sleep past the window if it means getting SOMETHING. Basically, I do try to go to bed around the time I'm scheduled, but I don't bother myself if I end up sleeping past wake-up time.

    Am I hamstringing myself by not adhering strictly to SR? I do follow the QHR quite strictly, so my sleep efficiency is good even if my hours/quality of sleep is not. Are the two techniques better for different types of insomnia (falling asleep vs staying asleep), or are they meant to be used in tandem no matter what? I guess I'm just wondering how much flexibility there is.

    Thanks!

  • Sleepio Member

    • 2 comments
    • 0 helped
    Graduate

    Hi.
    This is my first post and I am on day 1 of week 3…so far I have found everything relatively easy. Now I am struggling to comprehend why I have to stay awake until 12.45am before I go to bed? I'm generally nodding off by 11pm and wake up at 8am quite happily. I understand that if i wake during the night i must get out of bed if I'm awake for more then quarter of an hour, but I'm feeling pretty miffed with the idea of having to stay up and watch even more TV (which most of the time I don't enjoy watching) or look at photos.
    Can I go to bed earlier and get up at 8am?
    Thank you.
    Ali

  • Sleepio Member

    • 3 comments
    • 0 helped
    Graduate

    I've got to the stage where I'm told to do sleep restriction.
    My job (which I love) means that I never have a week where it's possible to do the same hours (eg, last week I sometimes worked till after 11pm, stayed in 3 different hotels abroad, had to get up very early for travel, etc). Sometimes I have jet-lag, and sometimes have to do something like 12 different cities (and hotels) in as many days.
    I don't usually have trouble getting to sleep (worn out!) but wake multiple times in the night.
    How do I proceed?
    Thanks,
    C.

  • Sleepio Member

    • 14 comments
    • 8 helped
    Graduate

    Hello there. I am on week 6 and not really showing any improvements. I have had insomnia for 35yrs and it is very severe. In common with many users of Sleepio i have tried many, many things to try to cure my insomnia. The only thing that ever had any effect was Mirtazapine, but this is not a happy option for me and began to be less effective after about 12 months. I am hoping and assuming that the worse the problem the longer the cure will take. I accept the premise that my subconscious needs to learn to associate bed with sleep not wakefulness and that sleep restriction and the QHR are, therefore, valid interventions. I am OK with the sleep window but I find the QHR almost impossible to adhere to for two reasons 1. because it is rarely clear to me exactly when I am going to sleep and waking up 2. I am so very tired that getting out of bed repeatedly in the small hours is too hard. I am feeling rather demotivated and depressed by my lack of progress. Is there any point in going on, does it take some people much longer and at what point does one give up on the basis that it is not going to work?

  • Sleepio Member

    • 121 comments
    • 45 helped
    Expert

    Good evening everyone and welcome to this week’s live session. I’m Dr Dimitri Gavriloff, a clinical psychologist with a special interest in sleep and I work in both clinical practice and research. I’m here to answer as many questions as I can over the next hour and a half and will aim to make my answers as helpful as possible to the community in general.

  • Sleepio Member

    • 121 comments
    • 45 helped
    in reply to Sleepio Member
    Expert

    Hi John,

    Thanks for the question. We’ve known for a long time that regular exercise is good news when it comes to health generally but we also know that regular exercise and dynamic daytime activity are great for nightly sleep too. However, as a rule of thumb, if someone is struggling with their sleep I tend to recommend that they try to keep their vigorous exercise to earlier in the day and to avoid exercise in the evening. It’s worth saying that as with many things this really does come down to the individual and there are plenty of people who exercise in the evening and don’t find that this affects their nightly sleep at all. What’s probably needed is a bit of trial and error and if you find it helpful to push the exercise earlier, then that might be the best plan.

    If the main reason for doing the exercise at that time was to keep yourself from nodding off involuntarily, then trying to find something else to keep you busy and engaged is probably the best way to address things. This is again likely to be very idiosyncratic and I know lots of people who spend time before their sleep window doing some general “life admin” (e.g. ironing) that they'd only end up doing on the weekend and thereby freeing up their weekend time. Alternatively, people sometimes choose to use that time for something that they might not otherwise have time for e.g. a hobby or something relaxing and enjoyable. I guess the key is to do something active enough to keep you awake but not so active that it gets the mind and body whirring.

    In terms of the sleep restriction, I can totally understand the trepidation. Sleep restriction is generally the most challenging part of the course but it’s worth bearing in mind that although it’s called sleep restriction, it’s really more about “time-in-bed restriction”. The 'restriction' is only brought down to your average nightly total sleep duration. It’s also worth bearing in mind that sleep restriction (along with stimulus control) is the most effective part of the treatment (with the largest “effect-sizes” in clinical trials). It certainly requires some courage and some gumption but the evidence that supports it is robust and so it’s a core part of the treatment that we recommend. It might be tricky in the short-term but the evidence tells us that it'll improve the consolidation of your sleep and will help you fall asleep more quickly. Hopefully, therefore, the sleep restriction will help improve your sleep so that you don't have to take any more time off. The key with sleep restriction is to stick to the plan and to push through the initial challenge. As the sleep efficiency increases, the sleep window is titrated and increased and with it more sleep. It's tough, but you'll be following in the footsteps of plenty of other Sleepio users along with millions of other people for whom CBT-I has helped improve their sleep.

    Keep up the great work and remember that the community is here to support you!

  • Sleepio Member

    • 3 comments
    • 0 helped
    in reply to Sleepio Member
    Graduate

    I wrote in earlier today but am not sure how this works. Do I need to ask you the question personally, or do you read and reply to my earlier message?
    C.

  • Sleepio Member

    • 14 comments
    • 8 helped
    in reply to Sleepio Member
    Graduate

    Trevbo, I just asked almost the same question(and then deleted it) as I think, looking at the first question above and the doc's first set of lengthy comments that he will be responding to each of our, already submitted questions in turn. But I'm new to this so could be wrong.
    Carty

  • Sleepio Member

    • 121 comments
    • 45 helped
    in reply to Sleepio Member
    Expert

    Hi Mint2,

    Thanks for the question and I'm really sorry to hear that you're feeling a bit dejected. I can understand why you might be feeling that way – it's not easy when this kind of thing happens.

    Without knowing a little more about what's going on it's difficult to comment on specifics. However, we do know that insomnia does tend to rear it's ugly head periodically even for people who've nailed it before. For whatever reason, something happens and it feels like all the hard work we put it has been lost – back to square one.The main thing is to remember that you know this situation well – this is where you were when you started Sleepio. Of course, the follow-on from this is that you know that you can beat it again!

    I'm sorry the techniques that you've tried haven't hit the spot straight away. Remember though, if we'd given you just the relaxation and the anxiety techniques back when you were new to Sleepio it may not have been that helpful back then either.

    My advice would be to put your skills back into action once again. Open up your library and step back in time. Allow yourself to put down the weight of having to “make it work” again and simply retrace your steps through the programme thus far. It might be that you find it easier this time. The important thing to remember is that you're never lost, you can always go back a step and start again – the science and the programme don't change.

    Nil desperandum!

  • Sleepio Member

    • 121 comments
    • 45 helped
    in reply to Sleepio Member
    Expert

    Hi CrouchingMouse,

    Great question, thanks.

    I'm sorry to hear things are tricky. As I mentioned a bit earlier, Sleep Restriction (as unpalatable as it is!) is one of the most powerful elements of the treatment. Although it's great for helping to consolidate fragmented sleep, it's also great for helping us fall asleep quickly (i.e. reducing sleep onset latency). The theory behind it mainly relates to 'priming' the homeostatic sleep drive, one of the two main ways by which our bodies regulate our sleep-wake cycle. The trouble is that it often requires people to get up in the morning when they're still sleeping (and feel like they're 'catching up'). The 'catching up' is the bit that's problematic as when we sleep in past the window, what we're doing in essence is to release pressure from the homeostatic sleep drive, the very opposite of what sleep restriction sets out to do.

    The two techniques (Sleep Restriction and Stimulus Control) work in tandem. They're the most powerful elements of the treatment and are backed up by solid evidence-bases. Whilst the Sleep Restriction is about helping you to keep the sleep pressure topped up so that you fall asleep quickly (and stay asleep), the Stimulus Control works by re-establishing an optimal bed=sleep association, something which has often become disrupted in people with poor sleep.

    In short, using them both together (and following the plan) is probably the best bet! Well done on managing the QHR so well. See if you can use some of that willpower on keeping to the sleep window and let us know how you get on!

  • Sleepio Member

    • 121 comments
    • 45 helped
    in reply to Sleepio Member
    Expert

    Hi Ali,

    Thanks for the question and welcome! At the risk of making myself sound like a fool – I'm feeling a bit confused: if you're able to drop off at 11 and then sleep through until 8am, I'm not sure what the problem that you have with your sleep is?

    If the programme has reduced your sleep window based on your sleep diary, that would suggest that your sleep efficiency is a little low (i.e you're spending significant periods of time in bed awake). Is that not the case?

    If so, the rationale for reducing the sleep window is to consolidate the sleep and reduce the night wakings. As I mentioned in my earlier answers, the way Sleep Restriction works is by reducing the time that you spend in bed so that the time in bed is the same as your average total sleep time. By chopping off the ends of the sleep window, the sleep becomes consolidated and less fragmented. The way this works is primarily by priming the homeostatic sleep drive (sometimes called 'sleep pressure') which is one of the two ways by which our sleep-wake cycle is regulated. In essence, it increases your sleepiness so that when you get into bed you fall asleep quickly and stay asleep. This isn't your new sleep window for ever, and as your sleep efficiency increases, so will the sleep window. The important thing there is that it is done gradually, so that the 'sleep pressure' continues to do it's thing.

    I hope this makes sense!

  • Sleepio Member

    • 121 comments
    • 45 helped
    in reply to Sleepio Member
    Expert

    Hi Trevbo,

    Thanks for your great question. It's a bit of a complex one to answer and so I'll do my best.

    It sounds like it'd probably be best to do the sleep restriction when you have a relatively stable period of time, rather than when you're travelling. Incidentally, there's an article on this kind of thing here (https://www.sleepio.com/library/article/im-going-on-holiday-should-i-stop-the-sleepio-cour/)

    Jet-lag and dynamic schedules can be really disruptive for people's sleep and it's important to remember that there are two processes that regulate our sleep. The first one, the homeostatic sleep drive, is something that we've talked about already this evening quite a bit. Essentially, we build up our sleep pressure ('sleepiness') from the moment we wake until the pressure is released when we go to sleep. The second process is called the circadian process and is essentially linked to our internal body clock. This is where our brains take in information from the world around us (principally through natural/ambient light) and determine whether we should be awake and active or resting and asleep. The key thing about these two processes are that they need to be in sync to be running optimally. Often when we change our schedules (for example with jet lag), the shift in timing will affect both processes. If we go to sleep earlier, the sleep pressure will have been 'released' that little bit earlier and so we'll wake up early. If we do the opposite and sleep deprive ourselves a bit, we'll notice that we might not have released all that sleep pressure if we continue to get up at our regular time. Changes to the circadian rhythm (particularly when we change our external environment – i.e. through long haul travel) mean that the circadian rhythm takes time to catch up. An example of this is our bodies being on New York time when we're in Hong Kong after a long flight. The body does 'retune' to wherever it finds itself, principally through light but also through other signals such as activity, meals, sound, temperature etc. The trouble is that this retuning takes time and if we've already moved on somewhere else or if we've changed our sleep window to try and cope with some of the difficulty, the body might get even more confused.

    Managing frequent jet-lag can be quite a complex issue in itself. Most people will actively use a kind of 'sleep restriction' when they go on holiday or overseas for travel. They'll simply try to keep their sleep to the new night time as soon as they can and try to stay awake when it's day wherever they are. This kind of schedule doesn't preclude you from doing the programme but it does make it a little more challenging. This is why I think it sounds like it would be best for you to try to the sleep restriction when you've got a period of relative stability from travel and schedule.

    There aren't really any easy answers with this one and I hope that all makes sense.

  • Sleepio Member

    • 3 comments
    • 0 helped
    in reply to Sleepio Member
    Graduate

    Thanks, it does make sense; I know most of this anyway, having been looking for an answer for years (hypnotherapy, mindfulness, etc etc). I never have more than a few days in one place, so I guess this may never work. But I'll keep trying for a while. I suppose I'll have to retire eventually – maybe that's the answer!

  • Sleepio Member

    • 121 comments
    • 45 helped
    in reply to Sleepio Member
    Expert

    Hi Cartycater,

    I'm sorry to hear that things have been so tough for such a long time.

    I'll start off by saying right off the bat that CBT-I doesn't work for everyone – I'm not sure if there is any clinical treatment that can honestly boast an 100% success rate. The tricky thing to work out is why some of these treatments don't work for some people. Sometimes this can be about chronicity (i.e. how long someone has been struggling with something – old habits die hard etc.) but in my experience it tends to be more about complexity. If there are lots of different factors that are impacting upon someone's sleep then there might need to be a more nuanced approach to managing these in a comprehensive manner. It's difficult to be clear what's going on in your case without knowing more about the specifics but giving the full programme a good old go, including the tricky bits, like QHR is a really sensible first step. The key is to give the full programme a go – including things like the QHR. It might be the case that it'll just take a little longer. Just going by my own experience, I see patients for whom CBT-I is over relatively quickly and people for whom things take a little longer. It's difficult to know or predict how people will fare and treatment time can be really variable. When it's tough, it's worth keeping in mind that from the clinical trials that have been done, this is the treatment with the best evidence.

    The QHR is a tough one. You've clearly got the theory – it's all about re-establishing a healthy bed=sleep association. It sounds simple but it's a very important part of the process. It's also pretty easy to say and yet, as you say, it's difficult to do. It really requires some gumption to get out of bed when we're really completely zonked and that's where the difficulty clearly lies. Finding small ways of making things easier for yourself might help (e.g. blanket on the sofa, rehearsing where you're going to go and exactly what you're going to do during the QHR period). Reminding yourself of the rationale and really trusting in the theory and research behind it may also help – especially during the night when our perception can be very different to that we experience during the day. Remembering that spending time in bed when you're not asleep only serves to increase anxiety and frustration at not being able to get to sleep and to prolong the sleep disturbance in the long run.

    Keep it up Carty. I know it's tough and doubt can really do much to derail the motivation but keep what I've said in mind. Also, draw on the strength of the community to offer help and support too – that's what it's here for.

    Sending you all well wishes and let us know how you get on.

  • Sleepio Member

    • 121 comments
    • 45 helped
    Expert

    Well, that's all we have time for this evening folks.

    Thanks for the great questions and keep up the great work everyone!

    We'll be back again next week for another Live Discussion.

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