Live Discussion with Dr Dimitri Gavriloff - 27th March 2019

Dr Gavriloff will be hosting a live online discussion here on Wednesday 27th March, from 7:30pm to 9:00pm British Time or 3:30pm 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 21 Mar 2019 at 10:58 AM
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  • Sleepio Member

    • 2 comments
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    Graduate

    I am on my third week of the programme but find it completely impossible to get out of bed even if I have been awake for an hour or more. I can't seem to find the energy to move and consequently lie awake for hours on some nights. How can I make myself do this? Despite this my sleep is improving I think because of the set bedtime and wake time.

  • Sleepio Member

    • 43 comments
    • 12 helped
    Graduate

    I've recently had a weeks' trip but worked hard to successfully stick to my sleep window of 5 hours 45 min. However my SE was poor and gone down. Is this common for travel? I'm feeling very discouraged about the lack of progress. I graduated 3/3. I am concerned about my future trips. Any tips or strategies to help?
    Thank you

  • Sleepio Member

    • 15 comments
    • 5 helped
    Graduate

    Is Sleepio (and CBT in general) useful for sleep issues other than insomnia?

    I'm able to fall asleep and stay asleep, and I have a good sleep efficiency, but I'm never refreshed by sleep (regardless of how much or how little I sleep). My apnea has been (and continues to be) well controlled with CPAP for seven month, but I'm even more fatigued and drowsy than before I was diagnosed (and it continues to worsen). I'm told this is called Residual Excessive Sleepiness, and that it's not well understood.

    Are you aware of recent research on RES? Is there a reason to believe that Sleepio can be useful for such cases?

  • Sleepio Member

    • 5 comments
    • 1 helped
    Graduate

    I have been prescribed anti depressant (citalopram) for anxiety – can we discuss how anti-depressants might affect sleep? I started them at around the same time I started the sleep restriction part of Sleepio course and not sure which is having an affect?

    Also my insomnia started when I had early menopause, would hormone replacement therapy therefore help in managing my insomnia (I used to take it but stopped at age 50)?

  • Sleepio Member

    • 4 comments
    • 1 helped
    Graduate

    I have graduated from the programme, but my early morning waking ( at around 4.15 am) hasn't improved.
    Do I just have to keep working at it?

  • 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 specialising in sleep disorders 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

    • 4 comments
    • 1 helped
    Graduate

    I have finished the course but am still very troubled by early morning waking-around 4.45 am-does this take a long time to resolve

  • Sleepio Member

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    in reply to Sleepio Member
    Graduate

    How do we hear the replies?

  • Sleepio Member

    • 121 comments
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    in reply to Sleepio Member
    Expert

    Hi JoanCph,

    Sure thing! There's not much to go on in your question and so I'll do my best. I suppose there are lots of reasons why people might wake up after six hours and it's going to vary quite a bit from person to person. It's also interesting to note that although most adults need around 7 plus hours of sleep each night into order to feel that they are functioning at a relatively normative level, there are a subset of adults for whom less sleep (e.g. 6 hours) might be sufficient. These people are rather imaginatively named “short-sleepers”. This may or may not apply to some Sleepio users but it's not what most of us experience in terms of sleep need.

    The structure of sleep also changes as we move through the night. Initially, typical sleep is deeper (slow wave sleep) and less easily disturbed. As we move through the night, we experience less slow wave sleep and more light sleep (NREM stage 2) and REM sleep, which is lighter and therefore more fragile. For some people, particularly those of use who experience some degree of anxiety during the day (particularly about sleep and getting enough of it), this lighter sleep can be easily disturbed by active/anxious dream content. We also wake briefly (or at least come up into very light sleep) at the end of our sleep cycles and often people who do suddenly find themselves awake (which is completely normal) get anxious about being awake again and are kept awake by the anxiety.

    In terms of more tools for falling asleep when you're worried and anxious, there are several things that people might find helpful. Much of this is covered in the programme – autogenic training, progressive muscle relaxation, paradoxical intention, thought challenging and diaphragmatic breathing but I also recommend things like a mindful body scan – something that can be found on YouTube as a means of helping to take the focus off falling asleep. Anxiety itself is a short-term process. It's evolved to serve a very distinct (and crucial) role in helping us to avoid danger. However, when we get stuck in a pattern of anxious thinking, we re-trigger and re-trigger the anxiety and so it appears that the anxiety is there to stay. Trying to start noticing these patterns is a crucial first step in managing anxiety longer term. Once we notice them, we can start to change the way in which we interact with some of the anxiety provoking thoughts. One technique I use with some of my patients is to help them see these stereotypical (and very familiar) anxious thoughts as a bit like old friends – “welcoming” them rather than cowering from them. This takes time and is more about the perspective shift that underlies it rather than encouraging any of these thoughts. Another route I sometimes use is to have people see their anxiety as an overprotective parent or a best friend – it's just trying to keep you safe. Sometimes “thanking” ones anxiety and noticing that it's just trying to look out for us is a new way to approach dealing with it. “Thanks again anxiety, I know you're just looking out for me and trying to identify a threat, but I'll be alright this time – I've got this”.

    I know these sound like counter-intuitive ideas but therein lies their power. Changing these old patterns of behaviour does take some getting used to, but will be really helpful in the longer term.

    Hope that helps.

  • Sleepio Member

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

    Hi Daleukkeepswakingup,

    Great that you've identified where you're anxiety is being triggered. Without wishing to shortchange you on the answer to the question, take a look at some of what I've just written in the response above.

    Part of what it sounds like you're experiencing is “emotional reasoning” – using our emotional state to make sense of what's going on. This is exemplified really well when I have to give a talk and as I stand up and look out over a sea of (often eager) faces, my heart and respiratory rate increases. My mind will interpret that as being an indication of danger and threat, and so part of my process is to notice this in my body and actively discount it. It's a bit like burning the toast in the kitchen and having the smoke alarm go off. When we know it's just the toast, we don't have to run around frantically and evacuate the house – we simply flap the tea-towel about and get on with our lives. Part of what I do when I experience my heart rate increasing is just to flap the metaphorical tea-towel and notice that it's just a natural response to a potential threat – thereafter it's “thanks anxiety for looking out for me, but I'm going to enjoy giving this talk now”.

    Hope that helps

  • Sleepio Member

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

    Hi Peter99,

    This is an interesting question. I think there's certainly a possibility that some people who wake too early might be experiencing the result of a circadian rhythm disorder but that is only one of many possible reasons why it might be happening. I suppose that in my mind this is less likely to be to do with the length of the circadian phase but more probably to do with where the phase sits. One possibility that I see incorrectly diagnosed is a significantly advanced sleep-wake phase. This is where someone is tired and goes to sleep very early with no difficulty. However, once their sleep need has been met, they will then wake early too. In my experience, this pattern is rare and more often I see people with the opposite – a delayed sleep-wake phase. With a delayed phase, you see the opposite problem, people getting into bed at what might be appropriate for others but which for them is far too early. They then have a commensurate delay in their rise time and get up later than most too.

    The principal way in which our circadian phase is entrained is through natural light exposure (a 'zeitgeber' or time-giver). Significant light exposure during the pre-sleep period (or before we reach our core-temperature minimum – which is conservatively estimated to be around 2 hours before you typically wake up naturally) will delay sleep and light exposure after the core-temperature minimum (or circadian nadir) will advance it. The effect is, however, relatively mild and so it takes time to shift the phase. Often these sleep-wake phases are linked to our chronotype (being a morning lark or a night owl) and to the length of our circadian phase and so we will have a innate tendency to drift back to where our clock wants to be if we do not maintain it. The best way to maintain your circadian rhythm longer term is to ensure a consistent rise time each day (regardless of whether weekend or weekday) and to get plenty of natural light after having woken up naturally.

  • Sleepio Member

    • 121 comments
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    in reply to Sleepio Member
    Expert

    Hi KySue,

    I can certainly talk a bit about it but it sounds like you're pretty clear about it just being an embedded bad habit. I think we all develop ways of managing our difficulties and if this is something that you've developed over time, perhaps trying to gradually reduce it instead of going cold-turkey (if you'll excuse the expression) is a good idea. There is clearly some element of being able to control this there for you and perhaps swapping out some of the “self-care” element that the eating provides for a relaxation strategy/exercise that you could enjoy might be a good idea? Then it sounds like it's all about practice.

  • Sleepio Member

    • 121 comments
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    in reply to Sleepio Member
    Expert

    Hi Mgriffin,

    This is really timely and thank you for bringing it up. I have a toddler and so, as any of you with children will know, this kind of thing has quite a big effect on ingrained sleep habits and structures too. The simple guideline is do things slowly and gently. If you're going to move things, rather than just deal with the “hit”, it'd be best to do so gradually. 15-minutes sounds like a good number and so gently moving your bed and rise times over the course of a few days will probably be less taxing than just doing it all at once. The cost of doing it gradually is, however, that it's more fiddly and so will require a little more attention. If, however, you're going to just ignore the time difference and let your alarm clock auto-update – which many of them do these days (especially those on your phone), then the change is in the right direction to mean that it will work _with _sleep restriction. Although the hour less isn't what any of us want, it will serve to further prime the homeostatic sleep drive (i.e. increase our sleep pressure) and will help with a swifter sleep onset the next night.

    So there are a couple of ways of approaching it.

  • Sleepio Member

    • 121 comments
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    in reply to Sleepio Member
    Expert

    Hi Surya Muthu,

    Thanks for the question. I suppose if you're struggling with hyperfocus, it's presumably associated with an activity that you're doing in the pre-sleep period. There's not a lot to go on from your question and so I'm making an assumption here. If you do notice yourself getting caught up in hyperfocus in an activity and it's stopping you getting to sleep, or at least keeping you wired in the pre-sleep period, perhaps pushing the activity to earlier in the day would be sensible. Another element to this might include padding out your pre-sleep wind-down routine a little to make it that much more relaxing and soporific. I've often heard people suggesting to people that they should do something they enjoy in the evening to wind-down. I think this is great advice, so long as they bear in mind that it should be something that is not overly stimulating. It's a tricky balance but making sure that it's both enjoyable (to some extent!) and relaxing will probably make it a perfect pre-sleep activity.

  • Sleepio Member

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

    Hi Rosieposie,

    Lots of us really struggle to get out of bed in the morning. When I think things are more tricky for people is when they struggle to get out of bed for the 15 minute rule, when they're not sleeping. I think there are probably several things that might help with this but, in all honesty, the most important one is simple gumption. It isn't easy to do when the house is cold, you're snuggled and you're also knackered, even if you're not asleep. I suppose, in a practical sense, one of the most helpful things to do is to prep what you're going to do and how you're going to do it. This might include putting a chosen book on the sofa with a blanket next to it, it might include putting your dressing gown on the end of the bed or next to the radiator so that you've got something warm to get into – the most important thing, however, is that you know what the plan is and that you've tried it out whilst awake. Another strategy is to reflect on the fact that we know staying in bed when we're not asleep isn't going to help in the long-run. If you want things to change, the evidence suggests that getting out of bed is a good idea. Don't beat yourself up about it though, if your sleep is improving and you feel alright lying in bed and doing a relaxation exercise instead, then try that or an exercise like paradoxical intention. The key is that we're clear on what we're going to do and we're doing something that is likely to be helpful. Lying there beating yourself up about not getting out of bed is neither! :)

  • Sleepio Member

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

    Hi Featherly,

    Thanks for the question, it's an important one. Clearly there are going to be lots of reasons why we might struggle when travelling. Part of it can be the general disruption (new bed/hotel room/stress etc.) and part of it could be due to jet lag and changing time-zones. It is relatively common for travelling (and certainly common for travelling long distances – hence we have a name for it: “jet lag”). In terms of future trips, there's a library article on travel that might help: https://www.sleepio.com/library/article/im-going-on-holiday-should-i-stop-the-sleepio-cour/

    I'll also suggest to the team that we might want to write some more on shifting sleep when going abroad – thanks for the prompt!

    I suppose the best thing now is to settle back into your routine again, you've got your sleep window and you can keep on with that. Stability will help and just as you saw before, your sleep efficiency will improve again. I know it must feel disheartening but remember that you've graduated and got through the programme and so can go back and use all the techniques that you now have in your repertoire.

  • Sleepio Member

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

    Hi NeverRefreshed,

    Your username says it all, eh? I'm sorry to hear that things are so tough. Residual Daytime Sleepiness is not something I know a huge amount about and being a clinical psychologist Sleep Disordered Breathing is not something I have a huge amount to do with clinically or in research. However, many people report unrefreshing sleep – there is a library article that touches upon this https://www.sleepio.com/library/article/what-accounts-for-unrefreshing-sleep-/

    I think this might be another area for a possible update on library articles though and so thanks for another prompt.

  • Sleepio Member

    • 121 comments
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    in reply to Sleepio Member
    Expert

    Hi ElleT,

    This is another important area, particularly because many people with insomnia take antidepressant medication, for both the antidepressant effects on mood disturbance but also because some of these medications have a sedative profile. Citalopram, for example, does have some sedative effects. There is a library article that looks at this in more depth here: https://www.sleepio.com/library/article/antidepressants-and-sleep/

    I'm afraid I'm not able to give any advice on whether or not to commence a pharmacological treatment but it's worth having a discussion with your family doctor about HRT if you think it might be of use. There are a couple of articles that look at the menopause and sleep in the library too:

    https://www.sleepio.com/library/article/menopause-and-sleep-problems/

    https://www.sleepio.com/library/article/menopause-and-sleep/

    https://www.sleepio.com/library/article/hormones-and-sleep-a-two-way-street/

  • Sleepio Member

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

    Hi Dory2,

    Thanks for the question. I'm sorry to hear that you're still waking early. It's tricky to get a sense of why this might be the case without more information. I suppose in part (silly though it may sound) this depends on whether or not you feel like you've had enough sleep by that time. If you're going to bed very early because you're tired then it could be that your sleep phase is quite advanced (see the response to Peter99 above). If, however, you've woken later during periods of better sleep then this is unlikely to be the case. The response to JoanCph's question above might also be helpful in terms of thinking more about why you wake early and what might be helpful to do about it.

    Do come back to us with more information or further questions if we can help iron it out though.

  • Sleepio Member

    • 121 comments
    • 45 helped
    Expert

    Thanks for the comments and questions today everyone. We'll be back again next week to pick up where we left off with another live discussion.

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