Live Discussion with Dr Dimitri Gavriloff - 3rd April 2019

Dr Gavriloff will be hosting a live online discussion here on Wednesday 3rd April, 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 28 Mar 2019 at 1:04 PM
  • 11 comments
  • 8 helped

Comments

  • Sleepio Member

    • 2 comments
    • 1 helped
    Graduate

    Hi Dr Gavriloff, do you have any advice to graduates who hit a bit of a blip in the months after the programme? I graduated over a month ago, with scores mostly over 90% for 4 weeks or more, to the extent that I was given 15mins each week by the prof for 5 weeks straight. Then Monday before last I had a bad night, let myself get a bit anxious again and I'm bumping around 70% now, on account of not being able to get back to sleep after early morning awakenings (and a few <40% with not getting to sleep at start of night).

    I posted on one of the previous live discussions about the fact that I was still waking at 4AM every night, but back then I was able to get back to sleep straight away for the most part and still feel refreshed.

    I'm working to challenge anxious thoughts about sleep, knowing that what worked before will work again. I'm also tackling stress in the day as advised by your colleague. I'm practising the QHR as required, and I know I can get back on track. The bit I can't work out is what to do about my sleep window. Would you advise folks in a similar position to me to narrow their sleep window down again i.e. increase sleep restriction? And if so by how much – back to what you're originally given as a window? The prof doesn't suggest this as such, he's just stopped giving me additional time.

    Thanks in advance.

  • Sleepio Member

    • 2 comments
    • 2 helped
    Session 4

    Dear Dr Gavriloff,
    Sorry if this info is given somewhere on the site and I'm not finding it – things seem to be focussed on on sleep efficiency, which makes sense as I wake up a lot during the night, I'm not so sure on how the length of sleep is going to be addressed…at times when I haven't had difficulties with sleep I seemed to need a good 8-8.5 hours. I haven't been sleeping as much as this for most of this year but am really hoping to reach this amount again and I can't seem to find info on how long the sleep restriction lasts and how it will go about increasing the amount again? I'm (predictably) really struggling with it as I have exams coming up with plenty of stress and need to concentrate and feel pretty delirious during the day. Is there a 'goal' of sleep length that I didn't pick at the beginning? I'm worried I'm training my body to run on very little sleep and it will get even more used to it.
    Any advice would be much appreciated.
    Many thanks,
    Anna

  • Sleepio Member

    • 4 comments
    • 4 helped
    Graduate

    In Sleepio if my sleep window is 12-6 but I only sleep from 12-3 and get out of bed at 3:15, I still get 92% Sleep Efficiency.

    I have seen other Sleep Restriction Therapy courses where the Time Asleep is defined differently and consequently would give a Sleep Efficiency of 50%.

    In Sleepio…
    Time Asleep = Time in Bed – Any time in bed not sleeping

    In other courses…
    Time Asleep = Time in Bed – Any time during the night not sleeping whether in bed or not

    I’m sure there are good reasons why Sleepio is different in this way, but they’ve never been explained and so I’ve always felt like I’m doing an inferior version of SRT. Can you give details as to why Sleepio is different in this regard, and some references that discuss this issue?

  • Sleepio Member

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

    I'm struggling with this as well. I'm definitely a person with higher than average sleep requirements… before the course I felt most refreshed with about 8.5 hours of sleep and now I'm getting 6.75–7.5.

    After a week of SR my average sleep efficiency is 93% (ranging from 91–98%) but the impact of a lower total sleep time is wreaking havoc on my ability to function during the day.

    I can't focus on work, I'm sluggish and in a daze, and I can't stick to my workout schedule because lifting heavy weights in this state is going to lead to injuries.

    I want to stick with it but I've read that TST goes back to normal after about 3 months of SR/CBT but I can't live like this for 3 months. Does the initial shock to the system wear off sooner than that?

  • 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

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

    Are you waiting until the end to answer the questions that have already been asked? I'd love to hear your thoughts on @Wcheallleo and my struggles with total sleep time. Thank you!

  • Sleepio Member

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

    Hi Admcd45,

    Thanks for the questions. I'll do my best to answer each of the points in turn.

    First of all, well done on your initial success and I'm really sorry to hear that you've hit a bit of a blip. Rest assured, this isn't uncommon at all and having small setbacks aren't, in themselves, something to be concerned about. I suppose, as you highlight in your insightful post, the initial blip can both knock our confidence and tip us back into unhelpful patterns that we'd thought we'd done away with. People may be able to stick with the behavioural elements of the programme but often unhelpful patterns of thinking that trigger anxiety seem to pop up again and keep us stuck. I suppose, as you also mention, the most important thing is to remember that if we've done it once we can do it again. Combining Sleepio or CBT-I with anxiety busting techniques from elsewhere can be helpful too and I'm glad that you're putting that into place in your overall approach.

    In terms of the clarification about the sleep window, I suppose there are a couple of options: a) leave it to the programme, b) self-directed restriction.

    The algorithm of the programme should be able to titrate (increase or decrease) your sleep window for you and changes will be made gradually (i.e. in 15-minute increments), which is in line with the accepted protocol for sleep restriction therapy. This should mean that if your sleep efficiency remains low, the window will be shortened over the coming weeks to allow for this. This will obviously require some patience. Although the treatment is only based on a six-week programme, sleep restriction may include several bouts of increasing and decreasing sleep efficiency. Therefore due to this natural fluctuation, the time it takes for this all to work through will vary between individuals. Remember that even though things have changed a bit and you have graduated, the sleep restriction treatment is still working away.

    The other option is to implement the restriction yourself. This is something patients I work with outside of Sleepio do for themselves once the therapy appointments come to an end if they experience a dip in sleep efficiency once again. The amount of time in bed that is used for the initial restriction is based on the total time for which you are asleep each night on average during the baseline period (i.e. before you start restriction). If you do decide to restrict again, then it should be down to the amount of nightly sleep you are getting on average each night now (this is presumably what the programme will do in any case), not the original figure you were given initially as that is now old data.

    The trick is not to allow the natural fluctuation that we experience to mean that we start to change our sleep window too much – inconsistency makes things more tricky in the long run. The programme makes allowances for this and so tries to help facilitate stability in the way in which it changes the timings.

    I hope this helps clarify a bit – bon courage and let us know how you get on.

  • Sleepio Member

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

    Hi Anna,

    No problem at all – thanks for the question – as with lots of these kinds of questions there are various parts to it and so I'll do my best to address each of them.

    We use sleep efficiency as a kind of proxy for how “good” the sleep that night was – the higher the value, the more sleep you got while in bed, the lower the value, the more likely it was fragmented and poorer sleep (i.e. you were in bed and not sleeping). The initial value that we use to determine how long you should be in bed for is the average total sleep time you are currently sleeping for during the baseline assessment (i.e. before you start treatment). If you're only sleeping on average 5 hours a night (despite being in bed for 10 hours) before treatment then we restrict the time in bed to the 5 hours initially, with a view to increasing the sleep efficiency. The sleep window (and therefore the total amount of time you have for potential sleep at night) is then increased by using your sleep efficiency as a guide each week. The higher the sleep efficiency, the more likely it is that if we increase the sleep window you'll be asleep for that extra time. We do this very gradually, partly because the body responds to small and steady change better than to abrupt change, and so it can feel like a very slow process, especially when we're desperate for more sleep. We then continue to increase the sleep window until we arrive at one that is optimised (this may mean that your eventual sleep window is very different from the initial sleep window but also that if you're only changing this by 15 minutes each week, it can take a bit of time to get there). I know it must feel like it but we're definitely not trying to train the body to get by on insufficient sleep – a) there's just no way to do that and b) it's not something that you (or us!) would want.

    The important thing to bear in mind is that sleep restriction is by far and away the most challenging part of the course for most people. However, it is also the treatment for which we have the largest clinical “effect sizes” (i.e. good clinical bang for your buck). It does take some time and patience and so stick with it and don't give up. People with poor sleep often report quite changeable sleep quality and sleep timings (it makes sense that if you have a 'better' night you'll try and catch sleep up, for example) and so getting the body to adapt to a new regimen can have some challenges. The first couple of weeks can seem like little is happening and the daytime effects of the initial restriction can be quite unpleasant. However, the key is to stabilise the sleep window and to make sure that the time you are spending in bed is being spent asleep (as much as is optimal for you). As sleep efficiency increases, the window will get longer! :)

    Let us know how you get on and best of luck!

  • Sleepio Member

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

    Hi DesertPenguin,

    Thanks for the great question – let me see if I can do it justice. I may be confused and so please forgive me if I explain things with which you are already familiar.

    The calculation for sleep efficiency is as follows:

    [Total sleep time (TST)/Total time in bed (TIB)] x 100

    In calculating sleep efficiency, we first calculate total wake time (TWT). TWT is simply the sum of a) sleep onset latency (SOL; the amount of time it takes to get to sleep after getting into bed to go to sleep), b) wakes after sleep onset (WASO; the total time spent awake at night after having tried to go to sleep) and c) early morning awakening (EMA; the time awake from the last awakening to the final 'getting up and out of bed'-time).

    The next step is calculation of TIB (more helpfully referred to as the “sleep window”, i.e. the total time from getting into bed to getting out of bed at the final awakening – this should also include any time that the person has spent out of bed either as part of the treatment or voluntarily e.g. for the 15-minute rule. We don't 'stop the clock' for these bits.) TST is then calculated by subtracting the TWT from the TIB. Then the TST is divided by the TIB (“total sleep window”) and then multiplied by 100 to give a percentage.

    A weekly average of sleep efficiencies is then calculated to give each week's sleep efficiency score.

    I could be just missing something glaringly obvious but I'm not sure why you'd be getting the sleep efficiency score of 92% unless your sleep window wasn't being taken into account properly. Let me chase this up for you.

    I hope the workings out above help clarify.

  • Sleepio Member

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

    Hi Ehstadolnik,

    Thanks for the question (and sorry for taking so long to get back to you on it!). It's quite similar to the one that was posted by Wcheallleo, as you mention and so hopefully you'll have found reading that helpful.

    Sleep restriction _can _ be/*is(!)* really tough, particularly when people start out. The initial restriction does induce some sleep deprivation, which is part of the mechanism and primes the homeostatic sleep drive (our sleep pressure) helping to reduce sleep onset latency (time taken to fall asleep) and increase sleep continuity (sleeping through the night). Despite how unpalatable it is, however, it is one of the most clinically “powerful” treatments we have for insomnia and so we don't recommend it without good reason. Simply put, it's challenging but we know it works. The initial 'shock' should wear off but remember that we're going to (typically) be increasing the sleep window as we go and so things are likely to get a little easier in any case. In part, the initial shock is due to the fact that for many people the body takes a few days to get used to the new sleep-wake schedule.

    It's also very difficult to predict how long it takes for people to return to their optimal sleep window and it's going to vary quite a bit from person to person. Your sleep efficiencies sound great at present and that will mean that you're on track for another 15 minutes of sleep.

    I know it's tough and it might mean adapting things during the day somewhat in the short-term but it's also worth reflecting on the fact that this is a great treatment and it's steadily moving you towards where you want to be with your sleep.

    Keep up the great work and let us know how you get on.

  • 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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