Live discussion with Dr Dimitri Gavriloff - 8th May 2019

Dr Gavriloff will be hosting a live online discussion here on Wednesday 8th May, from 7:30pm to 9:00pm British Summer Time or 2:30pm to 4:00pm US Eastern Daylight 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 she 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 2 May 2019 at 2:47 PM
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  • Sleepio Member

    • 1 comments
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    Session 3

    Im mentally tired but not sleepy because i think i have associated bed with awakeness. Thinking about bed just makes me anxious that it will be another night of wakefulness. I used to sleep at 1.20am latest and sleep almost immediately, waking up only at 7-8 on schooldays and 10 on weekends, i never woke up once at night.

    my problem now is being unable to fall asleep, and when i do, its mostly cycling between NREM1 (light sleep) and wakefulness. I feel like a zombie in the morning but then im not sleepy

  • Sleepio Member

    • 2 comments
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    Session 4

    Similar problem to me. I go to bed around midnight despite not feeling sleepy and irrespective of how bad the previous night was (logic says i should crash out instantly but i struggle again) and can't fall asleep until 5-6am again . Existing on 1-2 hours a day and often zero.
    If i lay on the sofa at weekends in the afternoon and watch TV i can sometimes fall asleep far easier .
    I guess i,ve come to view the bed as the equivalent of the rack from the Middle Ages
    Its as if i,m on some sort of amphetamine at night.

    Luckily i function sort of ok on 1.5 -2hrs but i feel bad when i've had zero. Switching the brain off for even such a short period makes the difference to me.

  • Sleepio Member

    • 2 comments
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    Session 5

    Dear Dr Gavriloff,

    I started on Saturday my sleep window routine, and I have a question re. progressive relaxation, which helps me sleep. I've read about the bed-sleep association, and I wonder if it's ok to practise relaxation techniques, such as the progressive one, in bed, once I've lied down to sleep (instead of reading as I usually do). Hope to hear from you. Many thanks!

  • Sleepio Member

    • 2 comments
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    Graduate

    Hi Dr Gavriloff

    I have a question about how and when to come off sleeping medication.

    I am in week 5 of the Sleepio course, and I have been given a 6 hour sleep window. At the moment I am taking various different types of sleeping medication: melatonin, nytol, phenergan – taking them on a rotating basis so that I am taking 1 of the 3 meds every night. Eventually I want to be able to sleep without them, but I want to get my sleeping back on track before trying to wean myself off.

    Would you recommend that I wait until my sleep window is in line with the amount of sleep I normally need (ie. once I have finished the need for sleep restriction) before I start to do this? I'm worried that when I start trying to wean myself off, I'll get a relapse of insomnia and I will have to start back at square one with the sleep restriction again.

    I'd be grateful for your advice.

    Many thanks

  • Sleepio Member

    • 2 comments
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    Session 4

    My question is regarding the theory of the sleep debt.
    I can go for 3-4 days and have between 1 and 2 hours each night .I can live with that . On the third night my mind seems even more resistance to sleep despite the so called debt building up and i often have zero sleep that night followed by the same the next.

    On night 5 i'll give up and reluctantly take a sleeper like zoplicane i have a few of to break the cycle. .
    I of course sleep well on the medication but refuse to continue longer than a single day on it and my sleeping the next night returns to what it was a few days previously but ironically sometimes a little better for a while.
    In my case a sleep debt does not seem to accumalate ,only more or harder sleep resistance.
    It would be so easy to continue to take the pill daily but its a route i,m unwilling to take and will just tough out the insomnia for several days until i get 2 zero sleep nights one after each other
    Zero sleep for more than 2 consecutive days and i start to really feel like my brain is floating in a dark custard like fog.

    Would be grateful for your thoughts on this
    Kind Regards

  • Sleepio Member

    • 3 comments
    • 0 helped
    Session 4

    Hello,
    Can breaking with a nicotine addiction cause serious insomnia? I stopped smoking cigarettes 75 days ago, I quit smoking in one day, 75 days ago I also had a laparoscopy (removal of twisted ovarion – 8 cm).I spent 8 days in the hospital. Severe insomnia appeared after 3 weeks after stopping smoking and after surgery. Despite anxiety I have been ill for 15 years and take medication, I have always slept quite well. Now everything has reversed, sometimes I can not sleep 1-3 days, or I sleep with many breaks into the night, I wake up an hour or one and a half after falling asleep, and so it lasts until the morning. I am exhausted by the lack of sleep, I stopped working because I was unable to work from exhaustion. Is it possible? How long can this insomnia last?
    Would be grateful for your answer.
    Kind Regards.

  • 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

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

    Hi Auntie Hoho,

    Wowza! What an absolutely lovely bit of feedback with which to start this evening’s discussion – thanks! I’m really glad that you find it helpful – that’s what I’m aiming for!

    First off, it is great to hear that you’re doing so well – that’s fabulous news. Well done!

    It’s clear that the intermittent early awakenings are sub-optimal. There are all sorts of reasons why these might still be happening, but it seems like you’re managing them well and, as you say, you’re willing to put up with them. I think it’s worth remembering that we all have variability in our sleep, regardless of whether we consider ourselves “good” or “poor” sleepers. One of the key differences between “good” and “poor” sleepers here though is the way in which this variability is made sense of or appraised by the individual. Our sense-making of the variability can be a stimulus for us to change our behaviour in a way that may make our sleep worse. There is, of course, the chance that the variability itself becomes a source of angst and then perturbs the whole thing once again and so it’s worth watching out for that one. From what you say it sounds like you’re managing these awakenings sensibly and not putting too much store by them because of the context in which they’ve arisen (i.e. a vast improvement overall). However, it’s worth bearing in mind that sleep is intrinsically linked to daytime function too and so we’ll definitely get similar variation in our daytime functioning from day to day. This may or may not be linked to our sleep (sometimes it’s pretty obvious but sometimes less so and yet we may still make the causal attribution). It's also maybe worth saying that if we're predicting feeling a bit rubbish, it might be the case that we actively look out for symptoms that “confirm” our sense of how rubbish we feel/ought to feel. Worth pointing out here that I'm not trying to insinuate that this is all in the mind! Our perception of how we sleep probably does affect how we feel during the day in terms of our experience of daytime symptoms. I published an interesting study that looked at this last year (https://www.ncbi.nlm.nih.gov/pubmed/29989248).

    It's also worth bearing in mind that our circadian rhythms do dictate how we feel during the day to a greater or lesser degree. For instance, mood is generally lower in the early hours, as is body temperature, cortisol levels, systolic blood pressure etc … the sequitur for this is that if we get up earlier and we are exposed to natural light earlier than usual, our functioning curves (i.e. our peaks and troughs) will be pulled earlier too.

    In sharp contrast to the theme of your warm feedback, this isn't a simple scientific answer here I'm afraid! I think what I might suggest is maybe doing some behavioural experiments that test your hypotheses about your ability during these difficult/periods). Does the feedback you're able to elicit from yourself about how much you can manage when feeling a bit zonked on those days make any difference? Can I do more than I predict I can manage?

    Hope this helps Auntie!

  • Sleepio Member

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

    Hi Featherly,

    We're grateful for the opportunity to answer them and be helpful! Thanks for the lovely feedback, I'm really glad to hear that the discussion helps and feels supportive. It's not easy beating insomnia (if it were there'd be no need for Sleepio or CBT-I!) and so we're best helping each other out to make the best go of it that we can.

    Sleep quality is a fascinating one – great question. I had someone come and see me in clinic the other day and ask me about the feedback that they'd been getting from their wearable device. They said that although they felt that they'd had a good night and woke feeling like the quality was good, the watch said otherwise! We had a chuckle and talked about how important our subjective sense of quality is – that's all “quality” can really mean, in truth. Simply put, the sense you get when you wake in the morning of how good or poor a night it was is probably where you get your quality rating.

    We tend to get quite interested in the deep vs light sleep distinction and people (probably quite rightly) seem to associate this “deep” sleep with good quality. The thing is that we naturally get our “deeper” sleep (NREM stage 3 sleep) in the first part of the night (first third usually). This “slow wave” sleep is the sleep from which if you wake you'll feel totally disoriented and zonked. The body craves this stuff and gets what it needs of it by hook or by crook (that's why people who are very sleep deprived can fall asleep whilst actually doing something else such as driving). The optimal time to wake is after sufficient sleep and at the end of a sleep cycle. For some, this might mean at the end of a morning REM period or from relatively light N2 sleep as a result of an alarm, morning noise or daylight. If we wake mid-cycle or after a period of REM during a period of high-stress or anxiety we might also feel a bit more groggy or disoriented (something we call sleep inertia). This probably then impacts quite a lot on the degree to which we feel we've had a good night and on our appraisal of our sleep quality.

    In short – there's no right answer, just how we feel about the night! Hope this makes sense!

  • Sleepio Member

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

    Hi Vreni,

    Thanks for the question. I think it's an interesting one. It's difficult to say with any certainty and I certainly don't mean to dismiss your observations but I expect that to some extent, you're probably not seeing as much of the clock as it might seem! We do cycle through sleep in chunks (helpfully termed “sleep cycles”) that last about 90/100ish minutes. Lots of us wake very briefly after each cycle and for many people, it's simply a case of going 'num num num', flipping the pillow to the cold side (my favourite) and then falling back to sleep. For many of us who struggle with sleep, however, these awakenings might be seen as problematic and a sign of broken sleep, thus triggering some arousal (angst) and then a check-in with the bedside clock.

    It's also worth mentioning that there are fairly well documented changes in our sleep make-up (what we call 'sleep architecture') as we get older. Older people tend to have less slow-wave sleep (see above posts) and will spend more time in the lighter stages of sleep (N1 and N2), which might explain what you're experiencing.

    I'm reassured that you feel that this doesn't affect you a great deal during the day and that you're doing so much too – that sounds fabulous! I notice that you're still in the early stages of the programme and so my advice is to stick with it, particularly if you feel that there are things that are worth working on.

    Hope this helps explain things a bit and thanks for the question!

  • Sleepio Member

    • 121 comments
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    in reply to Sleepio Member
    Expert

    Hi Earlyshift,

    Thanks for the question! Fitting this kind of thing into busy life schedules is clearly one of the more logistically challenging elements of the treatment. I suppose, there's no easy answer here and it really requires making sense of whether there are things that you feel you might be able to move around the alleviate some of the difficulty (e.g. evening commitments or business trips). When it comes to travel or holidays, there's an interesting library article here (https://www.sleepio.com/library/article/im-going-on-holiday-should-i-stop-the-sleepio-cour/).

    In terms of giving yourself a wind-down after a late night – this is going to probably vary from individual to individual. The bottom line has to be, experiment and see what works best for you. There might be sense in giving yourself a brief window in which to wind-down formally before initiating the sleep routine and heading to bed, then again you might be so zonked that you fall straight into bed. Either way, the guide will be what works best for you.

    When it comes to sleep restriction, the principal mechanism of action is the increase in 'sleep pressure' through the homeostatic sleep drive. If you miss an hour of the sleep window and so get a shorter night that night, that may make you a little more tired the next day but will only serve to work _with _ the priming of the homeostatic sleep drive for the following night. Hope that makes sense.

    Although we tend to advise eschewing naps completely during the treatment in line with stimulus control guidelines, if there is a risk involved (say in driving somewhere when very sleepy) it would be worth taking precautions to ensure your (and others!) safety. That might mean having a very brief nap (say 20 mins or so) before the drive and ensuring regular rest stops. Moving the rise time is probably less optimal because that affects the circadian process that regulates our sleep. Light entrains this and exposure to light at different times essentially 'confuses' the body clock and may lead to complications with the sleep phase.

    I hope this makes sense!

  • Sleepio Member

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

    Hi NoelleChu,

    Thanks for the question. The bed-sleep association is an important one. It might sound a bit far fetched when first you come across it (particularly when it's being explained by a psychologist like me!) but it's pretty solidly based in behavioural science. Paired associations (as they are known) exist all over the place. If I were to ask you to come down to the tennis courts with me and asked that you bring a racket and some tennis balls, without telling you that it was my intention for us to play tennis, you'd probably prepare yourself to play tennis. It follows then that if we arrived and I told you that we were there to make some handmade pasta instead you'd rightly be confused. If over time I invited you to the courts again and again and we did activities that didn't include tennis (e.g. learning to play the piano, flower arranging, alchemy etc.) you'd soon lose the paired association between going to the tennis courts and playing tennis. It's a similar case of affairs with bed and sleep. When sleep becomes disturbed, although we know there is an association with bed and sleep, the other associations (e.g. between bed and feeling frustrated at not sleeping etc.) tend to become stronger. Part of the treatment (called stimulus control) is all about reinstating and strengthening that association between bed and falling asleep (and doing so quickly).

    It also sounds, from your description that you're probably a later chronotype (more of an evening person than a morning person). The cycles in the past sound more like a delayed sleep-wake phase where your body clock is set a little later and so you fall asleep later. Trouble is that you then had to get up early for school and so necessarily had to chop the end off your sleep. This you then caught up on the weekends (i.e. 10am wake) and you probably had a slightly later natural rise time than the weekday rise time (which was presumably alarm-clock assisted). The lack of night wakings makes sense within that formulation.

    As you say, it sounds like the arousal (particularly re the disrupted bed-sleep association) may be inhibiting your ability to fall asleep initially, but it might also be worth thinking about your sleep onset time – if your body clock is still later then getting into bed too early will result in difficulty falling asleep.

    I'm also aware that you're still in the very early stages of the programme and so it's worth going with the flow of it and letting the treatment do it's work. The part of the treatment that deals with the bed-sleep association (stimulus control therapy) is one of the more clinically “powerful” elements of the treatment and this is something that is covered fairly early on.

    Hope this helps and best of luck with the programme. Let us know how you get on!

  • Sleepio Member

    • 121 comments
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    in reply to Sleepio Member
    Expert

    Hi Pinhead54,

    Thanks for the questions! I hope the post above made some sense. I really don't want to short-change you on the response but as your queries are similar I'm going to refer you to the answers above. It sounds like the bed-sleep association is also an issue for you too. Often this is something that I hear people with a delayed pattern struggle with. Because our sleep will naturally come when our body clock allows it to (in line with the circadian process by which sleep-wake is in part regulated), getting into bed too early will likely result in difficulty falling asleep. This would be exemplified in most adults if you asked them to go to sleep at say 6 or 7 pm, for instance. The more we do this, the more we begin to associate sleep onset (and bed) with a frustrating experience and thus arousal ensues that further inhibits sleep. The image of “the rack” is a powerful one! The fact that you might fall asleep more easily elsewhere is also a bit of an indication that the bed/bedroom might now be strongly associated with frustration and arousal that inhibits sleep onset.

    These are important things that are targeted in the programme content. Wishing you well with the next few steps and let us know how you get on.

    Bon courage!

  • Sleepio Member

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    Session 5

    Thanks for your response. I think I may have made the my question a bit too general, but your response has confirmed what I was thinking I'll have to do. In my work rota every now and then I have to do 2-4 consecutive days of working late (arriving home two hours after the start of my sleep window). I can't afford to be too tired on the second & third day if I have to work late then too, and can't afford to risk making a mistake at work. I will try sticking to the normal getting up time and having a nap (which I've sometimes had to do before starting sleep restriction anyway, as a natural early riser).

  • Sleepio Member

    • 121 comments
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    in reply to Sleepio Member
    Expert

    Hola Necesitodormir,

    Gracias por su pregunta (thanks for your question)! Progressive Muscular Relaxation is a great one and I'm glad to hear that you're finding it helpful. Although I take your point re the bed-sleep association, there's no problem in practicing that in your bed, should you find it helpful. I suppose this is particularly if it's only for a few minutes before you nod off. Ideally, I suggest to people that they practice the relaxation techniques somewhere where they're able to relax and engage with the technique. It could be, for instance, that there is a quiet space on an armchair in the living room. If you find the bed a very challenging place in which to be then doing the practices elsewhere is probably helpful. So long as you're finding the practice soothing, soporific and helpful for getting you to sleep then you probably don't have to worry too much about the bed-sleep association here because it will be associated with being relaxed and falling asleep. There are probably other opinions out there from other clinicians but that's my take on it!

    Hope it helps.

  • Sleepio Member

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    in reply to Sleepio Member
    Expert

    Hi Rosie88,

    Thanks for the question. It's a useful question and I don't mean to be dismissive but we have a policy of not giving any advice on medication during these discussions and so I'll have to refrain from that I'm afraid. The best thing to do is to have a chat with your GP (or whomever prescribed the promethazine and melatonin). Making sure you talk through a good plan for gentle discontinuation is something that you can do with them and feel confident about continuing the programme. It's something that lots of Sleepio users do and CBT-I is often done in the context of people taking sleeping aids or discontinuing them.

    Sorry to not be able to be more helpful here! Keep up the great work with the programme!

  • Sleepio Member

    • 121 comments
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    in reply to Sleepio Member
    Expert

    Hi Pinhead54,

    Thanks for the question. Sleep pressure is the build up of “sleepiness” throughout the day as part of the homeostatic sleep drive, one of the two processes by which our sleep-wake is regulated. When we sleep, our sleep pressure is 'released' and we wake with a 'clean slate' with it then building again throughout the next wake period. For those of us who don't manage to get rid of our accumulated sleep pressure overnight, we may retain sleep pressure the following day, a “sleep-debt”. The thing about sleep-debt is that although we may be completely zonked, our anxiety/frustration/arousal linked to the sleep disturbance or associated with the bed (“the rack” as you brilliantly put it above!) is something that 'trumps' the sleep pressure. The “sleep effort” we may feel that logically follows nights of unsatisfying sleep then also impedes sleep onset and so makes things more tricky. Of course, this is all happening in the context of our bed and so is steadily disrupting the bed-sleep association, compounding the problem.

    Sleep debt is an interesting one. The degree to which people can manage in the context of sleep debt can vary considerably and is based on several variables. It's also something that is dealt with quite efficiently by the body and something for which we get quite a good 'rate of return'. The debt and what we need to do to catch up on it are not equal in value, i.e. if you don't sleep for a whole night, you don't have to catch up your entire night of sleep. It might be that in part you're catching up a substantial portion of the sleep debt when you use zopiclone to help you off to sleep. The better nights that subsequently follow are then dealing with more of the debt.

    I hope that helps clarify a bit. It certainly sounds like a really tricky pattern to find yourself in and I'm sorry it's so tough. The good news is that this is exactly the kind of thing that CBT-I is designed to work on and so you're in the right place to be working on it!

    Best of luck with the programme!

  • Sleepio Member

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

    Hi MMaria,

    Thanks for the question. I'm sorry to hear that things are so tricky, although great news on stopping smoking. That's a great achievement!

    Smoking cessation is an interesting one and not something with which I'm hugely familiar I'm afraid. I think the main thing to say is that nicotine withdrawal is associated with a range of symptoms. This stands to reason if your body has become used to nicotine for years.

    Although these symptoms aren't necessarily permanent, often acute sleeplessness as a result of a change like this can lead to changes in our cognitions and behaviour that then perpetuate the sleep problems. This is the way longer-term insomnia tends to start and this is exactly what Sleepio and CBT-I are designed to remedy! So you've come to the right place and it's my hope that this will become more clear as you go through the treatment programme. It's worth also looking out for smoking cessation support through your GP or local healthcare services.

    Hope this helps to normalise what you're experiencing a bit and give you some reassurance that CBT-I is the best way to approach the difficulties.

    Wishing you all the best with the programme – let us know how you get on!

  • Sleepio Member

    • 121 comments
    • 45 helped
    Expert

    Well, that's all for this evening folks. Thanks so much for the feedback and the questions. Looking forward to another live discussion next week.

    Keep up the great work!

  • Sleepio Member

    • 43 comments
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    in reply to Sleepio Member
    Graduate

    Thank you! I'm learning that if I make positive intentions to not let negative thoughts about a bad night, rule or even effect my day, they don't :) The mind is so powerful. We can set the stage, so to speak, for a good day, or we can choose to allow negativity from a poor night create a poor day. Grateful for your explanations to increase my understanding! Blessings!

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