Live discussion with Dr Dimitri Gavriloff - 10th April 2019

Dr Gavriloff will be hosting a live online discussion here on Wednesday 10th April, from 7:30 to 9:00pm British Time or 2:30 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.

Please do note that, as per our guidelines, Dr Gavriloff will not be able to give personal medical advice, including that concerning 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. 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.

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Posted 4 Apr 2019 at 5:33 PM
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  • Sleepio Member

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    Graduate

    I fall asleep quickly but wake very early (~midnight-5:30am, with a SW of 2345-0615). Is there any particular advice about how to handle my mornings, once the sleep window ends? At the moment I'm powering straight into them (immediate caffeine, exercise, lights, work), but I worry that I'm training myself to be wide awake, early.

    Does the standard “avoid blue light in the evening, and seek it in the morning” advice still apply in this case? Making it to 2345 without falling asleep is tough, and I'm alert super early – does that mean that I should actually be trying to shift my clock, somehow?

  • Sleepio Member

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    Graduate

    I have a similar frustrating concern that I want to post here to get advice and guidance. It seems my fragmented early short wakings are much improved overall, but I'm starting to wake about 4 am. I get up and call it a night, since I don't feel sleepy. I'm seeing in the discussions early waking is not uncommon. I now sleep mostly solid those first 3 hours.With my sleep window 12:45-6:30 am, getting 3 hours is a killer after a couple of days. I read an article in the library saying that if the cause is outside depression, anxiety and apnea, over time 60% find that early wakening improves, but can takes >3 months. If I read it correctly (?) that's discouraging.
    I like to believe that the way CBT is set up, as the short sleep nights (with early waking) accumulate so does the sleep pressure (if you can resist naps). Then you're more likely to sleep toward your alarm. The waking time keeps the SW entrained. It seems to make sense the SW will eventually be utilized in gradually increasing amounts, with quality sleep. I want to believe. Is there truth to this? How can I break this cycle?

  • Sleepio Member

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    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

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    Session 1

    hi everyone have a goodnight rest tonight.

  • Sleepio Member

    • 129 comments
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    in reply to Sleepio Member
    Expert

    Hi Mgriffin,

    Thanks for your questions. I think there are a couple of things to touch upon here and so I'll do my best to be comprehensive.

    Generally speaking, for people with insomnia who suffer from early morning awakenings (EMA), I tend to recommend that (within reason) they treat the EMA as a night waking and use the 15-minute rule. If, however, the EMA is very close to the end of the SW (<30 mins), say 5:45 for a 6:15 am rise time, I'd recommend simply getting up and utilising the sleep-pressure boost for the following night. A 5:30 am waking for a 6:15 am rise time is probably an either one or the other scenario. I don't think that you're necessarily training yourself to be wide awake early by managing this in the way that you are at present. It sounds like a sensible approach based on the current situation you're experiencing.

    The next question about the clock is an interesting one. All of us have a natural pre-disposition to our chronotype (i.e. being a 'morning', 'evening' or 'neither' person) and this is often clear to people, at least to some degree, when asked. There are also questionnaires that help people to get a sense of their chronotype (e.g. the morningness-eveningness questionnaire [MEW; Horne & Ostberg, 1976]). For instance, I'm an early type and so tend to peak earlier in the day and need to go to sleep earlier in the evening than my wife who is an evening-type.

    On top of this, one also needs to layer/consider one's total sleep need, which can vary quite a bit even between individuals in similar age groups/demographics. Although the “8-hour a night” line is banded about quite a bit, this is something that is very individual and will likely fluctuate to some degree depending on various other variables. There are those of us who are “short-sleepers”, who naturally require less sleep and there are those who are “long-sleepers”, who require more than average.

    The timing of people's sleep phase (i.e. their natural sleep window – when they naturally tend to fall asleep and wake spontaneously after their sleep need has been met) tends to be in line with their chronotype. Some people experience something that is known as an advanced sleep-wake phase, where their sleep phase is significantly advanced compared to societal timings (i.e. it comes earlier than most). An example of this for someone with a total sleep need of around 7 hours might be the natural tendency to go to sleep at around 9:00 pm and wake at around 4:00 am. A delayed sleep-wake phase would, therefore, be one that is significantly later than most (e.g. 2:00 am to 9:00am). In either case, the person generally doesn't complain of poor sleep if they are going to bed in line with their phase, and once they are asleep they will generally sleep well.

    The admonition about trying to “avoid blue light in the evening, and seek it in the morning” is based largely on what might be sensible for someone with a non-advanced or delayed clock. Broadly speaking, exposure to light before the circadian nadir (when the core body temperature is at its lowest) will delay the sleep phase further and conversely, exposure to light after the circadian nadir has been reached will push the phase back (i.e. advance it). This is in line with something known as a Phase Response Curve and there are different phase response curves for light and for melatonin (i.e. when taken as a medication). The effect of the light is down to both the timing (how much before or how much after the nadir) and the intensity of the light (higher intensity has a more pronounced effect than low-intensity light). The circadian nadir may be conservatively estimated to occur around 2 hours before the person wakes naturally (i.e. at the end of their sleep phase, once their total sleep need has been met). For those with an advanced sleep-wake phase, exposure to bright light in the morning will only serve to maintain the phase, or even advance it further (i.e. keep it early). For these people, we do occasionally use scheduled bright light (known as phototherapy) to help delay the phase and help the person go to sleep later. Likewise, if you have a delayed sleep-wake phase, exposure to bright light before the circadian nadir will delay the phase further and light exposure after the nadir will advance the phase. Phototherapy here is used to help “push” back the sleep phase so that the person goes to sleep earlier and wakes earlier. The key to knowing when to use the light is knowing where/when the person's natural phase falls and then making sure that the exposure to the light is done at precisely the right time.

    I've done my best to explain and type this all out (at the risk of boring everyone with the longest post ever on Sleepio!) but it's very difficult to give advice on clock shifting through this kind of forum because of the other information that's necessary to be able to make a decision (i.e. data on sleep phases etc.). It's worth saying very clearly here that the vast majority of people with EMAs will not be people with advanced sleep-wake phases. If you're in doubt, then it's worth seeking a consultation with a sleep specialist who can analyse the data and help clarify things.

    I'm sorry for a gargantuan post but hope it helps clarify a bit!

  • Sleepio Member

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    in reply to Sleepio Member
    Expert

    Hi Featherly,

    Thanks for the question. I hope the reply to MGriffin's post above might be helpful in response to your question too.

    I think the thing about EMAs (if as you say they are not the result of something else), is that they will improve at different rates for different people and that this will depend on several factors – this makes it difficult to give exact timings on how long they take to improve as a general point.

    As you (rightly) say, the “mild” (I'm sure it doesn't feel mild!) sleep deprivation that is induced as part of sleep restriction will result in the accumulation of sleep pressure, which 'primes' the homestatic sleep drive and helps to induce sleep quickly and maintain sleep continuity throughout the night. Maintaining the same rise time each day is part of both stimulus control and sleep restriction and is very important in maintaining the sleep phase through entrainment of the circadian process by natural light exposure and by maintaining a consistent sleep-pressure. The thing is that it often takes a while for the patterns to become established and so the initial period of sleep restriction is generally quite tricky.

    Hope that helps clarify a bit.

  • Sleepio Member

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    in reply to Sleepio Member
    Expert

    Thanks Lospos, you too!

  • Sleepio Member

    • 129 comments
    • 46 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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