Live Discussion with Dr Jen Kanady - 13th May 2020

Dr Kanady will be hosting a live online discussion here on Wednesday 13th May from 8.00pm to 9.30pm British Time or 3.00pm to 4.30pm US Eastern Time.

They will discuss as many topics as possible in the hour 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, they may not be able to answer all in the time available, but will try to answer as many as they can.

Please do note that, as per our guidelines, Dr Kanady will not be able to give personal medical advice including those about medication. Their 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 8 May 2020 at 12:30 AM
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  • Sleepio Member

    • 2 comments
    • 0 helped
    Session 4

    Hi Dr Kanady,
    I have been suffering with anxiety and unable to sleep. Over the last week I've managed to get to sleep but wake up regularly after about 4 hours sleep. I'm then unable to get back to sleep deeply and end up dozing in a state of semi-consciousness and when I wake up in the morning I feel completely drained. Unfortunately I tend to drift back asleep within the 15 minutes and so never get up, but the sleep I get is really poor and I sort of drift in a semi-conscious state for most of the night with lots of dreams. Should I stay up late until very tired to try to get a better night? And why do I feel so ill the next day after light sleep?

  • Sleepio Member

    • 388 comments
    • 122 helped
    in reply to Sleepio Member
    Expert

    Hi Mike,

    Thanks for reaching out and I am sorry to hear that you are continuing to struggle with your sleep. It sounds like you are doing some really great work and to not see the payoff must be very frustrating. I have a couple of initial thoughts related to your situation.

    In terms of your 3:00 AM awakenings, it sounds like you have engaged in some really creative problem solving. It’s great that you have been experimenting with both the QHR and relaxation techniques and I am sorry to hear that neither have yielded much benefit. I am curious if you have tried any of the other cognitive techniques introduced during session 4 and session 5 of Sleepio? One thing that may be helpful is to pay attention to the thoughts that you are having when waking at 3:00 AM and then using cognitive techniques to reduce these thoughts. For example, if you wake up at 3:00 AM and immediately start thinking about what you have to do that day, one technique that could be helpful is writing your to-do list before getting into bed that night. Or if you wake up and start worrying about various different things, the “scheduled worry time” technique might be helpful. Or, if you are experiencing sleep related worries, you can try the technique of challenging unhelpful thoughts. One thing to note about both cognitive and relaxation techniques is that it is best to practice them when you don’t feel anxious. If you are able to master the skill when you aren’t feeling anxious, they will be easier to apply when you are feeling anxious.

    It is also worth noting that sleep restriction is anxiety-provoking for a lot of people, but for some it is especially worrisome. In those cases, an alternative to sleep restriction is something called sleep compression. Sleep compression is gradually decreasing the sleep window rather than gradually increasing the sleep window. For example, if you are sleeping 5 hours, but are spending 8 hours in bed, you gradually decrease the sleep window by 15-20 minutes per week until you see a sleep efficiency of above 90%. E.g., week 1, your sleep window is 7.75 hours, week 2 your sleep window is 7.5 hours, week 3 your sleep window is 7.25 hours … and so on. Once you achieve the 90% sleep efficiency, you can either keep your sleep window as is or start to gradually increase the sleep window again. The important thing to pay attention to is how you are feeling during the day rather than how much sleep you think you “should get.” While 8 hours is the typical recommendation, that need for sleep actually differs from person to person. You may find that you function just fine with 6.5 hours, for example.

    One final note is that Sleepio is a self-help program. For individuals that find that they are having a hard time tackling sleep on their own, the general recommendation is to consult a doctor. If you are applying all the skills taught in Sleepio, but are still struggling with sleep, you may want to consider consulting a physician about more personalized care.

    Thanks, Mike. Please feel free to reach back out and keep us posted!

  • Sleepio Member

    • 388 comments
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    in reply to Sleepio Member
    Expert

    Hi Rheum,

    Waking before your desired wake time can be so very frustrating. It sounds like you are already engaging in some creative problem solving about these awakenings. I think that both the options you highlighted would work just fine, it just depends on your preference (i.e., whether you want to keep 7:00 AM as your rise time). If you want to keep 7:00 AM as the new rise time, I would still generally recommend shifting your bedtime earlier gradually. For some, moving the bedtime too much too fast can result in difficulties falling asleep at night. Gradual changes create less of a “shock” to the system.

    Please feel free to reach back out with any additional questions or information. And please do keep us posted about your progress!

  • Sleepio Member

    • 388 comments
    • 122 helped
    in reply to Sleepio Member
    Expert

    Hi gravesjs81,

    Great questions, thanks for asking. The QHR can be really tricky! One suggestion is to not worry too much about how much time has passed. The 15 minute rule is really meant to be your best estimate. It can also be applied in a way that works best for you. If getting out of bed after a few minutes is less anxiety provoking, then that sounds like a good option. The one thing I would caution is making sure that sleep happens in your bed only (e.g., as opposed to other locations, for example the couch). That way you are reinforcing the association between the bed and sleep. And it sounds like you are paying attention to that, so keep it up!

    Sleep-wake transitions and transitions between different sleep stages can sometimes be associated with feelings of disorientation and confusion. E.g., not knowing whether you are awake or asleep. And as you guessed it, sleep deprivation can exacerbate these feelings of confusion. Interestingly, recent research suggests that we may need to look at sleep in a slightly different way from how we used to. It has traditionally been believed that the whole brain acts in a certain way when going through various sleep phases, however it may be the case that some of the brain, when sleep deprived, can act out-of-sync with the rest; some neurons are in sleep-mode, while others are in wake mode. This may lead to these strange phenomenons … isn't sleep interesting!

    Thanks for the great questions. Best.

  • Sleepio Member

    • 388 comments
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    in reply to Sleepio Member
    Expert

    Hi again Jemisaac,

    Another great question. It sounds like you are familiar with the idea of sleep debt, but to explain this model for those who may not be familiar:

    Sleep debt is essentially the idea that we accumulate sleep loss over time, accruing a debt that needs to be repaid. Fortunately, this is where the sleep debt model breaks down. Research demonstrates that you only need to make up for approximately ⅓ of sleep lost. Also, research suggests that the sleep achieved following a poor night of sleep may be deeper and more restorative. This is important to point out as some individuals try to make up for lost sleep by doing things like sleeping in on the weekends. Unfortunately, this can have an unintended consequence. While sleeping in on the weekend may feel good in the moment, it actually confuses the circadian rhythms and makes sleeping on subsequent nights more difficult. That is why it is recommended that individuals keep a consistent rise time, even if they didn’t get a good night of sleep.

    Another thought about sleep debt and sleep restriction: Sleep restriction works by restricting the time in bed to the actual amount of time spent asleep. So while some sleep deprivation may be accumulated through this process, total sleep time doesn’t often change significantly from pre-sleep restriction to post-sleep restriction, but sleep efficiency does! In other words, you are using your sleep period more efficiently and sleep is more consolidated.

    One final thought: sleep-related worry is often a maintaining factor for insomnia symptoms (e.g., worrying about the consequences of sleep debt). I see that you are on session 3. During session 4 and 5 of Sleepio, you will learn some cognitive techniques that can be helpful for combating sleep-related worries. After learning these techniques, if you have any follow-up questions, please don't hesitate to reach out.

    For more information about cognitive techniques, you can check out either of these Sleepio articles:

    1. https://www.sleepio.com/library/article/challenging-your-thoughts/

    2. https://www.sleepio.com/library/article/cognitive-techniques-in-depth/

    For more information about sleep debt, I would encourage you to check out this Sleepio article:

    https://www.sleepio.com/library/article/should-you-try-to-make-up-for-lost-sleep-on-subseq/

    Best wishes.

  • Sleepio Member

    • 388 comments
    • 122 helped
    in reply to Sleepio Member
    Expert

    Hi Iris Helen,

    Wow, that sounds incredibly frustrating. It sounds like you have put in so much good work and have incorporated some great lifestyle changes; I am sorry to hear that you are still experiencing RLS symptoms. Unfortunately, Sleepio isn’t a treatment for restless leg syndrome or other sleep disorders. For problems related to restless leg syndrome or other disorders, the recommendation is to consult a medical professional as they will be able to advise you properly.

    In case helpful, please find some Sleepio resources about restless leg syndrome below:

    Sleepio library article about restless leg syndrome: https://www.sleepio.com/library/article/what-is-restless-legs-syndrome-rls/

    A community discussion about restless leg syndrome: https://www.sleepio.com/community/discussion/does-restless-leg-syndrome-keep-or-wake-you-up-dur/

  • Sleepio Member

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

    Thank you very much for your reply.

    I have actually increased my sleep window by 1hr45 the past two nights as I was really struggling. I still got a sleep efficiency of 93% and 87%... i figure this is probably okay as improving sleep efficiency is the whole aim of sleep restriction… is that right? I just want to clarify that point as I do want to get the most out of the course. I think I might have possibly been underestimating the amount of sleep I was getting in my sleep diary some nights leading to a very short sleep window being calculated. Do you think sticking to this new plan of increasing my sleep window by 1hr45 and then increasing by 15 mins from there sounds okay??

  • Sleepio Member

    • 388 comments
    • 122 helped
    in reply to Sleepio Member
    Expert

    Hi Helen Mac,

    I am so glad that you asked this question! Your intuition is correct … no, the goal should not be to sleep through the night without waking. Everybody wakes up in the middle of the night, it is unavoidable. Some people just don’t remember these awakenings. Middle of the night awakenings only become problematic if they are prolonged and/or if they cause significant distress.

    I am sorry to hear that sleep restriction and QHR caused more sleep-related anxiety. Unfortunately, some people do experience this. One thing I like to emphasize in these cases is that these techniques are flexible and don’t need to be exact. For example, for the QHR, the 15 minutes is meant to be your best estimate and serves as a guideline. If getting out of bed after 5 minutes makes more sense, then it can be the 5 minute rule. Same thing with the sleep diary. When estimating how long it takes to fall asleep, this is also meant to be your best guess. No need to clock watch and be exact as this can be more anxiety provoking!

    Sleepio is a self-help program and it is up the the individual to figure out how best to apply the techniques taught in the program. It sounds like you were able to adapt the Sleepio program for you and your needs, which is so great. If QHR and sleep restriction were too anxiety provoking and weren’t helpful, then removing them from the program likely makes sense for your situation.

    Really appreciate you taking the time to share your experience!

  • Sleepio Member

    • 388 comments
    • 122 helped
    in reply to Sleepio Member
    Expert

    Hi Mrs. Beaver,

    Thanks for reaching out and congratulations on almost starting sleep restriction. Sleep restriction will be one of the most powerful tools in your sleep toolbox. Please reach back out if you have any questions about sleep restriction once you have adopted your new sleep window.

    And thanks for the great question. The passive vs. active activities highlighted in Sleepio are really meant to serve as a rough guideline. For some individuals, reading in the middle of the night is not a good idea because reading is too engaging/stimulating. If you are in the middle of a good book, that may not be the most sleep-promoting activity to do. Same thing goes for television. Television may also be very engaging for some and may not be a good middle of the night activity. I typically recommend that people experiment with middle of the night activities and figure out what works best for them. The general rule of thumb is that you want these activities to be relaxing, sleepiness-promoting, and these activities should be done in dim light conditions.

  • Sleepio Member

    • 388 comments
    • 122 helped
    in reply to Sleepio Member
    Expert

    Hi Barbarah11,

    Welcome to Sleepio and your first live session, happy to have you! As I mentioned to Mrs. Beaver above, sleep restriction will be one of the most powerful tools in your sleep toolbox. Sleep restriction works by both increasing your sleep drive and stabilizing your circadian rhythms, both of which eventually lead to more consolidated sleep and feeling more refreshed during the day. However, sleep restriction can also be quite challenging for some, especially in the first couple of weeks. Please don’t hesitate to reach out with questions or support as you are getting started.

    Check back in with us next week and let us know how you are getting along!

  • Sleepio Member

    • 11 comments
    • 4 helped
    Graduate

    Thanks for the response, Dr Kanady. It is a sobering thought, but I will try to give it a go with the gradual adjustment for the next few months. Did you have any advice for Iris Helen? Worried I may have thrown a spanner in the works there.

    I also wanted to ask: If sleepio proves ineffective, what else is out there? My GP has implied that there's not really anything on the NHS for insomnia beyond very short courses of CBTi, which on its own wasn't effective for me. There doesn't seem to be any meaningful tests either. It can all feel a bit 'last chance saloon', especially when the alternative seems to be 'maybe you just have unexplained chronic fatigue that we don't know how to fix'.

    -Rheum

  • Sleepio Member

    • 388 comments
    • 122 helped
    in reply to Sleepio Member
    Expert

    Hi Barna,

    The sleep-anxiety relationship can be so difficult. As I am sure you noticed, sleep and anxiety are closely related. When we are more anxious, we don’t sleep well, and when we don’t sleep well, we tend to feel more anxious. It can feel like a vicious cycle. Fortunately, improvements in sleep typically lead to reductions in anxiety and vice versa.

    I appreciate you explaining your situation and thanks for your questions. I am curious as to whether you are currently applying the sleep restriction tool? Sleep restriction can be helpful for deepening and consolidating sleep. As sleep pressure builds with sleep restriction, sleep tends to be deeper and more restorative. Another thing that can be helpful for deepening sleep is exercise. However, it is important not to exercise too close to bed (3-4 hours is the general rule of thumb) as that can make it more difficult to initiate sleep. Especially if you are engaging in high intensity exercise that significantly increases your core body temperature and heart rate -- that type of exercise should ideally be done earlier in the day.

    As you mentioned anxiety, you may find session 4 and session 5 of Sleepio to be especially helpful. The techniques taught in session 4 and 5 are based on cognitive techniques and can be helpful for sleep-related anxiety as well as other anxieties. Relaxation techniques such as progressive muscle relaxation can also be helpful for reducing anxiety.

    Why do you feel ill following poor sleep? Everybody reacts to sleep loss differently. Some people can be quite resilient to sleep loss and feel like they function fine during the day, whereas others experience significant impairment or distress.

    Below, please find a Sleepio library article that you may find useful on heightened awareness thoughts:

    https://www.sleepio.com/library/article/heightened-awareness-thoughts/

    Please reach back out with any follow-ups.

  • Sleepio Member

    • 11 comments
    • 4 helped
    Graduate

    Edit: Ah, just saw the response to Iris! These threads are a bit hard to read.

  • Sleepio Member

    • 4 comments
    • 0 helped
    Graduate

    Thanks so much for your advice! I guess the main problem at the moment is that I'm getting very sleepy in the wind-down period (10 till 12) and I have to fight to stay awake. And when I actually go to bed I have some difficulty falling asleep, because I'd been fighting sleepiness for the last couple of hours. Is it something typical or even part of the process? I hope sticking to the hours will build the sleep pressure and lead to longer sleep? Right now I wake at 5:10 am and don't go back to sleep, but at least I'm getting 5 hrs continuous sleep, which I didn't do before.
    My current bed time is 12 midnight till 6:15. I know it's too soon to change anything but I wonder whether perhaps it would be better to go to bed earlier?

  • Sleepio Member

    • 388 comments
    • 122 helped
    in reply to Sleepio Member
    Expert

    Sleep restriction is certainly a bit of an art form, isn't it? I am really happy to hear that your sleep efficiency has been high the last couple of nights and if it stays high for the rest of the week, then increasing the window by 15 minutes after a week should be okay. Sleep can fluctuate from day to day (for example, we tend to get better sleep after a night or two of poor sleep), so it is important that you have enough data to really understand where you are at with sleep efficiency. One week is generally enough data to move forward confidently. When increasing the sleep window, I usually tell people to pay attention to two things: (1) How they are feeling during the day and (2) whether their sleep is getting worse. If you are feeling good during the day, then you may want to consider keeping the sleep window as is. If your sleep is starting to get worse, then you may have increased your window too far and may want to decrease by 15 minutes for the next week. As sleep restriction is an art form, please do reach out with any additional questions.

  • Sleepio Member

    • 388 comments
    • 122 helped
    in reply to Sleepio Member
    Expert

    Thanks for following up, rheum.

    The general recommendation for people who are still struggling with their sleep after successful and adherent completion of Sleepio is to consult a medical provider for more personalized care. Unfortunately, I am based in the states and am not as familiar with resources through the NHS. My recommendation would be to speak to your physician if sleep and/or fatigue remains a concern. Please let me know if I can be of further help.

  • Sleepio Member

    • 388 comments
    • 122 helped
    in reply to Sleepio Member
    Expert

    And yes, navigation of the live expert chats is not super intuitive. We are working on updating, thanks for the feedback!

  • Sleepio Member

    • 388 comments
    • 122 helped
    in reply to Sleepio Member
    Expert

    Hi again Barbarah11,

    The phenomenon you described is actually more common than you might think. Individuals will often report feeling sleepy on the couch while watching television, but then feel wide awake upon getting into bed. The scientific term for this phenomenon is called “conditioned arousal” and boy is it frustrating! The idea behind conditioned arousal is that you are used to not being able to sleep at night, so the bed/bedtime becomes a place of anxiety/tension/arousal rather than a place for relaxation and sleep. For individuals experiencing conditioned arousal, relaxation exercises (such as progressive muscle relaxation) and imagery can be helpful. Following the quarter of an hour rule and maintaining a consistent relaxing wind-down routine before bed may also help combat conditioned arousal. Sleep restriction can also help to lessen conditioned arousal over time.

    Minor adjustments to the sleep window are typically okay. For example, if you want to shift your window from 11:45 PM to 6:00 AM now, this shouldn't cause too much disruption to sleep restriction. It is the large shifts in the schedule that confuse the circadian rhythms and make sleep more difficult.

  • Sleepio Member

    • 388 comments
    • 122 helped
    Expert

    OK, signing off now. Thanks everyone for the great questions and I hope to chat again soon. For any lingering questions, please check out our next live expert chat next week.

  • Sleepio Member

    • 4 comments
    • 0 helped
    Graduate

    Thank you very much, it's been very helpful indeed!

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