Live Discussion with Dr Jen Kanady - 18th November 2020

Dr Kanady will be hosting a live online discussion here on Wednesday 18th November, 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 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, 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 12 Nov 2020 at 2:30 AM
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  • Sleepio Member

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    Expert

    Hi David,

    Great question and this is one that I would get in clinical practice a lot. Especially after starting sleep restriction. Some ideas to help you stay awake while winding down include winding down on a stool or less comfortable chair, winding down sitting on the floor, and not engaging in any activities that are going to make you fall asleep before your prescribed bedtime. It's usually best to avoid winding down while lying on the couch or in a recliner chair if you are struggling to stay awake.

    And remember, if you feel sleepy at bedtime, that means sleep restriction is working -- the sleep drive is increasing -- and you are more likely to fall asleep quicker and sleep through the night.

    Please feel free to reach out with any additional questions.

  • Sleepio Member

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    Graduate

    Hello! If I am going to bed later in order to restrict my sleep time, but still wake early and at my traditional time of 4 am (eg an hour before my set getting up time), am I gaining anything, or just getting less sleep?

  • Sleepio Member

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    Expert

    Hi Cossak,

    Great question. One thing to keep in mind is the QHR rule is meant to serve as a guideline and is not exact. The generally rule of thumb is to get out of bed if you are spending around 15-20 minutes awake. Now, for those groggy states where sleep is likely to come soon, it’s probably fine to stay in bed as getting out of bed might be activating.

    The general recommendation is to avoid spending prolonged periods of wakefulness in bed to break that bed/wakefulness connection. Those wakeful periods in bed become even more problematic when associated with arousal/frustration because the bed can become a place of anxiety. But for those half sleep/half wake states, frustration usually isn’t along for the ride.

    My general recommendation is to experiment to figure out what works best for you in terms of when to get out of bed in the middle of the night.

    And remember that when you do get out of bed, it's best to engage in activities that are relaxing and sleepiness-promoting.

  • Sleepio Member

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    Expert

    Hi MerMaidVB,

    Thanks for reaching out. The recommendations provided in Sleepio are not one-size-fits-all. While it is recommended that no wakeful activities be done in bed (like listen to the radio), I usually encourage people to experiment with what works best for them. E.g., if falling asleep with the radio on is helpful and isn’t disrupting sleep, then it’s probably okay. I also usually encourage people to conduct mini experiments. E.g., try falling asleep a couple of nights with the radio on and a couple of nights with the radio off to figure out which is best for sleep.

    I am sorry to hear that you are struggling with your sleep. Sleepio does require users to put in some work (e.g., the quarter of an hour rule, sleep restriction) and it isn’t always a good fit or a good time to engage with the program. If you are continuing to struggle with your sleep and Sleepio doesn’t seem like a good fit, I would encourage you to speak to your doctor.

    Please follow up and let us know how you are doing.

  • Sleepio Member

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    Expert

    Hi RyanRobust,

    Thanks for the great questions. Sleep efficiency is calculated by dividing total sleep time by time in bed and is meant to be a measure of sleep consolidation. You are right, many short nocturnal awakenings may not be adequately captured using sleep efficiency and sleep efficiency may feel high in these cases. E.g., if you wake up 15 times for 2 minutes each in the middle of the night, you will probably still have a high sleep efficiency. If sleep efficiency doesn’t feel like a good indicator of how you are sleeping, I would generally suggest to use another sleep variable to measure progress. E.g., sleep quality or number of nocturnal awakenings.

    Sleep restriction is the most powerful tool for consolidating sleep, which you will be introduced to in session 3. Sleep restriction increases the sleep drive -- our biological need for sleep -- which helps individuals to fall asleep faster and sleep through the night.

    Another couple of things to note: (1) Nocturnal awakenings are completely normal and everybody experiences them. Just not everybody is able to remember these awakenings. These awakenings really only become problematic when they cause significant distress or when they are prolonged. (2) Multiple awakenings during the night may be the result of an environment factor (e.g., sleeping with a partner, sleeping with a pet, getting up to use the bathroom). I tend to encourage people to pay attention to what is waking them up at night. (3) Multiple nocturnal awakenings can sometimes be indicative of a sleep disorder. If you are concerned about these awakenings, I would encourage you to speak to your doctor.

  • Sleepio Member

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    Graduate

    Is an after-lunch nap really so bad, if it's only 15 mins? Might make it easier to stay up late…

    It's something I've always enjoyed as a halfway point in the day.

  • Sleepio Member

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    Expert

    Hi Jennifer,

    Thanks for the great question. You are absolutely right, sleep is closely linked to the hormones that regulate appetite. Following sleep loss, there is an increase in the hormone ghrelin, which is the hormone that tells us when we are hungry and there is a decrease in the hormone leptin, which is the hormone that tells us when we are full. A lot of the studies examining the link between appetite hormones and sleep were conducted using full or partial sleep deprivation paradigms. It is less clear whether you would see large fluctuations in these hormones following sleep restriction, but that doesn’t mean that it isn’t happening or that it isn’t happening to you!

    One thing you can consider doing is conducting a mini experiment. Monitor your hunger levels and see how that relates to your sleep, exercise, amount of water you drink, etc. This can help you to determine any correlates with your increased hunger.

    During this time, it’s important to remember that your current sleep window is only temporary and your window will gradually increase as you sleep better.

  • Sleepio Member

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    Expert

    Hi again Jennifer,

    Thanks for your candor and it sounds like you have done a lot of great creative problem solving. First, I want to commend you for adjusting the Sleepio tools in a way that feels right and safe to you. If you ever experience suicidal thoughts, we recommend that you speak to a doctor or someone you trust. There are also crisis lines that can be of help during these situations.

    Below, please find some additional thoughts:

    In terms of your experience in the second half of the night: We tend to get the majority of our deep sleep in the first half of the night and the majority of our REM sleep (which is a light sleep stage) during the second half of the night. Therefore, it is common to experience nocturnal awakenings and half sleep/half wake states during the second half of the night. In fact, some of the sleep stages are so light that often when you ask an individual if they were sleeping, they will answer “no.” I hope you are able to take comfort in the fact that what you are experiencing is experienced by many and is to be expected.

    I love your creative ideas for what to do during those middle of the night awakenings. To add to your already great ideas, another option is to set up pillows on the floor of the bedroom to meditate. That way you don’t have to go far (thus are less likely to increase alertness) and are still getting out of bed.

    In terms of how to fill out the sleep diaries: The sleep diaries are meant to capture the subjective experience of sleep. So it is really up to the user to figure out what makes the most sense for them. It sounds like you err towards under reporting sleep. If that makes sense for you, I would say go for it. One thing to keep in mind is that the sleep restriction is adjusted based on the previous week of sleep. If you err on underreporting sleep, it may take longer for you to get the option of adding 15 minutes to the window.

    For concerns about sleep apnea, I would recommend speaking with your doctor. Sleep apnea is typically diagnosed with a sleep study. Your doctor can provide you with a definitive diagnosis and treatment recommendations. And you are absolutely correct, sleep apnea is characterized by multiple awakenings during the night and waking up choking and gasping for air.

    Please keep us posted about how things are going.

  • Sleepio Member

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    Expert

    Hi dyale,

    Thanks for reaching out. First I just wanted to acknowledge that there’s no need to stop taking medication to use Sleepio. Many people have used Sleepio successfully while taking sleep medication. Unfortunately, I am unable to provide advice about medication use. Any questions pertaining to medication use should be directed to your doctor. Your doctor can provide you with information about how to successfully taper your medication use. Wishing you the best of luck!

  • Sleepio Member

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    Expert

    Hi Esparkles,

    It’s a really good question. Sleep restriction can be helpful for many different types of insomnia presentations. For the presentation that you described, sometimes going to bed later can push back the rise time and then gradually moving the bedtime earlier can increase the amount of sleep received. It sounds like you are doing some really great work and are still struggling with your sleep. One thing that stands out is your description of excessive daytime sleepiness. Interestingly, fatigue tends to be common with insomnia, whereas sleepiness is often indicative of other sleep disorders. That being said, I am unfortunately unable to provide personalized medical advice or diagnosis. Given the fact that you have put in such great work and are still struggling with your sleep, I would recommend speaking with your doctor.

  • Sleepio Member

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    Expert

    Hi David,

    Thanks for the great question. I see that you are on week 4 and thus in the early stages of sleep restriction. How long it takes to see improvements following sleep restriction differs from person to person. Sometimes people see improvements after a couple of days and others might see improvements after a few weeks. Usually, early in sleep restriction, things can feel worse before they start to get better. So you are definitely in the thick of it!

    Early morning awakenings can be tricky. A couple of additional thoughts about those 4AM awakenings:

    1. Try to pay attention to the amount of light you are exposing yourself to during those early morning hours. Light has an alerting effect and it's important to avoid light -- especially bright light -- when you want to be asleep.

    2. Try to pay attention to is your sleep schedule. All of us have different circadian preferences -- that is, different times we prefer to go to bed and wake up. When we get older, our circadian preference tends to shift earlier. One thing that can be helpful for some with early morning awakenings is to shift the sleep schedule earlier.

    Please keep us posted about how you progress with sleep restriction.

  • Sleepio Member

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    Expert

    Hi again David,

    Thanks for all the great questions today.

    Let's talk about napping.

    As you learned in Sleepio, napping impacts our sleep drive. The sleep drive is one of the processes responsible for regulating our sleep. The sleep drive is our need for sleep that builds the longer we are awake. When we take a daytime nap, we are depleting our sleep drive, making it less likely that we will be able to fall asleep easily that night. Thus, it is typically recommended that you avoid taking a daytime nap to keep that sleep drive high.

    For individuals who feel like they have to nap, then the general recommendation is to limit the nap to earlier in the day (preferably before 3:00 PM) and to limit the nap to no more than 30 minutes.

    It is also worth noting that there is a bit of a dip in our circadian rhythms during the post-lunch hours, which can make us feel more sleepy and is when most (without sleep problems) often nap.

    All that being said, it is up to you to determine whether taking a daytime nap will significantly impact your sleep. My general sense is that a nap of 15 minutes is probably not long enough to substantially impact the sleep drive. But I would encourage you to experiment. E.g., how are you sleeping on the days that you nap vs. the days that you don't?

    Also, there are several important exceptions to the no-nap rule. The most important one is feeling sleepy while driving or in other potentially dangerous situations. In those cases, taking a nap is absolutely recommended!

  • Sleepio Member

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    Graduate

    Thanks very much! I already record a food, exercise and water diary, as well as sleep and things like mood, stress etc. So far it seems the hunger pangs do correlate with nights where I get less sleep, but there is also a correlation between more hunger and higher stress levels, and perhaps it's the stress of less sleep that triggers it. I'll continue to monitor.

  • Sleepio Member

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    Graduate

    Hi Dr. Kanady,

    Thank you very much for the reply earlier.

    Any ideas for reducing baseline anxiety levels, which of course may contribute to poor sleep?

    To make sure I understand correctly, assuming there’s no sleep apnea, then sleep restriction as shown in Week 3 is the most powerful tool for sleep consolidation? Sleep restriction won’t lead to dangerous levels of exhaustion?

    Are there any disorders that can cause frequent awakenings / fragmentation besides sleep apnea? For reasons other than apnea, can medication help?

    If sleep efficiency might not be the right metric, how do we determine what the right metric is? If it’s number of awakenings, how many is too many? Or can it be determined by whether the individual feels okay versus exhausted in the daytime?

    Thank you
    Ryan

  • Sleepio Member

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    Graduate

    Thank you, this is all very reassuring and helps in reducing my anxiety about tweaking my approach to the QHR. Yes I probably should see a doc about the potential sleep apnea. I don't snore much, and I'm not overweight (though these recent hunger pangs may change that!) So I wasn't sure if I had enough symptoms, but I do wake gasping for air a lot, and get a dry mouth and sore throat. Mouth breathing is a problem I need to sort out. Maybe with a nose passage clip thing.

  • Sleepio Member

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    Expert

    Hi Ryan,

    Really great follow-up questions. See my thoughts below:

    1. You are absolutely right, anxiety and sleep are very closely related. The nice thing is that when sleep improves, anxiety often improves and when anxiety improves, sleep often improves. You will be introduced to techniques to tackle worry and anxiety in sessions 4 and 5. One technique that you could consider trying before then is scheduled worry time. Scheduled worry time entails worrying and problem solving for the same 20 minutes, in the same place, every day. That's what you do for those 20 minutes and when those 20 minutes are up, you are done worrying. That way, if worries/anxiety start to creep in that night you can either tell yourself, :I already worried about that earlier” or “I have time to worry about that tomorrow.” Over time, you brain will learn that there is a dedicated place and time for worrying and worries will start to interfere with sleep and functioning less.

    2. Sleep restriction does involve shrinking the sleep restriction window, but for safety reasons, the window never goes below 5-6 hours depending on your health status. That said, often during the first few weeks of sleep restriction, people start to feel worse before feeling better. But that's to be expected and means it's working. Feeling sleepy during the day means the sleep drive is high and that falling asleep and staying asleep will likely be easier.

    3. Sleep apnea is the disorder that comes to mind that is characterized by frequent nocturnal awakenings. Unfortunately, I am unable to provide diagnosis or medical advice. For questions like these, your doctor is going to be your best resource. The gold standard treatment for sleep apnea is continuous positive airway (CPAP) machines.

    4. This is a great question and really, it's up to you! It really depends on the person's sleep goals and/or primary sleep complaint. For example, if number of nocturnal awakenings are the primary concern, I usually work with the person to figure out a good goal for awakenings that they hope to achieve at the end of treatment. That being said, you want to make sure that your goal is realistic. E.g., a goal of “I don't want to wake up at all in the middle of the night” is not a realistic goal because everybody wakes up during the middle of the night. I would suggest looking at where you are now, and what feels good at the end of treatment. E.g., you are waking up 12 times in the middle of the night now and want to get that down to 6 times by the end of Sleepio.

    I hope this provided further clarity. Please feel free to follow-up with any lingering questions!

  • Sleepio Member

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    in reply to Sleepio Member
    Expert

    Thanks, Jennifer. Happy to hear that you will speak with your doctor about potential sleep apnea. While being overweight is certainly a risk factor for sleep apnea, it is not part of the diagnosis. Your doctor can definitely provide clarity around this matter. Keep us posted!

  • Sleepio Member

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    Graduate

    Thanks, that's a good method I may try.

    The sleepiness vs fatigue does get a bit confusing, I may not be getting the right terminology. From the library:

    _Sleepiness reflects one’s propensity to fall asleep (or inability to stay awake), while fatigue refers to lethargy, or an inability to maintain levels of performance on a given task
    _
    I don't have achy muscles. I've got 'heavy head', sore eyes, and can yawn if I just stand still for a moment. But I definitely can't perform as well on mental tasks on bad days. It can feel like jet-lag. But if sleepiness refers to ability to fall asleep, despite trying I've never been able to nap. Bedtime routing is needed for me to sleep.

    So do I actually have fatigue?

    Thanks

  • Sleepio Member

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    Expert

    Esparkles -- I hear you, the distinction between the two can be difficult. Very similar to what you pasted above, I generally think of sleepiness as being able to fall asleep easily. E.g., if you tried to nap, you would fall asleep pretty quickly. Fatigue, rather, is a lack of energy.

    Regardless of whether it is fatigue or sleepiness, that sounds really frustrating. Given that you mentioned feeling like jetlag, one thing to consider paying attention to is the amount of light exposure and your sleep schedule. You mentioned above that you keep a consistent sleep schedule, which is great -- keep up the good work. Bright light exposure during the day when you want to be awake and alert is helpful for combatting fatigue and stabilizing circadian rhythms.

  • Sleepio Member

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    Expert

    Thanks for all the great questions. Signing off now. For any lingering questions, please take advantage of our next live expert chat next Wednesday. Wishing everybody happy and healthy sleep!

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