Dr. Wendy Slusser 00:02
When is the best time to nap? And what is the ideal length? How can you rethink your diet to help you get a better night’s sleep? What does COVIDsomnia mean? Today, sleep neurologist and the director of the UCLA Sleep Disorder Center, Dr. Alon Avidan, explains the impact of COVID-19 on our sleep behavior, and share strategies to get a better night’s sleep. Dr. Alon Avidan, such a pleasure to have you here today. And I was so grateful when I opened up your email a couple of weeks ago, and one of the things you sent me and really piqued my curiosity and made me want to interview you for this podcast was this concept of COVIDsomnia. Before we talk about COVIDsomnia, I’d like to have you explain to me why quantity and quality of sleep is so important for us all.
Dr. Alon Avidan 01:03
Thank you so much Dr. Slusser for having me on board. And it’s always nice to speak on a topic that is near and dear to my heart. It’s Sleep Medicine. And this is such an important period of time in everyone’s lives, say when things are not the same. And something we take for granted, sleep, is nothing but routine since a pandemic, and I’m so delighted that you are having me on the show to talk about sleep. Your first question is a very important one. Sleep duration and sleep regularity. Sleep duration is by age and duration of sleep, we mean specifically how much time the patient is actually sleeping. And oftentimes patients, they forgot that we’re not really talking about the time in bed. We’re talking about the time in which you’re actually sleeping. And for people over age 18, their recommendation by the American Academy of Sleep Medicine, the Sleep Reearch Society, and the National Sleep Foundation all recommend seven to eight hours of sleep duration on a regular basis. So the duration is ideally about eight hours. Regular sleep implies that you go to bed and wake up at the same time every single night. Now why is that important? Well, it turns out that having a regularly occurring sleep timing aligned to the outside environment to the light and dark cycles outside is important for proper circadian function. And what do I mean by that? Well, you all know that the eye serves two functions, specifically, vision and circadian regularity. And when we’re getting light and darkness signals from the environment, we’re using the eye to tell the circadian clock in the brain when to go to bed and when to wake up. So typically speaking, when the sun goes down, and people kind of have dinner and relax and socialize, watch TV, etc. And by 11 o’clock, 12 midnight to the latest, most people go to bed and having an established normal pattern that is aligned with the outside environment is very important to maintain proper circadian function. This is really critical because every cellular process that takes place in the body is tied to that circadian clock. So when growth hormone is produced in children is timed when slow wave sleep occurs. And that’s regulated by the circadian patterns. Timing of immune response, immune function, very critical during the pandemic. Low sleep, less than six hours of sleep, reduces your immune response. Lower immunity, you’re going to be at higher risk for the pandemic, particularly even after getting vaccinated. The vaccine may not work as well. Timing of the turning on and off of certain physiological functions that relate to metabolism and handling of sugar in the bloodstream is all related to that circadian function. And delay or abnormal advancement of that circadian pattern is often associated with more abnormalities in normal physiology. Take for example, I’m going to, I’m not going to be very specific. I’m just going to give you one specific example, which relate to how you do when you have jetlag. Just two hours or three hour of difference between here in LA and New York City and the first day, the first day or two, most people feel a bit lousy. They’re tired the next day. They can’t think right. They often have stomach issues. And it all starts because our bodies need to adjust to a new level of physiology to handle when we usually eat, when we’re having conversations, and we make sense during the conversations, that all has to do with when the circadian function and how quickly it’s able to adjust to that new time zone. And of course, with the pandemic, things have gotten fairly abnormal in terms of the sleep duration, and equally and perhaps more abnormal related to abnormalities in circadian timing of one’s bedtime. So I know this is a very long winded answer to a rather simple question, but it’s very critical question that is really fundamental. We can’t talk about sleep without talking about, well, what is normal sleep?
Dr. Wendy Slusser 05:47
Well, starting with the basics, like what you just described to us: duration and routine. It sounds so simple. So let’s start with a few follow ups on duration. What happens if you aren’t sleeping through, like, you might get seven hours, but you wake up in the middle of the night?
Dr. Alon Avidan 06:04
Really, really important. So sleep duration, and the fact that you have uninterrupted sleep, that is absolutely critical. Give you an analogy. Imagine that you’re putting a cake in an oven, and the instructions are, you have to leave it for an hour. And you shouldn’t take it out and just leave it, and it will rise. Same with sleep. If you take that cake every 10 minutes, every 20 minutes and check on it, it will never rise. With Sleep Medicine, the same principle applies. When you go to bed, and hopefully you go to bed at a regular time, and you wake up at a regular time. But during that seven or eight hour interval that you’re in bed, it’s preferred and it’s physiologically more normal to have continuous sleep, uninterrupted sleep. What happens when sleep is interrupted, and why would sleep be interrupted? Well, sleep may be interrupted in the beginning of the night. We call this sleep onset insomnia. It may get interrupted in the middle of the night. We call this sleep maintenance insomnia, or it may be disrupted towards the tail end of the early morning. We call this early morning awakening. And knowing the timing, when one wakes up can tell us some very interesting anecdotes about the conditions that it may have that might precipitate this. So for example, early morning awakening is depression until proven otherwise. We see that very often that individuals who have awakenings at 3, 4, 5 in the morning, way before the alarm are often may have an underlying history of depression. Now, sleep onset insomnia, on the other hand, is often related to anxiety, stress, and we call it sleep onset insomnia. It’s often related to a condition type response in that the individual is associating the bedroom and the bed itself with not good sleep. That is they associate the environment as a place where they should worry and plan and make all kinds of lists in your mind, and it’s hard for them to shut their brain off. That is often what manifests as sleep onset insomnia. Now in the middle of the night, if you have a hard time maintaining sleep, that is often related to even noise coming from the environment or the bedroom not being at the right temperature being a bit on the cooler or a more hot side. We like the temperature to be about 60 to 65 degrees. I know that’s a bit cold, but that’s the ideal proper temperature for your bedroom. And they’re noises, also environmental insomnia. If you live by the airport, the noise, the outside environmental noise is sufficient to create environmental insomnia. And adding top of that is the fact that many people will have other medical conditions, primary sleep conditions and medical conditions, that can disrupt your sleep continuity. Some examples include untreated sleep apnea, pain, problems related to nocturia, which is excessive urination at night. Medications that may disrupt sleep architecture, as well as conditions related to menopause. Women going through menopause experience hot flashes and very unstable sleep and disrupted sleep during the menopausal and perimenopausal period. Now when we’re talking about the proper and the ideal time that someone spends in bed, it’s all about spending seven to eight hours in bed and taking it one chunk. And the other thing, when they, is we often see patients who tell us, “Yes, we’re sleeping for seven or eight hours.” But it’s not all in at night. It may be four or five hours at night, and then two or three hour power nap in the middle of the day. Sleep isn’t that additive. Sleep is not a bank account. You can’t average time of sleep you get in a 24 hour period, and say that it all averages to about seven or eight hours. If it’s very fragmented, it doesn’t work the same. It’s like that cake that never rises. If you’re sleeping less than that seven or eight hour period, you’re never going to wake up feeling refreshed, irrespective of the fact that you got seven or eight hours during the 24 hour period. It has to be taken all at once at night for that particular duration without having too many interruptions.
Dr. Wendy Slusser 10:47
Well, that just picked my curiosity for so many more questions. For instance, what else would we be doing in bed that might create a longer latency before we go to sleep?
Dr. Alon Avidan 10:58
Well, I can tell you about my patients, many of whom are students, as well as faculty. And, so the bedroom becomes a place for work. The mobile devices are often used before bedtime to check the news, and answer email, text. And sure enough, you find that people are often relying on electronics and gadgets that emit blue light. That’s the danger of this devices is that when people are using them, the light intensity and the light wavelength that the devices emit is enough to stimulate the circadian clock and turns it on, and often delay the release of melatonin, which is often ideal when darkness, and light exposure stimulates the circadian clock. And hence, it often creates a situation where the patient may actually find it hard to fall asleep. And they may end up waking up prematurely, 20 minutes, one hour flight explorer. But you know, most of my patients, say that they’re doing homework late at night, and they often delay and push and make all those requirements that often require them to use a computer to be pushed towards say 11pm, midnight. And we all know that that’s very detrimental to the normal cyclicity of the circadian rhythm. So blue light is absolutely an enemy. And I usually tell people, you know, by nine o’clock, 10 o’clock, you should probably put it away. And if you need to read, you can read by dim light, but not watching TV, working on computers. Electronics are not recommended. And also what you read is important. When I tell patients to read something and before going to bed instead of using a computer. We don’t want them to read novels or the Da Vinci Code. They will not be able to fall asleep until the next day. We often recommend something that’s not interesting. If it’s not interesting to the patient, when they’re reading, it’s actually beneficial. If it’s interesting, the patient keeps reading it, then I think we lose that therapeutic effect of trying to make the patient a bit bored and sleepy so they can go back to bed and actually be able to sleep in their own bed soundly.
Dr. Wendy Slusser 13:28
That’s great. Well, so I guess in bookstores, if there are some near you, you could have a whole section of boring books that you buy. That could be a part of the wellness section.
Dr. Alon Avidan 13:40
Exactly. Really reserve that time before bed for relaxation, and really for your own ability to unwind. You know, we don’t need to have a electronic device to unwind. That’s a technology that should be put away before you go to bed.
Dr. Wendy Slusser 13:56
Well, we won’t get into which boring books we would recommend because we might insult someone that’s listening. So we’ll, we’ll pass on that question. But I have a couple of other questions related to duration. And especially given the fact that you’ve mentioned three times you could have trouble sleeping or staying asleep. And one of them comes to mind especially when you think of circadian rhythm, which is food and alcohol. What would you recommend individuals about that?
Dr. Alon Avidan 14:23
Sure. So let me address alcohol first. Alcohol is very enticing, because it makes you relaxed. And when you go to bed, you fall asleep fairly quickly. But then the problem is when you go to bed, you stop drinking. And that’s the problem. Because as the alcohol levels begin to drop, when your body metabolizes the alcohol, you’re wakefulness centers begin to fire up because you’ve just taken a hypnotic in a way. So the problem with alcohol is as the blood alcohol levels drop, your sleep becomes more fragmented. There are many more awakenings and arousals. Two or three hours after you go to bad, sleep apnea becomes worse. You wake up more groggy. When you look at the brainwaves of patients who have taken alcohol, it looks like a brainwave of someone who is in severe pain in the hospital: very fragmented. The deep levels of sleep are often a disproportionately high, REM sleep is delayed, and the entire ability to have a natural rhythm goes into chaos. That’s just one night of having, let’s say one or two glasses of wine. But if you then rely on alcohol to help you fall asleep every single night, well, after a while, you find that one or two glasses of wine is not doing it because you develop tolerance, so you need more. And after a while you find that you, the patient begins to consume more alcohol in a fashion that eradicates any normalcy about their sleep, to have more degree of sleep apnea because alcohol also relaxes the upper airway muscles, making apnea more likely to occur and that can be very disruptive. So we recommend people to give themselves about four or five hours before going to bed if they do have a drink socially, that they should try to give it a little bit of time before going to bed and time the alcohol so it’s not close to bedtime. Let’s talk about dietary items. So definitely chocolate is not allowed.
Dr. Wendy Slusser 16:42
Dr. Alon Avidan 16:43
At night. Exactly. Chocolate is of course allowed during the day. And you know, it’s interesting, I’ve seen a children who are having chocolate ice cream and just this chocolate ice cream can do it. And I’ve heard from a parent who I told to stop the chocolate ice cream and her three year old is now sleeping better. So it’s you have to really inquire about you know, not only caffeine, not only chocolate, but foods that contain chocolate, and it doesn’t have to be dark to have caffeine in it. Definitely avoiding caffeine and definitely avoiding a heavy meal, like avoiding fatty foods and heavy foods because that then they tend to create more problems with fake gastric reflux. If patients asked me what diets I would recommend, let’s say if someone’s hungry before bedtime, I recommend having a banana, having a little bit of yogurt, granola, having some nuts. Those are foods that are high in tryptophan. Tryptophan is a precursor to melatonin. And we call those compounds soporific, meaning that they’re very sleep inducing. One other food item that has a lot of tryptophan in it is turkey. And that’s why everyone feels a bit sleepy after Thanksgiving turkey dinner. So those are helpful items to consider. There’s one other recommendation that I often make to patients, which is actually trying tart cherry juice. Tart cherry juice, and you don’t have to have a lot of it. It’s only about two ounces. It has melatonin and a tryptophan sleep inducing substances that is natural, and actually works pretty well for many patients who have problems falling asleep. It cuts down the the latency to sleep, which is the amount of time it takes you to fall asleep. And it’s natural. It’s not the pills. So people are more reassured by the fact that it’s a really a dietary supplement.
Dr. Wendy Slusser 18:42
That’s a great tip, something I’ve not heard of. Where do you get tart cherry juice?
Dr. Alon Avidan 18:47
Whole Foods, Trader Joe, you probably have it anywhere. You can get it actually in Amazon. You can get tart cherry juice capsules. So if you, if you’re traveling and you don’t want to take any beverage or yeah, you can take the capsules.
Dr. Wendy Slusser 19:02
So what we’ve just covered is a huge array of not only issues but also opportunities for enhancing your duration of sleep. And you mentioned a few items that actually do make me think of what people have been doing more of in the COVID period. And it really leads us to not just discussions of duration or the latency of going to sleep because we know everyone’s been bingeing or including me on, you know, different series. But the regularity is another piece that you mentioned, and that not only is important for a healthful sleep, but also one area that I’m sure many of us have had challenges during this period of the pandemic. So that might get us to this looming question in all of our brains is what do you mean by COVIDsomnia?
Dr. Alon Avidan 20:01
Yes, so euphemistically COVIDsomnia is a term that’s been applied to the abnormal sleep patterns and insomnia during the duration of this unprecedented pandemic. And it relates the fact that there are specific observations about the pattern of insomnia in that people do experience, have experienced difficulties with say anxiety, stress, fear of the unknown, difficulties falling asleep. And that is specific in relationship to the pandemic, a pattern. Very interestingly, there is a model that helps explain the chronicity of insomnia. It’s for people who really want to know it’s called the Spielman 3 P Model, and it uses the following: predisposing factors, precipitating factors and perpetuating factors. Insomnia is crossed above its threshold to become clinically apparent when one has a precipitating event. After having certain predisposition to insomnia, which is often related to genetics and having a prior history of learn insomnia, that something happens, something both good and bad. Marriage is a positive aspect that can trigger insomnia. The death of a loved one, surgery, pandemic: that’s a trigger. We found that amongst many patients that saw us recently, when we ask them when things started, and the majority went back to March of 2020, when they started to stay at home. They were away from family, friends, social interactions, social cues, that often help provide a signal for maintaining sleep/wake regularity. What else has happened? You have to stay home. You do not go to work. And we found that people are not getting light exposure. So now we have no social cues, no light exposure. People are almost very similar to living in a cave. You begin to lose sight of when it’s dark and when it’s light. And we found that people who have a certain circadian predilection to go to bed later at night, those are called the owls. You know, you have two types of individuals based on their sleep/wake preference. And those are phenotypes, meaning they characterize the sleep/wake patterns in individuals. There are the evening type, which are the owls, and there are morning types, which are the larks. And you’re one or the other. You can’t change an owl to a lark. And you know, that’s part of your genetic package. What we found is that individuals who are relatively prominent owls became even more owl like in having a more delayed pattern of sleep. That’s another aspect of COVIDsomia sort of definition in that in some individuals, there was some preservation. That duration has remained the same, but the patterns have gotten to that people are going to bed late. Now, this is important because the delayed sleep phase pattern is often associated with weight gain. And that is really critical. So despite the fact that they were getting regular sleep, their patterns were delayed in a manner that they were going to bed at 2, 3, 4 in the morning, waking up at 10, 11, midnight, some even later. And they were gaining weight. And that is fascinating, because it talks about the fact that earlier on I mentioned that sleep and circadian patterns are very much aligned in a manner that it has to occur in some degree of regularity. And when you don’t have that regularity, you begin to see metabolic disturbances. And one of those is related to a pre diabetic type condition. And it’s often related to loss of sleep, as well as delayed sleep that often made people more obese, caused them to gain weight, and also became somewhat diabetic. And that may be related to the fine control of blood sugars in the body related to specific hormones that are released in response to light and darkness. Those disturbances in the timing of the release takes place or decrease ability of one ability to control the blood sugars. So that is very problematic, particularly because of the fact that we’ve seen more of a obesity epidemic during this pandemic.
Dr. Wendy Slusser 24:51
That is a really fascinating interpretation of what I’ve seen in my work where you will see people with less sleep maybe gain weight but not necessarily people who have a healthy duration, but they’ve just created a shift where they’re spending more time sleeping in the daytime. Is that what you’re trying to say so?
Dr. Alon Avidan 25:14
Dr. Wendy Slusser 25:16
For these owls, the recommendation even though they might have a tendency to go to sleep later, they really should be trying to sleep during a good portion of the night if they can.
Dr. Alon Avidan 25:27
Yes, and there are ways that we can help them achieve that. So one of the problems of course, is the fact that the individual is getting abnormal signals of excessive light exposure during the nighttime, during the evening time, and lack of light exposure during the morning. Okay, so it’s a, the light therapy is actually phototherapy, we call it, is very effective in trying to mitigate and improve the and align people to a more natural and normal cycle. So we often recommend the avoidance of the blue light after 9 pm. And we often tell patients get up at around seven to eight o’clock and go outside for at least 45 minutes to an hour to soak up some sunrays. The light exposure in the morning is going to help advance the circadian patterns. As well as the recommendation is for light, for very low dose melatonin at 0.5 milligrams taken at around four hours before their bedtime. So if their bedtime is at three in the morning, they should be taking the melatonin at around 11 pm. The problem is, most patients who use melatonin, take it right before they go to bed, which for a lot of people is 3 or 4 in the morning, and they take the wrong dose. They take three or five milligrams. To achieve a realignment, resynchronization of the circadian pattern, we have to use low dose melatonin and time it early in the evening to advance and push this the sleep timing, to an earlier timezone and avoid the light exposure after eight or 9 pm or so. And the other thing that works really well and will know that through the work of Dr. Jerry Siegel is drop in temperature because his work in the looking at the sleep patterns in hunters and gatherers in Africa has shown that the primary signals for sleep was the absence of light and the drop in temperature together was a powerful signal for the timing of sleep. So what we’re trying to do also in our own patient population is create the bedroom is going to be a bit cooler. Now for a lot of people, they can’t turn the AC high enough or that there is a central AC, and one person in the house likes it’s a bit toasty. The other person has insomnia and likes it a bit cooler. So if that’s an issue, there are some cooling pillows that one can get. One of them is called a technogel cooling pillow. And that’s a pillow that has a gel mechanism in it that acts as a heatsink. So it takes away excessive heat from the head and drops the temperature, allowing people to fall asleep and maintain sleep for a longer period of time.
Dr. Wendy Slusser 28:26
Wow, to unpack what you just said, which has so much information. One is Dr. Jerry Siegel is amazing. And he also taught me how it’s not the light that wakes you up in the morning. It’s the rise in a little bit in the temperature that is happening.
Dr. Alon Avidan 28:42
Dr. Wendy Slusser 28:43
This is totally what I didn’t understand. You always think it’s the light, right, or the sun rising. I’d like to understand why is the sun so special in the morning or getting morning sun versus afternoon sun?
Dr. Alon Avidan 28:56
Oh, definitely. Remember I mentioned that light is probably the most powerful circadian giver or sight giver. In German, it’s a light giver. It is the signal that turns on the circadian clock. It tells you it’s time to wake up. And the primary time in which the circadian clock is primed to interpreting the light signal is in the morning. And in the evening. During the day, it’s fairly neutral. So after 10 pm and before 5pm or so, the light exposure is very neutral, but light exposure after 6, 7, 8 pm is going to turn the brain on and that’s treatment that we give people go to bed too early. That’s the opposite of delayed sleep phase. So in our population and in older adults, there is the advanced sleep phase circadian rhythm disorder where they go to bed early, and they wake up early, so we give them light therapy in the evening time. For the adolescents, for the extreme owls who need to advance their circadian patterns, we ask them to use a light therapy early in the morning at around seven to eight o’clock, because that’s when you stimulate the circadian clock, keeps the wake centers alert and awake, and allow them to then manifest and that wakes them a single, will exist and persists throughout the day. And you can also then add a power nap if someone is particularly sleepy as long as it’s not more than 10 minutes. But the critical issue is that in the evening time, you want to stop the light exposure after around eight to 9 pm. And to give a bit more signal for sleep, use of supplemental melatonin at 0.5 milligrams will be another chronotherapy that can actually be quite effective for those who are really challenged with delayed sleep phase pattern. To your question is, why is it sunlight? Well, sunlight is our primary light source. It is the one cue in the environment that our retina, the cells in the retina then move on to make up the track it goes and simulates the super cosmetic nucleus. Historically, and evolutionarily, we were adapted to that particular light source. So the problem is you can’t sit in front of a window and say, well, that’s enough light for me for the morning. It has to be outside. And for people who are worried or cannot go outside because immobility issues or because they don’t have enough light because they live in Fairbanks, Alaska, there are some light boxes that you can get. And you can get those on websites. And they cost about $50 to $100 dollars. But you have to make sure that it says 10,000 lux. Lux, L U X is a unit of light intensity. And we want to make sure it’s 10,000 lux, because that’s the light intensity of ambient light exposure in the middle of the day.
Dr. Wendy Slusser 32:02
So we’ve been talking about the owls and what you’re describing is a way for the owls not to get carried away and go to bed at four in the morning if they get their circadian rhythm awakened by the morning light.
Dr. Alon Avidan 32:15
Dr. Wendy Slusser 32:16
Okay, so that will help them get into a routine. So what about people who are and this has been a big challenge, especially during the pandemic, where you might be overworked or you’re really working through the night. What kind of recommendations do you give, especially some of our frontline workers who again, are being overworked and overtaxed once again?
Dr. Alon Avidan 32:37
That’s right, Wendy. This is a really, really difficult issue, because work is often a priority. But when I see patients who are frontline workers, there still is a need to maintain a balance between life and work. And the problem is many individuals, the moment they come back after a shift in the hospital, they go, and they check emails, or they spend time in front of computer or watching TV. So the light source is continuing to occur and increase the light exposure during a period which may not be ideal for the patient. What I tell people to do is as much as they can to give themselves some downtime, an hour, two hours, ideally, before going to bed. Many people work through the night, work until they’re done. They go to bed and guess what they do. They sit in bed, and they start thinking, and the bed then becomes a point of where you’re planning things, where you are making lists of things you have to do the next day. And part of the cognitive behavioral therapy for insomnia, which is a very powerful treatment recommendation. For people who have chronic insomnia disorder is the one arm of course is to use hypnotic drugs that just make you sleepy, sedated, but don’t really treat the underlying cause of the insomnia. Cognitive and behavioral therapy, in contrast, the patient learns how to sleep again. The sleep coach who delivers the cognitive and behavioral therapy helps give the patient some powerful tools to help them reassociate the bed in the bedroom with sleep that is minimizing the time that they spend awake in bed, moving away electronics, cell phones, alarms, anything that’s connected to electricity away from the bedroom area, and reassociating the need for sleep with the bed. And one of the techniques we do to make people sleepy is sleep deprivation. So if they only slept for three or four hours on one night, they cannot take naps and they cannot make up for it. We create the sense of sleep deprivation and with that, when they’re a bit more sleep deprived, when they go to bed in their own bad, all of a sudden they fall asleep quickly, and they maintain sleep in that bed. And slowly and surely begin to reassociate the bed with sleep. It takes about a week or two. It’s a bit challenging to do because people do not like to be sleep deprived. But it works wonders. And it’s the one thing we recommend is if you find that you’re taking naps as you’re sleep deprived, or if you’re not sleeping well, and you make up for it the next day, the pattern will just be perpetuated. So the third, the P that I mentioned, part of the Spielman Model is perpetuating factors that include actions and activities that are maladaptive and one of them is a long nap. Another one is worrying about sleep. Another issue is using electronics, alcohol, caffeine, and all outside interference that often perpetuate insomnia and just make it more chronic and more difficult to treat. Going back to the discussion about reassociating the bedroom with sleep through cognitive behavioral therapy is a technique that used to occur in person prior to the pandemic. So one good thing about the pandemic, not the pandemic is anything but a difficult time period, but through the pandemic, we’re able to adapt and innovate. And one of the innovations, of course, is telemedicine. We’re seeing so many more patients say online. Some patients really like to be able to see their patients without driving on the Los Angeles freeways. And they can see us online by video. And cognitive behavioral therapy for insomnia used to be very difficult to achieve before the pandemic because people had to drive and see their providers say five or six times during the course of the therapy. And during the pandemic, when everything is online, it’s easier. People are actually complying with it, and they like it. And there’s more access. There’s more availability of people to actually do it more effectively and efficiently. And the data shows that it’s no less effective compared to in person cognitive and behavioral therapy.
Dr. Wendy Slusser 37:10
Wow, that’s very encouraging. It’s always nice to have some gratitude even in times of tragedy or pandemic era. I’m sure many people are wondering, you say a long nap. How long can you nap without disrupting your sleep?
Dr. Alon Avidan 37:24
Oh, that’s a question that I always like, because most people know but some people have this misconception about naps. So let me tell you what the power nap is. A power nap is strategic by time and by duration. And guess what a time is ideal. It’s right after lunch time, noon time to about 3 pm, just around that period of time. It’s perfectly fine to take a nap. Now the nap has to be short, 15 or 20 minutes, half an hour max. Once you begin to nap longer, if you nap 45 minutes, an hour, two hours, you’re then likely to wake up when you’re in slow wave sleep. And when you do that, you’re depressed, you’re confused, you’re disoriented. That’s called sleep drunkenness, or increased sleep inertia. Meaning that when you wake up after coming out of slow wave sleep, which occurs an hour after you fall asleep, you’re more likely to be groggy. The nap is not going to be as restorative.You’re more likely to be depressed, tired, and it’s not going to be any benefit to you. So shorter naps partially restore sleep debt, especially early during the day between 12 to 3, 15 to 20 minute power nap equivalent to a tall glass about 20 ounces of caffeine, 200 milligrams of caffeine. And it’s cheaper to do that. And you get the same benefit.
Dr. Wendy Slusser 38:57
It’s such a tradition in many cultures. So that makes sense. People observed that it must have helped them enhance their well being. You’ve been mentioning different phases while you’re asleep, assuming you’re sleeping in our seven to eight hour period. And there was a number of research reports that you shared with me talking about dreams and how dreams have been disrupted during the COVID period. And I guess at other times as well. I want to understand the power of dreams and the role of dreams. And also there’s a lot of conversation around vividness of dream.
Dr. Alon Avidan 39:32
Sure, sure. So firstly, it’s very interesting that often as we go through the sleep cycle, we start at very light stages of sleeps, stage one and two, and we go into the heavier, slower wave, deep sleep that’s called slow wave sleep or stage three sleep. Stage one and two make up the light sleep. And then after about 90 minutes, you go into REM. REM is rapid eye movement sleep. And that’s when you’re dreaming. That’s when your, when your muscles are paralyzed. That’s when you’re dreaming. That’s when memory consolidation takes place. Same in slow wave sleep. And it’s vital that you go through all the sleep stages in the sequence. We found that during the pandemic, because the patterns of sleep duration, and regularity have been so abnormal, and because people have been more stressed, during this unprecedented period, there have been a number of reports of the so called pandemic dream. I’m just looking at the International Classification of Sleep Disorders that we’re now updating. And there was one area that we wanted to update for the 2021 version is to create a new category of nightmares, called pandemic dreaming, because pandemic dreaming refers to not only abnormalities of dreaming, but alteration of dreaming that is mediated by the lockdown during the pandemic. And individuals who have this problem are often depressed, anxious. They’re generally younger women who suffer from poor sleep quality, disturbed nocturnal behaviors, anxiety, depression, and also very vivid dreaming that is very negative. Now it’s very different than a nightmare, which is often manifested with an arousal and then anxiety reaction to the awakening to the arousal. That doesn’t happen with the pandemic dreaming. So there is definitely an alteration in the content, along with the fact that those patients are also very depressed, very anxious, and have alteration in their dreaming and dream experiences. Why we dream? I wish I knew the answer. You know, we probably need another 90 minutes to discuss the the function of sleep and the function of dreams. But dreaming is probably a way in which the brain learns to take experiences and put vital ones in special compartments to preserve those experiences for later use, because they’re evolutionarily advantageous, and get rid of experiences that may not serve an evolutionary advantage. Now, this is very, very basic and fairly simplistic view to look at dreams. But in essence, it’s a way for the brain to go through like your defragmentation function on a computer and put memories, package them to make room for new and more memories that can be coming in the future, but to also from connections. When those experiences have a commonality and provide an evolutionary advantage to that individual. The alteration of dreaming, of course, is brought by experiences that are fairly dramatic and fairly negative during the day. We know that very profoundly right after 9/11, the population in New York and Washington D.C. recorded significant levels of nightmares and dream alteration. With the pandemic, less nightmare type episodes, but more abnormalities in how patients interpreted what they were dreaming to be very negative, associated with more anxiety, more depression, and alterations of the dreaming to be more negative, in which the patient had to, for example, look for an exit to run away from negative experiences that may have some metaphorical similarity to what they were experiencing during the daytime.
Dr. Wendy Slusser 43:52
Well Alon, I think you’re right. We might have to do another podcast if you’re willing, because I think that this dream conversation, I have so many more questions, and but you’re describing just so I can understand about what you just mentioned about what you’re experiencing during the day is then expressed through your dreams. One of the solutions would you think would be to address those emotions and worries in the daytime? I mean, would that be one way to address that challenge?
Dr. Alon Avidan 44:21
Absolutely Wendy. It’s so true, that one of the primary theories in how we manage patients with nightmares and abnormal dreaming is through a process through a treatment called imagery rehearsal therapy, in which the patient is allowed to bring experiences that they see or images, visions that they experienced during the hallucination, during the dream experience and talk about it. And form more positive anecdotes and positive associations with those negative emotions. And the patient learns, say, mindfulness techniques and deep breathing exercise. So they’re not going to react as negatively when they see those images and confronted with by similar hallucinations during a dream experience. They’re not going to be as anxious.
Dr. Wendy Slusser 45:13
That’s hopeful for many people.
Dr. Alon Avidan 45:15
Dr. Wendy Slusser 45:15
That’s really. It sounds like you have a lot of answers. And I’m looking forward to hearing more about the dreams in our next podcast. And I learned so much from you. And I’m looking forward to learning more. And before we end, is there anything that you’d like to add to what we discussed or any pearls of wisdom.
Dr. Alon Avidan 45:36
As people are thinking about sleep, you know, sleep is one of the gifts that we often take away from. And remember, just as you are eating, breathing, sleep is one of those vital functions. Do not forget to sleep. It’s often, sometimes, people forget that it’s two or three in the morning, and they just finished a zoom call, and they have to do homework. But you just have to make sure that you protect your bedtime. It’s so important to your cardiovascular function to make sure you remain healthy, and you retain a proper immune function.
Dr. Wendy Slusser 46:14
Thank you so much for everything you do. So appreciative Alon and looking forward to our next podcast.
Dr. Alon Avidan 46:21
Thank you so much, Wendy. It’s been a pleasure and happy to participate in the future and good luck to everyone. And stay healthy and well.
Dr. Wendy Slusser 46:31
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