COVID-19 Q&A: Dr. Rachel Manber on Sleep Disturbances

Stay-at-home orders have our daily routines in flux, and uncertainty and fear are constant companions in this global pandemic. As part of our COVID-19 Q&A series, Rachel Manber, Professor of Psychiatry and Behavioral Sciences and Director of the Stanford Sleep Health and Insomnia Program (SHIP), discusses how these conditions can interfere with healthy sleep or exacerbate existing sleep condition, as well as ways to get help.

Dr. Rachel Manber

We’re hearing and reading about a general increase in reports of disturbed sleep in these times of COVID-19. Is this to be expected, even in those for whom healthy sleep was never an issue?

Dr. Manber: Yes, but not universally so. The two main contributors to potential worsening of sleep are changes in stress levels and changes in sleep behaviors. The pandemic and related shelter in place measures to mitigate its spread have increase stress levels among many. People may worry not only about the disease itself, other health issue that might not be optimally addressed, financial issue, as well as other psychological and interpersonal stressors. In general, worries and anxieties tend to have a negative impact on sleep. Distraction and other strategies people use to deal with the stress during the day are not helpful when they go to bed at night. The intrusive thoughts then make it difficult to fall asleep initially or return to sleep if awakened in the middle of the night. But there are also people who sleep better now than before the pandemic. Working from home allows them to maintain a more balanced life, and hence less stress and better sleep. For example, they may be taking more breaks and have more interactions with the people they live with. Another example is people who have not given themselves enough time to sleep and now they can, or adolescents who had the pressure of an early school day can now get the additional sleep they need.

Shelter in place also lead some people to alter the timing and duration of sleep in ways that can be detrimental to sleep. For example, they might be less regular in when they wake up or take long naps during the day. These behaviors have negative impact on the biological clock that regulates sleep and wakefulness and therefore lead to problems sleeping.

What kinds of diagnosed sleep disorders are most likely to be exacerbated by the COVID-19 pandemic

Dr. Manber: Insomnia disorder and circadian rhythm sleep-wake disorders, delayed type, are the two disorders most likely to be impacted by the pandemic. Insomnia disorder is characterized by difficulties falling or staying asleep that occur despite having adequate opportunity for sleep that are not better explained by other medical or psychiatric disorders or by use of substances. Circadian rhythm sleep-wake disorder, delayed type, is experienced as difficulty waking up in the morning and falling asleep at a societal normative time, but when going to bed and waking up at a later time sleep is not an issue.

Is it possible for temporary sleep problems to develop into a chronic one?

Are there other physical and mental health conditions that make us more likely to develop a sleep disorder in times of stress?

Dr. Manber: Yes. Indeed many physical and mental health conditions may have disturbed sleep as one of its symptoms. Examples include depression, post-traumatic stress disorder, night-time panic attacks, and physical conditions that cause acute or chronic pain. Sometimes medications used to treat physical conditions have insomnia symptoms as side effects.

How do disturbed dreams play into sleep?

Dr. Manber: We all dream but are more likely to remember the dream in the morning if we woke up from the dream than if we slept through it. When stress increases, such as during the pandemic, sleep tends to be more fragmented and people tend to remember more dreams. Disturbed dreams indicate a sleep disorder only if they are nightmares. A bad dream is a nightmare if it wakes the sleeper up and the sleeper remembers a dream with very unpleasant content and very strong negative emotions, such as fear. When that happens frequently, the person may have a nightmare disorder. For most people the pandemic is not expected to lead to a nightmare disorder; but front line health care providers and some patients who had intensive treatments might be vulnerable to nightmares.

What self-care practices might help? And, are these different for different age groups or genders?

Dr. Manber: People of all ages need to take time to unwind. During the unwinding period, do things that you enjoy effortlessly; but make sure they are not too activating. This is a personal choice. If someone tells you to read a book or listen to calming music that have helped them but you find boring, recognize that this is not the right thing for you.

If you are awake in the middle of the night and are having difficulty falling back asleep, take a break from trying to sleep. If you keep trying you will get frustrated or upset, which will only make it more difficult to sleep. Instead focus on resting. During this break from trying to sleep do something that is restful, such as reading or listening to content that you enjoy and that is not too activating. Getting oriented to what you need to do the next day is rarely very restful. Hopping on exercise equipment is too activating. These are obvious things you should not do. Again whet is restful for you might be unique to you, the important thing to do is stop trying to sleep.

Create a structure to your day. The pandemic may have disrupted the structure you used to have but you can still create a new structure. This begins with starting the day at roughly the same time every morning and ideally having some social interaction early in the day. This interaction does not need to be elaborate, a short phone call will do.

When should people seek professional care for sleep problems and where can they find experts?

Dr. Manber: It is time to seek treatment when the sleep disturbances are persistent and develop into one of the three sleep disorders that I discussed – insomnia disorder, circadian sleep-wake disorder, and nightmare disorder. All three disorders can be treated effectively without medications by behavioral sleep medicine specialists. To receive one of these treatments at Stanford, people can call 650 498-9111(Palo Alto main campus) or 650 723-6603 (Redwood City).

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