3rd night CPAP -- Sleep Hygiene vs. dangerous exhaustion

[AHI15]

Hi,

If one is borderline psychotic due to insomnia related extreme exhaustion, and is contemplating self-destruction, would you agree that the best choice is to take a sleeping pill or an anti-anxiety med. such as a benzodiazepine even if that ruins one's sleep hygiene, vs. attempting to endure such a state of mind?

Have you ever come to this level of anguish due to exhaustion and fatigue?

Last night I fell asleep in about 15-45minutes after retiring at about 10pm. I planned to wake up at 6:45 (my "sleep hygiene" time). I had 1-2 brief toss/turn wake ups of perhaps 15-30 minutes during the night, with some unusual hip pain. It seems the adjustments I've made to my side sleeping position to not disturb my mask are making my hips hurt. Peculiar.

But then I woke around 4:45 and couldn't sleep anymore. After laying in bed for a little longer than was conducive for sleep hygiene, I got up at 5:15. But when getting up at this time of morning, it is usually the case that I can't just go back to bed and expect to fall asleep again since the psychological pressure of knowing that my family will wake soon, getting hungry, and trying to decide whether to go to work, etc. all make further sleep impossible.

So I laid on the living room floor and descended into despair since the fatigue and tiredness was so awful that I had a headache and was dizzy. When my mind turned to thinking that I'd rather not exist like this anymore I went to drag my wife off the bed and brought her to the living room to lay with me.

There is no more powerful mental health medicine than your loved ones. No matter how miserable I've ever been, hugging my beloved wife always makes me smile.

So that stabilized things. But the thought of spending another whole f'cking day like this was unbearable so I downed a Sonata and put on the mask (yes I continued to use the machine!) and after about 30 minutes got another 2 hrs of sleep.

Fortunately this was enough to take away the extreme fatigue, but left my drowsy, hung-over, and still extremely tired, so I was out another whole day of work.

So on my 3rd night of CPAP I got about 9.5 hrs logged, and had AHI=3.5

But a horrible un-refreshing sleep again.

I've been debating about whether to try a week or more of just plain taking a med. every night to see if I can get some healing, then return to natural sleeping. Perhaps I will provoke another discussion about the pros/cons of this idea.

I will be starting CBT-I at Stanford in about 4 weeks.

[DoriC]

You're suffering and you need to find a way to get some quality sleep. My husband was prescribed Ambien for the first 3mos on cpap with no ill effects and his therapy progressed nicely. It's my understanding that it does not interfere with with sleep stages. I'm not sure but I think Sonata is in the same class but you could check with the Dr who prescribed it. We still take Ambien occasionally when life gets hectic. We were told to never take a pill later than midnight to avoid morning hangover. Keep us updated and good luck.

[kaiasgram]

Hi,
Have you ever come to this level of anguish due to exhaustion and fatigue?

AHI, you are not alone in your experience (feel free to PM me). There comes a point where you just need to be ok with some extra help, including pharmaceutical. You sound like you're at that point -- you describe 'dangerous exhaustion' and I take that seriously. You've already arranged for CBT therapy which is great -- in the meantime, you desperately need some sleep. Even if medicated sleep isn't ideal, it's better than the extreme fatigue and suffering you're describing. I don't know if benzos would necessarily be the best first choice, but you could work with your doc to find the safest effective short-term sleep medication that would work for you. You'll approach the CBT therapy a little better too if you're not so spiraled down. If my client tells me they're having suicidal thoughts and feeling near psychotic, I refer for a med evaluation. I don't make the decision about meds though. Somehow you need to interrupt the sleep-depression-sleep spiral and give yourself a chance to recover. Keep us posted about how you're doing. My heart goes out to you.

[gertrude]

15,

Sleep hygiene isn't a law, it's a technique and, in my mind, exhaustion trumps. I too felt horrible at the start of cpap and sleep hygiene wasn't the highest priority on the list. I was sleeping 10 hours or more to function at all. You'll probably adjust better to the cpap with some time; you've taken steps to deal with some of your other problems; and medications are NOT the worst thing in the world if they help you. I hope thought, that you're under a doctor's guidance on using them. In any event, I'm glad you have a loving wife who will join you on the living room floor.

Hang in there. Sounds as if work, and your need to be absent, is a major stressor. Any way to relieve that a little bit at least temporarily?

[zoocrewphoto]

If I have several bad nights in a row, I will take a muscle relaxer that helps me sleep. Lay week I skipped my cough medicine so that I could take the flexeril. My pharmacist said it was unsafe to take the two together. My cough was bad, but my sleep was worse. I just wanted to be asleep.

[AHI15]

Hi,

Thanks for the replies. I'll talk about my med. experience and options:

A few years ago, when I began experiencing frightening levels of despair from mid-night insomnia episodes, I made a decision to go to my Dr. and let him prescribe me Sonata. Before this, I had an almost religious opposition to psychoactive substances., due to the fact that my misuse of the illegal forms of them in high-school years was disastrous.

I was worried about spiraling back into addiction when I got the Sonata about 4 years ago. But that didn't happen. I used it very infrequently, only for the intended purpose--to put myself out of misery if I was going off the deep end from insomnia. For this is was useful, safe, and effective usually. I also avoided the psychological error of coming to believe that I could only sleep with a med. I know I can usually fall asleep naturally. What I haven't been able to do is avoid waking frequently, and it is after nighttime wakes that I can't return to sleep often.

I also tried Ambien for 5-7 days many years prior when a Dr. tried to help me with my early sleep troubles. This was revealing in that it only made me sleep uninterrupted for the 1st night. The 2nd night I had 1-2 wakes, and after that it did nothing and I had the usual interrupted sleep.

So in general, I have a high tolerance, and rapidly build tolerance to these sorts of meds. This is another reason I try to use them VERY sparingly, so as not to render them useless in case I really need them. Alternatively it may be that the underlying causes making me wake up are just too strong for any sedative to suppress.

My Dr. also prescribed Ambien XR and Temazepam for sleep after I continued complaining of worsening fatigue. The Ambien is nearly useless, since as described it doesn't keep me asleep. So, if it is only to get to sleep, only the Sonata is useful because it has the shortest half-life so doesn't kill the whole next day with hangover effects.

The Temazepam is also useless, as it doesn't keep me asleep, and has horrible next-day effects. Also I am very educated about drugs, so I know that benzodiazepines in general disrupt sleep architecture, so it would be foolish to expect to solve my non-restorative sleep problem with them. Also, they are outright dangerous to use continuously for any length of time more than a few weeks IMHO.

I keep the Temazepam around just as another option for acute panic or anxiety attack. I consider benzos to be dangerous drugs if misused, but extremely medically valuable drugs for occasional acute problems.

Most importantly, I seem to have experienced a major psychological transformation in the way my mind reacts to these drugs--in that I am successful at avoiding them unless really needed, rather than feeling compelled to use or abuse them as I did in the distant past. So while I have a healthy respect for them, I don't fear them or have an ideological opposition to them anymore.

For other classes of drugs however, my opinions have changed at different times for different reasons. I'll describe my opinions about other mental health related drugs at some other time.

So I think the point is that right now I have no opposition to using sleep meds. My only concerns are that whatever course of action I take is scientifically guided so as to produce a high likelihood of greater benefits vs. risk or harm.

Thanks for the replies!

[AHI15]

Honestly, and I'm not joking, you really need some weed. U'll sleep well and you won't be hung over in the morning.
Ambien? Benzodiazapines? That sounds like disaster waiting to happen.

Your perspective is similar to mine. Benzos are much more hazardous IMHO than weed. But don't worry, I am an avid reader about drugs, and never take anything until I have read and carefully considered the pros/cons, sometimes literally for months. I also would not even consider using anything illegal, for many reasons, even though I disagree with the law.

I used weed in the past, and vowed 24 years ago never to do so again. However, the intent in the past was to get high, which ended up leading to a disaster.

At this point, if marijuana were legalized, I would consider experimenting with it as a sleep aid. However, since I STILL do not want to get high, I would consider eating it so that it's effect occurred after I fell asleep. This would thus be a valid medicinal use, rather than a recreational use. I have no opposition to recreational use--for other people. Just not for me.

Marijuana most certainly should be legal. That it is not while alcohol and tobacco are, and all the costs and violence associated with its prohibition, disgust me.

[AHI15]

If my client tells me they're having suicidal thoughts and feeling near psychotic, I refer for a med evaluation. I don't make the decision about meds though. Somehow you need to interrupt the sleep-depression-sleep spiral and give yourself a chance to recover. Keep us posted about how you're doing. My heart goes out to you.

What kind of professional are you? Just curious since you mentioned "clients."

Thanks for the support. Check out my lengthy reply. I have been given some pharmaceutical assistance by medical professionals. I use them very infrequently. The biggest problem seems to be that none of them actually work to keep me asleep. They at best reduce sleep latency. However, I haven't yet tried Lunesta, which I have available. I haven't tried it yet since I'm a little afraid of it's possible weird side effects though.

[AHI15]

If I have several bad nights in a row, I will take a muscle relaxer that helps me sleep. Lay week I skipped my cough medicine so that I could take the flexeril. My pharmacist said it was unsafe to take the two together. My cough was bad, but my sleep was worse. I just wanted to be asleep.

Aren't muscle relaxants a big no-no with sleep apnea though?

[BlackSpinner]

Hi,

Last night I fell asleep in about 15-45minutes after retiring at about 10pm. I planned to wake up at 6:45 (my "sleep hygiene" time). I had 1-2 brief toss/turn wake ups of perhaps 15-30 minutes during the night, with some unusual hip pain. It seems the adjustments I've made to my side sleeping position to not disturb my mask are making my hips hurt. Peculiar.

The hip pain shows you are sleeping deeply. What usually happens is that you don't move while you asleep and your body objects, in the past you probably moved a lot while "asleep". My hips were very painful the first few weeks until I padded my firm mattress with two quilts folded double.

Use your sleep meds to get you over the hump of getting used to sleeping with the weird stuff on your face. Then worry about your sleep hygiene.

[Pugsy]

Aren't muscle relaxants a big no-no with sleep apnea though?

Well.....they aren't the greatest thing to take but they aren't horribly, horrible either.
Like anything else it depends on the med and the dose and the way the person responds to it as far as the relaxation of the airway tissues.
Risk vs rewards things. I broke my wrist last year and had to have surgery with pinning. Hurt really, really bad and I had to take some Percocet at bedtime to get any sleep at all. That isn't good for sleep apnea either but I discovered that it didn't make any real changes in my therapy. My pressures (APAP) didn't increase and my events didn't increase. Quite honestly I wouldn't have cared if they did. Getting sleep was more important...besides that is what I have the machine for...to prevent the events no matter what causes them.

Just like you in your situation...sometimes we gotta do what we gotta do. May not be the most perfect solution by the text book but in some situations the rewards more than out weigh the risks.
And yes. I am another who would vote...take something so you can sleep.

[AHI15]

Hi,

Last night I fell asleep in about 15-45minutes after retiring at about 10pm. I planned to wake up at 6:45 (my "sleep hygiene" time). I had 1-2 brief toss/turn wake ups of perhaps 15-30 minutes during the night, with some unusual hip pain. It seems the adjustments I've made to my side sleeping position to not disturb my mask are making my hips hurt. Peculiar.

The hip pain shows you are sleeping deeply. What usually happens is that you don't move while you asleep and your body objects, in the past you probably moved a lot while "asleep". My hips were very painful the first few weeks until I padded my firm mattress with two quilts folded double.

Wow that's an interesting hypothesis. I wouldn't have thought of that. I sure wish I had the ability to get EEG data of what is happening to see if I really am getting more deep sleep. I've looked at the Zeo thingy, but wasn't confident enough in its accuracy to decide to buy one. Plus, I probably don't need another thing on my head at this time.

Why if I am getting more deep sleep vs. before CPAP is there just NO evidence of it in how I feel yet? Puzzling, but I will give it more time. Not that I have any choice.

Use your sleep meds to get you over the hump of getting used to sleeping with the weird stuff on your face. Then worry about your sleep hygiene.

I wish there was one that made me sleep through the night. I have yet to try Lunesta. I guess I should take the Sonata if I have a hint of serious difficulty in the 3-5am timeframe, since if I abort the night's sleeping then, I am basically doomed to have a waste of a next day.

[BlackSpinner]

Wow that's an interesting hypothesis. I wouldn't have thought of that. I sure wish I had the ability to get EEG data of what is happening to see if I really am getting more deep sleep. I've looked at the Zeo thingy, but wasn't confident enough in its accuracy to decide to buy one. Plus, I probably don't need another thing on my head at this time.

Why if I am getting more deep sleep vs. before CPAP is there just NO evidence of it in how I feel yet? Puzzling, but I will give it more time. Not that I have any choice.

Well while you have it on, you are not being awakened every few minutes, you lay still and sleep until you wake up. Hip bones are heavy and press on the muscles, nerves and flesh.
Three nights is not enough to begin to help. Many people, once they get over learning to sleep with the mask, go through a couple of days to a few weeks of sleeping heavily and not wanting to get up as your body uses that time to do some rebuilding. Think of it at this point like a cast. You need to learn to walk with it and while you are wearing it the bones knit. Getting a cast on doesn't mean you can run a marathon, it means you can get around a bit without doing more damage.

[robysue]

Hi,

If one is borderline psychotic due to insomnia related extreme exhaustion, and is contemplating self-destruction, would you agree that the best choice is to take a sleeping pill or an anti-anxiety med. such as a benzodiazepine even if that ruins one's sleep hygiene, vs. attempting to endure such a state of mind?

First and foremost: Good sleep hygiene and CBT for insomnia do NOT necessarily preclude the use of sleeping pills or anti-anxiety meds. They focus on minimal use of sleeping meds, but it is NOT an either/or choice.

When I was first starting my CBT for Insomnia, I was given a prescription for Ambien with the following instructions: "You decide what a disastrous night is and you decide whether you can realistically stand to have two or more disastrous nights in a row. But after you feel as though you have had too many bad nights in a row, take an Ambien at the beginning of the next night and get some sleep." In essence, what my PA really wanted me to do was to take an Ambien the night after any really bad night so that I would NOT get to the point where you are now at: borderline psychotic due to insomnia related extreme exhaustion, and contemplating self-destruction.

So my heartfelt and sincere advice as someone who has fought this war: If you've had enough bad nights in a row and you feel you cannot cope, take a sleeping pill at the beginning of the night and see if that helps you get some sleep. The next night, try to avoid the sleeping pill. If it is another disaster, take a sleeping pill the next night. In other words, in the early days of the War on Insomnia, you may need to take a pill every other night for a while. And that's OK. Because the point of CBT is to win the War and not every single nightly battle with the insomnia beast.

And work on the sleep hygiene on the nights when you take the pill as well as on the nights when you don't. In other words, don't watch TV or web browse while lying in your bed for several hours before bedtime. Try to turn off all electronic gadgets at least an hour before bedtime. Take the sleeping pill at your normal desired bedtime---not before it. Keep the clock turned away from the bed. If you wake up anyway (which is NOT uncommon when taking sleeping pills), allow yourself about 20-30 minutes to get back to sleep. If you're not asleep by then, get out of bed for a while and go into a different room to sit until you feel sleepy. And force yourself to get up at your normal wake-up time even if you don't want to get up because you are finally sleeping. If you are keeping a sleep log, be sure to indicate that you took the sleeping pill at the beginning of the night.

Have you ever come to this level of anguish due to exhaustion and fatigue?

Yes. Many times before I started my War on Insomnia.

Last night I fell asleep in about 15-45minutes after retiring at about 10pm. I planned to wake up at 6:45 (my "sleep hygiene" time). I had 1-2 brief toss/turn wake ups of perhaps 15-30 minutes during the night, with some unusual hip pain. It seems the adjustments I've made to my side sleeping position to not disturb my mask are making my hips hurt. Peculiar.

15-45 minutes to get to sleep is an awfully wide range for an estimate. Sounds like you were very restless at the beginning of the night.

Hip pain and other pain doesn't seem to be that uncommon when we are adjusting to CPAP: Some of us move around significantly less with CPAP than we did before. So falling asleep in an awkward position can result in us staying in that position long enough to make things hurt. I'd suggest keeping a sleep log where you make a note (in the MORNING) about whether pain seemed to be waking you up.

But then I woke around 4:45 and couldn't sleep anymore. After laying in bed for a little longer than was conducive for sleep hygiene, I got up at 5:15. But when getting up at this time of morning, it is usually the case that I can't just go back to bed and expect to fall asleep again since the psychological pressure of knowing that my family will wake soon, getting hungry, and trying to decide whether to go to work, etc. all make further sleep impossible.

Ah---the "worries" kicked in---probably when you started staring at the clock. Between 4:45 and 5:15, how many times did you look at the clock?

One suggestion Dr. Krakow makes in Sound Sleep, Sound Mind for this situation of waking up too close to your intended wake up time to get back to sleep is this: Go ahead and get up, but do NOT jump into all the "work" that comes with your normal wake up time---i.e. the hustle and bustle of your family waking, getting breakfast for all, and getting yourself off to work. Rather give yourself a treat during that quiet time before the morning chaos starts. Read a bit of a book that you've been meaning to get around to. Make yourself your morning coffee and enjoy both it and reading the paper or a magazine. If it's warm enough, sit outside on the patio or front porch and listen to the birds. If you are into yoga, spend the time doing some gentle stretching. Maybe walk around the block if that appeals to you. Basically do anything that you enjoy and that will distract your mind from focusing on how little sleep you've gotten, how much you resent being awake, and how little time there is before morning.

So I laid on the living room floor and descended into despair since the fatigue and tiredness was so awful that I had a headache and was dizzy. When my mind turned to thinking that I'd rather not exist like this anymore I went to drag my wife off the bed and brought her to the living room to lay with me.

Allowing yourself to worry about the lack of sleep encouraged your descent into despair and contributed to making you feel even worse than you already did.

What could you have done differently---given how tired and exhausted and dizzy and in pain you were? Here are some things that you might have been able to do that may have helped get you through to morning and possibly may have salvaged your day:

1) Take something for the headache and make sure you are well hydrated. CPAP can dry out our nasal passages and we can wake up feeling somewhat dehydrated, which can in turn trigger both a headache and dizziness.

2) Lie down on the living room floor and turn your favorite music on and listen to it

3) Focus your attention in a positive way on how much sleep you probably got. Based on what you've written about the night, your worst case scenario indicates that you got at least five hours of sleep between 10:00pm and 4:45AM. Your best case scenario indicates that you may have gotten as much as 6 hours and 15 minutes of sleep between 10:00pm and 4:45AM. And while 5-6 hours of sleep may not be enough to feel wonderful all day long, it is usually enough for most folks to function on for a few days.

There is no more powerful mental health medicine than your loved ones. No matter how miserable I've ever been, hugging my beloved wife always makes me smile.

So---if you can comfortably lie in bed with the mask on hugging your wife, then add that to the list of things you can do when you wake too early. Just do NOT allow yourself to look at the clock and start worrying about the time. Lie there calmly enjoying hugging your wife. And don't sell yourself short: If you put your mind to it, you will find a way to hug her with the mask on.

So that stabilized things. But the thought of spending another whole f'cking day like this was unbearable so I downed a Sonata and put on the mask (yes I continued to use the machine!) and after about 30 minutes got another 2 hrs of sleep.

Kudos for putting the mask back on. If you are willing to take Sonata on an every other night basis, then you could have made the decision to take the Sonata as soon as you realized it was going to be tough to get back to sleep---as in maybe around the point where it felt like you had been trying unsuccessfully to get to sleep for about 15 minutes.

Fortunately this was enough to take away the extreme fatigue, but left my drowsy, hung-over, and still extremely tired, so I was out another whole day of work.

Not a big surprise since the instructions say to take Sonata only if you have at least four hours to sleep before you get up. The drowsy, hung-over feeling is the Sonata still hard at work in your system.

So on my 3rd night of CPAP I got about 9.5 hrs logged, and had AHI=3.5

It may be that your body still needs more time to acclimate to CPAP and that your AHI will come down as you start to sleep more soundly. Or it could be that your pressure is not yet optimal. But your AHI is acceptably low and so you need to focus on learning to sleep with the machine. And that takes time. *sigh*

I've been debating about whether to try a week or more of just plain taking a med. every night to see if I can get some healing, then return to natural sleeping. Perhaps I will provoke another discussion about the pros/cons of this idea.

As I said before: It's not an either/or choice. If you are leery of taking the Sonata every night, then take it only at the beginning of any night that follows a really bad night. In other words, if Tuesday night is a disaster, take the Sonata at the beginning of Wednesday night. If Wednesday night is not a disaster, then don't take a Sonata at the beginning of Thursday night.

I will be starting CBT-I at Stanford in about 4 weeks.

Congratulations on deciding to take the big step. Once you start the program, maybe you can tell us what they are asking you to do in it.

[kteague]

Just weighing in with a thought on your prior experiences with meds for sleep. If you had untreated OSA and took meds to sleep, it would be understandable if they didn't work or even made you feel worse. Your needs would have been beyond the scope of their ability to fix. With effectively treated OSA, if your insomnia is due mainly to adjustment to all the new sensations, you may find a pharmaceutical to be a very helpful temporary solution.

I went through several years of rarely sleeping more than minutes between wakings, and at best an occasional 2 hours of fitfulness, mostly because I had uncontrolled limb movements. I was both mentally and physically utterly depleted, and pain was ever present, which I read here is pretty common with sleep deprivation even without other sleep disorders needing treatment. Once I did begin getting some real sleep, the muscle pain improved, but I too had to face joint pain when I stayed in one position too long. Seems a cruel irony when the thing that makes you better makes you worse, huh? I got a memory foam mattress topper that helped me a lot with those discomforts.

I just want to encourage you that you are likely on the brink of some significant breakthroughs in your sleep, and hopefully you'll be reaping the rewards in the near future. It was that anticipation that kept me working toward that goal. The first time I got a taste of REAL sleep, deep sleep, I knew I was hooked, and that every effort was worth it. Hang in there.