My journey: Cognitive Behavioral Therapy for Insomnia

[papzombie]

IT FEELS GREAT: With a window 50cm x 150cm totally opened together with a door 80cm x 200cm widely opened for a room of 12 m2, I have slept last night.

This morning I feel just great, much better than any other morning since several months. I'll plan to sleep tonight totally outdoor, luckily summer now comes.

Note: I have Astma (almost to the severe level), and I am allergic to all kinds of fruit sold in the supermarket (containing a lot of conservative)

[robysue]

IT FEELS GREAT: With a window 50cm x 150cm totally opened together with a door 80cm x 200cm widely opened for a room of 12 m2, I have slept last night.

This morning I feel just great, much better than any other morning since several months. I'll plan to sleep tonight totally outdoor, luckily summer now comes.

I'm glad that you had a good night. It sure would be nice if you could do this every night ....

Note: I have Astma (almost to the severe level), and I am allergic to all kinds of fruit sold in the supermarket (containing a lot of conservative)

Any nasal allergies to pollen, dust, etc?

[mibbim]

ah ha...I am not alone. I also wake up 2-4 times at night, can fall into sleep when I go to bed, but can't stay in sleep. Will wake up every 1-3, sometimes a good one is 4 hours, but it's rare. I read that we should have at least 5 straight hours of sleep to consider we get the enough rest at night. I don't feel tired next day tho. But just very annoy, and sometimes hard to get back to sleep.

[mibbim]

By the way, does CBT really help and will change the sleeping habit?

[robysue]

By the way, does CBT really help and will change the sleeping habit?

Yes. But it can be very hard work. And you have to have realistic goals at the start. And it can take quite a bit of time before it makes a real difference.

In my case the very hard CBT-I that I did between Jan 2011 and May 2011. At the start of my CBT-I, I and my PA set two primary goals for the CBT-I: (1) Reduce my latency to sleep at the beginning of the night, and (2) reduce the overall wake after sleep onset (WASO) by reducing the amount of time it took me to fall back asleep after each wake. By the end of my formal CBT-I, it had made a huge difference in achieving both goals. By the time my CBT-I wrapped up:

(1) I had managed to teach my body to fall asleep at the beginning of the night within 10 minutes. That is a short enough time that the BiPAP does not start irritating me to the point where I become more alert, which, of course, makes it much tougher to fall asleep. And the more alert I am and the longer it takes me to fall asleep with my BiPAP, the more likely I am to have trouble all night long with discomfort issues, including aerophagia. (Prior to the CBT-I, my typical pre-CPAP sleep latency was usually 45-60 minutes; after starting CPAP I was in agony from aerophagia after about 30 minutes, and that made it very, very difficult to get to sleep at the beginning of the night.)

(2) I learned to NOT to worry about normal post-REM wakes AND I learned how to prevent normal post-REM wakes from becoming prolonged periods of tossing and turning while fighting to get back to sleep. Post-REM wakes that last no more than 5 minutes are usually NOT remembered in the morning and they are not particularly disruptive to the overall quality of a person's sleep, and in my case that is most certainly true.

I still wake up at night, and because of comfort issues, I routinely turn my BiPAP off and back on just about every time I wake up. Hence my BiPAP data gives a pretty accurate picture of how often I actually wake up each night. Most nights the BiPAP data shows that I wake up anywhere from 2 to 6 times, but currently I only remember 0-2 of the wakes. And the wakes I do remember are almost always very short---as in I have no trouble getting back to sleep as soon as I turn my BiPAP off and back on.

And when my BiPAP keeps my AHI below about 3.0 AND almost all of the wakes recorded in the BiPAP data are clearly normal post-REM wakes AND I remember no more than 2 brief wakes, I wake up feeling pretty rested and I even sometimes wake up feeling refreshed.

You also write:

ah ha...I am not alone. I also wake up 2-4 times at night, can fall into sleep when I go to bed, but can't stay in sleep. Will wake up every 1-3, sometimes a good one is 4 hours, but it's rare. ... I don't feel tired next day tho. But just very annoy, and sometimes hard to get back to sleep.

Some questions about your night-time waking pattern:

1) What do you mean when you write, "Will wake up every 1-3? Do you mean you wake up every 1-3 hours? If the wakes are often at 90 minute and 180 minute intervals, then chances are they're perfectly normal post-REM wakes. And in that case, the best thing you can do concerning the wakes is to NOT worry about them. Seriously, the more you worry about post-REM wakes, the more likely you are to extend the normal, less than 5 minutes long post-REM wake to a 15-20 minute period of restlessness and tossing and turning that really can affect the overall quality of your sleep.

2) What is the first thing that goes through your mind when you find that you've woken up in the middle of the night? Do you immediately start thinking negative thoughts about the fact that you are awake? Do you look at the clock immediately upon waking? Are you worried or annoyed or upset over the fact that you are awake yet again?

3) How long does it usually take to get back to sleep after a typical wake? 5 minutes or so? More like 10-15? Or more like 20+ minutes? How frequently do you have trouble getting back to sleep? On only a few wakes? On half the wakes? On almost all the wakes?

4) When you find yourself having a tough time getting back to sleep after a middle-of-the-night wake, what goes through your mind? And what do you do? Do you find yourself constantly looking at the clock and thinking about how little sleep you've gotten so far and how fast your normal wake-up time is approaching?

5) What does your typical sleep schedule look like? When is bedtime? When is wake up time? And how much actual sleep do you think you get during a typical night?


You also write:

I read that we should have at least 5 straight hours of sleep to consider we get the enough rest at night.

Most people with normal sleep patterns don't actually get 5 straight hours of totally uninterrupted sleep. Rather they arouse slightly at the end of each REM cycle, and may indeed actually wake up at the end of each REM cycle. But as soon as they realize there's nothing to concern them in terms of something being off/strange in their sleep environment, they turn over and immediately go right back to sleep within a minute or two. In the morning they don't even remember these short post-REM wakes because no wake lasted more than 5 minutes.

[mibbim]

Robysue wrote:

What do you mean when you write, "Will wake up every 1-3?"[

yes, every 1 hours, 2 hours or 3 hours...

Robysue wrote:

What is the first thing that goes through your mind when you find that you've woken up in the middle of the night? Do you immediately start thinking negative thoughts about the fact that you are awake?

, lol, yes, look at the clock first and say gosh...not again.... then turn off the cpap machine, go to bathroom, and turn on the machine again to see if I am able to back to sleep...

Robysue wrote: how long I can get back to sleep? It probably takes more than 15 minutes to get back to sleep again in a good night during the first wake, the second wake will be hard, it usually around 3 or 5am

Robysue wrote:

When you find yourself having a tough time getting back to sleep after a middle-of-the-night wake, what goes through your mind? And what do you do? Do you find yourself constantly looking at the clock and thinking about how little sleep you've gotten so far and how fast your normal wake-up time is approaching?

yes, yes, and yes...if I really can't sleep, then I start to make up story in my mind just like play a movie....

Robysue wrote:

What does your typical sleep schedule look like? When is bedtime? When is wake up time? And how much actual sleep do you think you get during a typical night?

I go to bed around 9:30 to 10, and make sure I am not thinking of anything, then turn on the cpap at 10:30 pm and go to sleep. Get up at 7 am. Probably 6 hours total with frequent waking up.

[robysue]

Robysue wrote:

What do you mean when you write, "Will wake up every 1-3?"[

yes, every 1 hours, 2 hours or 3 hours...

When the wakes are spaced at intervals that are greater than 90 minutes, they are most likely normal post-REM wakes. And the best thing you can do about normal post-REM wakes is to do your best to just ignore them. Literally. As in don't start asking yourself why are you awake and don't look at the clock; just turn over and go back to sleep as quickly as you can.

Robysue wrote:

What is the first thing that goes through your mind when you find that you've woken up in the middle of the night? Do you immediately start thinking negative thoughts about the fact that you are awake?

, lol, yes, look at the clock first and say gosh...not again.... then turn off the cpap machine, go to bathroom, and turn on the machine again to see if I am able to back to sleep...

It's a hard thing for many people to do, but if you can stop looking at the clock, things might just get better for you. Right now your behavior is prolonging the length of the wakes so that you will remember them in the morning. And by prolonging the wakes, you are making them much more disruptive to your overall sleep quality.

My advice: Ditch the clockwatching. Put the clock somewhere you cannot see it the instant you open your eyes and realize that you are awake.

And try to not start the negative thoughts about the fact that you are awake. Instead of "gosh darn it, why am I awake again?" try to make the first thought that goes through your head much more netural: "Is there something uncomfortable that I can fix?"

If your bladder if full, you go to the bathroom. If you are thirsty, you get up and get a drink of water.

If you've woken up hot, you throw the covers off or stick your feet out from under them. If you've woken up cold, you pull the covers up.

If the CPAP pressure is bugging you, you turn the machine off and back on. That way the pressure is back at your minimum pressure setting.

If there's a leak, you fix it.

If there's nothing identifiably uncomfortable, you say to yourself, "I guess it was just a post-REM wake" and you snuggle back down and allow yourself the luxury of going back to sleep without looking at the clock.

Robysue wrote: how long I can get back to sleep? It probably takes more than 15 minutes to get back to sleep again in a good night during the first wake, the second wake will be hard, it usually around 3 or 5am

How much of the difficulty getting back to sleep is tied up with watching the minutes tick by on the clock?

Back when I was doing the CBT-I, I was told to give myself what subjectively felt like about 20 minutes to get back to sleep after a wake. I was told to NOT look at a clock to measure that 20 minutes; accuracy in my estimate was not important, but the sensation that I'd been trying to get to sleep for 20 minutes was what was important. And if I was still awake after what felt like 20 minutes, I was told to get out of bed, go into a different room, do anything I wanted to do except for two things: (1) I was not supposed to look at a clock the entire time I was out of bed and (2) I was not supposed to do work related stuff. I was told to go back to bed only when I was starting to feel sleepy. The first couple of weeks was really rough since it felt like I was getting out of bed an awful lot. But by the end of the first couple of weeks, my body started to figure out that since it didn't want to be out bed in the middle of the night, it had to force my brain to shut up and go to sleep. By the end of the first month of CBT-I, I was getting out of bed because I couldn't get back to sleep maybe once a week or so. By the end of the CBT-I, I was getting out of bed because I couldn't get back to sleep maybe once or twice a month. Now? It's more like maybe one every 3 or 4 months.

Robysue wrote:

When you find yourself having a tough time getting back to sleep after a middle-of-the-night wake, what goes through your mind? And what do you do? Do you find yourself constantly looking at the clock and thinking about how little sleep you've gotten so far and how fast your normal wake-up time is approaching?

yes, yes, and yes...if I really can't sleep, then I start to make up story in my mind just like play a movie....

Ditch the clock. Quit focusing on how little sleep you've gotten. Quit focusing on how quickly morning is coming. All those things make you more alert and more awake and make it harder to get back to sleep.

Daydreaming is a good distraction. Instead of staring at the clock, as soon as you lie back down to go back to sleep, start making your story in your mind. Make it a nice, relaxing story. Have fun in your mind with it.

Pre-CPAP I did a lot of daydreaming both at the beginning of the night and if I happened to wake up during the night. And that kept me from even feeling like my insomnia was an issue. But once I started CPAP, however, I would get so uncomfortable from the aerophagia that I found it difficult to daydream while lying in bed. I still miss doing it though. And in the last year I have noticed that I'm now beginning to be able to do a small bit of daydreaming in bed with the mask on without getting the aerophagia.

Robysue wrote:

What does your typical sleep schedule look like? When is bedtime? When is wake up time? And how much actual sleep do you think you get during a typical night?

I go to bed around 9:30 to 10, and make sure I am not thinking of anything, then turn on the cpap at 10:30 pm and go to sleep. Get up at 7 am. Probably 6 hours total with frequent waking up.

So you are physically in bed for 9 or 9.5 hours, but you only get 6 hours of sleep.

That gives you an estimated sleep efficiency of 6/9 = 0.67 or 6/9.5 = 0.63. Sleep efficiency is defined as

• sleep efficiency = (estimated total sleep time)/(time in bed)

Back when I was a newbie, there was a sleep tech who used to post here a lot under a whole string of different names. When he was helping me, he went by Muffy and NotMuffy, but his last name that I recall was Sludge. At any rate Sludge told me a number of times that sleep efficiency is a really good measure of how bad insomnia is. The usual conventional wisdom is that if sleep efficiency > 0.85, most people will wake up feeling rested and won't feel like they've been struggling for sleep all night long. Sludge himself thought that a better standard was to aim for sleep efficiency >= 0.90 on a consistent basis.

The idea is this: The longer time you spend in bed struggling and worrying and fighting for sleep, the more exhausted you are from struggling and worrying and fighting for sleep. In other words, a person may feel more rested getting 6 hours of sleep if they spend only 7 hours in bed as compared to 6 hours of sleep if they spend 9 hours in bed. The sleep efficiency of getting 6 hours of sleep in a 7 hour "time in bed" window is 0.857, as compared to a sleep efficiency of 6/9 = .667.

The hardest part of my CBT-I focused on getting my sleep efficiency to increase from roughly 0.50-0.60 up to 0.85-0.90 or better. The way my PA had me do this was extremely hard work and, to be honest, quit painful at the beginning. She had me use what is called a "sleep restricted sleep schedule" to consolidate my sleep cycles (i.e. eliminate the wakes in the middle of individual sleep cycles) and also to minimize the total wake after sleep onset (WASO) time from the normal post-REM wakes. At the time I started my CBT-I, I was getting what felt like about 4 or 5 hours of sleep each night, even though I was usually in bed for 7-8 hours trying to sleep. In other words, my sleep efficiency at the start of the CBT-I was in the 0.50-0.71 range. The PA and I agreed on a 6 hour "Time in Bed" (TIB) window---I was not supposed to spend more than 6 hours in bed on any night---unless I had a major migraine or was sick with the flu. And the idea was to keep me at a 6 hour TIB until my body started consistently getting sleeping at least 5 to 5.5 hours every night for at least a couple of weeks. Then we'd gradually start increasing the time in bed by 15 minute intervals, but after each increase in TIB, I had to start getting 15 additional minutes of sleep on a regular basis before the next increase.

What I found by doing this crazy sleep restricted schedule was that I really did feel much more rested (sometimes even refreshed) when I was able to get 5 hours of sleep in a 6 hour TIB window than I ever felt getting 5 hours of sleep in an 8 hour TIB.

Even today, I seldom am in bed more than 7 or 8 hours. But when I am in bed, I am usually sleeping. Unless the insomnia is threatening to get out of control, my sleep efficiency is usually in the 0.83-0.90 range. And when it drops much below 0.80 for more than a week, I go back to restricting my TIB for a while until the sleep efficiency gets back up to the mid 0.80's.

Well it's now almost 2:00 AM here in Buffalo, and that's at the end of my "bedtime window" in the ongoing experiment my sleep doc has me doing right now to evaluate whether the Belsomra is actually helping control some of delayed sleep phase problems. So I need to head off to bed.

Good luck to you as you try to figure out what you are willing to do in terms of changing your sleep behaviors in an effort to get better, more restful sleep than you are currently getting.

[papzombie]

It is cozy here, welcome Mibbim.

Window open: Unlike yesterday's morning, this morning I feel less good than yesterday, also yesterday after lunch I took a nap and felt not so good afterwards.

[robysue]

It is cozy here, welcome Mibbim.

Window open: Unlike yesterday's morning, this morning I feel less good than yesterday, also yesterday after lunch I took a nap and felt not so good afterwards.

Was that nap with or without the PAP?

And when you've got serious problems getting or staying asleep at night, sometimes naps make the problem worse. Lots of times people with serious nighttime insomnia problems are told to avoid napping as much as possible as a way of encouraging the body and brain to want to sleep at night.

[papzombie]

It is cozy here, welcome Mibbim.

Window open: Unlike yesterday's morning, this morning I feel less good than yesterday, also yesterday after lunch I took a nap and felt not so good afterwards.

Was that nap with or without the PAP?

And when you've got serious problems getting or staying asleep at night, sometimes naps make the problem worse. Lots of times people with serious nighttime insomnia problems are told to avoid napping as much as possible as a way of encouraging the body and brain to want to sleep at night.

Yes, after yesterday's attempt to nap after 10 days not napping, I realize that napping or sleeping some extra hour does not help me at all. I'd rather do sport other than napping, even when I am tired.

Thanks

[mibbim]

Hi, Robysue, Thank you so much for your patient and help to have a such detail explanation. It sounds like really tough when trying to change one person's sleep pattern, especially when the pattern lasts more than 10 years. However, I tried to turn my clock back against me last night, I set up clock alarm at 7 usually even I will wake up before 7, my body knows when needs to get up to work. But subconscious, just need that alarm for peace of mind. So I went to bed at 10, probably fell into sleep right away, I usually feel very sleepy around 9:30 pm, and trying to stay up until 10:30 pm to go to bed. My first woke up last night was 2 and half hours later, I didn't look at the clock, but when I turn off the cpap, the usage hour is shown on the screen, it's 2:30 hours, went to the bathroom, and came back down and turn on my cpap, continue to sleep, it was not for long, I went back to sleep again. So I probably woke up 3 times after that, but I just stayed in bed (didn't look at the clock), and fell back to sleep again. I woke up around 6 this morning, turn off the cpap, and found out I already had my cpap mask for over hours, that's a big surprise, since I always take off the mask after 5-6 hours since if I can't fall into sleep, I can stand the dis-comfortable of the mask, the pillow tip hurts my nose, and sometimes I feel a light headache. It's only one night experience, will see what happens tonight. Can you sleep whole night now after the CBT-I? May I ask how did you start the CBT-I? Have you gone through the sleep behavioral evaluation prior setting up the CBT? The reason I asked is I have an appo with the U of M behavioral sleep medicine center, the first appo is with a PHD in Psychiatry. Then probably will set up CBT sessions from there. The problem is they are out of network for my insurance, so I am still debating if it's worth to go or not. U of m is 1 and half hour drive from me. I am planning to the CBT in local which is in network. So I am not sure if it's better to have an evolution first, then take the plan and go to the CBT in local? Do you have any suggestions? Again, I am really appreciate your time and help.

[PEF]

I am flaming insomniac - have been all my life. AND I AM DOING MUCH BETTER CONSISTENTLY since reading all about insomnia on this forum and getting some good thoughts and ideas from Robysue and others. Due to some craziness going on in my life now, I have not had much time to post about it recently. It is hard, because we try so many things and often when we begin to improve we don't really know how our improvement happened because there are so many variables. So I am in the process of getting all my notes together to share with the forum.

I have found that, regarding troubleshooting insomnia problems, some issues are individual and some are universal. I would say that the universal items include things like anxiety around the issues of sleep and poor sleep habits. I found that I just had to TAKE CARE OF THESE ISSUES and stop fighting. The SLEEP ANXIETY HAD TO GO, PERIOD. The individual ones involved finding out what issues, peculiar to ME, may be causing or aggravating my insomnia. These usually involve finding out what it was about my particular situation that caused me to not want to sleep at night. SAFETY was a big one for me and hard to solve. Another one was the deafening QUIET here at night that I can't stand. I needed to generate more noise. This was difficult because my husband, also an insomniac, is the opposite - noise tend to awaken him. The HOURS we both slept were causing us problems. My husband's natural hours of sleep are something like 8 pm to 4 am. Mine are like 2am to 10am. For example, it turned out that a lot of my issues were because of trying to deal with another insomniac living in the house.

So we are getting this sorted out, but we are both doing much better. I will post more about my journey, but don't have time right now.

[robysue]

mibbin,

I sounds like you may have made some progress last night. Do keep in mind that there's a lot of baby steps and a lot of two steps forward, one step back, when you're trying to change long established sleep habits. Or, in the case of insomnia, long established "not sleeping" habits.

You ask:

Can you sleep whole night now after the CBT-I?

Define "sleep the whole night"

If you mean: Go to sleep and not remember any wakes at all when I get up in the morning, the answer is, "Not really."

If you mean: Go to sleep, remember a few not very long wakes during the night, and usually waking up feeling rested and somewhat refreshed, the answer is, "Yep, pretty much."

May I ask how did you start the CBT-I? Have you gone through the sleep behavioral evaluation prior setting up the CBT?

The PA in my sleep doctor's office suggested it and she's the one who directed it. I'm not sure what you mean by a "sleep behavioral evaluation", but the PA had been working with me for 3 months while I was having a disastrous adjustment period to PAP therapy, that included among other problems, an insomnia monster that had grown out-of-control ...

I am planning to the CBT in local which is in network. So I am not sure if it's better to have an evolution first, then take the plan and go to the CBT in local? Do you have any suggestions? Again, I am really appreciate your time and help.

My nonmedical advice is to try the in-network stuff first: You probably already know much of what's wrong with your sleep behavior. If the in-network stuff fails to help, you can always reevaluate whether a sleep behavioral evaluation might be worth it to uncover more oddball problems.

[robysue]

I am flaming insomniac - have been all my life. AND I AM DOING MUCH BETTER CONSISTENTLY since reading all about insomnia on this forum and getting some good thoughts and ideas from Robysue and others.

PEF,

It's good to hear from you. It's also nice to know that things are going much better now in terms of your sleep!

[mibbim]

That make sense, I will start the in-network CBT first, at least 20 visits per year, if it's still working, try something else, I heard there is even a neuron treatment to change the brain wave to improve sleep.