First night on CPAP did not go so well :Update- a breakthru!

[Pugsy]

FWIW...if you can get used to using that old dinosaur..you will think the new machine is a piece of cake.
They are hugely improved over the old machines. We don't know but some of that 4 hour thing might even be related to lack of humidifier. Probably not all but maybe part of it. Most people needs some sort of added moisture and some people need a lot.

Do the best you can with what you have right now but remember that some people take weeks and months to finally be able to sleep through the night with the machine and those people are using the latest and greatest....

When I first started therapy..I had a lot of awakenings during the night but I didn't remove the mask...but then I didn't have the trouble falling back to sleep that you do. It's just plain weird having this alien sitting on our face and it just takes some time for the brain to accept its new buddy. Took me about 2 months before the presence of the mask didn't cause wake ups. Now I had other causes..but from the mask and machine point ....2 months. It took 2 months to go from 4 hours before a wake to 6 hours before a wake up.

[Drowsy Dancer]

Thanks Randy,

I appreciate what you are saying and it only makes sense. I have been reading through robysue's blog quite a bit lately. My problem is I always feel run down and like I want to sleep but when it comes time to sleep, I usually have a problem getting to sleep. I have a history of Insomnia already along with my other problems - Depression & Anxiety. So adjusting to this new environment with CPAP is proving especially rough. I'm hopeful that once/if this new DME works with me and gets me established on newer equipment with CFlex/AFlex, humidifier, ect... hopefully and a properly fitted mask that I will fair better. Right now I'm basically on my own along with the great help and suggestions Pugsy has provided which much of has helped me even tolerate to any degree. I just want that feeling for once in my life to wake up feeling rested and refreshed which I can never remember having.

Unfortunately it is a slow process. I found to my dismay that fixing my breathing was not the only thing I had to do to fix my sleeping--I'd picked up a lot of bad habits along the way that didn't fix themselves just because I could breathe at night. And I wasn't ready to change them all at once, nor could I really identify them all at once. I think your first task is to get used to CPAP, period. Your second task obviously is trying to get better equipment so that you have your best possible CPAP treatment. Then your third task, I guess, will be the long road to fixing insomnia--Robysue is the expert on this, hands down--with all the "sleep hygiene" stuff like getting up and going to bed at the same time every day ("sleep architecture"), restricting caffeine (maybe), not napping, etc., etc. But you might well feel this best tabled for later. I was on CPAP for about seven months before I started getting more serious about "sleep hygiene," and it's still a work in progress for me.

[lazer]

Thank you Pugsy and Drowsy Dancer,

I do think a new machine/mask may help me a lot. I know the PR System One REMStar 60 Series Auto CPAP with Heated Humidifier and Heated Tube I have sitting in my cart sounds a world better/different than this dinosaur I'm trying to work with now. I also get this slight odor (at first I thought it could be my imagination) of like a cigarette smoke type smell when running the machine. I know my buddy at work that gave me the old straight CPAP was/is a smoker... I'm not a smoker but I do use "Swedish Snus" - a form of chew in pouches...

I have learned to restrict my caffeine intake to just a coffee in the mornings and sometimes a Pepsi One for lunch but nothing after that. I try to get to bed generally the same time every night. I am guilty of going to bed early before ready to attempt to sleep and watching the TV with the volume down low. I have done this more so in the recent months because of my fear of never being able to get to sleep if I wait because I can never seem to get directly to sleeping whether I get in bed earlier or do wait until later when feeling even more sleepy. I have went from 1mg prescribed xanax to up to 2mg regularly now in the past couple weeks in an attempt to get to sleep better which has helped that some but I still seem to wake up after an hour or four and especially this past nearly one full week now since I've started to give CPAP a go.

[lazer]

Update: Another night, another failure

Got to bed about an hour later than my normal due to catching up on some yardwork and things. Put the CPAP on and still laid there about an hour before falling asleep at maybe midnight? Woke up at 2:30 AM and tried to force myself to leave the mask on but being so concerned that I wouldn't get back to sleep and had to be up at 7am for work, ended up taking it off yet again. Woke up this morning feeling awful like I didn't even sleep at all. At work now with my morning coffee struggling to get my motivation and feel productive. This is proving to be an exceptionally tough battle. I'm so looking forward to next week and hoping this new DME will follow through with getting me on some newer equipment -properly fitted mask, ect... and off to a better start. Meanwhile, I will keep trying.

[Pugsy]

Lack of sufficient hours of sleep will make anyone feel like crap whether they used the machine or not.
Or whether they even needed to use a machine or not.

Can you put a finger on why you are not being able to fall asleep quickly with the mask and machine on?
Is it the mind or is it the body (as in comfort with mask and machine and all)?
Anything we can do to make it more comfortable?

[lazer]

I'm just not sure. Right now it doesn't really seem like the mask/machine is having a detrimental effect on me falling asleep, it's more of me waking up an hour or two/four later. I have had an ongoing problem at falling asleep at night (prior to CPAP) in a timely manner and thinking back to last night, the more I put the mask on, the more comfortable and natural it is starting to feel. I even used the ramp feature set at 4 which has seemed to help make it feel better starting out. I have bumped the pressure back up to 8cm a few nights ago because it started feeling like I needed a little more to breath comfortably when awake as I have now become more accustomed to the exhale part not working so much against me.

I really thought last night as I was more active in the evening catching up on yardwork and stuff that come bed time, I would be able to get to sleep quicker but that wasn't the case. I sure know that I am really feeling it today ... So tired and sluggish, I'm feeling like I'm barely going to make it through the day. I know when I do get home, I'm going to have to attempt a nap. Do you think I would be best to stay on the couch rather than get in bed for a nap? Should I put the mask on even for a nap and see how that goes? Any further thoughts on my pressure settings since I noted that the 5cm has seemed less comfortable than putting it back to my initial attempt at 8cm again?

Thanks!

Lack of sufficient hours of sleep will make anyone feel like crap whether they used the machine or not.
Or whether they even needed to use a machine or not.

Can you put a finger on why you are not being able to fall asleep quickly with the mask and machine on?
Is it the mind or is it the body (as in comfort with mask and machine and all)?
Anything we can do to make it more comfortable?

[Pugsy]

If you must nap....use the machine. If you reward your brain with time off from the machine...guess what he is going to want the next time?
If you are comfortable with the pressure at 8...leave it alone. If you think pressure is say...causing you to focus overly long on your breathing then perhaps try 7... You already found that much lower is uncomfortable.

Actually, I was going to say "no nap" especially if it is after work (assuming you have 8 hour work day) because it is going to be much closer to bedtime than we would want. Now if the nap was at 1 or 2 PM...not so bad but napping in the later afternoon and early evening will decrease the need for sleep at night. Not what you wanted to hear was it?

[lazer]

Actually, I was going to say "no nap" especially if it is after work (assuming you have 8 hour work day) because it is going to be much closer to bedtime than we would want. Now if the nap was at 1 or 2 PM...not so bad but napping in the later afternoon and early evening will decrease the need for sleep at night. Not what you wanted to hear was it?

Not really .. Although usually when I have a day like today and say I'm going to go home and nap right after work, I just end up laying on the couch semi-awake for an hour or two and never really sleep either. One consistent with me seems to be come the weekend when off work, I tend to stay in bed for 12-14 hours feeling like I have to "catch up" on sleep missed during the week. Can't say even then that I wake up much more rested than usual but I know it feels good to just stay in bed when I can.

[Pugsy]

Napping....let me share this little story.
Back in March my Mom was really sick and ended up in the hospital and needing surgery. So for about 10 days I was going to hospital every day (hour drive one way) plus a lot of other stuff. I was totally worn out.
We got her home...so then I get to go over there and keep an eye on her frequently.
One day over at her house I was so totally exhausted I simply had to nap. Of course my machine was at home so I thought I would lay on my side in hopes not many events would visit me and since I am worse in REM sleep and since it takes about 90 minutes to get into REM sleep...I thought an hour nap wouldn't be so bad.
It was totally wasted nap. I woke frequently with every little snore and my mom said they were frequent.
She and my niece were laughing at me.
End result...45 minute nap with countless arousals from snores and gasping for air and I felt worse than when I started. At one point I dreamed I was suffocating. That actually was the first time I have ever dreamed that I was suffocating. Or I thought it was a dream......

No napping sounds harsh but if that nap delays sleep at night...not a good thing to do.

[robysue]

lazer,

First, my apologies for not noticing this thread earlier. With the flu, I've been picking and choosing what to read with a bit of randomness. And others have already mentioned by blog and you've said that you're reading it.

I'd like to review your history (from the other thread) for a bit since I have some questions to ask that are relevant to what I want to say on this thread. Your official diagnoses are

45yr old male. Diagnosed with "mild sleep apnea" and heavy snoring. Also have been struggling with depression, anxiety, and never feeling rested during the morning or day. Waking up throughout the nights. Had an in home sleep study done beginning of this year through NovaSom per my family physician.

In that first thread you mentioned your problems with the DME refusing to set you up with the machine even with pre-approval from your insurance company because your diagnostic AHI < 5. I've gone back through the data you posted there. And it does indeed appear that on this home sleep study your AHI ranges from 2.4 to 2.9, when computed by dividing the number of events by the time you had the equipment on. I point this out because it indicates that if sleep disordered breathing is a serious contributor to how lousy you're feeling, it's likely not the traditional OAs and H's that get scored on an in-lab PSG. Your snoring was noted as Snoring > 50db for 73% of the sleep study time. And loud snoring all by itself can cause symptoms of daytime fatigue and unrestful sleep. Snoring can also lead to arousals even if you don't remember waking yourself up with your snores. And the NovaSom home sleep study does not use an EEG so we really don't know whether you had an excessive number of arousals---either caused by snoring or perhaps caused by RERAs, which are similar to hyponeas, but do not quite meet the definition of hypopnea and do end with an EEG arousal.

So the net result is: You're a 45 year old male who snores a lot (and loudly) who wakes up a lot at night and never feels rested in the morning. You also have struggled with depression and anxiety. And you and your doc (and insurance company) all think it's a reasonable idea to try CPAP to see if it will improve your sleep. Which sounds rather reasonable given the short-comings of the NovaSom having no EEG leads to collect arousal data. And since the CPAP should prevent the snoring, and hence reduce or eliminate snoring-related arousals, a CPAP may help you sleep better even if you don't really have clinical OSA.


On going problems with feeling lousy in the morning

Here is my ongoing problem. I keep waking up sometimes 4 hours later, sometimes as quick as 1 hour later and things just don't seem right. I don't know if it is the mask feeling uncomfortable or the air pressure getting to me either too low or too high but I end up taking it off to get back to sleep for the rest of the night. I have yet to get a full night in. This morning I especially didn't want to get out of bed for work, it was a real struggle. I probably got a total of 8 hours sleep but took the mask off after the first hour.

The half sentence I bold-faced and italicized is particularly relevant since you want to give CPAP a honest trial.

And since you are currently sleeping much more WITHOUT the CPAP than with the CPAP, my best guess is that you're still struggling in the morning and daytime because of one of three things:

• 1) You really do have OSA or UARS in spite of your diagnositc test's low AHI and you body is remembering the 7 hours of sleep filled with OSA/UARS/snoring related arousals rather than the 1 hour with the CPAP.
  
  Or
  
  2) You don't actually have OSA, but you've got enough snoring going on that it's the snoring and snoring related arousals that are causing your symptoms and your body is remembering the 7 hours of sleep filled with snoring related arousals rather than the 1 hour with the CPAP, which should address the snoring by preventing it.
  
  Or
  
  3) Your sleep problems are not really caused by OSA/UARS/snoring in the first place and you're still feeling bad because the root cause of your sleep problems remains unaddressed. And in this case, CPAP might not make any positive difference in your sleep and it's may adversely affect your sleep in the long run.

In order for the CPAP to have any chance at all of helping you, you need to use it all night long. So since you want to give CPAP an honest trial, you need to break the bad habit of consciously taking the mask off and returning to sleep without it just because you've woken up in the middle of the night.



About those wakes where you take the mask off and then go back to sleep
Since you and your doc both believe that Snoring is a significant problem and "mild OSA" is likely a problem, you want to make a go of CPAP in the hopes that it will help. So we'll continue with the assumption that you need/want to make it possible for you to sleep all night with the hose attached to your nose.

You write that when you wake up in the middle of the night something doesn't seem "right" and it's difficult to get back to sleep with the mask on your nose. You mention several possible things that could have triggered the wake: The mask being uncomfortable, the pressure being too much, and the pressure being too low, but you indicate that you're not sure which it is. But you've also got a history of insomnia and frequent waking at night prior to starting CPAP, and that's got to be considered as well. And the waking up 1-4 hours after falling asleep with the CPAP on could simply be a continuation of an older, pre-CPAP wake after sleep onset (WASO) pattern. And you are simply arousing more completely with a sensation that "something's not right" because you've got this alien device attached to your face. What to do about these wakes, of course, depends on what's causing them.

And unfortunately you're the only one who's in your bed waking up with your problems. So no-one will be able to definitively figure out why you are waking up except for yourself. So you've got to do some careful analysis and trouble shooting. Some questions for you to think about that might help tease out what kinds of things are causing you to still wake up are:

1) What kinds of things can you remember about your pre-CPAP WASO patterns? How often did you usually wake up in the night? How often did you have trouble getting back to sleep after waking up in the middle of the night? How did you feel when you would awake in the middle of the night? Anxious? Tired? Rested? Coming out of a dream? None of the above?

2) Is there something qualitatively different about the post-CPAP wake than your usual pre-CPAP wake ups? If so, how would you describe this difference?

3) After you take the mask off for the night, do you continue to wake up periodically during the rest of the night? If so, how do you feel at those wakes?

Answering these questions will go a long way towards beginning to figure out whether these CPAP-wakes are really just a continuation of the old wakes and the thing that is "not right" is just the alien that's attached to your face. Or whether these CPAP-wakes are a new kind of wake altogether that indicates something needs to be done to tweak your therapy in some way in increase your comfort.

So right now I think your first task is to figure out whether the waking 1-4 hours after falling asleep with the mask on your nose is really a new kind of an awakening OR if it's just one of your old wakes with the sensation that something's not right being caused by the alien on your nose. Once you know the wakes are being caused by the CPAP, then it's a matter of figuring out what to do to increase your comfort.

In the meantime, here's what I'd do when you wake up in the middle of the night tempted to rip the mask of your nose:

• 1) While you don't want to get too carried away in the middle of the night with troubleshooting, it is worth spending about 2-5 minutes trying to figure out what the problem actually is: Is this wake qualitatively different than your old pre-CPAP wakes? Are you physically uncomfortable? If so what part of your body is uncomfortable? How is it uncomfortable? What could you do to make it more comfortable? Is the air pressure bothering you? If so, how is it bothering you? Can you breathe normally? You may need to leave the machine running with the mask on your nose while you are doing this. But keep it short---spend no more than a few minutes in bed pondering what's wrong and how to fix it.
  
  2) Address any obvious things to fix problems you've identified. Refit the mask, for example, if it's mask comfort or leaks that woke you up.
  
  3) Give yourself about 20-30 minutes to try to fall asleep WITH the mask on your nose. Do NOT look at a clock---guesstimate the time.
  
  4) If you are still awake at the end of 20-30 minutes, get out of bed, go into a different room and do something to relax and calm yourself and encourage yourself to get sleepy again. Once you are both sleepy enough and calm enough to mask up again, then go back to bed with the mask on your nose.

[lazer]

1) What kinds of things can you remember about your pre-CPAP WASO patterns? How often did you usually wake up in the night? How often did you have trouble getting back to sleep after waking up in the middle of the night? How did you feel when you would awake in the middle of the night? Anxious? Tired? Rested? Coming out of a dream? None of the above?

About the same pre-CPAP. Just wake up for no apparent reason. Sometimes I wake up just once, other times up to several times during the night. Usually I can get back to sleep I would guess within 20 minutes if I am comfortable. When I awake during the night, I usually just feel tired and first think it is morning already until I look at the clock then I feel upset because I woke up. Can't remember the last dream I've ever had.

2) Is there something qualitatively different about the post-CPAP wake than your usual pre-CPAP wake ups? If so, how would you describe this difference?

Not that I can think of other than feeling like the mask must not be working because I woke up still with it running so I get frustrated not wanting to chance feeling uncomfortable and another barrier to get over getting back to sleep.

3) After you take the mask off for the night, do you continue to wake up periodically during the rest of the night? If so, how do you feel at those wakes?

Varies. Sometimes I wake up, other times I don't. When I do, I just feel frustrated at waking up early and tired.

-------------------

Thanks robysue and I'll try your suggestions. Right now I have an hour and 15 minutes to go till off work. Feeling very tired and irritable

[Pugsy]

There's a little saying around here. CPAP don't fix bad sleep. At least it can't unless the sole reason for bad sleep is obstructive sleep apnea. Often the case is that we have more going on with regards to poor sleep quality than just OSA. CPAP is just a tool that we use to try to fix one part of "bad sleep".

Sounds like a good case of sleep maintenance insomnia. I don't remember if we have discussed meds or not and I don't know remember what you said you have been taking but you might want to research each one individually to see what the known side effects are..particularly for drowsiness and/or insomnia and/or fatigue.

[lazer]

Sounds like a good case of sleep maintenance insomnia. I don't remember if we have discussed meds or not and I don't know remember what you said you have been taking but you might want to research each one individually to see what the known side effects are..particularly for drowsiness and/or insomnia and/or fatigue.

I'm on quite a bit of meds. At least I feel so. Statins, Antidepressants, Anxiety.... Too tired to list them right now but I will as I've tried to research them but getting mixed results. Ironically my PCP feels that if we cure the sleep issue, the meds can be decreased or ultimately go away. That has been his goal with me and along with doing my part which I accomplished since Feb of losing 20 lbs on a low carb diet so my BMI index is low/normal now. He was hopeful that would have also improved my sleep but it hasn't although I have a slight bit more energy during a normal day than prior to the low-carb diet and weight loss.

Unless this drive home from work gives me a boost of energy OR I run off in a ditch, I'm going to bring the CPAP to the couch, hook up and go out and see if I can actually nap with it and how long. The way I'm feeling right now, I don't really care if I fall asleep and don't wake up to morning.

Thanks for the continued help.. I appreciate all of you.

[robysue]

lazer,

First, I agree with Pugsy: If you do take a nap, mask up. And if you can avoid taking naps altogether it may help you sleep better at night.

But given your long history of pre-CPAP insomnia and the fact that you're on some major medication that can play havoc with your sleep architecture, I think you're going to need to do some serious work to tame the insomnia monster.

In other words, some of why you're still feeling lousy in the day time is poor quality sleep caused by things other than your mild OSA and your loud snoring. And plain old garden variety insomnia can leave you feeling wiped out. So for you to improve the quality of your sleep (and hopefully) your daytime functioning, you've got to deal with the insomnia as well as the OSA. And until you tame that insomnia monster, you're not going to see much improvement in the quality of your sleep regardless of what you try.

Remember: Until you are sleeping with the CPAP, the CPAP cannot improve how you feel. And right now, you have issues with sleeping that go beyond sleeping with the CPAP.

So I think it's time to start looking at that sleep hygiene much more closely. Not just so that you stand a chance of giving the CPAP an honest trial but also because you've got that long standing history of insomnia, along with history of being on prescription meds that adversely affect sleep architecture.

At various points you write:

I have had an ongoing problem at falling asleep at night (prior to CPAP) in a timely manner and thinking back to last night, the more I put the mask on, the more comfortable and natural it is starting to feel.

Put the CPAP on and still laid there about an hour before falling asleep at maybe midnight?

I try to get to bed generally the same time every night. I am guilty of going to bed early before ready to attempt to sleep and watching the TV with the volume down low. I have done this more so in the recent months because of my fear of never being able to get to sleep if I wait because I can never seem to get directly to sleeping whether I get in bed earlier or do wait until later when feeling even more sleepy.

One consistent with me seems to be come the weekend when off work, I tend to stay in bed for 12-14 hours feeling like I have to "catch up" on sleep missed during the week. Can't say even then that I wake up much more rested than usual but I know it feels good to just stay in bed when I can.

I really thought last night as I was more active in the evening catching up on yardwork and stuff that come bed time, I would be able to get to sleep quicker but that wasn't the case.

The BIG implication of these statements is that you've got a pretty bad case of sleep onset insomnia. And that you've taught your body that it's perfectly acceptable to lie in bed awake for long periods of time. And that's a hard lesson to "unlearn." Adding CPAP to the mix just adds yet another stimulus that may be keeping you up a bit longer, but it's hardly the real reason that you find it so tough to fall asleep in a timely fashion when you go to bed.

One hard thing about CBT for insomnia is accepting that you've got to actively train your body to associate Being in Bed = Time to Sleep. And everything that allows your body to continue to believe that it is ok to lie in bed for hours while awake has to be brought under control. So one critical question you need to ask yourself is this: Why are you so afraid of not being able to get to sleep if you simply wait until you are appropriately sleepy enough to go to bed?

And several of these statements seem to imply that you don't make much of a distinction between feeling sleepy and feeling physically tired or exhausted. They are not the same feeling. And no matter how tired you are physically, if your mind is not sleepy when you go to bed, it can be very, very difficult to get to sleep. Getting some physical exercise everyday is an important part of controlling insomnia, but getting too much exercise in one day can lead to being too tired and too physically exhausted. Think of the stereotypical "terrible two-year old" who gets too wound up and too exhausted to actually take a nap.

I also think that you've got a bad case of what Dr. Krakow calls the Worries in his book Sound Sleep, Sound Mind. My guess is that you have a difficult time bringing closure to your day and choosing to not worry about all kinds of things once you go to bed. And that you're currently using the TV and the melatonin in an effort to ignore the fact that you have a hard time keeping your mind from focusing on worries and fears when you are lying in bed waiting for sleep to come.

You also write in various posts:

Right now it doesn't really seem like the mask/machine is having a detrimental effect on me falling asleep, it's more of me waking up an hour or two/four later.

I have went from 1mg prescribed xanax to up to 2mg regularly now in the past couple weeks in an attempt to get to sleep better which has helped that some but I still seem to wake up after an hour or four and especially this past nearly one full week now since I've started to give CPAP a go.

45yr old male. Diagnosed with "mild sleep apnea" and heavy snoring. Also have been struggling with depression, anxiety, and never feeling rested during the morning or day. Waking up throughout the nights.

Here is my ongoing problem. I keep waking up sometimes 4 hours later, sometimes as quick as 1 hour later and things just don't seem right. I don't know if it is the mask feeling uncomfortable or the air pressure getting to me either too low or too high but I end up taking it off to get back to sleep for the rest of the night.

Woke up at 2:30 AM and tried to force myself to leave the mask on but being so concerned that I wouldn't get back to sleep and had to be up at 7am for work, ended up taking it off yet again.

I do sleep but at times wake up frequently during the night. NEVER feel rested in the morning and don't want to get out of bed if I don't have to. And I can definitely tell that when my sleep is at the poorest, I am very irritable and just feel plain crappy the following day.

This collection of quotes makes it clear that you are also dealing with a long standing sleep maintenance insomnia problem. Here again, adding the CPAP doesn't help address this issue and it may have aggravated it, but the CPAP is not apparently the reason why you're having trouble maintaining sleep.

My guess is that your sleep maintenance insomnia has multiple roots. And sleeping meds often do very little to alleviate sleep maintenance insomnia. But many insomniacs have a significant behavior pattern that aggravates their sleep maintenance insomnia: They pay too much attention to the fact that they've woken up in the middle of the night.

Lots of folks wake up during the night, sometimes even multiple times, and most of them don't have insomnia. It's not uncommon for folks to wake briefly at the end of REM cycles, for example. Lots of folks have to get to full wake to comfortably turn over in bed. Folks wake up because they're hot and need to throw the covers off. Or they're cold and they pull the covers back on. But one critical difference between non-insomniacs and insomniacs is their reaction to waking up in the middle of the night.

The non-inosomniac seldom worries why he/she is awake unless there is some clearly identifiable external cause for the wake. He/she may casually glance at the clock (or not), and most likely rearranges the covers to get more comfortable, perhaps goes to the bathroom, perhaps gets a drink of water, yawns a couple of times and goes back to sleep. The insomniac is likely to be much more aware he/she is awake and much more troubled by the fact that he/she is awake. And this often leads to looking at the clock and then worrying about how soon the alarm clock is going to go off and mentally calculating how little sleep he/she has gotten during the night, which winds up making the insomniac wake up even more fully.

Non-insomniacs typically don't even remember a wake unless it's lasted at least 5 minutes or so. Insomniacs with sleep maintenance problems may inadvertently encourage themselves to stay awake long enough to remember the wake---by immediately looking at the clock and starting to focus on how long they've been asleep for example. Or by immediately going into Why Am I Awake? mode where they start trying to analyze exactly what woke them up when there really was no cause for the wake. Insomniacs may also have a tendency to remember shorter wakes than non-insomniacs.

So what you choose to do when you wake up in the middle of the night is pretty important for dealing with sleep maintenance insomnia. And the best choice is probably to do nothing for several minutes except snuggle more comfortably in your covers. But that's a hard thing for an insomniac to do. And unfortunately, the longer you spend in bed awake and worrying about being awake the harder it can be to get back to sleep. And after about 15-30 minutes of lying in bed awake, you are typically too alert to get back to sleep. And that's why one of the basic tenants of good sleep hygiene is: If you're not asleep in about 30 minutes, get out bed, go to a different room, do something soothing and relaxing until you are sleepy enough to get to sleep. This rule is highly counter-intuitive to the typical clock-watching insomniac who's already worried that they'll never get enough sleep to function the next day. But if you just get out of bed for a few minutes to clear the mind, relax for a bit, and allow yourself to get sleepy, you will likely get back to sleep faster than if you had stayed in bed tossing, turning, and worrying about being awake. And this is doubly important if what's keeping you awake is frustration with the machine.

You've written the following about your prescription drugs:

As mentioned, I have also suffered depression, anxiety, and insomnia for the past 6+ years and have been and still am on quite a cocktail of depression and anxiety meds which help somewhat with that but never seem to help with the sleep quality which actually seems worse when my depression and anxiety are in check with the meds.

I actually switched from being on Prozac for a year plus to Effexor earlier this year. I see that is one mentioned that can effect the deeper stages of sleep negatively now. I'm only on 75mg and was considering upping the dose as my mood has not been as in check lately. I'm also on .25 mg of xanax 3x daily and .50 mg at night. I also take 300mg Neurontin 4x daily but usually only remember to take it 3x. I've recently added some 5-htp to the mix at night as it worked for sleep in the past for me but so far not helping much lately.

I know and understand what your saying. Ideally I would like to be off these meds. I did try for a 3 month period at the end of last year. My mood was ok until the holidays then things went sour and my psychiatrist got me going again on the meds. Sleep quality never improved while off the meds though. This has been an ongoing issue with me for as far back as I can remember.

So while these drugs are known for adversely affecting sleep architecture, it's not entirely clear whether they are adversely affecting your sleep. Nonetheless, these drugs are powerful stuff and working with your all your docs is going to be required to get everything balanced. Does the psychiatrist know that your PCP has diagnosed mild OSA and that you are trialing a CPAP?

You've written the following things about your sleep hygiene habits:

I really thought last night as I was more active in the evening catching up on yardwork and stuff that come bed time, I would be able to get to sleep quicker but that wasn't the case.

Although usually when I have a day like today and say I'm going to go home and nap right after work, I just end up laying on the couch semi-awake for an hour or two and never really sleep either.

After my sleep study in January, my doc also indicated to me that he wanted me to lose about 20lbs so he put me on a carbohydrate restricted diet (40-60) net carbs per day. This was quite a change for me as my former regime included a lot of pasta, potatoes, sodas, pop tarts, ect... Well with his advice and a neat weight loss/diet tracking program for my Android called "LoseIt", I have lost 24lbs since Feb 1st and my BMI index is now in the normal range. We were both hopeful this would help with my sleep quality, however it hasn't seemed to make a difference. I have a slight bit more energy during the day which I suppose is the complete avoidance of any unnatural sugars but still don't want to get out of bed in the morning and never feel rested.

I have learned to restrict my caffeine intake to just a coffee in the mornings and sometimes a Pepsi One for lunch but nothing after that. I try to get to bed generally the same time every night. I am guilty of going to bed early before ready to attempt to sleep and watching the TV with the volume down low. I have done this more so in the recent months because of my fear of never being able to get to sleep if I wait because I can never seem to get directly to sleeping whether I get in bed earlier or do wait until later when feeling even more sleepy.

One consistent with me seems to be come the weekend when off work, I tend to stay in bed for 12-14 hours feeling like I have to "catch up" on sleep missed during the week.

We can conclude from these comments that you have

• problems distinguishing between feeling sleepy and feeling tired or exhausted.
• an irregular sleep schedule, even if you try to get to bed about the same time.
• a nap habit that includes inefficient sleep (if any sleep at all).
• a caffeine habit that is controlled enough where theoretically it should not be interfering with your sleep.
• one or more necessary prescribed medications that can seriously interfere with the quality of your sleep, but it's not clear they actually do affect your sleep.
• cleaned up your diet, are now eating healthy, and are now at a healthy weight.

On the positive side: You understand that sleep is intimately tied to other areas of your life and you've had the discipline to lose the weight and change the diet. You should be able to harness that same discipline in an effort to clean up some of the worst parts of your sleep hygiene. You've got the caffeine under control. You understand that physical activity should help the quality of sleep.

But there is still plenty to work on. But the most important thing in my opinion is to establish a pretty rigid sleep schedule. The purpose of the rigid sleep schedule is to help you body get into a circadian rhythm. In other words, to teach your body when it should be sleepy each day and when it must be awake each day. And it will also help teach your mind how to distinguish between being sleepy and being tired. The most critical part of a rigid sleep schedule is choosing the wake up time. It's critical that you pick a time that you can make sure you get up at seven days a week. In other words, until your body is capable of falling asleep and staying asleep at an appropriate time, you cannot allow yourself the luxury of sleeping in on days off.

Once your wake up time is set, then you need to set your bedtime. The usual guideline is to set bedtime about 7-8 hours earlier than wake up time. But you've got to factor in when you usually manage to fall asleep here too. There's no point in going to bed and lying there for an hour before falling asleep. So go to bed when both these conditions are met:

• (1) It is at or after your "bedtime and (2) You feel very, very sleepy

That's the only way to help teach your body and mind to go to sleep when it is time to sleep. And don't watch the tv in bed. Do the tv watching in a different room and only go back to the bedroom when you feel yourself just on the verge of falling asleep anyway.

Get all the CPAP stuff set up before bedtime in order to keep you from waking yourself up just to deal with putting the CPAP stuff together. Get the mask put together, prefit it if possible, fill the humidifier up (when you get one) all well before bedtime. Start your pre-bedtime routine of brushing the teeth, washing the face, putting the Lanisoh on, etc. about 15-30 minutes before your official bedtime. But don't go to bed just because the clock says "bedtime"---wait until your eyes start to get droopy and you are yawning.

And if/when you wake up in the night, try to not look at the clock. Allow yourself a bit of time to get back to sleep naturally. But if you can't, then get out of bed and do something soothing and relaxing.

Finally, I think you'd gain a lot by working through Sound Sleep, Sound Mind because I really think that while the loud snoring and the mild OSA are likely contributing to your bad sleep, the insomnia is the real monster here. And until you get that insomnia monster under control, I don't think your sleep will dramatically improve regardless of what you do.

[Pugsy]

Ditto to what RobySue has said.