Insomnia, UARS, or both?

[quitepositive]

I am new to this forum and seeking some advise/help from the more experienced people regarding sleep problems. I am not sure where to start, but perhaps I should mention a brief history of sleep problems.

I shall say that prior to June 2013 I had never experienced any insomnia or troubles falling or staying asleep. I am a 25 year old male, in good shape and physically active. In the beginning of June 2013, I had some emotional-related stress, which led me to the inability of falling asleep (1-4 hours - sleep onset) for couple of nights, which then settled in and I developed a real problem sleeping. Some nights I just couldn’t fall asleep at all, some nights I woke up early and unable to dose off, and most of the nights I woke up on average of 5-6 times for enough time that I would precisely remember those wakeups. The most paradoxical of all things was that although I felt fatigued and exhausted from little sleep that I was getting, I was always hyper aroused, I was not able to take naps despite sleeping for only couple of hours previous night, I never felt sleepy at night and was not able to yawn. My sleep drive, it seemed, disappeared and so did my energy, performance, and happiness. Some nights were so unbearable that I decided to go to see a doctor to ask for something to aid me with sleep. I got small prescription of 0.5Mg Clonozepam, which some night did help me at least to fall asleep. I took it occasionally, 3-4 times a week, in the past 3 month only once or twice per week as needed.

I also went to see a sleep specialist, who ordered a sleep study on October 20, 2013. I couldn’t fall asleep for 3-4 hours during the study and only was able to get some sleep in the morning before they woke us up at 6:30. The results of that study show that there was excess light (stage 1) sleep at 35% and a corresponding loss of deep sleep. Sleep efficiency 56%, REM latency was 317 minutes, which is very abnormal. Sleep disordered breathing was detected at a rate of 25.6/h RDI. RDI included breathing disturbances associated with arousals, which occurred at a frequency of 25.1/h (RERA index). No snoring, no PMLD, no RLS. Interestingly though, EEG arousal activity not associated with Respiratory of PLM events was at 251, which seems to be oddly high(doctor did not explain that). Basically for the first part of the night I was in an out of sleep every couple of minutes looking at my graph, but I was very anxious prior to the study so perhaps anxiety caused these abnormal findings.

As a result of that study doctor gave me prescription APAP, which I got with a nasal mask, tried to use it but often had difficulties falling asleep with it or still waking up often or early and unable to fall back to sleep. I asked my doctor whether these arousals were related to the sleep-related anxiety that I was experiencing, because I never had any issues with sleep prior to June 2013, and to my question whether I could have developed this syndrome overnight, he answered No you probably had it but never realized it.

He also recommended to try sleep restriction, restricting my time in bed to 6,5 to 7 hours a night to address my insomnia. I tried that for a week and it seemed to help somewhat, I became more tired at nights and fell asleep faster, but then it was too difficult to continue with it and I started to sleep in when I could, and screwed it up.

He had scheduled another study after a month of home trial of nasal CPAP. On November 27, 2013 I went in for another sleep study this time with CPAP, with prescribed pressure of 5 up to 10cm. Again I couldn’t fall asleep for an hour and after decided to take a 0.5 of clonozepam, so that they could have at least some data from me to work with. I fell asleep within 20 mins and slept ok for most night the mask on. Sleep efficiency was 80%, REM latency of 2:10 hours. Stage 1 = 20% , Stage 2 = 62%, Stage 3(deep sleep) = 4.6%, and REM was at 12.9%. RDI=7.9, while RERA index = 6.8. So clearly CPAP did something as the RDI was 3.5 times higher during my first sleep study.

The problem is that when I use CPAP at home I either cant fall asleep or still wake up several times with it, eventually giving up on it and taking it off. Lately for several past week I have been waking at around 4 am and not being able to fall back asleep for at least 4 times a week, but I do fall asleep faster than before, now takes about 10-20 minutes on average, but the sleep maintenance has gone down the drain.

Sorry for such a long post, I hope someone can help me figure this out, and perhaps give me some suggestions as to what to do. Thanks everyone in advance.

[49er]

quitepositive,

What does your nasal breathing look like? If it is in any way constricted, that can interfere with successful pap therapy, including staying asleep on the machine.

49er

I am new to this forum and seeking some advise/help from the more experienced people regarding sleep problems. I am not sure where to start, but perhaps I should mention a brief history of sleep problems.

I shall say that prior to June 2013 I had never experienced any insomnia or troubles falling or staying asleep. I am a 25 year old male, in good shape and physically active. In the beginning of June 2013, I had some emotional-related stress, which led me to the inability of falling asleep (1-4 hours - sleep onset) for couple of nights, which then settled in and I developed a real problem sleeping. Some nights I just couldn’t fall asleep at all, some nights I woke up early and unable to dose off, and most of the nights I woke up on average of 5-6 times for enough time that I would precisely remember those wakeups. The most paradoxical of all things was that although I felt fatigued and exhausted from little sleep that I was getting, I was always hyper aroused, I was not able to take naps despite sleeping for only couple of hours previous night, I never felt sleepy at night and was not able to yawn. My sleep drive, it seemed, disappeared and so did my energy, performance, and happiness. Some nights were so unbearable that I decided to go to see a doctor to ask for something to aid me with sleep. I got small prescription of 0.5Mg Clonozepam, which some night did help me at least to fall asleep. I took it occasionally, 3-4 times a week, in the past 3 month only once or twice per week as needed.

I also went to see a sleep specialist, who ordered a sleep study on October 20, 2013. I couldn’t fall asleep for 3-4 hours during the study and only was able to get some sleep in the morning before they woke us up at 6:30. The results of that study show that there was excess light (stage 1) sleep at 35% and a corresponding loss of deep sleep. Sleep efficiency 56%, REM latency was 317 minutes, which is very abnormal. Sleep disordered breathing was detected at a rate of 25.6/h RDI. RDI included breathing disturbances associated with arousals, which occurred at a frequency of 25.1/h (RERA index). No snoring, no PMLD, no RLS. Interestingly though, EEG arousal activity not associated with Respiratory of PLM events was at 251, which seems to be oddly high(doctor did not explain that). Basically for the first part of the night I was in an out of sleep every couple of minutes looking at my graph, but I was very anxious prior to the study so perhaps anxiety caused these abnormal findings.

As a result of that study doctor gave me prescription APAP, which I got with a nasal mask, tried to use it but often had difficulties falling asleep with it or still waking up often or early and unable to fall back to sleep. I asked my doctor whether these arousals were related to the sleep-related anxiety that I was experiencing, because I never had any issues with sleep prior to June 2013, and to my question whether I could have developed this syndrome overnight, he answered No you probably had it but never realized it.

He also recommended to try sleep restriction, restricting my time in bed to 6,5 to 7 hours a night to address my insomnia. I tried that for a week and it seemed to help somewhat, I became more tired at nights and fell asleep faster, but then it was too difficult to continue with it and I started to sleep in when I could, and screwed it up.

He had scheduled another study after a month of home trial of nasal CPAP. On November 27, 2013 I went in for another sleep study this time with CPAP, with prescribed pressure of 5 up to 10cm. Again I couldn’t fall asleep for an hour and after decided to take a 0.5 of clonozepam, so that they could have at least some data from me to work with. I fell asleep within 20 mins and slept ok for most night the mask on. Sleep efficiency was 80%, REM latency of 2:10 hours. Stage 1 = 20% , Stage 2 = 62%, Stage 3(deep sleep) = 4.6%, and REM was at 12.9%. RDI=7.9, while RERA index = 6.8. So clearly CPAP did something as the RDI was 3.5 times higher during my first sleep study.

The problem is that when I use CPAP at home I either cant fall asleep or still wake up several times with it, eventually giving up on it and taking it off. Lately for several past week I have been waking at around 4 am and not being able to fall back asleep for at least 4 times a week, but I do fall asleep faster than before, now takes about 10-20 minutes on average, but the sleep maintenance has gone down the drain.

Sorry for such a long post, I hope someone can help me figure this out, and perhaps give me some suggestions as to what to do. Thanks everyone in advance.

[quitepositive]

I dont find it constricted in any way, I always breathe through my nose, unlsess ofcourse, it is congested due to cold or allergies, but when that happens I use nasal spray to decongest it. Thanks

[syzygy]

Sometimes sleep problems can mess with your Circadian rhythms. Having such a high REM latency is suggestive of delayed sleep phase syndrome--a disorder in which your body's internal clock wants you to go to bed late and wake up late. Our bodies really do have clocks of a sort inside them, and if your clock thinks it's not time to sleep, you'll have trouble.

The usual way to cope with delayed sleep phase syndrome is to use bright light therapy. You can use something like this: http://www.amazon.com/Feel-Bright-Light ... ht+therapy. It's expensive, I know, but works fairly well. If you're inclined to try this, you should use it for 30 minutes immediately after you wake up. Or you could just go outside for an hour as soon as you wake up or it gets light outside.

Barry Krakow says there's a connection between PTSD and UARS. Not sure if other people agree or if this is relevant to your situation, but it might be worth googling.

There's fairly clear research saying that sleep deprivation causes weakness of the genioglossus (tongue) muscles. So the stress could cause insomnia, and the sleep deprivation could cause a sleep breathing disorder.

If I were in your shoes, I would probably try the bright light therapy for a month and see what happens. It can have quite a powerful effect.

With regard to CPAP, it's difficult to give good suggestions. On the one hand, you seem only to have RERAs without desaturations, so CPAP is probably not a medical necessity. On the other hand, you're young, and things could get worse. It may be that CPAP could slow this progression down. Further complicating matters is the fact that you're having trouble getting good sleep using it. And also, your range (5-10) may not be optimal. Of course, it's true that many people adjust over time to CPAP, so things might get better. But people with UARS seem to have the most trouble with it. Some such people do better with BIPAP or ASV. Finally, I would say that if you give it a good try and it doesn't help, don't sweat it. You did what you could.

Regardless of what you decide, you're not going to solve this problem overnight, so you needn't stress out over it. Use the bright lights and then do whatever seems best with CPAP. You might, for example, start with it on when you go to bed, and then just knowingly take it off when you wake up the first time. Over time, your body may adjust and cause you not to feel that you need to take it off as much. And one day, you'll be able to sleep through the night with CPAP. If you just can't get to sleep at all with the CPAP on, take it off, and tell yourself you'll try again tomorrow. You can also try hooking yourself up to it while watching tv or some other relaxing activity, just to acclimate yourself to the device. The key point is that you don't want to have a mental association between CPAP and stress/insomnia.

Good luck!

[49er]

I dont find it constricted in any way, I always breathe through my nose, unlsess ofcourse, it is congested due to cold or allergies, but when that happens I use nasal spray to decongest it. Thanks

Thanks for letting me know quitepositive.

You might want to look into dental devices since your RDI is in the moderate range with this caveat. People with UARS can also be intolerant of them.

Here is a study that is helpful in my opinion:

https://advancedbrainmonitoring.app.box ... 7pjn8s11y4

Best of luck.

[quitepositive]

THanks for you response. I do not think that I have delayed sleep phase syndrome, partly because I usually fall asleep relatively fast and have lots of dreams. The problem now, is that I wake up every 2 hours or so, and often upon awakening at 4 or 5, I am unable fall asleep for whatever reason, I just toss and turn, or im in and out of very shallow short sleep which typically lasts 20 or 30 minutes. When I wake up at night I feel pretty aroused and not very sleepy, and it usually takes me 5 to 10 mins to fall back asleep again. I do however, remember that I was dreaming prior to my awakening.

As for the Range of CPAP, 5-10cm was set as a trial range. However, looking at my 2nd study lab report I just noticed that at CPAP level 4cm -total sleep time was 102 mins and during that time I had 20 RERAs, at CPAP level 7 - I slept for 50 mins and had 4 RERAs, and at level 8 I slept for 96 mins and had 9 RERAs. Perhaps this indicated that my minimum titration should be increased to higher than 5?

[quitepositive]

I just realized that those 20 Reras at level 4cm, mostly occured during that first hour I was in and out of sleep till I took a pill, so the level is probably not very relevant.

[Pugsy]

Until Robysue comes along you might want to read up on her experiences with insomnia
http://adventures-in-hosehead-land.blog ... er_19.html

Sleep apnea or UARS isn't always the sole cause for sleep onset insomnia or sleep maintenance insomnia.
Lots of people have insomnia and don't have any sort of sleep disordered breathing issues.

UARS and cpap therapy doesn't have a huge reference to draw upon as to which is maybe the best way to address it but based on what I have read...
I agree with your idea about a higher minimum and I would also maybe restrict the maximum so that the range is minimal to none...just in case the minor pressure changes are potentially a factor in causing sleep disruptions.
You can set minimum to equal maximum in apap mode if you wish.

Which brand APAP machine did you get?

[Rustsmith]

A lot of your experience sounded exactly like mine, until you hit the part about no PLMS or RLS. My RDI numbers were very similar to yours. However, I was fortunate enough to have landed with a sleep doctor who did a preliminary diagnosis of UARS due to my thin build. Because of this, they performed the additional testing required for a positive UARS diagnosis both during the initial test and during the followup titration study. During my titration study, I did not get much sleep (in spite of a double dose of sleeping pills). But, due to the instrumentation, they were able to tell when they had achieved sufficient pressure to prevent my airway restriction. From what I was told afterwards, this was a slightly higher pressure than what they would have prescribed for me if I had been a classical OSA patient.

In your case, you may need more pressure than the 5cm that you are currently using. You should understand that the programing of most APAP machines is primarily intended for treatment of OSA and not UARS. The machines try to address the apneas and hypopneas an the AHI index that is associated with OSA and often will not adjust the pressure for the flow limitations that can be associated with the RERAs and RDI of UARS. This means that if you are starting out at 5cm and really need to be at 7 to control your RERAs, the machine may not adjust the pressure upward because your AHI is still low, even though you are frequently waking up.

If your machine is one that can detect flow limitations and you can look at the data, you might want to consider increasing the pressure gradually over the span of several days until you see the FLs reduced. There are a number of threads that discuss UARS and flow limitations on this bulletin board, so I will not try to go into that any further but suggest that you read through some of them to get an idea of what you would need to consider.

[mellabella]

So I'm definitely not an insomniac, but I do have UARS, and this is what it took years to figure out in my case:

--I was initially titrated at 7. This was to stop apneas and hypopneas--which means for someone with UARS it was way too low. At the 6 month mark, if you've experienced no improvement most insurers will pay for a retitration. I finally stumbled across a pulmonologist who understood that with UARS you have to titrate to correct for flow limitation--which put my recommended pressure at 11-14, and I'm now on a BiPap at 12-17 (see below)

--I not only have a bipap (which some argue are more comfortable for UARS as well as for high pressures), but I also have an auto bipap that detects and responds to flow limitations and RERAs (the RERA detection seems to be bunk....the software records one in the first few seconds I put on the mask and then right before I take it off and that's it). The response to flow limitation is the real deal, though, and my machine has the most comfortable, natural inhale-exhale curve I've ever tried. It was $$ out of pocket (though about half of retail since I bought it from a member here), but worth every damn penny. I'm finally getting a little bit of restorative sleep.

Disclaimer: none of this is medical advice for you personally, since I'm not you or your doctor.

[syzygy]

THanks for you response. I do not think that I have delayed sleep phase syndrome, partly because I usually fall asleep relatively fast and have lots of dreams. The problem now, is that I wake up every 2 hours or so, and often upon awakening at 4 or 5, I am unable fall asleep for whatever reason, I just toss and turn, or im in and out of very shallow short sleep which typically lasts 20 or 30 minutes. When I wake up at night I feel pretty aroused and not very sleepy, and it usually takes me 5 to 10 mins to fall back asleep again. I do however, remember that I was dreaming prior to my awakening.

Okay, fair enough. I'm a big believer in the effect of circadian rhythm disregulation due to disrupted sleep patterns as a general rule. Not sure about your own individual case, but it never hurts to be as consistent as possible in meal times and to get at least 30 minutes of sun outside per day if possible.

As for the Range of CPAP, 5-10cm was set as a trial range. However, looking at my 2nd study lab report I just noticed that at CPAP level 4cm -total sleep time was 102 mins and during that time I had 20 RERAs, at CPAP level 7 - I slept for 50 mins and had 4 RERAs, and at level 8 I slept for 96 mins and had 9 RERAs. Perhaps this indicated that my minimum titration should be increased to higher than 5?

A lot of the advice you've been given sounds pretty much on target: the pressure adjustment algorithms don't always work that well, BIPAP is often easier for people with UARS, and you should probably tighten up the ranges. It might be worth using just 7 or 6-7 for a week or so. It's usually prudent not to change pressures more often than once a week. When you do change them, you shouldn't change more than 1 cm or so.

[lullaby]

This is interesting info re UARS.

Due to a possible sinus infection, i recently saw an allergist/respiratory doctor who also happens to specialise in sleep disorders. When i told him that CPAP therapy wasn't really working for me, he suggested either UARS or Hypersomnia. He's given me a steroid spray for my sinus to see if this helps. No real improvements so far.

When i also recently had to go back to my original sleep doc for my annual checkup, i asked him about UARS. Basically, he doesn't seem to believe in UARS. When i asked him about it, he said it is no different to OSA and told me that i'm already being treated for it with CPAP! Info on here and elsewhere online seems to suggest otherwise. Looks like i might ask the allergist doctor to see if i can have a re titration study that can check for UARS - and keep it secret from my sleep doctor

[Rustsmith]

Lullaby said:
Looks like i might ask the allergist doctor to see if i can have a re titration study that can check for UARS - and keep it secret from my sleep doctor

If you do go back to your allergy doctor for a new titration, check to find out how the new sleep lab detects UARS. The "approved" procedures either use a nasal catheter placed to continuously measure pressure in the esophagus or else there are new high tech flow sensors that the can be placed in a cannula under your nose to measure air flow rates. If they say that they use a thermister sensor placed under your nose, don't waster your time with that lab since studies have shown that the thermister system is not sensitive enough to detect UARS type changes in air flow.

[quitepositive]

Thanks to all of you for your suggestions and remarks. I am hardly compliant with the machine partly because I already have issues with falling asleep and waking up too many time, and it seems that every time I try to use the machine if I do fall asleep with it for couple hours I am later awakened and cannot fall asleep with it, so I just take it off and continue without it. I still wake up while using it just like I do when I don’t use it. I should probably address my insomnia issues first and then try to implement CPAP. I am certain that my sleep problems which started literally overnight were not directly caused by UARS, I am sure that I did not develop UARS overnight, UARS just popped up as an issue when I went for an overnight study due to severe insomnia concerns. If anything, those who have UARS usually feel more tired during the day due to long yet unrefreshing sleep, I am thinking back prior to insomnia problem, I always slept for 8 hours and still felt pretty tired at times, and would drop off to sleep within 1 or 2 minutes, never waking up during the night other than my regular bathroom trip around 5-6 am.

So I really don’t know what it is. Perhaps the reason why I wake up so frequently at night is because I am so anxious, and frustrated with this insomnia thing that my body got use to this disturbed sleep. I also feel like I am waking up right after dreaming, so it might be the transition from REM to stage 1 when I go from cycle to cycle that I just wake up because my sleep is so light.

Any suggestions from people who had insomnia related/unrelated to breathing problems?

Thanks guys!

[robysue]

quitepositive,

As the honorary president of the CPAP&Insomnia club I bid you a sad welcome to the club.

I'm actually going to write two posts. In this one, I go through what you've previously written and respond to particular points---sometimes with questions and often with observations. In the second post, I'll actually make some suggestions about what you might want to try in order to tame this inso

As others have done a good job of addressing your UARS questions, I'll focus on some of your insomnia questions and concerns. To give you a sense of my own background and struggles with both insomnia and PAP

My official "Medicare" AHI was only 3.5 on my diagnostic sleep study, but because the lab scored hypopneas using Rule 4.B as well as 4.A, my RDI/AHI = 23.1 because of an excessive number of "hypopneas with arousal", which are similar to the problem in UARS. (Back when I was having serious adjustment problems, some of the sleep techs who post here speculated that my problem may in fact be more UARS-related than OSA-related.) I had off and on problems with insomnia my whole life, but prior to starting CPAP, I'd always been able to manage them with tightening up on the sleep hygiene and a healthy understanding that on any given "bad" night for the insomnia, I was likely getting more sleep than I realized. After starting CPAP, however, I've had to deal with two rather severe bouts of insomnia that simply would not resolve without a lot of help from my sleep docs.

For my full story you can read my post in the Success Stories sticky thread.

In your first post you write:

I shall say that prior to June 2013 I had never experienced any insomnia or troubles falling or staying asleep. I am a 25 year old male, in good shape and physically active. In the beginning of June 2013, I had some emotional-related stress, which led me to the inability of falling asleep (1-4 hours - sleep onset) for couple of nights, which then settled in and I developed a real problem sleeping. Some nights I just couldn’t fall asleep at all, some nights I woke up early and unable to dose off, and most of the nights I woke up on average of 5-6 times for enough time that I would precisely remember those wakeups. The most paradoxical of all things was that although I felt fatigued and exhausted from little sleep that I was getting, I was always hyper aroused, I was not able to take naps despite sleeping for only couple of hours previous night, I never felt sleepy at night and was not able to yawn. My sleep drive, it seemed, disappeared and so did my energy, performance, and happiness.

, It sounds as though the initial trigger for the insomnia was whatever was causing the emotional stress. I'm assuming this was caused by some rather specific, significant change in your life---such as a relationship ending or the loss of a job or the death or serious illness of someone close to you. It doesn't really matter what the event was; rather it's that insomnia was triggered by a specific event. That means that the original insomnia was essentially a particularly bad version of "transition insomnia" meaning the stress induced by the life change lead to the insomnia. Usually transition insomnia is self-limiting: As you begin to adjust to the new reality of your life, the insomnia abates and you start sleeping "normally" again in a few weeks to a couple of months. But in your case, you were unlucky enough to have the transition insomnia morph into a chronic problem with what sounds like pretty severe insomnia.

The question at this point is: Have you resolved the original trigger for the insomnia? In other words, have you come to terms with whatever caused the emotional-stress that lead to the insomnia? If not, then that's something that's going to have to be dealt with one way or another: If you are still experiencing a great deal of emotional stress caused by the triggering event, until you learn to accept what happened and find a way of moving beyond the emotional stress caused by the event, the insomnia monster will probably continue to feed on the emotional stress.

Some nights were so unbearable that I decided to go to see a doctor to ask for something to aid me with sleep. I got small prescription of 0.5Mg Clonozepam, which some night did help me at least to fall asleep. I took it occasionally, 3-4 times a week, in the past 3 month only once or twice per week as needed.

Clonazepam is not usually the first drug prescribed for insomnia. Clonazepam is usually prescribed to treat panic disorders and certain seizure disorders, although it does seem to be used off-label as a sleep medication. My question: Was clonazepam suggested because you felt as though you were dealing with panic episodes or anxiety attacks as well as the insomnia? Did the event that triggered the insomnia also trigger an excessive amount of anxiety or panic attacks?

The results of that study show that there was excess light (stage 1) sleep at 35% and a corresponding loss of deep sleep. Sleep efficiency 56%, REM latency was 317 minutes, which is very abnormal. Sleep disordered breathing was detected at a rate of 25.6/h RDI. RDI included breathing disturbances associated with arousals, which occurred at a frequency of 25.1/h (RERA index).

Lots of folks have some pretty strange sleep data in terms of sleep efficiency and sleep staging on the initial test. Some of it is undoubtedly due to the RDI = 25.6; some of it probably caused by the anxiety you reported having; and some of it is probably due to the insomnia itself.

To put your sleep efficiency number in perspective: I've had a total of 5 sleep tests in the last 3 1/2 years. The best sleep efficiency number I've ever gotten was around 67%. The worst was 28.8% on my first BiPAP titration study.

Interestingly though, EEG arousal activity not associated with Respiratory of PLM events was at 251, which seems to be oddly high(doctor did not explain that). Basically for the first part of the night I was in an out of sleep every couple of minutes looking at my graph, but I was very anxious prior to the study so perhaps anxiety caused these abnormal findings.

My guess is that the doc wrote off all the "spontaneous arousals" as "first night lab effect"---i.e. the doc probably thinks they were caused by the fact that you were sleeping for the first time in a lab with all the silly wires attached to your head and body and that you were very anxious prior to the sleep study. Those kinds of things do cause a lot of people to have trouble getting to sleep and staying asleep independent of any OSA/UARS problem that is also detected during the times you actually are asleep.

As a result of that study doctor gave me prescription APAP, which I got with a nasal mask, tried to use it but often had difficulties falling asleep with it or still waking up often or early and unable to fall back to sleep. I asked my doctor whether these arousals were related to the sleep-related anxiety that I was experiencing, because I never had any issues with sleep prior to June 2013, and to my question whether I could have developed this syndrome overnight, he answered No you probably had it but never realized it.

I tend to agree with the sleep doc. It's amazing how unaware many of us are about our sleep problems until the sleep test is done. Sometimes our partners are even unaware of the real severity. In my case: I had no real daytime symptoms of OSA/UARS in terms of daytime sleepiness prior to my husband insisting that I have a sleep test done because he would occasionally notice me not breathing for a while. Both he and I thought I'd be diagnosed with mild sleep apnea, but my initial RDI put me squarely into the "moderate OSA" range for the lab and doc that did the diagnosis.

That said: The adjustment to PAP is hard enough for some people who AREN'T fighting insomnia. Add a nasty and persistent insomnia monster to the mix of trying to adjust to PAP, and yeah, it's pretty easy to develop some problems with sleep maintenance insomnia---repeated wakes with periods of not being able to get back to sleep. That sleep maintenance insomnia can be caused by any number of things: In your case, the on-going sleep anxiety (more on that later); any residual anxiety or stress over the event that triggered the sleep problems back in June 2013; and the discomfort associated with using the mask itself.

In my case serious discomfort issues caused directly by trying to sleep with the mask triggered horribly nasty insomnia and it took me over a year to really get "used" to sleeping with the mask and even now I cannot stand lying in bed for more than 20 minutes with my mask on: Sleep latency became a central issue for me to deal with in reining in my insomnia monster.

[The sleep doc] also recommended to try sleep restriction, restricting my time in bed to 6,5 to 7 hours a night to address my insomnia. I tried that for a week and it seemed to help somewhat, I became more tired at nights and fell asleep faster, but then it was too difficult to continue with it and I started to sleep in when I could, and screwed it up.

Sleep restriction was what finally allowed me to get to where I no longer dreaded bedtime. (My sleep restricted schedule was even more severe than yours: At the start I was restricted to no more than 6 hours in bed each night.)

But sleep restriction does take time and a one-week trial is not usually long enough for sleep restriction to really make a difference. The idea behind sleep restriction is to teach your body that it needs to be asleep in the (relatively) small amount of time that it is in bed. If you could manage to do a month or two on a sleep restricted schedule with a maximum of a 6.5 or 7 hour time in bed window, that might very well eliminate most or all of the current problem with multiple night time wakes.

That said, sleep restriction is not for everyone. It is not an easy thing to do and it can take a real toll on people.

But I want to ask more about what happened after you gave it up. You say:

then [the sleep restricted schedule] was too difficult to continue with it and I started to sleep in when I could, and screwed it up

You say you started sleeping in "when you could." How late were you sleeping in? An hour? Two hours? More??? And what was the quality of the "extra sleep"? Decent enough? Or no better than the lousy sleep that lead to your seeking treatment for the insomnia? And how much did sleeping in mess with your ability to fall asleep relatively quickly at the sleep restricted schedule's bedtime?

More important: What does your current sleep schedule look like?

About your titration study you write:

He had scheduled another study after a month of home trial of nasal CPAP. On November 27, 2013 I went in for another sleep study this time with CPAP, with prescribed pressure of 5 up to 10cm. Again I couldn’t fall asleep for an hour and after decided to take a 0.5 of clonozepam, so that they could have at least some data from me to work with. I fell asleep within 20 mins and slept ok for most night the mask on. Sleep efficiency was 80%, REM latency of 2:10 hours. Stage 1 = 20% , Stage 2 = 62%, Stage 3(deep sleep) = 4.6%, and REM was at 12.9%. RDI=7.9, while RERA index = 6.8. So clearly CPAP did something as the RDI was 3.5 times higher during my first sleep study.

Did the sleep efficiency number surprise you??? You got a lot more sleep on this study than you did on the previous one. Certainly some of that effect may be the clonazepam at work. But some of it may be the CPAP as well.

At home can you tell a difference in the number of wakes on the nights where you do and where you do not take the clonazepam???

More in my second post