Insomnia, UARS, or both?

quitepositive,

Here's the description I can find of your sleep prior to all the beginnings of your sleep troubles

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.

Prior to the onset of the insomina, you had a super-short (as in abnormally short) latency to sleep and a bathroom break, which is exceptionally unusual for a "a 25 year old male, in good shape and [who is] physically active." Those may have been night time symptoms of the UARS and the daytime fatigue in spite of getting 8 hours of seemingly uninterrupted sleep may also have been a symptom of UARS.

That said, let's now turn to the problem you are currently dealing with. You describe your current sleep patterns in this language:

quitepositive wrote: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.

and

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.

First and foremost: As tough as it sounds, I think you need to address both the CPAP adjustement and the insomnia at the same time.

Here's why: Although your insomnia problems predate starting CPAP, it seems likely to me that if you did manage to "fix" the insomnia problems while not using the CPAP for a while, just as soon as you start trying to use the CPAP, the insomnia is going to come back. So you're still going to be fighting both issues. Better to do it now and just get it done.

So how do you go about fighting both the insomnia and the CPAP at the same time? Here are some of my ideas tailored to your specifics:

1) Clonazepam and whether it positively influences your sleep efficiency: The sleep test with CPAP and clonazepam had a sleep efficiency of 80%. One question you need to ask yourself: Do you have fewer wakes and are the wakes shorter on the nights where you take the clonazepam? If so, then that's evidence that some (or all) of the wakes may indeed be triggered by ongoing anxiety issues since clonazepam is prescribed for panic attacks. If you don't know whether you sleep any better with the clonazepam than without it, you may need to keep a sleep journal and track the difference.

2) Deal with what ever triggered the insomnia in the first place. If you have not resolved the problems that lead to the emotional stress that first triggered the insomnia, you have to do that. As long as you have not come to grips with whatever happened in your life, the insomnia is likely to continue to plague you. How to deal with it, of course, depends on what the triggering event was. But do deal with it instead of allowing it to continue to fester.


3) Wake up time: Have you got a regular wake up time that you use seven days a week instead of a "week day wake up time" and a "week end/days off wake up time"? In the long run, your body will have an easier time consolidating the sleep cycles and not waking up so much if you are getting up at the same time every single day.


4) Bedtime: Have you got a regular bedtime---or at least something that passes for a regular bedtime? And are you usually sleepy at bedtime? Are you sleepy enough to mask up and get to sleep with the mask on your face at bedtime?


5) Middle of the night wakes: What happens when you find yourself awake in the middle of the night? Do you immediately start to worry, get upset, or fret about "Why am I awake?" Do you immediately look at the clock and start calculating how much (or rather how little) sleep you've been able to get since the last wake up? Do you start calculating on how little time there is before you have to get up in the morning? If these things sound like what happens to you when you wake up in the middle of the night, then part of the solution is retraining yourself to not make the wakes worse than they are.

It's important to realize that even "normal" people---those without sleep disordered breathing and those without insomnia often wake up a few times during the night. These wakes are often right after coming out of REM, and they're considered "normal". But a non-insomniac typically doesn't remember these post-REM wakes because they wake up briefly, establish that everything is ok and there's no need to be awake, and quickly settle back down and go back to sleep, usually in less than 5 minutes. But many insomniacs' reaction to finding themselves awake in the middle of the night prolong the middle-of-the-night wakes and that in turn makes them much more disruptive to the overall sleep architecture.

So---if your first response to finding yourself awake in the middle of the night is to look at the clock and start calculating or worrying about how little sleep you've gotten, you need to turn the clock around and not watch it. If you get over anxious in the middle of the night just because you're awake, you need to work on trying to undo the anxiety feedback loop. (Yes, I know that's hard to do.)

6) The troublesome 4am wake in particular. You need to analyze what's triggering this particular wake. Are the garbage trucks on a new schedule and waking you up? A neighbor's dog barking at 4am? Does the heater kick on about that time every night? In other words, see if there is some external trigger for the wake. You might not be able to do anything about it, but if you can figure out that there's an external trigger, then that reduces the anxiety and that in turn may make it easier to get back to sleep: In my case it's a lot easier to get back to sleep after thinking "Darn the snowplow went by again" at 4:00AM than it is to get back to sleep after thinking "Why can't I just get one night's sleep without waking up at 4:00AM?"

If there are no apparent external triggers for the 4:00AM wake, then it's time to start thinking about what you can do to get back to sleep quickly instead of tossing and turning and worrying about the wake. It may be that the easiest thing to do is just get out of bed for a few minutes. Go to the bathroom (even if you don't think you need to.) Get a drink of water. Maybe read for a bit (outside of the bedroom). And go back to bed after you start feeling sleepy again. And don't look at the clock when you are out of bed. Looking at the clock feeds the anxiety.


7) Adjusting to CPAP at the same time as working on the insomnia. The trick here is to teach your body and brain to make a deep triple association:

• Time in Bed = Time to Sleep = Time to Mask Up

This requires some real effort and discipline, but it can be done. In particular you should keep the following things in mind

• At the beginning of the night, you need to mask up. If you can't get to sleep in 20 minutes OR if you find yourself getting very anxious or mad at the CPAP, it's time to get out of bed and do something else to get your mind off the CPAP. Go back to bed only when you are calm enough and sleepy enough to face masking up again.
• If you wake up without the mask on, don't worry about it[/i]. Just calmly put the mask back on and try to get back to sleep. We can't control our unconsciousness and it happens to some people.
• If you wake up and feel as though you can't stand to have the mask on any more, take the mask off and get out of bed. Go do something soothing and calming. Make yourself a cup of sleepytime tea or read a boring book for a while. When you are both sleepy enough and calm enough to face masking up, go back to bed and try again.

8) Work on fixing any identifiable comfort problems with the CPAP and mask. If you often wake up in a panic feeling like you can't breathe, post about the problem here. If you feel as though your stomach is going to explode from excess air, post about it here. If the mask irritates your nose or your cheeks or your forehead, post about it here. If the noise from the CPAP keys you up and keeps you from being able to get to sleep, post about it here. If your throat or nose is too dry, post about it here. If nasal congestion is a problem, post about it here. All of these are pretty common problems and there are a lot of folks who've worked through them. In fact, it's really very, very rare for a newbie to experience a problem that is genuinely unheard of here. So when you can identify a specific kind of problem, post about it.

In my case, I had to deal with serious aerophagia and I also had to figure out a way to prevent my lips from getting badly chapped and to keep my arms and chest from feeling the exhaust flow from the mask among other things. The help from people here was critical in solving those problems.

robysue wrote:Here's the description I can find of your sleep

Very well explained and some excellent suggestions.

I began taking medication for anxiety when I began CPAP therapy, and I slept like a dog. The problem was I still felt drowsy during the day, which I suspected was a side effect of the medication. I stopped taking the medication almost 2 weeks ago to verify if the daytime sleepiness was indeed a side effect. So far my level of daytime drowsiness has not changed, but I now have trouble sleeping at night. My nighttime symptoms are almost exactly the same as the ops. And just like you described, each time I wake up I look at the clock and try and calculate if I should roll over and try to get more sleep or just give up and get out of bed.

I would prefer to live without medication so I plan on implementing some of your suggestions to try and make that a reality.

robysue wrote: It's important to realize that even "normal" people---those without sleep disordered breathing and those without insomnia often wake up a few times during the night. These wakes are often right after coming out of REM, and they're considered "normal". But a non-insomniac typically doesn't remember these post-REM wakes because they wake up briefly, establish that everything is ok and there's no need to be awake, and quickly settle back down and go back to sleep, usually in less than 5 minutes. But many insomniacs' reaction to finding themselves awake in the middle of the night prolong the middle-of-the-night wakes and that in turn makes them much more disruptive to the overall sleep architecture.

Excellent comments, Robysue. I think many folks don't understand where REM fits into their sleep patterns. Here's an updated graphic that I find is helpful to understanding RobySue's statement regarding REM wake-ups, it also shows current thinking about the four recognized sleep stages:

Robysue,

Hello, thank you so much for such extensive post I really appreciate your time and effort for being here and helping others. I was out of town this past weekend and hence was not able to reply sooner.

I will try to address and provide more details on the points where you raise more questions.

To be honest with you I have had ongoing stress for quite some time and did not have any issues with sleep, and insomnia itself was triggered it seems, by a rather minor stressor (relationship concerns) which has been resolved a long time ago. I was anxious and worried about the situation, and that one night had difficulties falling asleep due to a weird adrenaline-rush like sensations that would overwhelm my body just as I was about to drift to sleep. Now, I have never experienced something like that before and when this happened over and over again for hours, I became to worry even more. That initial bout lasted for about a week, where I would sleep on average 3-4 hours because of those sensations and some anxiety over it. But over the weekend I had calmed down and forgotten about and it went away for two weeks. Then at some random night those sensations appeared again, I immediately related that with my 5-day insomnia earlier that month and the new bout of unremitting insomnia had began. Now, its important to note, that I no longer experienced those sensations, even if I did, they were rare, I just couldn’t fall asleep, or would wake up many times, or would wake up early and couldn’t get back to sleep. Very bizarre. So to answer your question, yes the original stressor had been resolved and forgotten due to its mere insignificance.

Clonozepam was my suggestion to my GP due to his total lack of interest in my situation. I did some research and found that clonozepam helped most people with falling asleep, and calming sleep related anxiety. I have never experienced a panic attack before nor do I suffer from seizure disorders, it is generally considered to be an anti-anxiety/panic med, so I asked for some of it to help me with nights when I did not sleep at all.

I don’t know why I had such a high RERA number, I hardly slept, I remember I was very anxious and my heart was beating hard and I couldn’t fall asleep at all. That is why I tend to think for some reason that some of those RERAs were related to my anxiety, however, I do not know how to relate the ‘respiratory’ in there.
During the first study I had 251 Arousals, what do those mean anyways, does that number include all respiratory related arousals as well?

After my initial apt with sleep doc. he recommended me to start on sleep restriction with 6.5 to 7 hours in bed. I did it for about a 10 days, began to see some improvements, again it was on and off, but generally my sleep onset decreased greatly for most days, and I think I woke up 2-3 times less than I usually did. After I started to see progress and I realized that I could sleep longer in the morning naturally I just went ahead and slept longer in the am specially on the weekends and would go to bed earlier than my prescribed time because I tend to became a bit anxious when I was the last one in the house who was not in bed sleeping. To be honest, sleep restriction does give me a bit of anxiety, I am afraid of staying late because I think that it will take me long time to fall asleep, and I do not like to wake up earlier if I am already sleeping, because extra hour of sleep does wonders with my mood, energy and happiness.

On my second titration study, I felt less anxious about being there, but still could not fall asleep for an hour, so after consulting with a lab clerk, I decided to take a pill. I fell asleep I think earlier than the pill would have kicked in, that is by looking at the graphs, and slept for about 5 hours with 1 or 2 subjective wake ups.
Yes, prior the onset of insomnia, I fell asleep pretty fast. Perhaps a minute or two was slight exaggeration but around 5 minutes and I would be out dreaming. I also, almost nightly had a bathroom break at 5 or 6 am, and would get back to sleep right away. Now, when my sleep is poor, I could go to the bathroom 2-4 times a night, but that is usually due to anxiety if I wake up and cant sleep I will just take a bathroom break, thinking that I would fall asleep easier if I don’t have the urge to go.

Now, I will try to briefly answer the questions that you pose in the end of your post:
1) Clonozepam definitely helps me to fall asleep and to stay awake. When I take clonozepam, I definitely do wake up less, but again sometimes it is hit or miss. Couple of times I would take a pill and it wouldn’t help me as it did the previous time. This whole thing is all over the place, there is no consistency, there is no identifiable trend. The only thing though that I can say happens 80% of the time is that I sleep better on the second night following the night when I took a pill. I fall asleep faster and sleep (I think) better and longer sometimes even 7.5 hours (although with several wake ups). But that could be just the effects of the medication due to its long half-life. Having sad that, I really, really try to take it as per needed basis, in the past 6 month, there were weeks when I took it 4 times and other weeks I did not take it at all.
2) Like I said the trigger was not that significant, and I have dealt with it.
3) I have a regular wake up time during the week 7:30, but often wake up waay before my wake up time. On the weekends if I am already sleeping I will just let myself sleep, but I have not slept in later than 9:30.
4) Bedtime is pretty stable during the work week (around 11-11:30), weekends usually later. Often I do not feel sleepy whether it is 11 or 3am. If I do feel sleepy around my bedtime I would usually try to catch the wave. As I have read on other sleep forums, some people specified that for them catching the sleep wave was really important as that was one of the main factors in determining whether they would fall asleep fast or not.
5) Even back in December, I was not really paying attention to wake ups at night, as I would wake up and in 5-7 mins would be sleeping again, but recently because of the wave of early wake ups that I have been experiencing, I do fear the wake ups because as the previous experienced showed, there is high chance of me not being able to fall asleep after I wake up early. So to answer your question I do tend to worry and fret about why I woke up, and how nice it would be not to wake up. Regarding waking up post REM I do notice that sometimes I do wake up right after I have been dreaming heavily, so I usually assume that this happens due to the transition from REM to lighter stage of sleep and since I became super sensitive to any sleep issues, my sleep became very fragile and light, that is why I notice these wake ups or wake up fully.
6) The 4-5 am awakening is cause by an unknown factor to me… My room is quite, dark and the temperature is comfortable, there is no external trigger. Also, even if I do manage to fall asleep after 5 am awakening, my sleep is light and fragmented that I wake up every 20 minutes, but do dream a lot during these sleep fragments. I also do not know why my sleep is so broken in the early morning until my wake up time. Also my therapist told me to get out of bed after 30 minutes if I am not sleeping, sometimes in the beginning of the night if it is not too late I can do it, but almost always the idea of getting out of bed to go to the living room while the whole world is sleeping is giving me anxiety, and often I do not get sleepy doing that anyways.
Again thank you so much for your attention and your helpful responses.

quitepostive,

Again, I want to split my response to your post into a couple of posts, each focusing on one part of your current problems. In this one I want to focus the anxiety and insomnia issues and not deal with the CPAP adjustment issues.

To summarize some of your more important points about the insomnia:

1) The trigger of the original insomnia has been dealt with. The original insomnia involved "weird adrenaline-rush like sensations that would overwhelm my body just as I was about to drift to sleep," but you also say you are NOT experiencing this particular problem any more.

2) The current insomnia seems to continue to feed on the following things:

• too many night time wakes with trouble getting back to sleep
• some significant anxiety about finding yourself awake once again in the middle of the night
• an inability to not worry about perfectly normal post REM wakes even though you realize that some of your wakes are nothing more than post REM wakes.
• the regular (or semi-regular) wake that occurs between 4 am and 5 am most mornings. You have no idea about what might be triggering this wake. You have real problems trying to get back to sleep after this wake. If you get back to sleep, you don't sleep well after this break. And you get quite anxious during this wake.

3) Anxiety about sleep (or rather insomnia) is real problem. Clonazepam has been prescribed and because it does work as an anti-anxiety med that can help specifically with sleep-related anxiety, it makes some sense to use that drug instead of something like the much more commonly prescribed generic Ambien. You use it on an "as needed" basis. Some weeks you might use it as much as 4 times; other weeks you don't take it at all. It also sounds like the clonazepam is not 100% effective (but then NO sleeping medication used for insomnia is 100% effective). You say that the clonazepam's affect is hit or miss, and you state, "The only thing though that I can say happens 80% of the time is that I sleep better on the second night following the night when I took a pill."

4) You seem to have developed a very real and significant fear or anxiety induced by the night time wakes that has gotten worse in recent weeks: You write: "... recently because of the wave of early wake ups that I have been experiencing, I do fear the wake ups because as the previous experienced showed, there is high chance of me not being able to fall asleep after I wake up early."

5) Some important things about your current sleep schedule:

• You have somewhat different sleep schedules on the weekend vs. the during the work week.
• During the work week your desired sleep schedule is usually something like: Bedtime between 11:00 and 11:30, and wake up time 7:30, for a total of roughly 8-8.5 hours in bed.
• On the weekends, you tend to sleep in until 9:30 (two hours later than workdays); you would like to go to bed at around 11:00-11:30 like you do during the work week, but you often are NOT sleepy at "bedtime" on the weekends. Some weekend nights you are not even particularly sleepy even at 3:00 AM.

6) You have at least a basic understanding that it's usually a good idea to try to go to bed when you are actually feeling sleepy. And in your own words, "If I do feel sleepy around my bedtime I would usually try to catch the wave."

7) You tried a sleep restricted schedule for 10 days. There was some improvement in your insomnia symptoms. In particular, your initial sleep latency (time between going to bed and the first onset of sleep) did decrease and the number of middle of the night wakes was slightly reduced. But as your insomnia symptoms started to improve, you started ignoring the sleep restricted schedule by sleeping later in the morning (on weekends) and going to bed earlier, in part because you "tend to became a bit anxious when [you were] the last one in the house who was not in bed sleeping." Overall, you feel that the sleep restricted schedule increased your anxiety level about the insomnia.

Have I summarized the situation reasonably accurately?

Given what you are saying, I think that you're trapped in a "negative feedback loop". The more you worry and fret about the insomnia, the more you wake up and the harder it is to get back to sleep. In other words, the worse the insomnia is, the insomnia feeds the anxiety and fear about your on-going sleep problems, which makes the insomnia worse, which increases the anxiety about the insomnia, and so on and so forth. Moreover, you've even gotten anxious about the moderately restricted sleep schedule that had some promising results and, perhaps even got anxious enough about the whole idea of sleep restriction that the anxiety itself undermined the progress you had made with the sleep restricted schedule. Likewise, you know that if you haven't been able to get back to sleep in 30 minutes after the 4:00 am wake, but doing so increases your anxiety rather than allowing you to calm down and get sleepy again.

And somewhere in all this anxiety and insomnia, there's also the CPAP adjustment problems, which probably increases both the general level of anxiety about the (lack of) quality of your sleep and the insomnia. More on that in the next post.

So the question then becomes: What can you do to try to end the feedback loop?

It seems to me that reducing the anxiety is going to be the key to taming your insomnia beast. If you could find a good therapist with experience in dealing with cognitive behavior approaches to both anxiety reduction and treatment of insomnia, that might help you tremendously. But such therapists can be hard to find.

If you've got to do this essentially on your own, the thing that you've got to get a handle on is all that anxiety. Because what seems to be happening is that you're worrying so much about the possibility of night time wakes and taking too long to get to sleep, that the anxiety itself may be triggering some of the wakes AND the anxiety is certainly prolonging how long each wake lasts AND by prolonging the wakes, the anxiety is making it much more difficult for you to get decent quality restorative sleep.

It would be worth working your way through Sound Sleep, Sound Mind by Dr. Barry Krakow. But many of the things he suggests are not going to be easy for you because of your current anxiety about "being the last person not sleeping" and the fact that you get more anxious when you get out of bed. Still, I think it's worth reading and seeing how much of yourself you see in the typical insomniac behaviors he describes.

And the most important piece of advice Krakow gives to people with the kind of anxiety problems you describe is this: Give yourself permission to NOT worry about your sleep. If you're simply NOT sleepy, embrace that fact and do something you enjoy doing rather than worrying about getting back to sleep. And when you are doing something you enjoy while you're up in the middle of the night, don't ruin your fun by worrying about the fact that you're not getting sleepy.

It won't be easy for you to try to implement this kind of a strategy at first. But the fact is, you need to re-teach your body and mind that Time in Bed = Time to be Asleep in order to help you consolidate your irregular and choppy sleep cycles into a more continuous and more restorative sleep.

And here's a list of some other things to think about and try in an effort to tame this insomnia beast. The order I've put the ideas are in the order I'd recommend trying them:

1) You need to focus on baby steps and have reasonable expectations. Given the current entrenchment of the insomnia, you are NOT likely to suddenly be sleeping for 8-8.5 hours without waking up on a nightly basis. Don't beat yourself up if you're not getting a full 8 hours of sleep or if you still have some wakes every night. Reward yourself if you feel rested in the morning regardless of how little sleep you got or how many wakes you had. The idea is to try to gradually reduce the number of wakes and the amount of time it takes to get back to sleep. If you do that, the total amount of sleep will gradually get back to where you want it to be.

2) You would benefit from a more regular WAKE UP time. If you need to be up by 7:30AM during the week, you need to make yourself get up at 7:30 (or 8:00 at the latest) on the weekend. By sleeping in late on the weekends, you are making it harder to get to sleep the next night, which in turn seems to increase your anxiety level about your sleep. Getting up at the same time every day---including the weekends---helps the body get sleepy at the right time each evening, which in turn makes it easier to "catch the sleep wave" as you put it. And there is some truth to "catching the sleep wave" leading to better quality sleep overall.

3) Since you say you sometimes don't even get sleepy (on weekends) until 3:00 AM or later, you might have a bit of a circadian disorder kicking in along with the insomnia monster. So you might want to give light therapy a trial. You need a light box that can provide the super bright light needed. The idea is that you sit in front of the light box when you get up (ON TIME) each morning for about 15-30 minutes. This helps to reset the WAKE/SLEEP cycle so that your body starts to accept and expect to be awake starting at your desired WAKE time and that in turn helps encourage the body to get sleepy at or near the desired bedtime. To encourage your body to start getting sleepy on time, you might also consider taking a very, very small dose of melatonin about 6 hours before your desired bedtime. Taking the melatonin may also help a bit with the sleep continuity by reducing the middle of the night wakes, but it might also not do anything for you. Since you are on clonazepam, you need to check with the prescribing doc about whether it's ok to take both melaton and clonazepam at the same time.

4) You are allowing yourself an 8-8.5 hour "Time in Bed" window. If you are getting less than 7 hours of sleep in those 8-8.5 hours, then it may be difficult to properly consolidate your sleep cycles without cutting back at least a bit on the Time in Bed window. But any drastic sleep restricted schedule is going to feed your insomnia. So for now, don't go to bed too early---i.e. make yourself stay up until 11:30 and try to get up by 7:30 every morning. (So there's no sleeping in on the weekends.) In other words, limit yourself to an 8 hour Time in Bed window for now. (Note: If it didn't increase your anxiety, I'd say you ought to try to stay up to midnight every night giving you a 7.5 hour Time in Bed window.) And if you are NOT sleepy at 11:30, don't go to bed until you are sleepy. And don't increase the Time in Bed window to 8.5 hours until you think you are getting at least 7.25 hours of sleep on a consistent basis in your 8 hour TIme in Bed window.

5) You need a strategy to take your mind off the anxiety particularly during the middle of the night wakes. My own strategy for middle of the night wakes has been this:

• I don't look at the clock and I don't try to figure out what time it is or why the heck I'm awake. Rather I focus on comfort issues: Do I need to kick the covers off or pull them on because I'm too hot or too cold? Do I need to turn my BiPAP Auto off and on so the air pressure goes back to its minimum settings? Do I need to turn over to make a sore knee or a sore back feel better? Do I need to get a drink of water? Once the comfort issues are taken care of, I snuggle back down and try to go to sleep.
• If I can't seem to get back to sleep for what feels like 20 minutes or so, I ask myself: Am I getting sleepier or am I getting more restless? I do NOT look at the clock to tell when 20 minutes is up: The "20 minutes" is measured completely subjectively---if it feels like "20 minutes" I call it "20 minutes". In reality, sometimes that "20 minutes" might be as long as 30 or 40 minutes, and sometimes it's as short as 10 minutes. But when the "20 minutes" is up, I evaluate whether I'm making any progress towards getting back to sleep. If I feel sleepy and comfortable, I'll continue allowing myself to try to get back to sleep for a few more minutes. But if I feel as though I'm becoming more restless or more awake or more angry (night time anger is my issue), I'll throw the towel in and get out of bed for a while.
• Once I make the decision to get out of bed, I leave the bedroom, and go do something soothing for a while. I do NOT look at the clock during the entire time I'm out of bed. That keeps my mind from going into "calculate" mode---as long as I don't look at the clock I can avoid worrying about "how little time I've slept" and "how little time there is before morning". If my mind is not too actively thinking or worrying and I'm just physically restless, sitting in a semi-dark room and listening to some quiet music usually does the trick for me. If my mind is thinking a mile a minute, however, I'll go into a different room and read for a while. If I'm angry or anxious, reading or crocheting is usually a better way to handle the middle of the night wake than listening to music. And when I'm out of bed, I don't worry about whether I'm getting sleepy or not. It's very rare now, but when my insomnia was really bad, there were times that I would read from 3:00 or 4:00 am until it was WAKE UP time. And then I just muddled through the day as best as I could. It did increase the probability of me having far fewer problems getting and staying asleep the next night.

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My guess is that my strategy won't work for you unless you make some modifications: You've said you've tried getting out of bed, but it makes you anxious---particularly when you don't seem to get sleepy after getting out of bed.

So best of luck in reining in your insomnia monster

quitepositive,

This is going to be a much shorter post since it's now my "bedtime" (1:30AM) and I need to get to bed because I'm actually getting to be a bit sleepy.

You are also dealing with CPAP adjustment problems while fighting your insomnia monster.

It's important for you to understand that you have to train your body and mind to accept a deep triple association about the time you are lying in bed: You need to teach your mind and body that

• Time in Bed = Time to Sleep = Time to Mask UP

In order to do this, you need to accept that whenever you are trying to get to sleep, the mask needs to be on your nose. If the mask triggers anxiety or anger or simply way to much wakefulness, you need to get out of bed, go into a different room, and do something to get your mind off the mask for a while. Only go back to the bedroom when you are able to fact masking back up and trying to get to sleep.

At the start, you may have a few nights where you spend a great deal of time out of bed. And you need to still force yourself to get up at your regular wake up time and muddle through the day as best you can. This should make it easier to fall asleep the next night.

Another extremely important idea to try is to use your sleeping medication (the clonazepem) to try to insure that you don't have to endure two or three genuinely sleepless nights in a row. The idea is this: If on Monday night you try to sleep without taking any clonazepem and you feel as though you were up out of bed for much of the night and its tough to get through Tuesday (the next day) because you got so little sleep, then on Tuesday night take the clonazepam even if you think you could get to sleep without it. That will help you have less anxiety and should help you get to sleep a bit better on Tuesday night and it may help you sleep more soundly on Tuesday night. All of which should make Wednesday easier to get through. If you sleep ok Tuesday night and get through Wednesday ok, then try going to sleep without taking the clonazepam on Wednesday night.

Over the course of a a month or so, you ought to start to see some improvement in terms of being able to get to sleep with the mask on your nose. And once you're sleeping with the mask on your nose, the wakes that are currently being triggered by respiratory effort related arousals should start to decrease. And as you get used to the mask, "CPAP adjustment" as an insomnia-feeder will also start to decrease.

quitepositive wrote: I don’t know why I had such a high RERA number, I hardly slept, I remember I was very anxious and my heart was beating hard and I couldn’t fall asleep at all. That is why I tend to think for some reason that some of those RERAs were related to my anxiety, however, I do not know how to relate the ‘respiratory’ in there.
During the first study I had 251 Arousals, what do those mean anyways, does that number include all respiratory related arousals as well?

An arousal is a sudden change in sleep stage from a deeper sleep stage to a lighter one or from a sleep stage to WAKE that lasts only a few seconds (as opposed to a "change in sleep stage" when you normally transition from one stage to another). Arousals on a sleep test are usually lumped into three broad categories:

• Respiratory related arousals. These arousals are clearly tied to a sleep disordered breathing "event" of some type. Many people will briefly arouse after apneas and hypopneas as part of the body's strategy for jump starting the breathing after the airway collapses. The RERAs on your sleep test were arousals that followed a clearly defined pattern of sleep disordered breathing indicating increasing respiratory effort, which indicates that your upper airway was beginning to collapse. But in a RERA, you arouse (you go from a deeper stage of sleep to a ligher stage or to WAKE) before the breathing deteriorates far enough to be scored as an apnea or a hypopnea. And for some people, almost all of the RERAs trigger an arousal that goes all the wake to WAKE, which of course, can increase the sense that you got very little sleep during the sleep test. (Sleeping in the lab for the first time or for the first time with a CPAP mask can make you more prone to arousing all the way to WAKE than you would ordinarily be in your own bed in the familiar surroundings of your bedroom: The sleep lab is a strange place and we tend to sleep more lightly in strange places and things that ordinarily would not wake us up can bring us to a full wake that lasts long enough to (vaguely) remember on a sleep test.)
• PLMD related arousals. Folks with periodic limb movement disorder have multiple uncontrollable "twitches" or movements of the legs (and sometimes the arms) that can be severe enough to cause an arousal. These are scored as PLMD arousals if there is no evidence of a sleep disordered breathing event that is happening at the same time.
• Spontaneous arousals. These are arousals (brief wakes or brief shifts to a ligher sleep stage) that are NOT associated with any sleep disordered breathing event and are NOT associated with any PLMD movements. They're "spontaneous" in the sense that they have no "apparent" cause in the other data gathered in the sleep study.

Your overall anxiety level during the sleep test probably did lead to a high number of Spontaneous arousals. Whether the anxiety lead to RERAs being scored is another question all together. It seems more likely that a large number of RERAs would have lead to increased anxiety rather than the other way round: RERAs can have many of the same "I can't breath right" or "I'm suffocating" symptoms that some folks experience when they wake up right after a full-fledged apnea, and all those brief wakes with the sensation that there's something wrong with your breathing can increase the anxiety you're feeling during the night.

Hence it makes some sense to hope that if you can reduce the number of RERAs you experience each night by using your CPAP all night long every night, then one source of the anxiety might disappear. And getting rid of the RERA-releated wake induced anxiety might reduce the overall anxiety enough to help you figure out a way of taming the sleep related anxiety coming from other sources. And that, in the long run, may help you tame the current insomnia monster.

If I was in your situation I would then forget for now any issues with the UARs and focus on the Insomnia. UARs have to do with the flow restrictions at the nose or mouth or pharynx . The graphs from my CPAP machine show that I been having Flow Limitations (which include UARs and RERAs) for the last three years, but I manage to sleep 6 to 7 hours nightly regardless. A plain stuffed nose could also cause UARs. The optimal treatment for patients with UARS is not currently known. Continuous positive airway pressure (CPAP) has been quite useful in the treatment of sleep-disordered breathing and there are some notable positive results in CPAP treatment of UARs.

To treat the Insomnia I would put the emphasis on taking sleep medication while also starting a Cognitive Behavioral Therapy for Insomnia (CBT-I). As a matter of fact, I would look for a CBT-I therapist who initially combines behavioral therapy with medication to help me sleep. As I become better at reducing stress related to Insomnia and other factors and gain better control over my sleep environment the therapist sould gradually reduce the dosage until I no longer need medication.