Still waking up... can someone help?

[robysue]

mcsheltie,

Here's my response to some of the things you've written in recent posts.

You write:

Which is what I am trying to figure out too. But it seems to be a frustrating game of the chicken or the egg :-( I tried a week at 8 and 10 fixed to see if the pressure changes might be an issue and I was miserable on CPAP. Put it back to 8-13 (95% is 9.5-10) and felt better. Still waking up tho. Mask is good, leaks don't bother me... maybe it is just habit that needs time to be broken??? But I am not a patient woman. So waiting to see if that happens is not a do-able game plan for me. I am waking up for some reason and I want to know why NOW!!!! (LOL)

You are not going to want to hear these things, but I'm going to say them anyway:

1) When you say, "maybe it is just habit that needs time to be broken???" I think you are close to the real issue. Unless you are experiencing discomfort coming from the mask or the pressurized air, your too many wakes problem is most likely no longer being directly caused by either the APAP therapy or untreated/under treated OSA. (Your treated AHI < 3.0 and your diagnostic AHI = 30.) The untreated OSA may have been the root cause of your insomnia problems and a difficult adjustment period may have added to the sleep maintenance insomnia, but what's keeping it going now is your brain's unwillingness to simply relax into sleep and stay there. Through the years your brain has grown accustomed to waking up frequently during the night (because of the untreated OSA) and during the adjustment to APAP, all the novel stimuli coming from the machine gave your brain another whole set of reasons to "wake up". But now you've dealt with the comfort issues and the machine is taking care of the OSA issues. So it's up to you to train your brain that Time in Bed = Time to Sleep. And that takes work and effort. It may also require you to change some of your night time behaviors. It may also require you to adjust some of your beliefs about what a good night's sleep is supposed to look like.

2) Sometimes there really is no specific identifiable cause for the wakes. And trying to figure out why you are waking sets you up for a wild goose chase down a very deep rabbit hole. I know: I've been there and have the T-shirt as they say. Sometimes it's best to work on the solution to the too many wakes problem rather than continuing to try to figure out why the wakes are occurring in the first place. (More on this in a bit.)

3) Patience is critical when you are fighting what is, in essence, a sleep maintenance insomnia issue, particularly since you do not want to take prescription sleeping medication. The more you look for a "quick fix" to your problem, the harder it is going to be to do the necessary work to actually solve the problem.


About your current sleep schedule, you write:

What does your typical sleep schedule look like? And how variable is it?

I try to be in bed by 10 and get up at 7. Sometimes I get involved in doing something (like right now...LOL) and time gets away from me.

and

I am not getting a lot of sleep when I wake up every hour. In bed from 10 pm to 6-7 am. Out of 8 hours I probably sleep for 4. With CPAP those four hours are better quality. I slept fairly well during my PSG and I was told I never got out of Stage 1 sleep. I was surprised because for me that was a good night!

The most common way to address sleep maintenance insomnia without the use of sleeping pills is cognitive behavior therapy for insomnia (CBT-I).

And you've got a serious case of sleep maintenance insomnia since your self-reported sleep efficiency on a typical night at home is around 50%. And if you were in Stage 1 sleep most of the PSG and you thought that you slept "fairly well" that night, you probably do have a long history of drifting in and out of very light sleep instead of going through normal 90 minute sleep cycles. And your brain has likely trained itself to remember a large number of wakes as well as learned a large number of tricks to prolong any individual wake so that you are more likely to remember many of the wakes and hence feel unrested then next morning.

As I explained before sleep efficiency = (Total time you think you were asleep)/(Total time in bed) and most people with chronic lifelong insomnia often spend too much time in bed not sleeping. All that time spent in bed not sleeping tends to make the insomnia worse rather than better. Most people with insomnia start to feel like they're getting restful sleep only when their sleep efficiency is above 85% or even 90%.

But it's tough to get the sleep efficiency up without doing some hard work to consolidate the sleep cycles and teach your body that Time in Bed = Time for Sleep. One of the more effective CBT-I techniques that can be used to teach the body how to consolidate the sleep cycles is called a sleep restricted schedule. A sleep restricted schedule usually involves the following things:

1) A time in bed window (or "sleep window" or "time in bed" window) that is not much longer than the actual sleep you think you get each night at the beginning of the sleep restricted schedule. If you are self reporting getting about 4 hours of sleep a night, a CBT-I therapist may suggest using a 6 hour Time in Bed window at the start of the process.

2) Ditching anything that allows you to tell what time it is during the middle of the night.

3) Rules about when to go to bed and (just as important) when to get up out of bed. The rules usually seem harsh and counter-intuitive to the insomniac at the beginning of the CBT-I designed to reteach the body to not wake up during the night. The usual rules are something like:

• Pick your desired wake up time FIRST. (In your case it would be 7:00). Count back 6 hours to establish your (temporary) official "bedtime".
  
• Only go to bed at your "bedtime" if you are actually sleepy at bedtime. Otherwise, stay up until you ARE feeling sleepy. And be sure to understand that feeling sleepy is not the same as feeling exhausted or tired.
  
• Give yourself an estimated 20 minutes or so to get back to sleep at the beginning of the night and after any wake. If you feel like you are still awake after what feels like 20 minutes, get up out of bed (even if it's just to go to the bathroom) and only return to bed when you start to feel sleepy. What you do when you are out of bed is totally up to you.
  
• NO clock watching during the Time in Bed window: If you can't fall back asleep, you're not supposed to look at the clock to figure out whether 20 minutes have passed. If you are out of bed, you are not supposed to look at the clock.
  
• Get up at your fixed wake up time regardless of how much or how little sleep you got during the night.

4) Keeping a simple sleep log that records

• Bedtime
  
• Estimated time to sleep
  
• Estimated number of wakes you remember
  
• Time you got up for the morning
  
• Estimated time you slept
  
• Sleep efficiency = (estimated sleep time)/(Time in Bed) where Time in Bed is the difference between the time you got up in the morning and the time you first went to bed. In other words, if you get up in the night, that's still part of your "Time in Bed" window.

5) Once the sleep efficiency is consistently up around 85% or so, the "bedtime" is adjusted earlier in increments of 15-30 minutes every 4-7 days or so as long as the sleep efficiency remains at least 85%. To put that in perspective, if your Time in Bed window is 6 hours long and you get about 5 hours of sleep during those 6 hours, you sleep efficiency is 83.33%, or roughly good enough to increase the Time in Bed window to 6.25 hours or so.

6) An acceptance/understanding that for most people, normal sleep is not totally continuous and "solid". In other words, it can be necessary to accept that even under the best of circumstances you may continue to wake up (briefly) every 90 minutes or so since post-REM wakes are often a part of a typical, normal person's sleep pattern. But most non-insomniacs do not remember wakes that last less than 5 minutes: They wake up, determine there's no need to be awake, turn over and immediately go back to sleep. Insomniacs, however, tend to remember even short wakes, and sometimes if all the wakes are very short and the overall sleep efficiency is good (over 85%) and the total sleep time is 7+ hours, then learning how to not worry about the remaining short wakes may be the last part of getting to the point of feeling like your sleep is restful and restorative.

As you can tell from this description, using a sleep restricted schedule is not for the faint of heart. Or rather, it's not for a person who is not committed to doing some hard work to fix the sleep problem. But it can work wonders. After my initial CPAP-induced insomnia grew way out of control, I started working with a PA in my sleep doc's office using a sleep restricted schedule along with judicious use of Ambien to consolidate my sleep cycles. At the start of the process I was self reporting getting about 4-5 hours of sleep even though I was typically using my CPAP for 7 hours or more each night. It took a good 2 months to see much of any progress and it took a total of 6 months before I was consistently getting 6 hours of decent to high quality sleep every night. But I was feeling substantially better if I got 5.5-6 hours of sleep in a 6.5 Time in Bed window than I'd felt before starting the CBT-I. Even now I feel better if I get 6 hours of sleep in a 6.5 Time in Bed window than I do if I get 7 hours of sleep in a 9 hour Time in Bed window. And now I usually wake up feeling pretty rested and even somewhat refreshed as long as my sleep efficiency is at least 85%. But whenever my sleep efficiency drops below 85% for a week or more, I usually start to feel wiped out, and I have to go back to restricting the schedule for a week or so.

Some comments about your sleep related behavior:

I have to check email and work website before I go to bed. But there is no blue light getting through both the app and glasses.

What happens if there's an email that's is screaming, "Here's a problem that MUST be fixed ASAP"? Does reading it right before bedtime stress you out?

What do you do in the last 30 minutes before you climb into bed for the night?

I let the dogs out for last call, shut down the house and do my bathroom things.

You might want to build a little bit of "downtime" that allows you to properly relax after you do that last check of email and before you let the dogs out ....

It doesn't need to be much time and it doesn't need to be anything elaborate. Just something to allow your mind to draw some closure to the day and stop focusing on work related issues. Might be something as simple as doing a crossword (with pencil and paper) or reading a book in the living room for 15-20 minutes before letting the dogs out and shutting the house down.

I am not waking up from anything external. The problem is me. Be it physical or mental. I am not sure my problem can be classified as insomnia. I thought that was what it was. But the sleep doc said there was no evidence of it. And I am starting to agree. Usually I fall asleep within 30 minutes of starting to read and if I wake up I go back to sleep. But I am waking up too much and too often. And I want to know why.

As I said earlier, there may not be any explanation of why you wake up so often beyond that's the pattern of sleep your brain is used to.

And I don't know why neither you nor your doc is willing to call your problem insomnia.

There are three types of insomnia, and it's possible to have more than one type at a time:

Sleep onset insomnia. This is characterized by lengthy sleep latency times. In other words, you have a problem with sleep onset insomnia when it consistently takes you too long to fall asleep at the beginning of the night and the length of time it takes you to get to sleep is disrupting or disturbing to you and prevents you from feeling rested the next morning. Normal sleep latency is about 20-30 minutes if I recall. But if a person is not bothered by how long it takes them to fall asleep, the it usually doesn't matter if the latency to sleep is a bit prolonged.

Sleep maintenance insomnia. This is characterized by the inability to stay asleep throughout the night. While a few short wakes (usually post-REM) are normal, a person with sleep maintenance insomnia typically has enough wakes during the night to be disruptive OR they have a difficult time falling back to sleep after a middle of the night wake OR both. Typically the amount of time spent in WASO, wake after sleep onset, is excessive when someone has sleep maintenance insomnia.

Waking too early insomina. This is usually characterized by one major wake in the wee hours of the morning that is usually 1-3 hours before the desired "wake up time." The problem is you just can't get back to sleep at all before you have to get up in the morning, but you're (often) not rested enough to just get up and start your day at the time of the "wake too early" wake. This kind of insomnia can often be "fixed" by simply going to bed earlier since it is often nothing more than a circadian rhythm issue. But some people find that going to bed earlier just makes the "wake too early wake" happen earlier as well. Sometimes the "wake too early wake" is accompanied by a racing mind and an inability to just relax and go back to sleep.

Given that you say you get about 4 hours of sleep between 10pm and 7am most nights and that you wake up once or twice an hour, it seems to me that you definitely have a problem with sleep maintenance insomnia.

My problem is not going to sleep it is staying asleep. Thinking is what keeps me from going back to sleep.

So you need to learn how to not think when you are in bed and you find that you've awoken for some reason.

Question: When you do wake up in the middle of the night, what is the very first thing that goes through your mind?

To be clear I want to know the very first thought that you are aware of even before you pull out the phone to start the boring YouTube video with the screen turned off.

I put on a boring YouTube video on my phone (the screen is turned off) if I can go back to sleep that does it in five minutes. I pick out a couple that are about 20 minutes long before bed each night.

Even a boring YouTube video without the screen on can allow the brain to wake up enough to follow the sound track.

Actually that is what I am trying to do! Thinking is what keeps me from going back to sleep. Listening to something (my brain following the sound track) stops that process. Besides, if I am awake enough to turn on a video my brain is already awake :-)

What are you thinking about that keeps you from going back to sleep?

I still have to wonder if there was already something boring and dull playing in the background when you first woke up if that would allow your brain to focus on the sound track rather than the thinking right at the start.

In other words, I'm wondering if your brain is tricking itself into prolonging the wakes using this kind of a process:

• Wake up and start to worry about the fact that you are awake and start trying to figure out why you are awake, because it can't just be as simple as "you woke up for no reason" can it? Then you can't get back to sleep because the brain is thinking a mile a minute. So you wake up further thinking, "It's time to grab the phone" and wake up enough to actually grab the phone, turn the video on and possibly double check the screen is really off (and check the time at the same time?), and then, and only then, does the brain start to relax as it focuses on the sound track because that stubborn part of your brain now knows that you've been awake long enough to insure that you'll remember the wake in the morning, and even if you don't there will be evidence of the wake because the phone will tell you how many videos you listened to during the night

Another question: What happens if you don't fall asleep by the time the video is over?

When you say "boring YouTube video" can you provide an example?

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We're different here. That's just the kind of thing that would key my mind up in the middle of the night. And I'd be lying there thinking is this video almost over yet?

You might find it more useful to have a very long playlist of very boring music that you can play all night long---something that's already "on" for you to listen to when you wake up. As an example, I use a four hour long playlist of Gregorian chants playing on my iPod every night. When I wake up, the chants are already playing and I don't have to do anything but relax and listen to them.

Music wakes me faster than anything. As I said I need to distract myself from thinking. There is nothing to do but think when listening to music.

What kind(s) of music do you listen too? If the music has lyrics, then I can't use it to distract myself at night because I get wrapped up in actively listening to the music. But Gregorian chants are in Latin, which I don't understand, and all sound a like (so I don't develop "favorites") but at the same time are not so repetitious to make me think about them. But that's just me.

How about lining up enough boring YouTube videos to play all night long on your phone for a few nights. And just going to sleep with the videos already playing one after each other?

I am starting to find that it is better to read in bed. If I go in the living room by the time I get back to bed I am cold and wide awake again. I used to read a real book. But by the time I feel sleepy, sit up to turn off the light I am wide awake. I have to start over from scratch. If I read on my phone and start to fall asleep I just close my eyes and go to sleep. Like I said I am using Twilight set to 2700K and using blue blocking glasses.

How often do you read in bed? Every night? 4 or 5 nights a week? 1-2 nights a week? A few nights a month?

And how long do you read before falling asleep when you are reading on your phone?

And do you fall asleep with or without the mask on after reading in bed?

And remember: You say that you are spending 8 hours in bed each night, but that you are only asleep for 4 of those hours. One problem with reading on the phone is that you are continuing to teach your brain that it is just fine to be awake while you are in bed during your desired sleep window. And that's part of why your brain wakes fully up so often in the middle of the night: It is convinced that it is OK to be wide awake (and doing something) instead of sleeping when you are in bed.

Sometimes a simple trip to the bathroom (even if you don't think you need to go) and a small drink of water is enough to calm the brain enough to let you get back to sleep in a timely fashion.

That is what I do every time. Most times I do go back to sleep

How many bathroom trips do you need to make during a single night?

Again, it comes back to the fact that you say you are in bed for 8 hours, but you are only sleeping for 4 of those hours. What are you doing during the other 4 hours that you are supposed to be in bed sleeping? And why does you brain think it is ok to be awake during those 4 hours? What's the brain doing that is more attractive to it than sleeping is?

And then there's this: Given your long history with sleep problems, it is unreasonable for you to expect to go to sleep at 10pm and sleep all the way to 7am with NO briefs wakes at all. A person with perfectly normal sleep patterns might go to bed at 10pm, fall asleep 20 or 30 minutes later, and wake up at 7am having woken up 3-5 times during the night for maybe 4 or 5 minutes per wake. The person may or may not remember any of the wakes, but the total WASO is maybe 20-25 minutes at most and his/her sleep efficiency is probably between 87 and 90% for the night.

I fooled around with my Sleepyhead settings and flagged 50% flow restrictions under 8 secs and started charting my RDI. My AHI would be <1 and my RDI would be 8. My awakenings always seem to happen after a couple of these. OSA and CA are well controlled now. I bumped up my starting pressure and the flex settings and RDI has improved.

Did bumping up your minimum pressure settings make you feel any better? Any worse? Or do you still feel about the same?

Did reducing your RDI change the number of wakes you are experiencing? Did it decrease the amount of time you are awake after sleep onset? Or did these stay about the same?

And what data are you using to say that your "awakenings always seem to happen after a couple of these [user flagged flow restrictions]"?

It sounds to me like you are still grasping at the idea of an "easy" fix: You're looking for a holy grail---the "right" APAP settings that will suddenly eliminate all your wakes during the night with no need to change your own sleep behavior patterns.

My best guess that your wakes won't stop just because you find settings that give you a "better RDI" in SleepyHead. I could be wrong, but since you are still complaining about the number of middle of night wakes AND you report that you only get 4 hours of sleep in spite of being in bed for 8 hours, I don't think your insomnia is being caused by under treated OSA or residual custom flagged flow limitation events at this point.

[robysue]

Sleep restriction might have been me, I have been known to foam on about it. https://en.wikipedia.org/wiki/Sleep_restriction
<much deleted>
I also found that when the therapy started working that it dramatically lessened the life-long depression and anxiety. It is not 100% gone, I still do better with a low dose anti-depressant.

I've looked into it and have been resisting it...LOL From what I've read it does work. I'm using the excuse that I'll try it after the holidays How long before you saw results?

Six years ago I did extended work with a sleep restricted sleep schedule when my CPAP-Induced insomnia was incredibly out of control. The CPAP-Induced Insomnia monster moved into by bedroom by night 3 of PAPing and it continued to grow fat and nasty for the first 3 months I was on xPAP. I was dealing with both sleep onset and sleep maintenance insomnia. After a switch from APAP to BiPAP took the edge of the aerophagia that I was experiencing, I was ready to accept the PA's suggestions that I do serious work on taming the Insomnia beast.

It took about 2 months to start seeing some results. They were baby steps in the right direction. My first results were that my sleep onset dropped from 40-60 minutes on a good night to 15 minutes on a bad night.

It took a longer time for the number of middle of night wakes to start to drop, but then many of my middle of the night wakes were directly caused by waking up with aerophagia; and a strategy for dealing with the aerophagia had to be worked out before anything would reduce the number of those wakes. At the start of my sleep restriction therapy I would typically have anywhere between 3 and 10 wakes, but just as importantly, some of those wakes were really long---lasting 20-30 minutes or more---and my total WASO was 90-120 minutes or more most nights. (WASO = Wake after sleep onset). After a couple of months of sleep restriction therapy, the number of wakes was still in the 5-6 range most nights and the WASO was still often over an hour. But aerophagia was still causing many of the worst of my middle of the night wakes. It took another couple of pressure adjustments to bring the aerophagia well enough under control for the sleep restriction therapy to start reducing the number of middle of night wakes.

After about 4 months of sleep restriction therapy I was still remembering 1-2 wakes per nights, but experiencing about 3-4 wakes on a typical night. The only reason I know this is that out of habit to turn the machine off and back on whenever I wake up in the middle of the night. The wakes that I was not remembering were typically very, very short wakes: I'd wake up, cycle the machine off and back on, turn over, and went right back to sleep all within a minute or two. The WASO was usually no more than about 30 minutes, and was often much less than that. And usually the wakes were at least 90 minutes apart, indicating that I had completed a full sleep cycle between the wakes. And most important: For the first time in about a 7 month period I was no longer waking up feeling like I'd been run over by a Mack truck. Instead, I was waking up rested and even refreshed most mornings.

I spent the last couple of months of my official sleep restriction therapy working on increasing the total time in bed from 6 hours to more like 7 hours. Quite frankly there were a number of other health issues going on that made this take far longer than either I or the PA expected.

Is my sleep great today? No, not really, but its still far better than it was before I did the sleep restriction therapy. As long as my sleep efficiency is > 85% I usually feel decent during the day time. If the sleep efficiency drops to below 80% for more than a few days, I feel pretty lousy and I know it's time to tighten up on the sleep hygiene and pay a lot more attention to bedtime and wake up time and not go to bed too early regardless of how tired I am.

My sleep does remains somewhat fragile, but that's because of a number of other non-OSA related health problems and the fact that I still have real problems with aerophagia caused by the biPAP therapy. The insomnia itself waxes and wanes with the seasons and I continue to remember 1-2 wakes on many nights. I continue to turn my machine off and back on at every wake, and the data shows that even on a good night I will wake up 3-5 times, but almost of those wakes are 1-2 minutes long and they are at least 90 minutes apart. I've learned not to worry about those super short wakes since they are not tied to how I feel during the day.

When the insomnia is at its worst? I'll remember a lot of restlessness during the night or early morning. I'll usually remember repeatedly turning the machine off and on because my stomach is bothering me. Or I'll remember a lot of "brain racing" if I'm under a lot of stress at work. (That is fortunately unusual). This past summer I started doing a lot of thrashing around in the bed (which I don't typically remember) and my sleep doc recommended a low dose of gabepentin to deal with any restless leg syndrome stuff that might be going on as well as on the grounds that there is some small amount of evidence that gabepentin can be effective in reducing WASO in people who have a lot of spontaneous arousals/awakenings. It's helped some, but I still rely on making sure that if the insomnia gets too far out of control, to go back to working on the sleep efficiency.

[mcsheltie]

You are not going to want to hear these things, but I'm going to say them anyway:

Actually you are very wrong! I definitely want to hear what you have to say and value your opinion or I would not be here! I can close my office door and talk to myself if I only want to hear my own ideas...LOL

I've been researching sleep restriction in conjunction with morning light therapy. Considering the way things have been falling into place (see the end of this paragraph) I don't think it is a coincidence that both you and Chill are also steering me in that direction. I've been working for a long time to overcome the worry about not sleeping. I am mostly past that now. But I still lose my temper periodically. Pre CPAP I found ways that work so that I can get back to sleep. Not too long ago once I was awake I was done for the night. Never in a million years did I think apnea was even a possibly. But now that my treatment is doing well (I increased the pressure another 0.5cm and bumped up the EPR setting and have had three nights under 0.3) and I am off the Benzos I think my depression, brain fog and memory loss will start resolving. I am very lucky (probably divine intervention rather than luck) that things have fallen into line like they have or I could easily have gone on like this for another five years (perish the thought!) Now you have given me the another piece of the puzzle. Hearing a personal account of of working SRT is a great help!



Some comments about your sleep related behavior:

I have to check email and work website before I go to bed. But there is no blue light getting through both the app and glasses.

What happens if there's an email that's is screaming, "Here's a problem that MUST be fixed ASAP"? Does reading it right before bedtime stress you out?

What happens is I have to fix it. The amount of stress it generates is usually equal to my ability to fix the problem.

What do you do in the last 30 minutes before you climb into bed for the night?

I let the dogs out for last call, shut down the house and do my bathroom things.

You might want to build a little bit of "downtime" that allows you to properly relax after you do that last check of email and before you let the dogs out ....

Good idea. The past couple days I have started doing that stuff an hour and a half before bed and then sitting down and reading for the last half hour.

I am not waking up from anything external. The problem is me. Be it physical or mental. I am not sure my problem can be classified as insomnia. I thought that was what it was. But the sleep doc said there was no evidence of it. And I am starting to agree. Usually I fall asleep within 30 minutes of starting to read and if I wake up I go back to sleep. But I am waking up too much and too often. And I want to know why.

As I said earlier, there may not be any explanation of why you wake up so often beyond that's the pattern of sleep your brain is used to. I can accept that. To me that is an answer to "why".

And I don't know why neither you nor your doc is willing to call your problem [i]insomnia. I have always said I have insomnia. That is the reason why I went to my PCP in the first place. It was the PSG tech and sleep doc that said I didn't have insomnia, based on my sleep efficiency in both PSGs. During the tests I woke up and went right back to sleep. My latency to sleep was 20 minutes both nights. He said apnea, causing me to stay in stage 1 sleep was the reason for my waking, not insomnia. His explanations made sense.

There are three types of insomnia, and it's possible to have more than one type at a time:
Given that you say you get about 4 hours of sleep between 10pm and 7am most nights and that you wake up once or twice an hour, it seems to me that you definitely have a problem with sleep maintenance insomnia. That is what I thought too. I used to have (bad) sleep onset too. But I worked through that. It left when I was able to stop worrying about whether I slept or not.

My problem is not going to sleep it is staying asleep. Thinking is what keeps me from going back to sleep.

So you need to learn how to not think when you are in bed and you find that you've awoken for some reason. That is the reason why turning on the vid works for me. I don't think when I do that. Just like you can wake up and turn your machine on and off. It is pure habit.

Question: When you do wake up in the middle of the night, what is the very first thing that goes through your mind? To be clear I want to know the very first thought that you are aware of even before you pull out the phone to start the boring YouTube video with the screen turned off. What is the fastest way to go back to sleep this time... Get up or video.

What are you thinking about that keeps you from going back to sleep? It can be anything. Finances, work, someone who has P*ssed me off, my ex... whatever my brain pulls out of it's hat. That's why I don't let it get started.

I still have to wonder if there was already something boring and dull playing in the background when you first woke up if that would allow your brain to focus on the sound track rather than the thinking right at the start. Like I said I have tried a lot of things over the years, including that. Having something on in the background WILL wake me up. I pick 20 minute videos because they go off shortly after I've gone back to sleep. So there is nothing playing to wake me up.

In other words, I'm wondering if your brain is tricking itself into prolonging the wakes using this kind of a process:

• Wake up and start to worry about the fact that you are awake and start trying to figure out why you are awake, because it can't just be as simple as "you woke up for no reason" can it? Then you can't get back to sleep because the brain is thinking a mile a minute. So you wake up further thinking, "It's time to grab the phone" and wake up enough to actually grab the phone, turn the video on and possibly double check the screen is really off (and check the time at the same time?), and then, and only then, does the brain start to relax as it focuses on the sound track because that stubborn part of your brain now knows that you've been awake long enough to insure that you'll remember the wake in the morning, and even if you don't there will be evidence of the wake because the phone will tell you how many videos you listened to during the night

"The stubborn part of your brain" explanation is highly possible. I don't worry why I am awake at night. This is something I am pursuing during the day.

Another question: What happens if you don't fall asleep by the time the video is over? I'll start another. If I can't sleep I'd rather spend the time listening to something. It is relaxing. But that rarely happens. Usually I go back to sleep... only to wake again an hour later

[quote]When you say "boring YouTube video" can you provide an example?

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We're different here. That's just the kind of thing that would key my mind up in the middle of the night. And I'd be lying there thinking is this video almost over yet? I don't care about that.

You might find it more useful to have a very long playlist of very boring music that you can play all night long---something that's already "on" for you to listen to when you wake up. As an example, I use a four hour long playlist of Gregorian chants playing on my iPod every night. When I wake up, the chants are already playing and I don't have to do anything but relax and listen to them.

Music wakes me faster than anything. As I said I need to distract myself from thinking. There is nothing to do but think when listening to music.

What kind(s) of music do you listen too? If the music has lyrics, then I can't use it to distract myself at night because I get wrapped up in actively listening to the music. But Gregorian chants are in Latin, which I don't understand, and all sound a like (so I don't develop "favorites") but at the same time are not so repetitious to make me think about them. But that's just me. ANY music will wake me up from a deep sleep. Monotonous talking puts me to sleep.

How about lining up enough boring YouTube videos to play all night long on your phone for a few nights. And just going to sleep with the videos already playing one after each other? As I said before, tried that. Something playing in the background will wake me right back up.

I am starting to find that it is better to read in bed. If I go in the living room by the time I get back to bed I am cold and wide awake again. I used to read a real book. But by the time I feel sleepy, sit up to turn off the light I am wide awake. I have to start over from scratch. If I read on my phone and start to fall asleep I just close my eyes and go to sleep. Like I said I am using Twilight set to 2700K and using blue blocking glasses.

How often do you read in bed? Every night? 4 or 5 nights a week? 1-2 nights a week? A few nights a month? 1-2 nights a week now. I am just trying it out and I am finding I go to sleep faster that way

And how long do you read before falling asleep when you are reading on your phone? 15 minutes

And do you fall asleep with or without the mask on after reading in bed? Mask on. I never sleep without it. I've got the machine going, light out etc... while I read. When I get sleepy I just close my eyes and go to sleep. I don't have to walk into the bedroom, fall over the dogs, get cold, put on the mask, get the bedding right etc... I just close my eyes and go to sleep.

And remember: You say that you are spending 8 hours in bed each night, but that you are only asleep for 4 of those hours. One problem with reading on the phone is that you are continuing to teach your brain that it is just fine to be awake while you are in bed during your desired sleep window. And that's part of why your brain wakes fully up so often in the middle of the night: It is convinced that it is OK to be wide awake (and doing something) instead of sleeping when you are in bed. That's what the SRT books also say.

Sometimes a simple trip to the bathroom (even if you don't think you need to go) and a small drink of water is enough to calm the brain enough to let you get back to sleep in a timely fashion.

That is what I do every time. Most times I do go back to sleep

How many bathroom trips do you need to make during a single night? Before CPAP three, usually four. Now maybe once. But often I will get up, stretch my legs, get a drink (as you suggested above) and go back to sleep. Not because I had to use the bathroom.

Again, it comes back to the fact that you say you are in bed for 8 hours, but you are only sleeping for 4 of those hours. What are you doing during the other 4 hours that you are supposed to be in bed sleeping? And why does you brain think it is ok to be awake during those 4 hours? What's the brain doing that is more attractive to it than sleeping is? I am a type A, workaholic and I have had a lot of trauma in my life. I think that my sympathetic dominate system doesn't shut down at night. My cortisol is high at night and low in the morning. Now that I've been dx with apnea it isn't a big surprise that I am that way.

I fooled around with my Sleepyhead settings and flagged 50% flow restrictions under 8 secs and started charting my RDI. My AHI would be <1 and my RDI would be 8. My awakenings always seem to happen after a couple of these. OSA and CA are well controlled now. I bumped up my starting pressure and the flex settings and RDI has improved.

Did bumping up your minimum pressure settings make you feel any better? Any worse? Or do you still feel about the same? Better

Did reducing your RDI change the number of wakes you are experiencing? Did it decrease the amount of time you are awake after sleep onset? Or did these stay about the same? I think they are decreasing slowly. Too soon to tell for sure.

And what data are you using to say that your "awakenings always seem to happen after a couple of these [user flagged flow restrictions]"? SleepyHead

It sounds to me like you are still grasping at the idea of an "easy" fix: You're looking for a holy grail---the "right" APAP settings that will suddenly eliminate all your wakes during the night with no need to change your own sleep behavior patterns. Of course I am! LOL

My best guess that your wakes won't stop just because you find settings that give you a "better RDI" in SleepyHead. I could be wrong, but since you are still complaining about the number of middle of night wakes AND you report that you only get 4 hours of sleep in spite of being in bed for 8 hours, I don't think your insomnia is being caused by under treated OSA or residual custom flagged flow limitation events at this point.
My reason for this post was to make sure I was doing everything I could to optimize my therapy, to eliminate that cause of waking up. Since unbeknownst to me it is a root cause. It is a huge bonus that I have gotten a lot of great additional advice Before CPAP I'd been able to stop worrying about both waking up and not sleeping (still have the occasional temper tantrum, but I do that during the day too...LOL) I've found a way that works for me to be able to go back to sleep. So hopefully learning to consolidating my sleep will be able to bring everything together.

[cpdaniel]

Two + months have gone by and I am still waking up at least three times per night. Sometimes I can go back to sleep, more than often I cannot. This is the main reason I did the sleep study in the first place, as I had no idea I had apnea.

This might not be something you want to hear, but I offer it in the hope that it will be helpful.

I've been on PAP for just over a year now. Like you, I adapted well and instantly to the mask and the pressure. Like you, I fall asleep quickly - usually within 5 minutes. Like you, my main complaint was waking up frequently during the night, and sometimes not being able to get back to sleep.

What I can tell you is, at least for me, it gets better over time. In my case, I've only just now, after 11-12 months, started having a few "almost good" night's sleep. Nights where I woke only once. I'm still looking for that "Ah Ha!" night where I sleep the night through, but it hasn't come... yet. But it is getting better, little by little.

Stick with it. Hang in there. Your life is too important to give up. Try not to worry. It does get better over time.

[mcsheltie]

WOOHOO!!!! It seems to be working! KNOCK ON WOOD!!!!!

Did another .5 bump in pressure and one more raise in the EPR and have had two great nights. Last night I only remember waking up once and I went right back to sleep. AHI is 0.15 The night before was only twice. That is a world record for me!!! Hope I didn't just jinx myself...

[kwhenrykerr]

WOOHOO!!!! It seems to be working! KNOCK ON WOOD!!!!!

Did another .5 bump in pressure and one more raise in the EPR and have had two great nights. Last night I only remember waking up once and I went right back to sleep. AHI is 0.15 The night before was only twice. That is a world record for me!!! Hope I didn't just jinx myself...

It is called Fine Tuning, and girl you are doing Fine.