Finally- an appointment with Sleep Doctor

[beautifuldreamer]

Interesting, after 3 years of diagnosis with sleep apnea, this week I had a real appointment, not a phone appointment with a Sleep Doctor at Kaiser.

He looked in my throat and nose, and checked my heart/breathing. He said that I have what looks like people who have sleep apnea, in terms of extra tissue in my throat area.

The Sleep Doctor asked several questions related to my history of sleep issues, and was familiar with SleepyHead. He increased the settings slightly on my device, and if I can tolerate the change but it doesn't seem to help, he will increase it more- but if I can't tolerate it, he will reduce the settings. His hope that a more aggressive treatment of the sleep apnea will help me to stay asleep longer during the night. I had been averaging between 4 to 5 hours of sleep per night, with a 2 to 3 hour of being awake trying to fall back to sleep.

He also gave me a brief discussion of CBTi, a type of therapy used for insomnia- about getting out of bed and do something calming, if it takes me longer than 20 minutes to fall back asleep, and not to linger in bed in the morning, so my body doesn't think it is supposed to be awake while in bed. Also to try to put less pressure on myself if I wake in the middle of the night, as the worrying often keeps me from being able to fall back asleep. The Sleep Doctor said to "Remind yourself that you can get through a day following a bad night of sleep as you have done this many times in your life before."

Here are my new settings that I took from the display of the ASV:
Max Pressure 25
EPAP minimum 9
EPAP maximum 15
PS minimum 4
PS maximum 16

From SleepyHead - this is what it says the new settings are:
Min EPAP 7.2
Max IPAP 20.0
PS 3.2 - 12.8 (cmH20)

Older SleepHead settings:
Min EPAP 6.4
Max IPAP 20.0
PS 0.0 - 13.6 (cmH20)

The appointment and settings were changed on Wednesday, and I look forward to seeing positive outcomes . . .

[avi123]

You don't give your age but 5 to 6 hours of sleep may be appropriate for older adults:
https://sleepfoundation.org/sites/defau ... nges_1.png
I take a small dose of 5 mg Zolpidem (generic Ambien) tablet when I mask and I assume that it helps me sleep 6 1/2 to 7 hours, non stop. If I wake before I then rinse my eyes and mouth with faucet water and go back to sleep. Usually, I manage to sleep with the CPAP for 2 more hours up to 7 hours.

p.s. I changed to "may be appropriate" from "is appropriate".

[ChicagoGranny]

He also gave me a brief discussion of CBTi, a type of therapy used for insomnia

That's usually not necessary if you follow these basic instructions:

- Practice good sleep hygiene (Google it and read several sources)
- Eat a good diet
- Have a regular, moderate exercise program
- Try to avoid daytime naps
- Practice total abstinence of caffeine including sources like chocolate (sigh)
- Review all medicines, vitamins and supplements you are taking to make sure none are interfering with sleep
- Use the bedroom for sleeping (and sex) only, and make sure the bedroom and bed are comfortable.
- Learn to appropriately handle emotional stress in your life
- Do not listen to your breathing or the sound of the machine as you are falling asleep.
- Distract your mind by thinking of a pleasant, relaxing activity that you enjoy. Thinking of sitting under an umbrella on a quiet beach with a warm gentle breeze works for me.
- Use CPAP software, such as the free SleepyHead, to make sure your therapy is optimized
- If you still don't feel or sleep well, make sure you have regular medical checkups to confirm there are no other medical problems

CG

Certainly, you would want to adopt these practices before starting on CBT.

On the other hand, the adjustment your doctor is making to your CPAP settings may solve your problems. You don't mention what your AHI is. Since your doc is adjusting the settings, I assume your AHI is somewhat high. This could be causing your problems of early awakening and difficulty falling back to sleep.

[ChicagoGranny]

You don't give your age but 5 to 6 hours of sleep is appropriate for older adults:

Disagree. That's not enough hours to be healthy and energetic.

small dose of 5 mg Zolpidem (generic Ambien) tablet

That's a nasty drug and the effect wears off after a few months. There are many other things, with no bad side effects, to be done before resorting to this chemical bomb.

[zonker]

You don't give your age but 5 to 6 hours of sleep is appropriate for older adults:
https://sleepfoundation.org/sites/defau ... nges_1.png
I take a small dose of 5 mg Zolpidem (generic Ambien) tablet when I mask and I assume that it helps me sleep 6 1/2 to 7 hours, non stop. If I wake before I then rinse my eyes and mouth with faucet water and go back to sleep.

you may want to look at that chart again. not to be argumentative, but the chart you linked says that 5-6 hours sleep "May be Appropriate" for adults 65+. it states 7-8 hours of sleep is " Recommended" for adults 65+.

hope you are getting enough sleep!

[avi123]

small dose of 5 mg Zolpidem (generic Ambien) tablet

That's a nasty drug and the effect wears off after a few months. There are many other things, with no bad side effects, to be done before resorting to this chemical bomb.

Comment,

In 2012 Consumer Reports reported on a survey of nearly 9000 people with sleep problems. The people surveyed were asked what kinds of treatment they had used and whether it had "helped a lot." This was the result:

[ChicagoGranny]

a survey

lol That's a non-scientific survey based on self-reporting of "feelings". If they had asked does exercise and proper diet promote good sleep, 90+% would have said, "Yes."

[chunkyfrog]

I would advise anyone with insomnia to read the entire article that Avi cites.
CR indicates that drugs are not advisable for use over a long time.
The article lists some excellent NON-DRUG tips that are effective for attaining good sleep.
I agree that the term "sleep hygiene" sounds didactic and useless, but it is a powerful tool.

[robysue]

He also gave me a brief discussion of CBTi, a type of therapy used for insomnia- about getting out of bed and do something calming, if it takes me longer than 20 minutes to fall back asleep, and not to linger in bed in the morning, so my body doesn't think it is supposed to be awake while in bed. Also to try to put less pressure on myself if I wake in the middle of the night, as the worrying often keeps me from being able to fall back asleep. The Sleep Doctor said to "Remind yourself that you can get through a day following a bad night of sleep as you have done this many times in your life before."

Beautifuldreamer,

As you probably know I've done a lot of CBT-I and I have posted a lot about dealing with insomnia issues while on CPAP.

Your doctor has given you some really sound advice: You do need to "Remind yourself that you can get through a day following a bad night of sleep as you have done this many times in your life before."

And getting out of bed to do something calming when you've been lying in bed for 20 minutes is a good idea when the problem is that your body no longer remembers that Being in Bed means it's Time for Sleep.

And you definitely need to take the pressure off yourself in the middle of the night: Worrying about getting back to sleep is a surefire way of making it almost impossible to get back to sleep. If you find yourself worrying about getting back to sleep for more than about 20 minutes, it's a good idea to go ahead and get out of bed and do something calming and relaxing to get your mind off the worrying about your sleep.

Finally I'll add something else about the argument that is going on right now between Avi and ChicagoGranny:

Sleep hygiene vs prescription sleeping pills vs CBT-I is NOT an "either-or-or" debate. What I mean by that is this:

1) Take what your doctor said about CBT-I seriously. He's given you good insight into a major source of insomnia for a lot of people: Worry. And if what your sleep doc told you about worry sounded like he was describing what you know is going on in your bed each night, then it's very important on working on how to reduce the worry.

2) Good sleep hygiene can encourage to get sleepy and even help you sleep through the night---if there are no other issues with your sleep. For many people good sleep hygiene and the rest of ChicagoGranny's suggestions are enough. But for some people, they're not enough by themselves to conquer a very persistent and stubborn insomnia beast. When good sleep hygiene is not enough, the combination of good sleep hygiene and some CBT-I focusing on reducing the worry about sleep and the need to reteach the body Time in Bed = Time to be Asleep can be a powerful combination to rein in an insomnia monster.

3) When insomnia is very persistent there is also a role for prescription sleeping medication. Ambien is well tolerated by most people, but it is not tolerated by everybody. And Ambien is not the only prescription sleeping medication on the market. Proper, judicious use of sleeping pills can even be a part of a CBT-I program when a person's insomnia is so severe that it has become hard to cope with day-to-day life. Back when I started my CBT-I some 6 years ago, the PA treating me insisted on also prescribing a small dose of Ambien with the following instructions: "If you have a really bad disastrous night where it feels like you got less than 2 hours of sleep, then take the Ambien the next night to minimize the chances of you having two really bad disastrous nights in a row." That's an intelligent starting point for sleeping pill use with insomnia. But the sad fact is that some people may need pharmaceutical help even after CBT-I. However, that's something to revisit after you've given the CBT-I a chance to work.

Best of luck reining in your insomnia monster!
Robysue

[avi123]

From the Consumer Reports on Health:

Cognitive behavioral therapy

One group of nondrug treatments—collectively known as cognitive behavioral therapy or CBT—has proved to be quite effective in treating insomnia. This involves getting help from a therapist to learn a new set of behaviors regarding sleep. For example, you might be prohibited from watching TV in bed, or be directed to get up at the same time every day. Or you might have your actual time in bed restricted while you “relearn” to associate being in bed with sleep.

You might also learn relaxation techniques and mental tricks to help you get to sleep. Generally, CBT involves three to six one-hour sessions with a trained therapist, plus directions for at-home activities.

Studies have found behavioral therapy to be effective—it helps 70 to 80 percent of people with chronic insomnia—and it appears to be at least as effective as sleeping pills. In some studies, a combination of the two has helped people the most.

For many people, behavioral therapy can provide a long-term solution for insomnia, as opposed to sleeping pills that treat only the symptoms but don’t address the underlying issues. If you see a primary-care doctor or therapist for chronic insomnia and they prescribe pills without mentioning behavioral therapy as an option, you should mention it. If they don’t know anything about it, finding a physician who does.

Question,

How do you find a trained certified therapist for chronic insomnia and how much it costs?

[robysue]

Question,

How do you find a trained certified therapist for chronic insomnia and how much it costs?

In my case the sleep doc's PA was competent at directing my CBT-I. Many sleep docs or their PAs can direct CBT-I.

Many psychologists who are skilled at CBT are also capable of directing CBT-I.

But the usual starting point is your PCP: If the insomnia is not so severe as to warrant being seen by a specialist, the average PCP can direct basic CBT-I. Guidelines for PCPs on how to treat insomnia now contain clinical information about basic CBT-I such as:

• The importance of patient education about what is meant by good sleep and education about what can be expected from CBT-I,
• The need to set realistic goals: It is NOT a realistic goal for most insomniacs to expect that after 6-12 weeks of CBT-I that they will suddenly be falling asleep within 15-20 minutes of going to bed and sleeping 8 hours straight with no wakes at all. What realistic goals are, however, depends on the particular person, the particulars of how their insomnia manifests itself, and how committed the person is to making potentially significant changes in their lifestyle in order to manage the insomnia long term.
• Encouraging the patient to attention and clean up the sleep hygiene.
• The need for a patient to keep a short-term sleep log with some basic information to determine both the scale of the problem (before the CBT-I) is started and progress towards the goals once CBT-I is started.
• Useful measures for determining the success of the CBT-I for an individual patient.

Basic CBT-I typically takes maybe 2 or 3 months---if the patient does the work they're supposed to do. As for the cost? In my case I had my standard insurance copay for each visit.

And then there's this important idea: The best of the "self-help" books on treating insomnia without drugs are essentially self-directed CBT-I programs. In other words, CBT-I is not rocket science. It helps to have a professional guiding your CBT-I because then there is an external person who can help you focus on realistic goals and help you see signs of progress that you might otherwise dismiss as not being important. But dedicated person can do CBT-I on their own if they really want to.

[avi123]

Here is SHUTi online:

http://www.myshuti.com/

Description (with price):

Referenced as “the best-studied program” by Harvard Health, SHUTi is designed to actively help retrain your body and mind for great sleep through six engaging Cognitive Behavioral Therapy for Insomnia strategy and learning sessions. Unlike printed material, video collections, or recorded lectures, each online Core is personalized to your current sleep patterns and goals, and walks you, step-by-step, through exactly what you need to do to maximum your sleep improvements, now and for the future.

SHUTi is an industry leading online CBT-I program with unsurpassed, proven results.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

From:

http://www.cbtforinsomnia.com/

A 20-minute sleep clinic visit with a sleep psychologist/CBT-I specialist averages about $120 and a two week supply of non-generic sleeping pills or two co-payments at a sleep clinic are about $40.

[robysue]

Here is SHUTi online:

http://www.myshuti.com/

On the surface, the link looks interesting and it looks like it is probably a legitimate website. But I'd have to do a lot more poking around to determine for sure that it's a legitimate site.

The price is $135 for 16 weeks of access (without a doctor's involvement) or $156 for 20 weeks of access "if a doctor has provided you with a Clinical Access Coupon." That works out to $8.44 per week of access for the 16 week access program and $7.80 per week of access for the program. In my humble opinion, that's not excessively expensive, but it's also not dirt cheap. In other words, it's just expensive enough that I wouldn't sign up without some very, very thorough investigation of the site and evaluation of just how serious my insomnia was. I'd also consider asking my sleep doc if he ever heard of SHUTi if I didn't feel like I could afford to throw $135 away on something that might not work out or might be a scam.

You can request a free CBT-I guide from the site by going to http://info.myshuti.com/cbti-guide-request and filling in the required information. I have not done this, but I may request that free guide just for the heck of it later tonight. At any rate, that's the first step in investigating whether this program is worth considering under some kind of circumstances.

In other words, if I were looking for a self-directed CBT-I program that could provide me with some personalized guidance and feedback that you can't get from a plain old fashioned book like Sound Sleep, Sound Mind AND if I had $135 to spend, I'd spend some real time poking around the MySHUTi site to figure out whether to spend the $135 on this program or not.

It is worth pointing out that Sound Sleep, Sound Mind can be bought from Amazon for $12.99 (Kindle) to $32.95 (hardback). If the insomnia is not too bad, working through Sound Sleep, Sound Mind would be cheaper, but you wouldn't have any personalized feedback.

Finally, for what it is worth: Working my way through Sound Sleep, Sound Mind *did* do a lot to help me, but at the same time I was already involved in doing a formal CBT-I program under the direction of a PA in my sleep doc's office.

[ChicagoGranny]

The discussion about CBTI (Standard acronym form is CBTI, not CBT-i, despite incorrect usage in some journals.) is premature. Basic things should be tried first:

- Practice good sleep hygiene (Google it and read several sources)
- Eat a good diet
- Have a regular, moderate exercise program
- Try to avoid daytime naps
- Practice total abstinence of caffeine including sources like chocolate (sigh)
- Review all medicines, vitamins and supplements you are taking to make sure none are interfering with sleep
- Use the bedroom for sleeping (and sex) only, and make sure the bedroom and bed are comfortable.
- Learn to appropriately handle emotional stress in your life
- Do not listen to your breathing or the sound of the machine as you are falling asleep.
- Distract your mind by thinking of a pleasant, relaxing activity that you enjoy. Thinking of sitting under an umbrella on a quiet beach with a warm gentle breeze works for me.
- Use CPAP software, such as the free SleepyHead, to make sure your therapy is optimized
- If you still don't feel or sleep well, make sure you have regular medical checkups to confirm there are no other medical problems

CG

[beautifuldreamer]

Thanks for all the ideas and encouragement -
I do not take meds/drugs, but am open to more naturopathic healing. About a month ago, I tried Dr. Mercola's Sleep spray, and that seemed to help me, so I just ordered some more

This sleep situation started at least 30 or 40 years ago - I maybe have had less than ten days where I can remember getting a full 8 hours of sleep in a night.

I am glad to start with the CBTI ideas that the sleep doctor gave me to try for now. And the Great sleep hygiene information- Things have gotten chaotic in my bedroom, and today a friend came and helped me to get things more organized- I think that having the room less cluttered and more organized will help also.