My CBT for Insomnia

  Or how I learned to tolerate my BiPAP

Anybody who's followed my saga knows that I started a CBT-based approach to tackling my rather serious CPAP-induced insomnia back on 12/31/2010.  This is a lengthy post for a blog, but since CBT is, itself a lengthy process, I didn't really want to skimp on the details.

The short, sweet version of my CBT for Insomnia story 

My CBT involved a significant amount of hard work and dedication on my part. It was not easy. But it has made a huge difference in my ability to both sleep in general and sleep with my BiPAP in particular. And I'll get to the details of what my particular CBT involved later on.

Overall, I've been happy with the results---even though I've been "stuck" at not sleeping much more than 5 1/2 to 6 1/2 hours a night for a very long time. Right now, I'm typically going to bed between 2:30 and 3:30 AM and sleeping until 9:00 or 9:30 AM. The key, however, is that I am sleeping during this 5 1/2 to 6 1/2 hour "time in bed" window rather than tossing, turning, fighting the machine, and in general NOT sleeping while I'm in bed.

I feel substantially more rested and more refreshed when I wake up in the morning that I did when I started doing the hard CBT work for the CPAP-induced insomnia. And most mornings now, I actually feel better and more rested than I felt before my crazy CPAP adventure began. And so while I still wish I was sleeping more and at more normal hours, my insomnia feels like it's "under control", I no longer dread bedtime, and I no longer have a deep emotional resentment of my BiPAP's presence in my life.

I often get questions from members of the CPAP&Insomnia Club about what my CBT for Insomnia involved and how well the pieces of it worked. And that's why I'm writing this essay.

Some general comments about CBT for Insomnia

For anybody who is looking for a long-term, non-pharmaceutical way of improving insomnia-related sleep issues and who is willing to make some real commitment to changing their behaviors and who is willing to work on a solution for several weeks to a few months, I'd strongly recommend giving a CBT approach to dealing with insomnia. But if you are impatient or need a quick-fix solution or are unwilling to make some significant, long-term changes in your lifestyle, then CBT is probably not going to be your cup of tea. It's also important to remember that I had no long term history of taking prescription sleeping medication prior to my starting my CBT for Insomnia when you read my story. Trying to rein in insomnia without using sleeping medication in the first place is one thing; trying to wean oneself off of a long term habit of using prescription sleeping medication is something else altogether.

There's a huge amount of "self-help" for insomnia out there too. And much of the self-help stuff has a heavy dose of CBT in it. Two of the most useful resources I've found for dealing with the combination of insomnia and CPAP are the following two books, both written by doctors with plenty of experience in sleep medicine:

• Sound Sleep, Sound Mind, by Dr. Barry Krakow
• Sleep Interrupted, by Dr. Stephen Park

Park's book is hands down the best extensive book about OSA written for the patient that I've run across. He goes through both exactly what kinds of things cause our airways to collapse and what the consequences of untreated OSA really are. He also talks at length about why CPAP works and some of the problems that patients have with CPAP. And along the way there are plenty of suggestions on how to conquer those pesky adjustment problems.

Krakow's book is a wonderful resource for successfully conquering insomnia without drugs. He writes at length about a whole host of behavior patterns that are common in both light sleepers and insomniacs that tend to aggravate our sleep problems. And for each behavior pattern he offers plenty of concrete, hands-on suggestions on how to change the behavior from a pattern that encourages poor sleep to a behavior pattern that encourages high quality sleep. Moreover, he usually gives plenty of alternate approaches for "fixing" a particular pattern. And he clearly understands that most insomniacs have multiple behavior patterns that wreck havoc with their sleep, and so many of his suggestions are designed to work together to help foster quality sleep. His book also ends with a long discussion of sleep disordered breathing (SDB). (OSA is the classic example of sleep disordered breathing.) He makes a sound case for the idea that SDB is a major cause of insomnia for folks who are sleeping with undiagnosed SDB. And he talks at length about how a properly titrated PAP therapy can work wonders for curing some folks' long standing insomnia, but he is also astute enough to note that for some of us insomniacs, the initial adjustment period to PAP therapy can temporarily make things worse not better----because, after all, there's a lot we have to learn how to deal with when starting PAP therapy and some of what we have to deal with can aggravate our insomnia.

As for whether CBT for Insomnia is effective, here are some links to a few published research papers:

Psychological treatment for insomnia in the regulation of long-term hypnotic drug use K Morgan, S Dixon, N Mathers, J Thompson and M Tomeny Health Technology Assessment 2004; Vol. 8: No. 8 Health Technology

Cognitive Behavior Therapy and Pharmacotherapy for Insomnia A Randomized Controlled Trial and Direct Comparison Gregg D. Jacobs, PhD; Edward F. Pace-Schott, MA; Robert Stickgold, PhD; Michael W. Otto, PhD in Archives of Internal Medicine

A Primary Care “Friendly” Cognitive Behavioral Insomnia Therapy INSOMNIA Jack D. Edinger, Ph.D.1,2 and William S. Sampson, Ph.D. in Journal of SLEEP

My Pre-CPAP history of insomnia

Because CBT ought to take the back story of the person's problems into account, I thought I'd start with a description of both my pre-CPAP insomnia history and the development of my CPAP-induced insomnia. That puts my CBT for Insomnia into perspective.

Prior to my OSA diagnosis I frequently had random nights of insomnia, but most of the time I'd sleep "decently enough." In other words, I didn't fight insomnia night after night pre-CPAP. And when the insomnia would raise its ugly head, it was typically bedtime insomnia---I had problems getting sleepy at bedtime and falling asleep if I went to bed at a decent time. I also had (and still have) serious problems with both getting to sleep and staying asleep in hot, humid weather---unless the AC is set to something like 68-70 degrees. And even then the AC can bother me if it is blowing directly on me. And I'm somewhat sensitive to changes in barometric pressure---I don't sleep well when the pressure is dropping because of a big storm system coming through for example.

I had dealt with a number of bouts of "adjustment insomnia" that had lasted two or three months. The stressors that led to the two biggest bouts of adjustment insomnia were the death my mother when I was 8 months pregnant (and living some 600 miles away from my parents) and my husband being seriously injured in a car accident (he was hospitalized for about 3 months). In all my bouts of more serious insomnia, my insomnia was predominantly bedtime/sleep onset insomnia: Once I got to sleep, I'd usually manage to stay asleep well enough.

And in these previous bouts with insomnia, I was able to rein them in with careful attention to good sleep hygiene. Pre-CPAP, the most useful techniques for me had always been:

• Go to bed only when sleepy and know the difference between feeling sleepy and feeling tired or exhausted.
• Use the bed (and bedroom) only for sleeping and sex. (So no reading in bed for me.)
• Cut back on the caffeine in the afternoon and evening
• Don't watch the clock when lying awake in bed. (Hubby and I would switch sides of the bed when the clock was posing a problem for me.)
• Don't focus on worrying about how little I was sleeping. Focus on realizing that I likely get more sleep than I think I do.

Well before starting CPAP, these basic rules of good sleep hygiene had become a well established part of my daily life and they typically kept my pre-CPAP insomnia under control in the sense that most nights I'd be able to go to bed at a reasonable time, manage to fall asleep within about 30-50 minutes without getting anxious about not being asleep, and not consciously wake up multiple times during the night. I did a lot of daydreaming and fantasizing while waiting for sleep to come.

The growth of my CPAP-induced insomnia

I started CPAP on 9 /23/2010. And by 9/26/2010 I was already sensing the onset of the "bedtime dreads." (See Dreading bedtime on night 4 if you want to see how I described it at the time.) And almost immediately I started to crash and burn in the sense of my daytime functioning. By night three, insomnia was starting and I was getting serious aerophagia issues. By 10/12 my hubby had insisted that I call the sleep doc's office to discuss the extreme daytime sleepiness, extreme daytime fatigue, air getting into eyes without any apparent mask leaks, serious aerophagia, and whole host of other issues. The PA who met with me ordered a week of auto-titration and asked whether wanted a prescription of Ambien. I turned down the idea of taking sleeping pills and we spoke about sleep hygiene. In addition to discussing the things I was already doing, she suggested that I avoid all naps, including micronaps---micronapping immediately became a serious problem for me once a started CPAP; it had never been a problem before CPAP. She also suggested that I work on establishing a more regular bedtime/wake-up time sleep schedule. But I was dealing with so much misery from the machine that not much of this registered. (Two relevant posts from this time period are Starting AutoPAP tonight---almost 3 weeks into therapy and Update for week 4 of CPAP/APAP.)

I continued to struggle with a wide variety of sensory overload problems, all of which continued to feed my really nasty case of bedtime insomnia. My sensory overload problems included:

• aerophagia
• air blowing into my eyes through my tearducts
• pressure tickling the back of my throat
• chipmunk cheeks
• an inability to talk to my husband
• a sense of becoming more alert as soon as I put the mask on
• an inability to find a genuinely comfortable sleeping position at the start of the night
• chapped lips
• being excessively bothered by the exhaust flow of the FX mask
• being excessively aware of my own breathing
• conducted noise through the hose

In addition to these sensory overload problems, my sleep patterns were becoming increasingly disturbed by:

• waking up angry in the middle of the night
• waking up with painful aerophagia in the middle of the night
• waking up with a stiff neck both in the middle of the night and in the morning
• waking up with some numbness in my arms or legs from not moving around in the morning
• an inability to wake up in the morning even with a loud alarm

In short, the bedtime insomnia was morphing into sleep maintenance insomnia as well bedtime insomnia. During this period of time, I was in bed with Kaa on my nose for anywhere between 5 and 11 hours. Most nights, I'd be in bed somewhere around 6-8 hours, But it sure didn't feel like I was getting 6-8 hours of sleep. I felt almost as tired and exhausted as I'd feel back in grad school after pulling an all-nighter. But it was happening night after night.

Fast forward three months to the end of December 2010. By this time the PA and sleep doc had switched me from CPAP to APAP to BiPAP because of on-going misery due to aerophagia. The insomnia continued to grow and had begun to morph to include some significant sleep maintenance insomnia as well as the bedtime insomnia. (See The insomnia monster raises its head again and again .... for how I felt at the time.)

By late Decemeber 2010, I had finally gotten to the point where the sensory stimuli from the BiPAP was no longer making me quite as miserable as the APAP had back in October, but I was still getting no more sleep and feeling only marginally better in the daytime than I had during late September and early October. And I had finally gotten to the point where I realized that I was not going to be able conquer this particular insomnia monster all by myself. And with hubby's insistence, I called the sleep doc's office again and asked to meet with the PA to talk primarily about the insomnia, rather than all the sensory issues with the PAP machine.

The CBT program designed for me

On Dec. 31, 2010 the PA and I met to talk about the insomnia. The PA started the meeting with me talking about sleep hygiene and together we developed a CBT plan for fighting my insomnia. We started with setting some goals:

• Reduce my "time to sleep" down to something I could tolerate with the mask on. One on-going problem at bedtime had been that I would get very uncomfortable with aerophagia if I was lying awake with the mask on my nose for as long as about 20 minutes. And on the worst nights this would trigger real, uncontrollable anger at bedtime.


• Consolidate my sleep cycles so that I spent less time being awake during the night. The idea was that if my sleep could become less fragmented, I'd have more energy and more emotional reserves for dealing with things in the daytime and at night.


• Reduce the number of nightly wake ups AND reduce my anxiety and anger on waking up in the middle of the night. The long and multiple wakes were both fragmenting my already fragile sleep and were a constant source of anger at my whole situation. Poor hubby never knew when I'd wake up and explode with anger---anger about being awake; about being a freak; about having OSA; about aerophagia; and so on and so forth.

Note that Sleep soundly for 8 hours without any conscious wakes was not one of the goals: Such a goal would have been unreasonable at the time. And setting reasonable, attainable goals is important part of CBT.

The CBT program itself consisted of:

• Paying more careful attention to the sleep hygiene techniques already was using on a nightly basis.
• Imposing a strict bedtime and a strict wake up time on me. This was the only one of the standard good sleep hygiene rules that were not already part of my standard sleep pattern.
• Imposing a sleep restricted schedule for several months. More on this later.
• Imposing the following rules on my time in bed:
• If I got angry or upset when trying to get to sleep, then I had to get up out of bed and leave the room. I could return to the bed only after I was no longer angry or upset.
• If I could not get to sleep in what I estimated to be about 30 minutes OR if I felt as though I was becoming more ALERT and less SLEEPY, then I had to get up out of bed and leave the room. I could return to the bed only after I was feeling SLEEPY again.
• Keeping a sleep log
• Trying to get some light exercise on most days
• Cutting out all caffeine after 10AM. And making sure I didn't eat supper too late.
• No naps
• A prescription for Ambien with the idea that I would take the Ambien only to prevent multiple "disastrous nights" in a row. More on this later.
• Monthly follow up appointments to talk about the progress I was making along with strong reminders to expect some two steps forward, one step back in overall progress.

In my opinion, the most critical parts of this program for me were the rigid wake up time, the sleep restricted schedule, the rules about getting out of bed if I am angry, upset or NOT sleepy, and the sleep log.

The point behind the rigid wake up time was to help me get sleepy at a more regular time during the evening. And to make sure that I was able to get up in time to get to my first class. (I'm a college professor.) The PA allowed me to choose the wake up time. I chose 7:30 AM since I could not imagine trying to make myself get up any earlier than that on weekends AND it was early enough for my class schedule in the Spring 2011 semester.

The point behind the sleep restricted schedule was to encourage my mind and body to sleep more efficiently in the limited time I was allowed in bed. The PA started me out on a maximum six hour time in bed schedule. By intentionally making me a bit more sleep deprived, the idea was that my body and mind would learn how to get to sleep faster at the beginning of the night, learn how to wake up less frequently during the night, and fall asleep faster after waking up during the night.

The sleep restricted schedule was established by the PA telling me that my bedtime for the foreseeable would be 1:30 AM---precisely six hours before the wake up time that I chose. During the active CBT phase of treatment, I was NOT ALLOWED to go to bed any earlier---no matter HOW sleepy I was. I was supposed stay up that late every night. And if I was not sleepy at 1:30, I had to stay up until I was sleepy enough to go to bed and try to go to sleep. And I still had to get up at 7:30 regardless of when I actually went to bed.

The rules about not lying in bed for long periods of time while awake or angry were to help my mind and body to make the firm connection that Being in Bed = Time to Sleep. Lying in bed for long periods of time essentially rewarded that part of my mind that did NOT want to be asleep.

The sleep log had a dual purpose: It held me accountable for sticking to the program and it gave me a place to track data that showed my slow, but steady progress in reining in the insomnia. I kept track of when I went to bed, estimated how long it took me to fall asleep, how many times I woke up each night, and how much sleep I thought I got each night. I also kept track of when I actually had to get out of bed and how long I wound up staying out of the bedroom. Of course all this time stuff had to be done without looking at a clock---I was to estimate all of these things in the morning. Well, except for looking at the clock when I headed off to bed or when I woke up.

And at the start of the CBT program, the PA expected that we would be able to relax the sleep restricted schedule by the end of two or three months. The idea was that once I was self-reporting that I was consistently getting 5 to 5 1/2 hours of sleep in my six hour sleep window, that I would be able to start moving bedtimes back in 15 minute increments until I was sleeping a normal amount at a normal time.

Along with doing the work the PA wanted me to do, I also started working my way through Krakow's Sound Sleep, Sound Mind. From Krakow, I discovered that closure had been a long time issue for me, and since starting CPAP, closure had become a huge issue. There were a number of things from Krakow that I also implemented---mainly by adding them to the sleep log I was keeping.

How Well Did It Work For Me?

Some things worked really well.

Latency to Sleep.
By the end of four weeks of this program, I was consistently getting to sleep within about 10 minutes of going to bed for the first time in my adult life. Now I am usually able to fall asleep within 5 to 10 minutes if I'm appropriately sleepy when I go to bed. And this has largely ended my bedtime dreads. I don't always get to bed as early as I'd like to, but once I'm sleepy enough to know I'll have no problem falling asleep, I can mask up and get to sleep with no problems at all. That's made a huge difference in my life.

Waking at night.
 I still wake up a lot at night---usually 2--4 times that I can vaguely remember. The Zeo often records more wakes; but I'm pretty sure some of those are nothing more than misscored REM periods. And the wakes I vaguely remember are now very short---seldom more than 5 minutes long AND when I get up in the morning they have not really bothered me. A year and a half ago I'd wake up and often get angry or I'd wind up waking up to FULL ALERTNESS. Now? When I wake up it's usually to turn over or fix a leak or apply chapstick, but I can do all of these things without having to wake all the way up to FULL ALERTNESS. And so my sleep feels much more continuous. As the PA told me back in March or April 2011: If the number of wakes are very few and they are all so short that they don't really feel like they're fragmenting your sleep, then they're not problematic.

Night time anger issues.
These are almost nonexistent now. When I started this program, I was getting angry at bedtime or waking up and getting angry at least once or twice a week. Now? It's maybe once every month or two. Huge difference.

Prescription sleeping pills.
 I originally had a prescription for 14 Ambien tablets. The idea was that I would take an Ambien at the beginning of a night that followed a "disastrous night" for the insomnia. This would prevent me from having two or three disastrous nights in a row. The PA told me that what qualified as "disastrous" was up to me to decide for myself. I took about 6 of the Ambiens during the first month or so of this CBT program. Because you have to have a six window for sleep time for Ambien and because I needed to be able to make the decision to take something much closer to WAKE UP TIME, a month into my CBT, the PA wrote me a prescription for 30 Sonata capsules since Sonata can be taken as little as 4 hours before WAKE UP time. In the last year, I've taken about 7 of the Sonatas. The last time I took a Sonata was 6/30/2012, the night I broke my left pinky: At the ER all they did was take x-rays, tell me I needed to see a hand doctor the next day, and buddy taped the broken pinky to the ring finger. By bed time I was in pretty severe pain in spite of the 800 mg of ibuprofen given to me at the ER and it seemed prudent to take the Sonata so that I had some chance of sleeping.

Subjective Quality of My Sleep.
This is far, far better than it was when I started the CBT. But it's not perfect. Indeed, I would describe my nightly sleep as "ok" to "pretty good" on most days. I'm still not getting as much sleep as I would like--my time in bed is typically between 5 and 7 hours. However, I do feel that the insomnia is more or less under control: I certainly wake up feeling like I've gotten some high quality sleep almost every night now. And on those nights when I'm tossing and turning, there's an identifiable NON-PAP related cause. (Pain from a torn MCL was a problem last spring; pain from the broken pinky has been a problem the last month.)

Some things have not worked out quite the way PA/doc intended them to.

Wake time, Bedtime, and Sleep Window.
 By the end about two months of CBT my sleep cycles had consolidated enough that I got the go ahead for starting to move the bedtime back 15 minute increments. My instructions were to move bedtime back to 1:15 as long as it didn't trigger any problems with sleep latency or additional wakes. Unfortunately I've always been something of a night owl----left completely to my own preferences, I think that I'd wind up with a sleep schedule that would look something like 3:30 or so for bedtime and about 10:00 or so for wake up time. (I probably have a touch of a circadian rhythm problem.) And at the time I was trying to move my bedtime back from 1:30AM to 1:15AM, I was also dealing with serious side effects of some prophylactic migraine drugs and the start of my spring allergies. So that never quite happened. Every time I tried going to bed a few minutes earlier, it would trigger more wakes or significantly longer latency to sleep.

After being fired by sleep doc #1 in May 2011, sleep doc #2 suggested that I try extending my sleep period by sleeping a bit later in the morning and not worrying too much about moving the bedtime at my first meeting with her in June 2011. But unfortunately throughout Summer 2011, this resulted in my bedtimes and wake up times growing more ragged. (I'm still working on the necessary discipline to make regular wake up times and regular bedtimes a real part of my life.) In June August 2011, sleep doc #2 also suggested using a light box to try to stabilize my melatonin cycle and encourage my body to get sleepy at a more appropriate time. (An aside: The PA for sleep doc #1 had suggested melatonin when i was trying to move my bedtimes back and having that cause additional wakes. All the melatonin did was aggravate my TMJ problems.)

And how does the "sleep schedule" look now-a year or so after the CBT ended?  During the 2011-2012 school year, I typically got to bed sometime between 2:00 and 3:00, depending on when I got sleepy. And I was pretty consistently waking up (without an alarm clock) by 8:30 or 9:30 AM. Now that summer is here and I'm not teaching, bedtime has become even later: Bedtime is usually between 3:00 and 4:00, but I'm also allowing myself to sleep in until 10:00 or 10:30 most days. (I am dreading the start of the semester, but fortunately, I have a very late schedule in the fall.)

I typically get between 5.5 and 6.5 hours of sleep most nights; occasionally I get as much as seven; and on some nights I only get about 4 to 5 hours of sleep. The Zeo often tells me that I slept less than I thought. Again, I think it's because my Zeo seems to misscore REM and light sleep as WAKE. I can function on the sleep I am getting without having serious issues with daytime sleepiness or fatigue. And so I don't really feel alarmed about the amount of sleep I get anymore.


Light therapy.
In August 2011 when I expressed my unwillingness to take a sleeping pill on a nightly basis, my second sleep doc suggested that one way I could try to make it easier for me to get sleepy earlier in the night was to use a SAD Light in the morning. The SAD light approximates the level of natural daylight shortly after dawn. The idea is to help normalize the melatonin cycle.

So far I've had mixed results with the Light therapy. It definitely helped me wake up in the morning and improved my mood during the late summer of 2011 through March or April 2012. But after several months, the light therapy started to sometimes trigger a very low-grade, but nagging headache that had some characteristics of my chronic migraines. With the return of morning light this spring, I've quit using the light box and those "light induced" headaches went away.

I fully intend on using the light box again once my semester starts since difficulty with getting up in the mornings in fall and winter have long been problems for me. And while I love winter if there is snow on the ground, when it's cold and gray and snowless, the dark and the gray affects my mood pretty substantially.

Interaction between the CBT, the PAP therapy, and OTHER medical issues affecting my sleep

Taming the insomnia and my full adjustment to PAP also required working on four other things: Dealing with the sensory overload coming from the PAP machine; dealing with my chronic migraines; dealing with my TMJ issues; and dealing with  the anger that followed my OSA diagnosis. Technically these were NOT part of the CBT plan designed in Dec. 2010. But I add them here because I regard coming to grips with the necessity of doing the work on these "problems" as critical to my finally taming the insomnia monster and finally becoming a more-or-less happy PAPer. And it took me a very, very long time to figure that out as far as the migraines and TMJ were concerned.

Dealing with the sensory overload from PAP

The switch to the Auto BiPAP finally got the aerophagia genuinely under control. I still have problems, but they are not severe and they are not night after night. Sleep Doc #1's PA was critical in managing to get me switched to the right machine and was patient in figuring out the correct pressure settings.

Multiple ideas from posters at cpaptalk.com, sleep doc #1's talented PA, and my PCP and his PA were critical in helping me find solutions to many of the sensory problems I was encountering.

And time eventually played a role. By using the dang machine every single night, eventually my highly sensitive body started to teach itself to ignore some of the more subtle, but irritating sensory stimuli from the BiPAP. I no longer feel like the back of my throat is constantly tickled for example. Gregorian chants provide distraction from the sound of my own breathing. Custom chapstick takes care of the chapped lips. And so on and so forth.

Controlling the migraines.

Just before my CBT-for-Insomnia started, I was also diagnosed with chronic migraines. And controlling the migraines turned out to be a double-edged sword. I had serious side effects to three different prescription meds and this set the Insomnia War back by quite a lot. And one of the frustrations I had in Spring 2011 was in dealing with the sleep doc's PA for the insomnia and the neurologist and his PA for my migraines. The migraine drugs kept triggering rather severe side effects that tended to cause temporary backsliding in terms of the progress of taming the insomnia. And whenever I had a meeting with the sleep doc's PA while in the middle of dealing with serious migraine-med side effects, the meeting turned out to be rough on both of us. The sleep doc's PA, who was in charge of my CBT, did not seem to be willing to think about how the migraines and migraine meds might affect my battle with the insomnia. And that left me very frustrated. (And this was one of the causes of why Sleep Doc #1 eventually fired me.)

But the neurologist's PA was interested in how the meds were affecting my sleep and was pleased when I dropped off a copy of my sleep logs for her before my meetings with her. And she clearly read them and she eventually figured out a solution to how to treat my chronic migraines without using meds with intolerable side effects that aggravate the insomnia.

And by September 2011 the migraines were pretty much under control with Deplin, Riboflavin, and Magnisium. And that meant the sensory overload from the machine was significantly less likely to trigger a migraine, with both the resulting pain and anger. And that, of course, furthere decreased the problems with insomnia.

Fixing, rather than managing, my long-term TMJ issues.

I've worn a night guard for over 25 years. And I've chewed through night guards at an alarming rate the whole time: A soft one would typically last about 12-18 months; a hard one lasts two or three years.   And for most of that time, the night guards managed my TMJ pain issues adequately well in the since of allowing me to wake up with little or no pain in my TMJs.  But my jaw would pop very loudly whenever I ate and sometimes when I was talking---it didn't bother me much, but it drove my two kids crazy.  During the Insomnia and Migraine Wars, my old (hard) night guard broke due to my intense nighttime grinding.  My primary care dentist made me yet another hard guard. And the new guard cracked within two month or so.  And so my primary care dentist finally referred me to a specialist; and the specialist ordered some diagnostic work, which was done during the summer of 2011. In September 2011, I started a six month course of intense TMJ therapy. Treating the TMJ has allowed my TMJ to genuinely heal and has changed my bite by correcting my overbite without braces. This allows the BiPAP to keep EPAP = 4 for long periods of time and has helped eliminate some residual snoring. It's also reduced pain levels. And TMJ headaches are gone when I wake up. I still have some residual TMJ (muscle) pain in the daytime, but it is much less than it was a year ago. And the elimination of some of the residual snoring, the TMJ headaches, and the jaw pain have all helped keep the insomnia monster properly tied up.

Counseling for on-going issues with anger 

During the first three dark months of CPAPing, not only was my insomnia growing strong and fat, but my anger was also growing strong and fat:  Anger with my body for developing OSA, anger at my PAP machine for destroying my life when it wasn't that broke in the first place, anger the sleep doc (and other docs) for a variety of reasons concerning my care, anger at my insurance company for its lousy (and secretive) replacement schedule for parts and my 50% copay for all things related to CPAP, and so on. Anger can eat you alive, and in my case, the anger was making a bad situation (my difficult CPAP adjustment) much worse.  By March 2011, PAs in both my sleep doc's office and my PCP's office had suggested counseling of some sort for dealing with the anger.  The PCP's PA helped me to understand that a good CBT trained counselor could help me deal with the anger without mood stabilizing drugs and gave me contact information for several potential counselors.

It took a while to get into the guy who I'm still seeing for this (and some other related problems). And I was very skeptical of the whole thing at first.  But the psychologist I see has been invaluable for giving me concrete suggestions for coping strategies.  He's also shown more positive interest in my data crunching about my sleep than anyone else connected with my health care at this point.  And in retrospect, I really wish I'd started counseling during those first three months from hell instead of waiting until the major battles with the insomnia had been won.

My Overall Satisfaction with the CBT for Insomnia

I now feel that subjectively my insomnia is under control, even if I'm sleeping the crazy hours of 3:00-4:00AM for bedtime and 9:30-10:30 for wake up time. I continue to be amazed at how much better I feel if my sleep efficiency is around 88% rather than 82%. (Sleep efficiency is (Time asleep)/(Time in Bed).) In other words, I've learned that I feel better getting 6 hours of sleep out of 6.5 hours of time in bed than I do getting 7 hours of sleep out 8.5 hours of time in bed.

I wake up feeling like I've slept decently enough most mornings. And my definition of "decent" have gotten much more stringent than it was pre-CPAP. I consistently wake up pain free and this is important: During the last several years prior to my diagnosis I had woken up with hand and foot pain almost every morning. This has vanished with the BiPAP.

My sleep seems less restless most night. I don't tend to toss and turn as often anymore. Hubby reports that I seem more "calm" in my sleep.

I am amazed at how nice it is to go to bed and fall asleep quickly. I'm also amazed at how I can now wake up in the middle of the night and not worry about it. I'm pleased that I've made real progress in learning how to deal with issues like minor mask leaks or putting additional chapstick on my lips without becoming so alert that I have a difficult time getting back to sleep.

I continue to keep the sleep log. I probably could (maybe should) give up keeping it. But it gives me a reality check to keep working on keeping my wake up time reasonably regular all seven days a week. I am getting much sloppier about doing it every single day. If there's nothing of note, I'll let it slide for a couple of days and fill in the "numbers" based on data from SleepyHead and the zeo.

Overall, I am happy with my choice to work on taming my insomnia monster mainly through CBT. I am glad that I am no longer on a maximum of six hours in bed even though I still often don't get much more time in bed than six hours. It's nice to know that IF I'm sleepy enough to go to sleep some seven hours before I intend to get up, I'll still likely feel like I slept pretty decently.

In conclusion, I was not really willing or able to believe that this kind of hard work needed to be done in the earliest, darkest days of my PAPing back in Fall 2010. In retrospect, I wish I'd worked towards establishing the more rigid wake up time and bed time regime that the PA imposed once I finally did ask for CBT for the insomnia. It might have made things much easier for me back in the Fall of 2010. And it might have made the CBT less time consuming and potentially more effective.