Barry Krakow, M.D., is an internist and sleep medicine specialist who has worked in the field of sleep research and clinical sleep medicine for more than 30 years, pioneering innovative techniques and approaches for the treatment of chronic nightmares, chronic insomnia, complex insomnia, upper airway resistance syndrome, obstructive and central sleep apnea, and restless legs syndrome.
His upcoming book “Life Saving Sleep: New Horizons in Mental Health Treatment” describes how to fix your sleep and improve anxiety, depression, and post-traumatic stress while decreasing sleeping pill use, destructive thinking, self-harm, chronic pain—and nighttime trips to the bathroom.
This interview has been edited for length and clarity.
How does this physical side interplay with psychological factors in sleep disorders?
This physical measurement reveals whether your sleeping brain waves are normal (indicating good sleep quality) or whether sleeping brainwaves are abnormal (poor sleep quality).
This part is simple, but tricky because we don’t measure sleep very well—indeed we don’t even measure sleep breathing very well. Our measurements give us more of the big picture, but the good news is this info is very revealing and helps us appreciate the physical things that need to be addressed in a poor sleeper.
For example, we know high-quality slumber is consolidated, consistent, and deep for most of the night. Now, that doesn’t mean every single stage of sleep is super deep or super consolidated. But it means over the course of the night something physically is not disturbing the brainwaves while you sleep.
In poor sleepers, brain waves frequently look fragmented. That literally means you’re sleeping for 20 seconds, and then you wake up for five seconds, then you’re sleeping for 60 seconds, and then you wake up maybe for 45 seconds. The process alternates so much and so quickly, a person is not aware it’s happening.
Then there are individuals who wake up at night and can’t get back to sleep. They remember the one awakening because now they’re wide awake—but they don’t have awareness of all the other brief awakenings occurring as well. Most importantly, because they were asleep before the big awakening, they have no clue as to what woke them up.
When we studied this phenomenon, we found 90 percent of awakenings were preceded by a physical event disrupting the brain waves. We call this sleep fragmentation, and it’s clearly where the action is in trying to understand and treat sleep disorders. To clarify, sleep fragmentation means inconsistent, unconsolidated, and lighter sleep. If an individual says, “There’s something wrong with my sleep, I don’t feel rested when I wake up, I’m tired or sleepy during the day,” chances are 90 percent or greater sleep fragmentation is the cause. In my book, we use the term “bad and broken sleep.”
So the question becomes, why would anybody think this is strictly psychological? We’re not downplaying the psychological aspects. After all, anxiety, depression, and PTSD [post-traumatic stress disorder] can also cause some of this fragmentation—but keep this singular point in mind—the fragmentation is still physical, which means if a drug doesn’t solve the brainwave problem, then the drug is not the correct treatment.
In short, it’s all about your brain waves. Your brain waves are physical and designed to work to give you healthy sleep.
Once mental health patients hear about this research from the field of sleep medicine, they’re totally sold. They say, “Oh, my goodness, you’re saying all this time, I’ve had this physiological sleep condition with my mental health problem, and you’re saying we could do something about it?”
The psychology of sleep should never be underestimated and never be put off to the side. And one of the places where the mental side of sleep is so concerning is in the problem called “losing sleep over losing sleep.”
When your mind ratchets up the anxiety, the worries, and the rumination, your racing thoughts go beyond your finances or relationships—rather, now you’re getting upset by the loss of sleep itself. You may think if you don’t sleep you’re going to go insane, or you’re going to harm yourself, or that it’s dangerous to not sleep—once you go down this pathway, unfortunately, you’re right—it can become dangerous.
Losing sleep over losing sleep is actually a precursor to suicidal ideation. Patients have gotten so wrapped up in the fact that they can’t sleep, they’re making themselves sicker and their sleep worse. And that’s when you will find medication is imperative.
Just like kidneys and the liver are major areas for detoxification, the brain has a capacity as well. In all likelihood some of this “waste matter” is eliminated to help you gain energy, some to alleviate your sleepiness the next day, and some appears to remove metabolic toxins—possibly related to neurodegenerative diseases like dementia.
Once we learn more about the glymphatic system, it will open up pathways to different treatment methods for sleep disorders. For now, the one thing we do know is the brain-washing system works best during periods of deep sleep, so once again we see why sleep-quality problems are at the core of most sleep disorders and why their impact is so pronounced on both mental and physical health.
Why do some people have memory problems earlier in life than other people? The most common reason is there’s something wrong with their sleep. It’s that basic. Poor sleep makes you age faster. And when you fix poor sleep, you’re coming close—literally—to reversing some of the brain damage that has occurred from poor sleep.
This trifecta of inflammation, oxidative stress, and dysfunction of the blood vessels means blood no longer flows properly. Where do you have blood vessels? Everywhere. So now you have a global explanation for how you end up with cognitive difficulties, heart problems, kidney dysfunction, diabetes, and more.
Contrary to conventional wisdom, the largest determinant of a sleep breathing disorder is not your weight—but your facial structure, your throat, all the anatomy inside your throat involving your upper airway—things like your palate, tonsils, tongue, even your bite. One simple fact is a square-shaped head is usually associated with a larger airway compared to a narrow-shaped face which suggests a smaller airway. We’ve known this information for decades. Having crowded teeth suggests the airway could be more crowded in the back of the throat. So that’s the greatest determinant.
When you look at obese patients with sleep apnea, you often find very crowded airways. That wasn’t from obesity. That was their anatomy. Many patients with sleep breathing disorders are normal or underweight. In fact, this point explains why so many doctors and therapists don’t recognize this significant physical paradigm. That is, they look at their patients and if not overweight they immediately dismiss the possibility of a sleep breathing disorder. Regrettably, some sleep doctors suffer this same misperception.
“Sleep apnea” suggests you stop breathing. But “sleep-disordered breathing” means there’s a range of difficulty with your breathing while you sleep, which makes things more difficult to detect. Even very minor fluctuations in the volume of air you breathe in is enough to break up sleep throughout the night.
That person often stated in follow-ups, “You know what? I’m already sleeping better. Wow.”
And then we’ve got at least two more strategies. One is nasal strips. Another is nasal dilators. We did a study 20 years ago, and 75 percent of insomniacs achieved improvements in their insomnia in just one month of using nasal strips every night.
That means the nasal strip was improving airflow while presumably decreasing arousal and sleep fragmentation. We think there may be even more potential with some of the nasal dilators on the market.
The marketplace is heating up with numerous innovations to attempt to treat SDB with simpler or easier methods. Of course, there’s a lot more you can do with different positive airway pressure (PAP) machines and oral devices that go in the mouth to hold the jaw forward. It’s great news that more options are coming into play because continuous positive airway pressure (CPAP) is difficult for a fair number of patients to use. We stopped using CPAP in 2005 and only recommend now the more advanced PAP machines, known as auto-bilevel and ASV (adaptive servo-ventilation). These devices are much gentler in delivering pressure, so adaptation is easier and the response is better as well.
Most of the time, health care professionals try to be diplomatic and say, “Well, you’ve got a lot of anxiety, let’s try these medications.” Regrettably, their sincerity is dwarfed by their considerable ignorance about sleep. They just don’t recognize how limited and outdated their toolbox is, and they certainly don’t recognize the tools they’re missing.
Nonetheless, the good news is patients are hearing these new ideas and think, “Well, wait, you’re telling me there’s another way to deal with sleep? And you’re saying if I breathe better or I get better sleep quality, that’s going to make a difference?”
The answer is: Yes, it’s going to make a big difference. Try these new approaches to sleep. I think you’re going to like them for a very long time.
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