Why Do You Wake Up At Night: Barry Krakow (Transcript)

Barry Krakow at TEDxABQ

Fulll text of sleep disorders specialist Barry Krakow’s talk: Why do you wake up at night? at TEDxABQ conference.

Listen to the MP3 Audio here:


Barry Krakow – Sleep disorders specialist

20 years ago, this little purple box saved my life. It all happened in one night, a night of the most restful sleep I’d ever known.

Earlier that day, I was talking with my friend and colleague, Dr. Thomas Meade, a pioneer in dental sleep medicine.

I was belaboring Tom with my two-year running battle with chronic insomnia, frequent awakenings, trips to the bathroom, struggling to get back to sleep, exhausted in the morning and tired and sleepy throughout the day.

Plus two car accidents tied to sleep deprivation.

Tom’s cheshire cat grin told me he’d heard this story before, as he pulled this magic box out of his oversized briefcase. He pulled it open, took out this piece of plastic, plopped it in a mug of water, boiled it in a microwave.

And then he handed it to me and said, “Bite this.”

After clenching my teeth into the warm plastic mold, I handed it back. He smoothed the surface, handed it back to me and he said, “Well, let’s see if you breathe any easier tonight”, which was a strange thought to someone who was complaining about insomnia.

That night was so memorable. I can still picture in my mind’s eye, waking up, turning over and asking my wife, “Jessica, what happened?”

Nothing happened that night. There were no awakenings, no trips to the bathroom. I felt incredibly rested from the best sleep I’d had in two years, really 35 years as the true nature of my sleep disorder finally dawned on me.

This exact moment changed my life dramatically, because that day I experienced an enormous burst of energy in my mind and in my body, the likes of which I never dreamed possible for my own health.

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This moment also revolutionized my thinking, practice, and research in the field of sleep medicine.

The irony is Christian Guilleminault made this discovery linking sleep, breathing and insomnia in 1973.

Nearly 50 years later, we’re here discussing how something physical could cause insomnia. An idea that has flown so far below the radar of the general medical profession and even portions of the sleep medicine community.

All because of the failure to ask this singular question: Why do you wake up at night? Why do you wake up? How common are awakenings in this audience at minimum?

Probably one-third of you struggle with sleep or make trips to the bathroom. Yet because so many of us wake up we think it’s normal.

Well here’s news flash Number one: if you wake up, suffer from broken sleep, trips to the bathroom, you’re tired and sleepy the next day, you suffer from a serious sleep disorder, chronic insomnia, a devastating and costly condition.

Chronic insomnia damages your brain and your heart and worsens anxiety and depression. It even inhibits your ability to fight off infections.

Billions of healthcare dollars are used up through the ravages of sleepless nights on your mental and physical health. Billions more are lost economically from sick days, workplace accidents and decreased productivity.

And of course, billions more are spent in the desperate search for sleep aids over the counter drugs, prescription sedatives, vitamins, minerals, supplements, herbal remedies, yet few find truly lasting relief.

Mental health patients suffer the most from insomnia. Yet more drugs are prescribed – tranquilizers, antidepressants, anti-psychotics, anti-seizure drugs. They may help mental health, but these drugs cause side effects to worsen your sleep.

Millions more insomniacs believe or are led to believe that the only solution to sleepless nights are drugs. And yet they suffer for years without finding a cure and often never hearing of any other options.

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So if drugs are not the answer to this very vexing condition that drives some people so crazy, they become suicidal or make some people feel crazy out of the embarrassment, shame and fear from not being able to sleep, what is the answer?

Well for these psychological problems, cognitive behavioral therapy for insomnia (CBTI), is a potent tool because so many insomniacs frustrate themselves lying awake in bed, tossing and turning, checking the clock, trying to force sleep. All of which, just aggravates their sleeplessness.

CBTI is empowering to you far beyond drug therapy, because it teaches you to stop losing sleep over losing sleep. Yet, neither CBTI nor drugs answer our question:

Why do you get up at night?

Normal sleepers wake up and go right back to sleep. Why? Because they’re sleepy.

Insomniacs wake up and go from zero to 60 in about two seconds. Not only are they wide awake, but they may suffer racing thoughts, heart palpitations, anxiety, stress worries, all because they’ve been jarred out of their sleep to being fully alert.

Normally we gradually ascend from slumber into waking consciousness in the morning with or without coffee.

So why would you suddenly wake up at night unless something was waking you up?

This clue would have explained insomnia, but was ignored for a long time.

Research does show that insomniacs lineup the usual list of suspects to explain awakenings: anxiety, stress, worries, racing thoughts, but even insomniacs know they are asleep before they wake up.

So they don’t know with certainty, why they’re waking up and they remain perplexed about being fully alert in the middle of the night.

We researched insomniacs in the sleep lab and monitored them before, during and after these awakenings. And the results were breathtaking.

Not only did they wake up more times than normal sleepers, but they suffered hundreds of many awakenings, what we call arousals. They were fracturing their sleep and destroying their sleep quality.

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And if you’re ready for snooze flash number two: 90% of their awakenings and arousals were caused by… (please take a deep breath) 

That’s what they didn’t do. Their breathing was compromised and obstructed because they suffered from obstructive sleep apnea. The same condition that fueled my insomnia 20 years ago.

On this graphic, you will see the three main breathing events of sleep apnea:

At the top is normal breathing: smooth, rounded, curves up and down, suggesting breathing in and out.

At the bottom is the apnea – a flat line, complete suffocation as your throat collapses. Obviously anyone would awaken from that blockage.

Next are the hypopneas – a 50% reduction.

And then the flow limitation – a 25% reduction.

All of these breathing events can awaken you. Insomniacs have more of the moderate type.

So perhaps you’re asking would a 25% reduction in your breathing wake you up?

Well, let’s try this experiment. Go ahead, put your hands out in front of you. Just take a moment. Now bring them up to your throat and start choking yourself about 25… 

Okay. You get the picture.

Breathing is good, Not breathing is life threatening. Which explains where all the skepticism comes about this theory, because how could you possibly wake up all night long from a breathing problem and not know about it?

Well, consider the case of severe sleep apnea. They suffer hundreds of suffocations all night long, complete loss of their breathing.

When do they seek help at a sleep center?

Only after someone in their bedroom freaks out, watching and listening to them not breathe.

And the afterwards, do they seek help a few months later? No.

How about a few years later? No, only after suffering a life threatening disorder for about a decade, might they seek help.

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