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

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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.

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.

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?

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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.

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.

So if the worst case doesn’t get it, how would insomniacs detect the problem when they only suffer this more moderate breathing disruption that still wakes them up?

This recognition gap caused us to delay our understanding of the link between insomnia and sleep breathing problems. 

Now we comprehend that so many insomniacs suffered two disorders in one. The psychological side is easy to see: you’re awake, but the physiological side is hidden from you because you are asleep.

This radical paradigm shift in knowledge demands a new term to designate the complexity of this problem.

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So we call it complex insomnia, which indicates the need for in-depth, physiological testing, an overnight sleep study to identify and diagnose what’s waking you up.

For any diehard skeptics still out there, we’ve got one final and astonishing piece to the puzzle.

Remember insomniacs make trips to the bathroom and complain about it. That’s called nocturia.

Snooze flash number three: Who would have thought it sleep apnea causes nocturia.

Sleep apnea pushes excess blood flow into your heart all night long. The heart responds by releasing a natural diuretic, making the kidneys work overtime throughout the night.

So sleep apnea causes insomnia and nocturia. Actually a very nice two for one deal when it comes to treatment.

There are three levels of therapy to treat sleep breathing.

First, focus on nasal breathing, nasal saline rinses, neti pot washes, prescription nasal sprays will eradicate chronic congestion.

Last, we strongly recommend nasal strips because we studied insomniacs with moderate sleep breathing symptoms. And 75% of them reported a decrease in insomnia just by using the nasal strip on a nightly basis.

Next, oral mandibular advancement devices or oral appliance therapy. Like the type provided to me by Dr. Meade.

These are becoming first-line therapy. They gently anchor onto your dental arches and thrust the jaw forward, opening the airway permitting more air through and eradicating the majority of your breathing events.

Last is PAP therapy – Positive Airway Pressure, the gold standard. Most know it as CPAP. The C stands for continuous or constant pressure breathing in and breathing out. And that’s the problem.

You probably know someone who’s failed CPAP because they couldn’t tolerate breathing out against that constant pressure.

Mental health patients and insomnia patients can’t tolerate CPAP. They develop panic attacks, claustrophobia, and even traumatizing experiences so harmful to them, they will drop out of care for a few years just after brief exposure to CPAP.

Unfortunately, some insurance carriers and even some sleep centers do not recognize these side effects and instead blame patients for not using CPAP.

Fortunately, technology has found a better way. In 2005, we switched all of our patients over to bi-level devices, dual pressure: high-pressure when you breathe in and low pressure when you breathe out.

This matches your natural breathing pattern. They’re even advanced bi- level devices that monitor your breathing and adjust pressures all night long.

Last, sleep technology has expanded with numerous masks that can fit into your nose, over your nose or as full face masks. And there are mask liners that enhance comfort.

Virtually anyone can learn to use the gold standard breathing treatment.

If they’re prescribed the right pap device, accurate pressure settings and the best mask fit, are you ready to put this to bed?

I trust you’ve learned three things:

Insomnia is a common disorder with serious consequences to your mental and physical health. But you probably won’t seek treatment until you realize that frequent awakenings and broken sleep are not normal.

Second, insomnia and sleep apnea are joined at the hip using this term complex insomnia. We’ll encourage you and your providers to attack the mental and the physical part of your sleepless nights.

For so many of you that suffer as incredible as it sounds, insomnia is not only in your mind, it’s also in your airway.

Last, there are plenty of treatment options available and all of them produce good to great results.

I would like to close by saying, I sincerely believe… sincerely that if you apply this information with the aid of your doctors, dentists and sleep medicine professionals, you will conquer insomnia and discover and experience the rest of your life.

Thank you.

Resources for Further Reading:

How To Trick Your Brain Into Falling Asleep: Jim Donovan (Transcript)

Dan Gartenberg: The Brain Benefits of Deep Sleep – and How to Get More of It (Transcript)

Penny Lewis on Sleep-Engineering: Improve Your Life By Manipulating at TEDxGrandRapids (Transcript)

The Healing Power of Music: Robin Spielberg (Full Transcript)

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