Barry Krakow, MD on Sleep and Trauma Part 1

1s Hi, this is Rachel on recovery. We're back, and we've got a special guest today, uh, Dr. Barry 1s Kycro U2 0:10 Kraco. U1 0:13 And he's going to tell us a little bit about himself if you want to give an elevator speech. U2 0:21 The elevator speech. Well, I've been in sleep medicine for about, uh, 35 years, and, um, it's an incredibly interesting field. Of course, I've had my own sleep problems to deal with, and that was part of my fascination. U1 0:38 But the unique aspect of my work has been that I entered the field by working with psychiatrists. So instead of just being a regular sleep doctor because my training is internal medicine, uh, my specialty is mental health patients with sleep disorders. And this goes back all the way to 1988 wow. When we began doing research on nightmares in mental health patients. And from that time forward, I've stuck with that focus. Of my nearly 100 publications 150 if you include the peer reviewed abstracts. Nearly all of them are about mental, um, health and sleep. And there's a special sub interest or subspecialty group where we probably have been the leading research team for U2 1:32 the treatment of sleep disorders in post traumatic stress disorder. And we've actually helped redefine the concept because a key point to get across for your listeners, which I reiterate many times in my book life Saving Sleep. U1 1:49 Is that too U2 1:51 many people in mental health and even general health care look at sleep disturbances as if they are secondary problems. So let's just give somebody a pill or have somebody work on their depression or their PTSD. Somehow the sleep is going to get better. We're the first group that emphasized and published repeatedly on the phenomena that these sleep disturbances are actually their own disorders, which sounds like common sense, but it actually was never proven until our paper was published in JAMA in 2001, showing that if you independently treat somebody's nightmares, their post traumatic nightmares, their PTSD gets better. And I'm not talking about treating their nightmares with a pill or even really psychotherapy. I'm talking about some unique techniques that we have developed for this that are very, very different. And they speak to this big issue that sleep disorders are independent. And once a person recognizes that they realize they have a new objective, they can actually work on treating their sleep disorders, and it will make their mental health get better, which is a pretty amazing thing. U1 3:11 And. 1s Yeah. M. 1s Well, I know for me, my sleep got better after doing EMDR. 1s That's U2 3:21 great, because any form of emotional processing that is effective and produces good results is going to decrease emotional tension. And you raise a very good point because U1 3:35 you're showing that there is both the psychological and physiological side to sleep, and that's what's been lost or never really understood about in the field of mental health. I'll give you the best example. Most people think that PTSD sleep problems are strictly psychological. The average practitioner, whether it's a psychotherapist with a background in psychology, or whether it is a neurologist with a background in neurosciences, U2 4:09 whomever you want to talk to, who treats PTSD, the standard approach is treat the PTSD. Let's see if the sleep gets better. Again, not unreasonable, because if the emotional processing is effective, we would expect results. However, 1s an enormous proportion of patients who have PTSD U1 4:30 do not see their sleep problems get better just by doing effective therapy. The leader in the field, uh, Edna Foa and others have published finally recognizing that nightmares and insomnia often persist after people have done exposure therapy, another variation of EMDR. And so people always wondered, well, why would that be? Why would these nightmares and insomnia persist? And the answer turns out to be twofold. One, nightmares and insomnia became independent disorders. And so they residually sit with the patient and continue to plague them. But the other part that is the most amazing aspect of our work and the most amazing discovery regarding PTSD is that most PTSD patients who are not responding well to treatment and or who are describing, uh, treatment resistant sleep disorders, most of those patients have sleep apnea, and they don't know it. And the sleep apnea could be very gross. Sleep apnea, where you stop breathing, it could be a more subtle form called upper airway resistance syndrome, which is more difficult to detect. U2 5:46 But the key point of this is that it's physiological. So something physiologically is destroying your sleep, fragmenting your sleep. And in those cases, when your sleep is being fragmented, your medications won't work to treat the PTSD. Even psychotherapy may not work to treat the PTSD. Makes sense. U1 6:08 Thank. A little bit. Um, because I know 1s when you have sleep apnea, you don't sleep at night because you wake up in the middle of the night because 2s you just stop breathing for U2 6:26 period. That's the classic case where you stop breathing. That's a 100% secession of the the air volume. But you can drop your breathing by 50%. It's called the hypopnea, and you'll still wake up. But remember, the awakenings are very short for most people. The average sleep disordered breathing patient is waking up hundreds of times during the night, but they only have awareness of three or four or five or ten of these episodes. But they could be waking up 500 times through what are called arousals or microarousals. And these arousals are the response to just what you said. If you don't breathe, obviously your body doesn't like it. Your brain doesn't like it. It says, I better wake up because I need to take a better breath to get more oxygen in. So that's exactly what the body U1 7:18 does. Okay. Um, and I'm also thinking, I mean, I work with my chiroprACT and talks about fight or flight and the adrenal glands and how that can also impact sleep with PTSD. Absolutely. There's many different pathways to look at. However, one of the things we're very interested in trying to understand. 2s And certainly we've theorized on it for a long time now, is when you think about flight or fight, what U2 7:52 is the most primal experience any living human being can have? And the answer is very simple. If you think about U1 8:00 it, it's U2 8:02 not being able to breathe. Because when you actually are experiencing the sensation of not being able to breathe, you actually believe you're going to die. 2s Uh, 2s this is not something I like to talk about much, but it's a technique I have to use with patients to get the point across. If a patient's sitting across from me in my office, I'll say, I don't want you to really spend a lot of time imagining this. Let's make this a thought experiment only, but which one of these is scarier? U1 8:39 Somebody U2 8:40 who walks in the door over here and says, I have this gun and I'm going to shoot you and I'm going to kill you. That's pretty scary, obviously. But what if that same person doesn't have a gun? What if they walk over, put their hands around your throat, and starts choking you? And the people who understand this, hopefully just intellectually, we don't want the imagery, U1 8:58 they realize the primal nature of not breathing is the most powerful fight or flight response you can have. There's actually nothing that I can think of. Nobody's ever given me an answer to the question and said, oh, well, this is worse. I don't think so. If you think you're going to die because it feels like you're going to die, then U2 9:20 you have to respond to that. And that's what's happening in sleep disordered breathing. So I believe that's probably a larger response than the hormonal effect you're talking about. However, I will say this, U1 9:31 that kind of repetitive response night after night, week after week, most people with PTSD who have sleep disordered breathing have had it for years, and nobody ever recognized it. There's no question that affects the hippocampus, the pituitary gland, and the adrenal gland. So that could be part of what your chiropractor may be referring to. Sleep disordered breathing is a huge elephant in the room. It affects every aspect of the human organism. Every aspect. And so think about PTSD patients. They're trying to get better. They're trying to recover. We've got a few things here to mention about why they can't. One is they're sleep deprived. 1s And they're sleep deprived because sleep apnea means if you slept x number of hours in bed, the sleep was actually fragmented so badly that that number of hours is off. You could have been in bed 6 hours, you could have been unconscious for 6 hours, but the sleep apnea is knocking it down to 4 hours. That's number one. Number two, you have very very light sleep with sleep apnea. So instead of getting deeper sort of delta sleep or REM sleep, you're not getting any of that. U2 10:45 So now you're handicapped by well, how are you supposed to have energy the next day? How are you supposed to be thinking clearly? And the worst part, the part that is really amazing in terms of the research of just in the last decade, are you familiar with the glymphatic system? U1 11:03 not really. You know, at lymph Fatic system is of course we all have lymph system in the body, but the brain has its own lymphatic system and because of the glial brain cells, they call it the glymphatic system. So. U2 11:19 That system has to remove waste from your brain and guess when the best time it does that? When you're sleeping. When you're sleeping and when you're in deep U1 11:30 sleep. So U2 11:32 you've got this really three strikes and you're out. You're getting bad sleep, you're getting less sleep. But now the brain is not even functioning to remove the waste products from inside your brain that normally allow you to feel better during the day. Many people, for example, who have bad nights of sleep, who have this sensitivity will say gosh, I wake up, I feel terrible, I feel almost like I'm getting sick, I feel like I have the flu or I feel like I've got all these symptoms and eventually they go away. But I mean, why would I wake up feeling like that? And the answer is what do we just described? If you have this fragmented sleep during the night then that is going to cause you to feel rotten the next day. And you can just imagine what impact that has on somebody trying to recover from a trauma and post traumatic stress. U1 12:27 Well and is it kind of more like the chicken or the egg? Especially when dealing with childhood sexual abuse or rape victims because those typically happen at night. 1s Absolutely. 2s I think there's a huge population out there that struggles to sleep at night because that's what time it happened, U2 12:51 right? That's correct. There's a conditioning effect there where they would have learned to have had the nightmares and insomnia in to protect them. Because what's the best way to be protected? Don't go to sleep. U1 13:03 So that's classic avoidance behavior, which is very healthy because you go, why do I want to put myself at risk? And this is where it gets really interesting, because those same people, by going through these nightmares and insomnia episodes for years, there is speculation out there by many researchers that suggest that that psychological distress is interfering with your sleep so much and lightening the U2 13:30 depth of the sleep so much. Now, that may create a risk factor for developing the sleep breathing U1 13:37 condition. So now that's total bi directionality where it's not just sleep disorder breathing is making your PTSD worse, it's quite possible that we're going to discover that PTSD makes your sleep breathing worse. And so that's incredible double whammy that these individuals have to deal with. and as I describe in my book, repeatedly, life saving sleep, so U2 14:02 many people in the mental health profession U1 14:05 do not have any awareness of what we're talking about right now. They really think that somebody's PTSD sleep problems need a pill, or they need psychotherapy or they need something else, instead of actually what they really need is a sleep study, a diagnostic sleep study to evaluate. And I want to just make this sort of final summarizing point on this particular topic. We can stick with it, whatever you want, but most people with insomnia and nightmares where those conditions are chronic, they've had them for years, and they haven't responded well to medications. They haven't even responded well to certain kinds of therapies. That's a huge red flag that those nightmares and those insomnia problems are often coexisting with sleep disordered breathing. U2 14:57 And we first published on this in the late 1990s and the early two thousand s twenty some years ago, showing the rate of sleep breathing problems in people with insomnia, people with nightmares. We published a paper on a small group of crime victims where we did a study. They all had PTSD, they had suffered various types of assaults, they all had nightmares and insomnia and they came to us because they wanted us to treat them for their nightmares and insomnia, which we did using these specialized techniques that we can get into. One is called imagery rehearsal therapy for nightmares. One is called cognitive behavioral therapy for insomnia. So we did all that on them and we treated them and we published that paper in the American Journal of Psychiatry in 2001 and it clearly demonstrated the same idea. Treat their nightmares, treat their insomnia and their PTSD, their anxiety, their depression actually improves markedly. U1 16:00 But. 1s They U2 16:01 still had residual sleep problems. We put them in the sleep lab, and, 90% of the people we put in the sleep lab from this study, this involved about 50 people. U1 16:13 90% had a sleep breathing disorder, and they were shocked. So were we. They were shocked. They're like, what's going on here? Why do I have this sleep breathing condition? And this then went back again. 2025 years ago, people began asking the question in research circles, well, why do they have these conditions? Did the nightmares and insomnia break up their sleep so much that they ended up with a sleep breathing disorder? Did they have some other risk factor? Like, did they have enlarged tonsils? Did they have a crowded airway? Did they have a small jaw? All these things had to, be taken into account. And we still don't know. We still don't know. There are so many people with PTSD that have sleep apnea, and some of them had it a risk factor growing up because U2 17:01 of the anatomy of their airway. 2s And some of them developed it later on after the trauma, and yet nobody has been able to pinpoint exactly how that process occurs. But this is a huge elephant in the room. U1 17:18 Well, and would you consider it with multigenerational trauma, like if it's been in the family that 2s the the body takes those genes and reproduces, it in the next generation. U2 17:35 That's a great concept, because we do know that sleep breathing disorders do run in families. And we know about I like your idea. The most we do know is about you do inherit your facial structure, your oral and nasal airway anatomy from your parents. Therefore, if your parents do have some sleep breathing risks themselves, they're probably passing it on to their children and. 4s Let me make a couple more comments that might 2s give us an important segue to this conversation. U1 18:17 Sleep disordered breathing brings up the awful image of CPAP machines. U2 18:23 Who wants to use a CPAP machine? U1 18:26 Well, most people don't. I didn't want to. I was diagnosed with sleep disorder breathing in 1993. And being a highly avoidant doctor who doesn't want to follow instructions, it took me nine years before I actually learned how to use a PAP machine. And I've been on one ever since for almost, 1s 21 years now. But it's a process that exactly I want to talk about that it is not natural. A PAP machine is awkward. It's foreign, it's cumbersome. It can be overstimulating. if you get the wrong machine, like CPAP, I consider to be the wrong machine, it U2 19:05 can be traumatizing because you could feel like you were drowning in air. So the point I want to get across for those who are interested in this, and you can again read all about this in two different sections in the life saving sleep book. There's a section in the main book and is a section in the appendix. We love to promote what we call early conservative treatment steps for sleep disordered breathing. And we have been so surprised 2s and, appreciative. 1s Of some of the entrepreneurial spirit that's out there that has produced some of these possibilities. So people don't have to jump to a CPAP machine. So let me run through a couple for you, because it's such an easy treatment pathway, and especially if the person sitting and listening to this and they're going, gee, I wonder if I have this condition. I wonder if I have sleep disorder breathing. So let me mention a couple of things about that, and then we'll come back to the early treatment. Most people do not know U1 20:06 that U2 20:08 one of the greatest reasons why people wake up at night to use the bathroom to pee is from sleep disordered breathing. Most people would think it's too much water at bedtime or a bladder problem, or a prostate problem, or a medication. Those are all possible. But sleep disordered breathing actually produces a diuretic in your U1 20:33 heart to U2 20:34 be released into your system while you're sleeping. So your kidneys make more water. If you treat sleep apnea, your trips to the bathroom decrease dramatically. Many people with sleep apnea, no longer go to the bathroom at night. So you're going, Wait, that's pretty interesting. No doctors ever told me that. They told me, Well, I thought it's normal to get up at night to pee. Well, it could be in some people, but we've used these, very advanced technologies. We don't use CPAP. We use something called Bi level and auto. Bi level. 1s And we have more than 50% of the cases we've worked with that people are saying they no longer get up at night to pee. And before that, they were on a CPAP device, and they were still getting up at night for once or twice, and they thought that was normal. So that's what I mean by advanced technology. Anyway, there's a variety of symptoms people should be thinking about. Not just do you snore or do you stop breathing. Those are very difficult symptoms to use to make the diagnosis. U1 21:34 The U2 21:37 psychiatry fields, psychology fields, needs to learn that if a person says my sleep isn't very U1 21:43 good, 1s the quality of my sleep isn't very good, that's a huge red flag for a likely sleep breathing problem. Why? Because that means their sleep physiology is messed up and other things can happen. You wake up with a dry mouth, you wake up with morning headaches. You wake up and you don't feel that good. You get U2 22:04 sleepy and tired during the day. All those things can help people begin to ask the question, well, wait, my doctors told me that was my PTSD. They told me that was my depression. They said that was my anxiety. Well, it U1 22:18 could be, but U2 22:19 sleep actually turns out to play a larger role for any of these symptoms compared to the psychiatric elements. So the person, if they do that inventory, and your listeners may be doing that inventory, as we're talking right now, is saying, gosh, I wonder if this is me. I wonder if I have this condition. And this is the beauty now of this early conservative treatment. 2s So the number one early conservative treatment is just nasal hygiene. And on my website, Barrycracomd.com, I have a free 1 hour video. It's six short sessions all about nasal hygiene. And what it's teaching is U1 22:57 that U2 22:58 if you have a sleep breathing U1 23:00 disorder, you U2 23:02 tend to create much more friction inside your nose and throat. That friction, therefore, irritates the lining of the nose and the throat. You now have more allergies. You're now more susceptible to cough, to, upper airway, infections. And so it turns out that people with sleep disordered breathing have very high rates of allergic and non allergic rhinitis, which are two of the basic components of runny nose, congestion stuffiness and so on. So it's extremely common that when we would meet our PTSD patients in the sleep clinic, not to mention anxiety and depression patients as well, U1 23:47 that they would suffer from nasal congestion. And we'd say, well, U2 23:51 we don't have to start you on a PAP machine, because guess what? You can't even use a PAP machine. If you're congested, it's not going to work. You're going to hate it. It's going to be even more suffocating. So we would start these patients on a series of programs to improve their nasal breathing. 1s And the simplest treatment of all was just nasal saline. Person could do nasal saline. Rinses so about 20 plus years ago, when we first opened up this particular private, community based sleep U1 24:22 center, we began doing nasal hygiene, especially nasal saline. And we get patients coming back to us saying, this is really weird. I don't think I ever knew what it meant to breathe normally through my nose. And they were using nasal saline five, six, seven times a day, cleaning out their nose, blowing their nose, going into the shower, make it a steam shower, cleaning out their nose again. U2 24:46 And when they learn U1 24:48 that, they go, I'm actually already sleeping better just by improving my nasal breathing. So that was step number one. And then the next steps again. These are talked about on my website, Barrycracomed.com, and they're also in the book Life Saving Sleep. There's U2 25:05 a variety of nasal sprays out there that U1 25:08 treat this U2 25:10 congestion. But the big issue is the individual must determine, are they suffering allergic rhinitis, which tends to mean you seasonally have the problem, or do you have non allergic rhinitis, which tends to mean you have the congestion, the stuffiness, or the runny nose all. Ah, year long. U1 25:31 And that is interesting because anxiety itself seems to be a trigger that worsens nasal congestion. Most people don't realize that. So there's different sprays for both allergic and non allergic. And we get people on these different sprays. Some of these are steroid based, some of these are antihistamine based. Some are anticolinergic. again, you can read all about them. But the point is, many people will start there and experiment with these sprays over time and again come back to saying, I'm already sleeping better. In fact, research has already published most people have heard of the drug flonase, which is a nasal steroid. Research has been published a decade ago showing the breathing event index s decreases in a sleep apnea patient just by using flonase. That's a pretty big deal. And then the last phase of the really conservatives are these nasal, treatments where you can put a nasal strip over your nose or a nasal prong inside your nose. 1s And these things are some of the most powerful treatments we've had. People in one study that we did 15 years ago published it in the journal Sleep and Breathing. We U2 26:54 had 40 insomniacs, chronic insomniacs for U1 26:58 years, absolutely did not believe they had a breathing problem. Absolutely. There was no question in their mind. Their condition was all psychological. We evaluated them, and we knew through our evaluation they U2 27:13 had a high probability of having a sleep breathing condition. U1 27:18 But we didn't tell them that. We just said, we don't know. We didn't test you. We don't know. We put them on just nasal strips. That's it. Nasal strips. And I think in a few people, there was some nasal hygiene. 75% of those chronic insomnia patients one month later U2 27:37 reported benefit and improvements in their insomnia just from using a nasal strip. And they didn't even believe that they had a breathing disorder to start the program. But of course, by the end of the program, they're going, well, this is pretty remarkable. I'm sleeping better for some reason. I guess I have a sleep breathing condition. So that's the beauty of this stuff, that nobody has to rush out and say, I got to get a sleep study, and I've got to get a CPAP machine. U1 28:04 Believe me, the PAP machines that they make nowadays are phenomenal. And I again, write about it in the book tremendously in ways so people can understand it. And I do recommend these advanced devices instead of PAP therapy, instead of CPAP, which is the older version, the original version. but it's just wonderful that a person can actually U2 28:25 take control of their sleep this way by recognizing that all this physical stuff is happening that they didn't realize before. U1 28:33 2s I do know that there's the implant, and then there's the thing you put in your mouth, and then there's one that just for the nose 4s right there's, for example, the oral appliances that hold the jaw in a thrusted pattern. There's all kinds of devices coming onto the market, and this is great news because so many people do have difficulty. I'm on a device called ASV Auto. It is manufactured, uh, by ResMed. It's the Cadillac device in the world. It's the best PAP machine in the world. I've been on it now for over a decade. U2 29:15 And it's a phenomenal way U1 29:17 to sleep. U2 29:19 it produces unbelievable amounts of delta sleep, U1 29:23 deep sleep. It, produces an enormous amount of consolidated REM. My dream life is just so enriched by being on this device. And these are very important things for how people recover, because these stages of sleep, delta and REM, are very important in emotional processing, an improvement in memory, an improvement in cognition, all the things that you go through U2 29:52 in effective, psychotherapy. U1 29:57 Thanks for tuning in. Tune in next week to learn more about sleep with Dr. Barry Krakow. And if you have any questions, follow us on Rachel recovery, reach out on any of your favorite podcast and social media, and if you have any questions, reach out to Rachelandrecovery.com. And always follow and subscribe on YouTube. Thanks.