Episode Transcript
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Hi. This is Rachel on Recovery. We're back with Dr. Barry Creek Co, and he's going to tell us a little bit about a little bit more about sleep.
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Let me make a couple more comments that might 2s give us an important segue to this conversation. Sleep disordered breathing brings up the awful image of CPAP machines. Who wants to use a CPAP machine? I don't. 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 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. 1s If you get the wrong machine, like CPAP, I consider to be the wrong machine, it 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 there's 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 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. 1s 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 that 1s 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 heart to 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 decreased dramatically. Many people with sleep apnea no longer go to the bathroom at night. 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 bilevel. 1s And we get 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. The 1s psychiatry field, psychology fields needs to learn that if a person says my sleep isn't very good, 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 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 could be, but sleep actually turns out to play a larger role for many 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. 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 that if you have a sleep breathing disorder, you 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 infection, s. 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. 1s 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, that they would suffer from nasal congestion. And we'd say, well, 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. 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 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. And. And when they learn 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, Barrycracomd.com, and they're also in the book Life Saving Sleep. There's a variety
of nasal sprays out there that treat this 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 nonallergic rhinitis, which tends to mean you have the congestion, the stuffiness or the runny nose all year long. 1s 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. 1s 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 that breathing event index 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 had 40 insomniacs, chronic insomniacs for 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 had a high probability of having a sleep breathing condition. 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 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. 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. 1s But it's just wonderful that a person can actually take control of their sleep this way by recognizing that all this physical stuff is happening that they didn't realize before.
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So what do you do if you have a patient that's scared of the dark? Because I know that can.
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You. 3s So let's take that question and move into the psychological aspects of sleep because they're just as important. And that's a great segue because now you're talking about the concept of when people have conditioned responses that are so powerful, what do you do about it? And the answer is, of course, you go slowly and you have to work out the desensitization program. Somebody needs to be asleep in a lit room, you say, then that's what you do. You don't say to them, you can't do that. You say, no, that's what you do. And what we're going to figure out is what else is going on with your
sleep that we can work on? Because there's almost always multiple things. Very few people have just one sleep problem. Most people have as many as five to ten different variables that all are relevant. And so at any given time, you want to work with the individual and say, well, tell me a little bit more about your bedroom. What is it about your bedroom that has made you into a poor sleeper, besides just the fact that you notice that you're sleeping with a light on? And that's not such a good thing? And often that person might not be aware, for example, that the temperature. 1s In their room is a very crucial factor to how people sleep. A person may just not be aware of it. You would think they would be because it's so simple, but they may not be. And there's also a budget. A person may have a budget and say, well, I can only keep my temperature at a certain level. We know for a fact that 1s most people sleep better in a cooler temperature with one huge caveat. Insomniacs, which is a lot of what we're talking about here, have a vasoconstriction problem where their hands and feet can be very chilly when they go to sleep. And so if that happens, they're thinking, wait a second. I can't go to sleep in a cold bedroom. I'm never going to go to sleep. My hands and feet are already cold. Now, the good news for them is that for most insomniacs, through the process of actually going to sleep, that vasoconstriction in the hands and feet will relax. And now the blood will get into the hands and feet and they will no longer feel that chilly sensation. That's why it's not uncommon for an insomniac to do what? They'll go to sleep with all these covers on because they needed them to go to sleep. But then they wake up in the middle of the night and they've got to remove the covers because now they're too warm. And then you have the problem what if they can't get back to sleep? 1s Because that is the single greatest complaint, by the way, of all insomniacs. I can't get back to sleep. Many people talk about falling asleep as being a big deal. It is, of course. But if you think about it, falling asleep at bedtime 1s is no different than falling asleep in the middle of the night. It just happens to be at two different times of the night. In the beginning of the night, it's easier, because you put in a day, you're already exhausted. You have what's called high sleep pressure. But in the middle of the night, you've already slept some. You've eaten up some of your sleep pressure. Now you wake up. Maybe if you're too hot, you're too warm, you can't get comfortable again. You can't easily go back to sleep. And that is the single greatest complaint of all insomniacs. And that's why, when they go through the medication approach, the doctors are always saying, well, this one will keep you sleeping through the night. And of course, just briefly, just to interject, it doesn't solve the problem of waking up at night to pee. So the insomnia patient who has a sleep breathing disorder, who wakes up at night to pee, and it takes a couple of minutes to pee, and then they come back to the bed, now they're wide awake. That's a very big deal for them. So for them, of course, they would want to look into this whole sleep breathing connection. But nonetheless, most insomniacs do have the problem. 2s Of waking up at night and not being able to go back to sleep. And the big question is, what do they do? So we can discuss that now, unless you want to go into a different question. Well, I was going to
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ask one question I was going to ask is for, like, asthmatics. How does that correlate with sleep apnea? Because they're both breathing problems.
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I thought we were going to stick with the psycho logical for a while. Okay, why don't we come back to that one? On the psychological front, 2s the issue of being able to go back to sleep is huge. And the ultimate answer that it sounds like you would be very familiar with, since you mentioned the EMDR, is that in the middle of the night, when you wake up, 1s you have to be able to get sleepy again. And if you could get sleepy again, you solve the problem. So somebody who doesn't have PTSD, somebody who doesn't have insomnia, they wake up in the middle of the night, and what do they do? They roll over and they go back to sleep. 1s But for people who have suffered from insomnia in their life, and I've suffered from insomnia, and anybody out there who knows this experience, they goes, well, you're just not sleepy. So how do you go back to sleep? 1s And so that really does require a lot of discussion and analysis of what exactly happened beforehand to wake you up. What are you doing in bed after you wake up and what are you willing to commit to doing to change to overcome that? And the biggest problem is that most people think that they can force themselves to go back to sleep. So the most common response to waking up at night and not having the ability to go back to sleep is to lay in bed trying to go back to sleep. Which in fact makes the problem worse because that produces the conditioned response of, well, my bed is not a place to sleep. My bed is place to lie here and be awake and worry or stress or look at the clock or listen to the traffic or again, worry or just have self talk. And so all that's natural because you're kind of awake or wide awake. But the person has to recognize that's enhancing what's called the behavioral 2s conditioned response. And so that means the fastest way to confront that problem is to do it someplace else. So if you wake up at night and you go, I just don't think I'm going to fall back asleep, the goal should be to say, well, I want to make my bedroom and my bed sanctified. This is a place where I sleep or make love. This is not a place where I read books or watch TV or listen to the radio or listen to podcasts even. I want to get up and go into the next room and do something different until I get sleepy again in then I'll come back to my bed and then I'll go to sleep. That's a huge step to take and very difficult when insomniacs, first hear it because it's counterintuitive. 1s You're going to say, Wait a second, I'm now spending less time in bed. So if I'm spending less time in bed, how am I going to get more sleep? And this is the classic example of less is more that if you allow yourself to accept the fact that you're making the sleep worse by lying in bed, not sleeping, and teaching yourself to not sleep. If you learn that, you can get out of bed and appreciate that difference, and it can work in pretty quick fashion, but it's a big step, it's often important to be coached for that, for people who really struggle with these things. In addition to my book, I have a coaching service 1s at my website, theberrycracomd.com, and I will coach people and help them to understand these principles so they can apply them, because some people really just need more education and instruction to be able to implement the idea.
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The other thing is, I know a lot of people with PTSD. They struggle with, like. 1s Not being able to sleep unless there's like noise or TV or 2s they just can't sleep.
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Right. And that's a very good point because we're talking largely about two things. One might be a
fear response where that noise in a certain way may be making them feel comfortable, but the other is they may have self talk and they chatter just as something that's right now uncontrollable. So I've used these before, things like 2s the black screen on your phone that's playing the sound of rain. That's a very good thing. And that can absolutely dampen some of the self talk. And I encourage people when they're in that level of distress and that's what they need to do. That's what they need to do. There's nothing wrong with that. It's very important to apply these kinds of tools and principles. If they work. If they don't work, then it's go back to the drawing board and say, what's going on here? And I'll give you the best example. If a person has been spending way too much time in bed awake, that person may not have as much luck trying to put the phone on rain because they've already spent too much time in bed being awake. Whereas if they got up out of bed for an hour or a half an hour, then they went back into bed, then they put the phone on rain. Much more likely to work at that point.
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Makes sense to me.
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Makes sense. It. Right. That's very important for people to understand their behaviors have a dramatic impact on their insomnia, and they can learn to take control of that just by changing a few behaviors. 2s Now, we haven't spoken about nightmares, which are big in PTSD. Would you like to talk about that? Go into that area. So the nightmare research is how I got into all of this in 1988, where we did the first randomized controlled trial on the technique called Imagery Rehearsal Therapy, and it was compared to a technique called Desensitization. At the time, this was the University of New Mexico Department of Psychiatry. Just a few years early at the University of New Mexico Department of Psychology, they had tested Desensitization station and a protocol for nightmare patients. So basically, Albuquerque, New Mexico, was the nightmare treatment capital of the world in the 1980s. And so in 1988, when we did our study. 2s We compared the desensitization that had already been proven to work with IRT. And the thing about IRT that was unique is that it's got nothing to do with desensitization. Even though many mental health researchers and mental health professionals thought in the beginning that's what IRT was, they thought, well, they're just rehearsing the nightmare. That's all that's happening. Exposure therapy. But IRT really doesn't do that. IRT is saying that images in your mind may end up being there because they become learned. In other words, you are traumatized and have a very, very bad event occurring, a bad stressful life event, something that where you think you're going to die, or worse, you're having these kinds of events, and that leads to PTSD. So you go, well, naturally, that caused you to have nightmares. Nobody's surprised about that. 1s Um, 1s but the question that many PTSD patients have had, as well as researchers, is, why do those nightmares linger? And when we first began doing this research in the if you'd ask a PTSD patient, Why do you still have nightmares? The answer would be, well, from the trauma, naturally. And we'd say, okay, well, that's certainly a great and I'm not saying you're wrong, but there is another theory. And they go, okay, what's the other theory? And you go, well, it's the learned behavior theory. And they go, 1s what do you mean, a learned behavior theory? Say,
well, if you have nightmares for a long enough time, it's quite possible your brain has learned to keep having nightmares. And so they'd hear that, and they go, and this is very interesting. Half the people who would hear that discussion, because we were doing these in group sessions, so it'd be like 8910 people and very fascinating people, fascinating discussions. Half the people would go, that's ridiculous. You don't learn to have nightmares. It's the trauma. I say, okay, other half a light bulb went off. And they go, that is so funny, Dr. Freco, that you said that. 1s Because I recently have begun wondering whether my bad dreams have actually become like a bad habit, that they re just there and they just don't go away. So these sessions would last for a few weeks. We'd have these very intense discussions about all these different principles. And what we learned was that for most people, even though they had horrific traumas, 1020 years out, they began to see these nightmares had taken on a life of their own, and they really had begun to develop as an independent sleep disorder and therefore might have been functioning as a learned behavior. And the proof was this when we treated them, we didn't give them a medication. We didn't talk about trauma. We didn't give them psychotherapy. We gave them an educational instruction. We said, if your nightmares are learned well, that means they're susceptible to being unlearned. So how do you do that? Well, simple. Go take a bad dream. Over here. 1s Change it to something else, and person might go, what do you mean, change it? Well, that's exactly what I mean. Just change it. I'll come back to that in a minute. Because when they first asked about it, said, well, what do I change it to? No, you decide. You decide. You make the change. So people just made various changes to their nightmares. Then they practiced the images. That's where you get imagery rehearsal therapy. You just practice us the images you created from that new dream. And the people did that every day or every other day. And within just a couple of weeks, not only did their bad dreams start getting better, but often the intensity of the dreams got better. And then a month or two months out, their PTSD started getting better. So they bought in very quickly. Once this process unfolded, like, wow, I have control of my dreams. I just have to picture certain things. Not to say that what you picture shows up in the dream, but just by the fact that you're taking control of your imagery during the waking hours and paying attention to it. Is having this effect on your nighttime
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a lot like inner child work, except for with childhood situations, you work with your sleep.
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I'm not familiar with that
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term. With inner child work, you go back to the time period where the trauma happened, 3s and you start, 3s if you could pick a mom, what would that mom be like? What would have happened? How would she have responded in that sort of situation? And so I kind of feel like that's kind of the same thing, but with dreams,
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I think it's very similar, very good parallel. Thank you for educating me. So, yes, it's not like going back to relive the trauma. It's going back and saying, I'm doing something different with this dream. And so we had people who would change the whole dream. 1s We have people who would change, like one color in the dream, three words in the dream, one scene in the dream, the whole dream. So it was a process of saying I'm changing the dream. I'm taking control of the dream. And the one paper we published on it showed that the people who had the best response appeared to make changes where they showed mastery over the situation. So if the dream was one of being out of control, which often dreams are, and under attack and so forth, the dream change made it more masterful that the individual now had more control and that seemed to be associated with the best outcomes in people who used IRT. And we have said I've got lots of sections on this in the book Life Saving Sleep. And I want to put in a little note, though, that research again, going back to what I said in physiology. 1s We're huge proponents of IRT. It's such an easy technique to learn. Again, some people need coaching on it. My wife and I did a special manual called Turning Nightmares into Dreams that many mental health professionals purchased to use to teach themselves that training. We also have introductions to IRT videos on my website, Barrycracomd.com, 2s but I just want to get across that. Through the years, we have been surprised how many of the nightmare patients also have the sleep apnea. And now there's nine studies in the scientific literature over the last 20 years. They're not the best studies. They're more like anecdotal case reports, retrospective studies, but they didn't encompass a lot of patients. Over nine years, we've published only two of them. Seven other research groups out there have published 2s and. And they all show the same thing. You put somebody on CPAP who has nightmares and their nightmares get better. So that's pretty remarkable. Here we've been talking about a psychological aspect to nightmares with IRT, which is incredibly powerful technique by the just. It's in the world of what they call effect sizes. In research, they're huge effect sizes for IRT. And yet on the other side of the equation, we now know that CPAP or PAP therapy reduces disturbing dreams and nightmares in every study that's been published on it. So that's going to become a whole new field as well. 1s Thanks
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for tuning in. Tune in next week to learn more about Sleep with Dr. Barry Cracko. 2s And if you have any questions, follow us on Rachel on recovery. Reach out on any of your favorite podcasts and social media, and if you have any questions, reach out to rachelonrecovery.com. And always follow and subscribe on YouTube. Thanks.
