Episode 327 Dr. Barry Krakow Sleep Solutions for Veterans Transcript

This transcript is from episode 327 with guest Dr. Barry Krakow.

Scott DeLuzio: [00:00:00] Hey, everybody. Welcome back to Drive On. I’m your host, Scott DeLuzio. And today my guest is Dr. Barry Krakow. Barry is a sleep medicine specialist who has worked in the field of sleep research and clinical sleep medicine for more than 30 years. And he’s here today to discuss techniques. techniques to treat nightmares, insomnia, and other sleep related issues, which seem to plague the military and the veteran community.

So, uh, before we get started, welcome to the show, Dr. Krakow. I’m glad to have you here.

Dr. Barry Krakow: Thank you very much. Very, very glad to be here.

Scott DeLuzio: Yeah, absolutely. So, uh, talk a little bit about your background already in the, the intro here, but, um, for the, the folks that aren’t familiar with you, can you tell us a little bit about yourself and, and who you are?

Dr. Barry Krakow: Sure thing. Um, I trained in internal medicine, yet, uh, by 1988, uh, my career basically [00:01:00] involved working with mental health patients who have sleep disorders. Uh, we started out with some very innovative research, uh, treating chronic nightmare patients, and that broadened and led to discoveries of the great complexity that we find in the sleep disorders that are in psychiatric or mental health patients, whatever terms you like.

Um, in my, in my career, one of the things that’s been very interesting and relevant to our discussion is that, um, many military institutions. have brought me in for trainings, um, actually all over the world. Landstuhl in Germany, uh, Center, Tripler in Hawaii, Fort Bliss, Fort Campbell, Walter Reed, South Dakota VA.

I mean, I’ve been to probably 20 or 25 places. specifically trying to broaden their understanding of this complexity. We call it, um, sleep dynamic [00:02:00] therapy is the model that we use. And, and by the way, I recently, uh, published this book, Life Saving Sleep, uh, this year, which is designed to show that, uh, sleep disorders are a lot more a component.

of the mental health disorders that people are suffering from. And so a much more active, aggressive, comprehensive plan needs to be formulated to actually get people not only to have the sleep get better, but by getting the sleep better, improving mental health.

Scott DeLuzio: And that’s such a strong, uh, tie between the two, between the sleep and the mental health.

Um, and. I know through various people that I’ve spoken to, a lot of times they, they talk to people who suffer from all sorts of different mental health conditions. And there is that, that tie where they also aren’t sleeping. And now maybe it’s as a result of, [00:03:00] um, you know, maybe the nightmares of a traumatic event that they’re having, that they have experienced, I should say.

Um, and, and that’s causing the sleep problems, but then those sleep problems aren’t. Making the mental health condition any better. And it’s just like this vicious cycle where it’s like one thing happens and then another and then another, and it snowballs out of control.

Dr. Barry Krakow: Right. And it’s most important to take that point you just said, because that’s where.

The problem originated in this distinction about mental health and sleep as if somehow, well, you’re traumatized. So naturally you have nightmares. Naturally you have insomnia and that sounds all very logical, but that’s not really the way to understand this. The nightmares and the insomnia and the sleep apnea, they take on a life of their own.

And that’s what I mean, that if, if, if they’re not being treated directly and comprehensively, and we’ll get into that, that’s where [00:04:00] the mental health community in general, and even many military, even the ones where I’ve trained, they have had far less implementation of this component that you must aggressively treat the sleep disorders and we’re losing people.

People are dying because their sleep disorders are not being treated and this results in more suicidal ideation and behavior.

Scott DeLuzio: And I want to get more into that in just a minute here. We’re going to cut to a quick commercial break though, so stay tuned. Everybody welcome back to drive on. Um, we’re here with Dr Krakow who is here to talk about various sleep issues that affect the military community, the veterans and the service members.

And, um, Dr. Krakow, the sleep issues, there, there’s so many that are prevalent amongst veterans. Uh, could you talk to some of the origins of the sleep problems, especially talking about, um, you know, maybe some of the unique experiences that many [00:05:00] veterans, uh, go through during their service?

Dr. Barry Krakow: Well, why don’t we even start with a case?

I’ll give you an example of a couple of different, very typical cases. A person could come into a sleep center, um, a veteran, active duty, and they’re saying that their insomnia and their nightmares really are not under control. And then you go, okay, well, what, what have you been doing? And they go, well, I went to a psychotherapist and they’re trying to treat the PTSD.

I went to a psychiatrist and they’d given me some meds for the insomnia. They gave me some meds for the nightmares. And I say, well, do any of these things work? And what’s interesting is that. The individual often say, well, I think they work, but I don’t think they work that well. But they even struggle with answering that question because they’re not, they’re asking the question of like, Oh, what does work even mean?

Like, should I not have nightmares anymore? Should I not have insomnia anymore? Now, if you take [00:06:00] this case, this hearkens back to the beginning of my career. Where in the early 1990s, we did this major study showing, it was published in JAMA, which shows that if you take someone who has PTSD nightmares and you treat them with a technique called imagery rehearsal therapy, it’s a cognitive technique, there’s no drugs, we’ll talk about it more in depth later in the show, it’s something that was so powerful that when it treated the nightmares of these patients.

Their PTSD got better. Their anxiety and depression got better. So you’re thinking, wait, now that sounds really weird. Like I thought the nightmares were part of the PTSD. And so you’re supposed to take the drugs for it or the psychotherapy, whatever. And so that was only the beginning. What happened next in the 1990s, this is now 30 years ago.

We discovered that the insomnia and nightmares were simply the tip of an [00:07:00] iceberg and that those individuals would always tend to have sleep apnea along with insomnia and nightmares, and many of them also had restless legs and leg jerks. So what I’m getting at is that. In the early going, we started to see that people were having both mental and physical sleep disorders and you couldn’t separate them.

In other words, all these patients would come in with nightmares and you would do IRT and that’s great and it would help, but you would look at all of their outcomes and you go, well, yeah, their nightmares are better. But they still have horrible sleep quality. What’s going on? So now you treat their insomnia, not with medication, something called cognitive behavioral therapy with insomnia.

So you treat that. The insomnia gets better, but their sleep quality still doesn’t get better. And you’re going, wait, I don’t get it. What’s going on? Now you look at the physiology and this is where the gap is huge in the military and elsewhere. where people are not [00:08:00] recognizing the physiology of the sleep must be evaluated if we’re going to actually understand the full spectrum of problems these individuals are going through.

So let me just summarize. They come in presenting with nightmares and insomnia. It all sounds like it’s psychological, so we’ll send them to a psychologist, send them to a behavioral sleep specialist, send them to a psychiatrist. Nobody is there going, wait a second, what’s underlying their sleep quality problem?

Is it the nightmares? Is it the insomnia? No, it’s also the sleep breathing disorders. And we publish more papers than anybody in the world on PTSD and sleep disorder breathing. And we’re convinced that the rate is astronomical. We’re talking about rates as high as 70, 80, 90% of, uh, Various PTSD cohorts have sleep disordered breathing.

Scott DeLuzio: And so the, the physical, uh, sleep issues and the [00:09:00] mental side of things, the, the nightmares and, and, and those types of things, um, are they, are they kind of like a package deal? Is that what you’re trying to say with, with the, the PTSD and the, those types of things, or, or is it? It just happens to be that they also have this as

Dr. Barry Krakow: well.

No, no, no. It’s a package deal. Absolutely. These things are interconnected in ways we people really haven’t been able to figure out why yet. I mean, there’s lots of theories. The point is it’s a package deal and yet institutions are not set up to deal with that. In other words, somebody walks into a doctor’s office and they go into the psychotherapist and the psychotherapist goes, Okay.

Well, how are you doing with your CPAP machine? And the guy goes, terrible. I can’t use it. It’s horrible. And they go, uh, well, I don’t know what to do. Go back to the sleep center. And then the sleep center listens as well. How are you? How are your insomnia nightmares? Oh, we’ll go back to the psychotherapist.

People get tossed around when we develop this model. Yeah, yeah, yeah. We developed this model sleep dynamic therapy, which I describe in [00:10:00] depth in my book, life saving sleep. is all about integrating this. It’s all about concurrent treatments. If you’ve got nightmares, I want you to have imagery rehearsal therapy.

If you’ve got insomnia, I want you to have cognitive behavioral therapy for insomnia. If you have sleep apnea or upper air resistance, Some kind of breathing condition. I want either aggressive, conservative treatment steps like nasal hygiene, nasal strips, dental devices, or I want you on pap therapy. And I want all of that.

I want you to have all of that. I don’t want to hear that, okay, well, you can go to the sleep center six months from now. We got a big backlog right now. We’re just going to work on your insomnia, but that is the way the institutions are set up. So I can’t, I can’t blame people. So to speak for this problem.

I’m simply saying people have to begin to recognize this as a system, a systemic problem that unless it is fixed. The level of care is going to be so, uh, weakened and [00:11:00] diminished compared to what it could be. At our center that we had in Albuquerque for 20 years, we did all of this. We had our own sleep center, Maimonides Sleep Arts and Sciences in Albuquerque.

I live in Savannah, Georgia now, and I do sleep coaching services at my website, BarryKrakoMD. com. But in Albuquerque, we had this all set up. You came in, you could get any of these treatments at any time. We worked on all of it all the time. That’s exactly how sleep centers have to operate. And if it’s not going to be a sleep center.

It needs to be a psychiatric clinic or a psychological clinic or, you know, whatever kind of clinic that says, we’re going to do all of this, not just in parts. Does that make sense?

Scott DeLuzio: I think so. Yeah. Because I, I’ve experienced it myself where I’ve tried to get an appointment for one thing or another, uh, VA.

And They tell you the, the soonest we can get you in is going to be four or five, six months from now. Um, and it’s like, okay, well, [00:12:00] so I’m just going to deal with this problem for this period of time. Uh, that doesn’t make a whole lot of sense. There, there has to be, you know, they’ve gotten better now where now they, they’ll refer you out to community care and they’ll, um, you know, they’ll, they’ll get you.

And to see someone, but, um, still like it, it, it’s, uh, it, it’s not a comprehensive solution. Like you’re talking about, it’s like they’re, they’re, they’re piecemealing it together.

Dr. Barry Krakow: Right. And it brings up a huge research question, which is now starting to come out in the scientific literature. And that is somebody has these conditions.

Do you start in a particular place for a particular reason? Well, so everybody’s got their own niche, so they’re gonna go, Yeah, well they start with me, cause I do this, you know. Alright, but here’s the bottom line. The research that’s coming out now is raising very good questions. What if you have sleep apnea, and from your sleep apnea, which causes horrible sleep fragmentation, oxygen desaturation, screws up your memory, your concentration and attention, [00:13:00] Can you successfully do psychotherapy if you’re cognitively impaired?

And so now a couple of studies have come out actually showing if you went to do exposure therapy, which is a major treatment for PTSD, and you are using your CPAP machine or you’re getting exposure therapy, but you’re not treating your sleep apnea. It turns out there’s a difference. Wow. And the difference is that the person who’s using CPAP is getting a better response to exposure therapy.

Same concept for cognitive behavioral therapy for insomnia, which does require a certain amount of intellectual firepower to implement the steps. The same question is being asked, whether or not, can you do the CBTI if you’re cognitively impaired from sleep disordered breathing and sleep disordered breathing is the granddaddy of all.

Sleep disorders in [00:14:00] terms of producing cognitive impairment. You are literally not sleeping deeply most of the night, if not the whole night. You never get restorative sleep. And therefore, absolutely, you’re going to be impaired.

Scott DeLuzio: And when you have people who… are sleep deprived. They haven’t gotten a, you know, good full night’s sleep, that, that, that restorative sleep.

And, um, they, they haven’t gotten that for, especially for long stretches of time. Um, you do end up having that, that kind of, uh, cognitive, uh, breakdown where, where, um, you’re probably not even safe behind the wheel of a car. Nevermind, you know, trying to dig up traumatic memories and all of that and trying to, uh, process them and everything.

And, um, you need that, that brain function in order to, uh, in order to actually process the stuff the way you need to. Um, but if you’re not getting the sleep that you need, um, then, [00:15:00] then it’s like you’re, you’re trying to fend off a bear with your hands tied behind your back. Like it’s just not going to happen.

Dr. Barry Krakow: Right. And you used a key word cause you said sleep deprived, but sleep deprived is tricky cause sleep deprived always sounds like I didn’t get enough sleep. The real problem is you’re not getting enough good sleep. You have to get high quality sleep to be able to get to the place where this impairment is resolved.

Um, your, your listeners, your, you know, family members, everybody in the audience needs to know that the recent Evidence is showing that during the night, when we go into deep sleep, we actually have a system that’s called the glymphatic system. We know what the lymph system is, you know, draining various, you know, waste products away from the body, you know, so they can be excreted.

In the brain, it has its own special lymph system that’s called glymphatic, and it turns out it works best when? You’re sleeping. And when does it work even better than just sleeping [00:16:00] when you’re in deep sleep? So all these people are not getting successfully brainwashed, as we like to say, because the cleansing process is not happening or it’s happening in a diluted fashion.

And so they’re thinking number of hours of sleep when the real problem is, and this happens, like if, if you tried to explain this to a psychotherapist who’s doing. These, this clinical work, you know, you go, do you ever get the impression that your patient didn’t hear you? Do you ever get the impression that your patient is not remembering what to do?

Do you ever get your, the impression that the patient’s struggling to try to understand a concept? That should be a huge red flag. That there’s a sleep physiology problem in play, but instead what they’re told is, well, the patient must be depressed. Patient must have PTSD and we shouldn’t laugh at it because there’s no question that, that those things are relevant to.

I’m not saying [00:17:00] that they aren’t. I’m saying it’s only part of the puzzle. The puzzle is missing. Is the sleep physiology is so broken up. It is absolutely unequivocally leading to suicidal ideation, suicidal behaviors, and all kinds of other harmful medical and mental health. degradation that compromises these people tremendously.

Scott DeLuzio: I want to talk more about this, uh, part of it in, uh, just a minute here. We’re going to cut to another quick commercial break here. So stay tuned. Hey everybody. Welcome back to Drive On. Um, I’m here with Dr. uh, Craico who is talking about, uh, sleep issues, uh, especially with regards to veterans and service members.

Um, and I know a lot of times we talked about, uh, this earlier in the episode, a lot of times there’s a link between, And they are going to talk about trauma and nightmares that people might have. Dr. Krekow could you talk a little bit about how these nightmares might be able to be more effectively managed and [00:18:00] even

Dr. Barry Krakow: treated?

Right. So the oldest theory of nightmares is very obvious. It’s common sense and it’s actually correct that when you go through any kind of stressful life event. You’re very likely to have disturbing dreams and that process can last for weeks, months, years, decades, depending upon, you know, the severity of that trauma and also depending upon whether there’s an intervention or not.

Um, what we now know though, that’s different. that was very surprising when we learned this in the 1980s and the 1990s, is that nightmares do something to take on a life of their own, almost as if they’re rewiring your brain, and now, believe this or not, they’re no longer technically connected to the trauma.

And you go, well, wait, what does that mean? How can they not be connected to the trauma? Well, this is what we say. In our work with imagery rehearsal therapy, [00:19:00] the trauma is the cause. But what happened was that seeded this problem into your brain, which then sprouted and blossomed into its own tree, its own disorder.

And so it turns out part of that is a learned behavior. And that means you can teach people with chronic nightmares how to unlearn the process of having nightmares. And the way to do that is through this technique where people work on the imagery. that they know from their bad dreams, they make a decision about changing it to something different.

And then they practice rehearsing that. And if you think about it is a bit of common sense because when you dream, you’re obviously dealing with your mind’s eye and your imagination. So if you’re spending time while you’re awake, working on the content of your bad dream to turn it into something that’s obviously not as unpleasant.

And [00:20:00] then you say, I’m going to practice that. It’s quite possible that’s going to influence, uh, your dreaming. By the way, nobody knows how IRT works. Nobody knows how it actually does this, but there’s been about 25 or 30 people around the world who have done research on image rehearsal therapy or variations.

All of them, all of them worked. I think there was one study that was not well done where it didn’t work. All the other studies shows that it works. And that is strong evidence that these nightmares are functioning differently than we thought. In fact, major trauma experts around the world are now beginning to recognize that if you do exposure therapy or cognitive processing technique, you know, other specialties, EMDR, but the nightmares are still there, send it to the person, to a sleep doctor and see what they can come up with.

Now, [00:21:00] this is where it gets really interesting because We did all that. We did that all through the 1990s. I, my, my name in research and my reputation all comes from that work in the 1980s and the 1990s as a nightmare expert. And yet by the mid 1990s, We were stunned when we began to realize that 90% of these patients had sleep apnea.

And the only reason we found it out was because we first began evaluating their insomnia. So we went from nightmares, to insomnia, to sleep disordered breathing. And we suddenly, along the way, at the sleep center, had a very interesting model of care that was very surprising to me. We started having a number of nightmare patients come in, and because of the way of our evaluation, we said to them, Well, you know, yes, you have nightmares.

Yes, you have insomnia. And you know what? Looks like you’ve also got a sleep [00:22:00] breathing problem. Well, you know what? Most of these people said, I want to try pap therapy first. I said, you’re kidding me, right? They go, no, no. If I’ve got something physically wrong with me, that’s actually causing some of these problems, I want to treat that first.

So what did we find? We discovered that well more than 50% of the people who would do that, they’d come back to us a couple of months later. And I’d say, so tell me, you know, you’re doing pretty well now with the PEP. How, how are the nightmares? They go nightmares. What, what are you talking about? Disturbing dream?

Don’t you have any more bad dreams? Oh, that’s funny you mentioned that, Dr. Keiko, because, yeah, I did have that problem, but they’re gone. And so we began to realize that pap therapy, and now there’s nine published studies in the scientific literature. These are not, you know, perfect randomized controlled trials, but they are…

Very relevant because the patient is a historical control. [00:23:00] They’ve had the problem for, you know, X number of years. If you do something to make it go away, then that’s got to mean something. Even if you call it anecdotal, it’s still a higher level because they were the historical control. And many people have used CPAP, even just CPAP, even though we’ll come to that.

We don’t use CPAP anymore. Um, and nine studies out there, they all say the same thing. Treat somebody’s nightmares with a CPAP machine. and their nightmares will be reduced as much as 50% or more. So you’re talking about a, a, a trajectory here that starts out with all these psychological aspects, you know, well, you’ve got nightmares, you’ve got insomnia, and both of them function with insomnia too.

Functions like a learned behavior, which means the patient has tremendous ability to take control of it and say, okay, well, I want to unlearn the insomnia. I want to unlearn the nightmares. And there are fantastic results. So I’m never saying to somebody, [00:24:00] don’t pick that first. That’s fine. If that’s what you want to do, but the trajectory led us to the point of like, holy cow, if all these people have, uh, have sleep disordered breathing, or another term is upper airway resistance.

And, and they can get a benefit from a pap machine or a dental device, or even a nasal strip on their nose. We go, well, why wouldn’t we be giving that to them right away? Why wouldn’t that be, well, here’s part of your choices. And we were stunned at how many people said. Well, no, if it’s physical, I, I want to do something about that physical thing right away.

Scott DeLuzio: Yeah, I would think that they all would want to do something about it right away because that’s like the low hanging fruit. If there’s a easy solution to a problem, like why not just go and go and do that solution? Um, and like you said, eventually they may not have the nightmares, uh, You know, maybe even at all, but certainly reduced, uh, as time goes on.

Dr. Barry Krakow: Right. And you should know, you should know that [00:25:00] in the field of psychiatry, everybody gets thyroid tests. If they’re depressed, everybody it’s standard of care now. And why was that? Well, because a long time ago, people began to realize, Oh, thyroid problems are directly linked to depression. And patients are like, Oh, holy cow.

Like, great. I’ve got, I’ve got thyroid problems. I’m not really depressed. I mean, that’s how people do operate. Eventually. It’s the same thing. Virtually every depressed patient, virtually every PTSD patient in those two in particular, really merit a sleep study. And nowadays you can do these sleep studies by putting a little ring on your finger, or you can do your own.

Modified sleep study off of a phone or something. So there’s no reason not to do it. And the results are going to be positive in enormous numbers of cases.

Scott DeLuzio: Well, and I think with, especially with the types of treatments that you’re referring to here, uh, even worst case scenario, it doesn’t work for you.

It’s [00:26:00] not harming anything to give it a try. So, um, you know, That, that to me just seems like the easiest, uh, solution right there is, is just go give that a try. Go, go try, um, you know, even just the, the strips that you said that you put on your nose, like those, those, um, you can do that tonight and you can go get that and be done with that and just see how that works, you know?

Dr. Barry Krakow: Yeah, let’s, let’s, let’s get into that because that’s what I have learned is an excellent. introductory pathway, because so many people actually do have harmful, bad experiences with CPAP. And so that’s something that is its own scandal within the field of sleep medicine that’s not getting solved anytime soon, because too many people in the field and insurance companies think that CPAP is the answer to everything, when in fact CPAP really only works well with about one third of patients.

There’s other modes of treatment that we’ll talk about perhaps in the next segment. Right now, I want to point out that what we learn [00:27:00] is that if you give somebody an aggressive nasal hygiene treatment, and what does that mean? And in fact, on my website, the barrycracomd. com, there’s a free one hour, six episode session on nasal hygiene.

It’s called the Nose, N O S E, Nose, K N O W S. And in it, I talk about all of these problems with allergic, non allergic rhinitis and congestion, stuffiness, runny nose. And it turns out most people with anxiety and sleep breathing issues, to name a couple, often have problems with their nasal breathing. And then they normalize it.

They think that, well, this is the way I breathe. So that must be normal. It’s not. Most people with sleep apnea, for example, have allergic or non allergic rhinitis, which is a condition of just the stimulation inside the nose produces mucus, congestion, stuffiness, you know, whatever the symptoms happen to be.

[00:28:00] So what we learned was Simple steps, rinsing your nose with nasal saline a few times during the day, using a nasal dilator strip at night, um, learning to use a small nasal dilator which goes into the nose, any of these steps within a week or two, not to mention I should say, The nasal sprays, not Afrin, but things like Flonase sprays, anti histamine sprays, anti cholinergic sprays, all these things are over the counter or prescriptions, doctors prescribe them freely, they produce dramatic results in nasal breathing.

And when that happens, the average individual in this situation, a week or two later goes, I’m already sleeping better just because I’m breathing better through my nose. That’s a much better introduction to the problem of sleep disordered breathing than say, Hey, slap on this CPAP mask. [00:29:00] So, so we’ve gone down that pathway now for several years, encouraging people, let’s work on your nose because your nose doesn’t work anyway.

There’s no way pap therapy is going to work, but if you start on your nose and you get benefit, why not? There’s actually research showing that the drug Flonase reduces the number of breathing events you have on a sleep study. That’s how powerful this is. And,

Scott DeLuzio: and that type of thing is such a great place to start because like you said, a lot of this is just over the counter and you can, literally, you can start tonight if that, if that’s what you want, versus waiting However many months before getting into whatever appointment that you might have.

So, um, that that’s, that’s to me, that that’s the, the best, uh, introductory way to, to try to solve some of these issues. I want to talk more about some of these issues in just a minute. We’re going to cut to another quick commercial break here to pay the bill. So stay tuned. So, Dr. Krajko, uh, we were talking, uh, before the, [00:30:00] the break, uh, a little bit about the different types of, uh, treatment options that are available.

And you mentioned, uh, something about how CPAP is something that’s not being, uh, used anymore or shouldn’t be used, uh, you know, going forward, um, that there’s other types of therapies as well. Could you talk a little bit about that and, and, you know, what, what types of treatments are available that are more

Dr. Barry Krakow: beneficial?

Sure. There’s a segue here that we, you know, went from the conservative steps into, well, the person now say, am I excited to try PAP? Because I already see that this is working. So I want more, I want more treatment. So that’s the model. Uh, an interesting anecdote, uh, though, coming back to this gap in knowledge, I want to just pass on.

When I started to train mental health therapists in this model, They brought up the fact that they were very uncomfortable with the idea that they could tell their patients to start [00:31:00] using nasal strips, nasal sprays, and so forth, because they go, well, somebody’s gonna say I’m practicing medicine and I’m not, I’m not trying to say they’re doing something wrong.

I’m saying this is a problem. Mm-hmm. If, if, if a, if a therapist is involved in a comprehensive care, And they know about all this knowledge. They should be able to pass it on to the patient and say, well, why don’t you try these conservative steps? I heard they’re, they’re really valuable. And some of them have actually told me they were afraid to do that for fear of somebody comes back and says, well, you’re practicing medicine.

That’s nonsense. That’s a horrible thing in the field and all of healthcare that that would be like that. And that’s another one of these gaps that’s causing major problems. for people, um, who have these complex sleep issues. Now on to the CPAP, what we learned in 2005 is very simple. CPAP is one pressure.

C stands for continuous. So you have this mask on, it’s [00:32:00] delivering pressure, it’s keeping your airway open. Because your airway is open, your body is no longer fighting to get air in and therefore it says I can sleep. A lot of people get confused about sleep apnea and think it’s all about the oxygen.

That’s actually a small part unless you have to have a very severe case of sleep apnea. And then oxygen is very important because it’s dropping too much. For the average person, it’s this blockage in the airway. that is leading to the sleep fragmentation. Why would you stay asleep? If you can’t breathe, why wouldn’t you constantly wake up and try to breathe even though you don’t know that.

So CPAP is a great device in the sense that it was discovered in 1981, invented in 1981 by reversing a vacuum cleaner. Dr. Colin Sullivan in Australia did that. And, um, Ever since then, unfortunately, too many people think that that C [00:33:00] in CPAP is all that individuals need. Well, it turns out when you try to breathe against that continuous air, it’s uncomfortable.

And you may have heard these stories before. Many people who use CPAP, especially PTSD patients, will say, I felt like I was drowning in air. Yeah. I felt like I was smothering in air. I felt like I was, you know, getting claustrophobic. Now some of that might be the mask, but the largest part of it has to do with a very specific physiological sensation.

And that is when you breathe out, you’re not aware of any resistance to that. If you take a breath right now and breathe in and breathe out, you’re going, well, I’m just breathing. Right. That’s not what happens with CPAP. With CPAP, when you are breathing out, you still You’ll feel that air coming in and you cannot [00:34:00] tolerate it.

And if you ramp up your anxiety in response to it, which is exactly what happens, it’s called the tension amplification. It’s extremely common. And two thirds of all CPAP patients probably have this problem and they go. I can’t use this. I can’t even fall asleep with this. In 2005, when we finally put this together, we actually saw this problem of the expiratory problem.

We saw it on the sleep lab, you know, tracings. And we said, well, let’s try bi level. What’s the difference? Well, bi level you breathe in and most people can breathe in with pep therapy. It’s very comfortable. It’s actually a very satisfying sensation, but then bi level drops the pressure noticeably so that when you breathe out, You don’t even notice there’s air there.

So we started doing that in 2005, but by 2010, these great inventors at [00:35:00] ResMed and Respironix invented devices that have auto adjusting algorithms that literally measure each of your three breaths and then change the settings on the device To fix whatever is going in those three breaths and then the next three breaths and then so on and so on.

So all night long, you’ve got a machine that is trying its best. It’s not perfect yet. And they’re very good though, um, to match your breathing needs perfectly. And when we switch people over to these devices called auto bi level or ASV, which is an even more sophisticated bi level device. They’d be saying things like, is it working?

I don’t feel anything. Like what’s, what’s going on here. And these are people that I’m talking about with PTSD, anxiety, depression. These are very, very sensitive people. who had very [00:36:00] poor responses to CPAP. In fact, ugly responses. The average CPAP patient who fails quickly won’t come back to a sleep center for one to five years.

They’re so disgusted and turned off by the cure being worse than the disease. They say, I’m not going to do it. I’m just not going to do it. And so they come back, they go on bi level, auto bi level, they go, Why didn’t I get this when I first came here? Why did it take 10 years for me to be introduced to the technology that is far superior to CPAP?

And what I’m describing to you right now is something I have preached now for over 15 years, and it is still not… Anywhere close to the standard of care. Most sleep centers, most mental health centers that are helping people with this problem of sleep apnea, they’re not telling their patients, Demand a bi level device.

Demand an auto bi level device. Because the sleep centers [00:37:00] won’t even, I just had a patient just recently went into the center and said, I’m failing CPAP. I want bi level. And the doctor said something ridiculous like, Well, I can’t just give you bi level. And that’s, that’s wrong. You can, cause when somebody fails a treatment, just like if somebody fails antidepressant number one, you get antidepressant number two, antidepressant number two, you get antidepressant number three, exact same model.

If you fail CPAP, then you already qualify for bi level and yet it’s not being done.

Scott DeLuzio: You know, I have never personally used a CPAP or any kind of, uh, you know, breathing devices like that. Um, but I know what you’re talking about with, with that continuous flow of air. Cause you know, go outside on a windy day when the wind’s really windy day, when the wind’s blowing in your face and you, it’s like, you feel like you’re struggling to catch your breath as, as, cause it’s like, Shoving air down as you’re trying to breathe out.

And it’s just, it’s just a super uncomfortable [00:38:00] feeling. And I could not imagine trying to sleep that way. Like just a few breaths when you’re outside is, is almost painful. Um, then try, trying to do that for seven or eight hours over the course of a night, uh, that, that would just be miserable, I would think in my mind.

Um, but yeah, having that, that device that. Automatically adjust to, you know, the type of breathing that you’re doing. And, um, you know, yeah, sure. Maybe it’s not perfect, but it’s gotta be better than a continuous flow of air. Um, you know, I’ve often said, uh, when you get a lot of information coming to you, it’s like drinking out of a fire hose, but this is, this is almost like breathing out of a fire hose.

Like it’s just too much coming at you all at once.

Dr. Barry Krakow: Right. Yeah. We say, we use that example. You’re driving in a car 60 miles an hour. You stick your head out the window. Tell me what it feels like. Well, for most people, it’s, it’s, it’s not, yeah. And so you would think it’s so logical that if you’re dealing with somebody who already suffers from anxiety, which obviously if you’re a [00:39:00] mental health patient, you probably have some anxiety somewhere in your symptom load.

And if you have that anxiety, that means if I give you a new foreign stimuli, which is unpleasant, uncomfortable, irritating, weird. it actually can become traumatizing. And this is where this is a very big deal in the field of medicine, because you’re not supposed to do harm to a patient. You’re supposed to recognize, wait a second, I’ve got a PTSD patient here.

They have bad anxiety. They’re not doing well with their meds. You know what? I don’t know that giving them CPAP is a good idea. I think it actually could be very anxiety producing for them. And the number of PTSD patients in the world who’ve been told they have to start with CPAP is in the millions.

You’re talking about millions of patients were told, well, no, no. The insurance company said this, [00:40:00] and this is the standard of care. You must start with CPAP. And then the ball gets dropped and these people are not going back to the center because they’re so disgusted with it. They’re in so much pain and agony to go, why would I go back?

Why did they give me this ridiculous device to make my sleep worse? And by the way, that is what happens. For the people who can actually survive using the device for a week or two weeks or four weeks, whatever, they almost always, if they’re in this category, they’ll say, No, this didn’t make my sleep better.

It made my sleep worse. I feel worse. I’m more exhausted. And I told that to the doctor. And the doctor’s response was something like, Oh, well, maybe we should raise your CPAP pressure or you should just do it for longer. And they don’t actually dig into the details and say, what exactly is your response?

And they go, Oh, you know what? Maybe you would benefit from bi level. This is maddening. This is [00:41:00] maddening. And it’s very sad. It’s very tragic because all these people who could be on a pap machine are losing the opportunity by somebody who refused to consider the possibility that CPAP was not a good fit.

fit for this individual.

Scott DeLuzio: Right. And it doesn’t make sense that, um, someone’s having trouble with, with the CPAP machine and, Oh, let’s, let’s increase the pressure. That’s like, instead of sticking your head out of the window when you’re going 60 miles an hour, it’s like, now let’s go out, stick your head out the window when you’re going a hundred miles an hour and see if that makes it any better.

Like the logic there just doesn’t make any sense, but you got even, you got it. Even just the fact that they’re not willing to use the better technology, just because the insurance companies or whoever is saying, no, you got to start with, with this other technology. Look, technology evolves. It gets better over time.

And so why wouldn’t you go with a better technology [00:42:00] and use that? Sure. Yes. I completely understand. It’s probably a little bit more expensive, but is it more expensive than Using the one therapy that’s not going to work at all, and then eventually going to use the other therapy. Like, it, you’re, you’re spending money on something that you didn’t need in the first place.

Now you’re spending it on the stuff that you probably do need, and maybe that will work a little bit better. I don’t know. It just, to me, it’s mind boggling that that’s the, the, the mindset that people are

Dr. Barry Krakow: using here. Yeah, you’ve nailed it, and let’s now go to the physiological side. I mean, all of these people who have untreated sleep apnea, Many of them will eventually develop, if they don’t already have it, high blood pressure, heart arrhythmias, heart disease, heart failure, heart attacks, strokes, and they’ll also discover they can’t treat it.

their diabetes as well. They’ll also see compromised kidney function. Sleep is a very big deal. It’s basically the missing vital sign that people just never have [00:43:00] figured out how to measure. So all that money that’s now going into treating all these other conditions, some of that money would have been salvaged.

If somebody had just said, skip CPAP, put them on bi level, get them on something comfortable and see if they can have a more positive experience. Now I’ll tell you one other anecdote here, which is how this entrenched idea, and this is going on through many areas of healthcare right now, we have a lot of problems.

We saw a lot of this kind of narrowed thinking during the pandemic. CPAP

is pretty much all anybody needs. And that the other technological advances really don’t add much to the mix. As if to say, Oh, this is that model of like, you’re trying to buy a fancy car, you know, because you really need that [00:44:00] fancy car. No, you just need CPAP or the model of, you know, oh, well, these are much more expensive pharmaceuticals.

They’re not really that much better. Just go back with the traditional antidepressant and look, there can always be arguments one way or the other, but we have spent years working with thousands of patients Who came to us saying one thing, I either can’t use CPAP or I use CPAP and it did nothing for me.

That’s thousands and thousands of patients and we published on them and we switched them all over to bi level, auto bi level, ASV, whichever model. And you know, 70, 80, 90% of these people are now using PAP and they’re getting benefits from it. Whereas before they had given up, they had quit. And you would think that the field of sleep medicine would be much more open and have the courage to fight against the [00:45:00] insurance companies and say, well, I don’t care about your insurance rules.

I am interested in my patient’s health. Yep. And I want to give them a better technological device compared to CPAP.

Scott DeLuzio: You would think, and you would hope, um, but unfortunately that seems like that’s, you know, not the case, uh, yet anyways, but, um, we’re gonna cut to another quick commercial break here, uh, so stay tuned.

Well, Dr. Krakow, it’s been a pleasure speaking with you today. I’m sure we could have gone in so many different directions with this episode and talked about so many different things in much more detail. Um, uh, we’ll probably have to have you back on to talk a little bit more, uh, detail about some of the issues that are affecting, uh, sleep with people.

But, but it’s been enlightening, uh, to hear some of the things that, um, you know, affect sleep and affect some of these mental health conditions. Uh, so, so drastically. Um, I know you mentioned your book and your websites a little bit earlier, uh, in the episode, but can you tell people where to [00:46:00] go to get in touch with you, find out more about everything that

Dr. Barry Krakow: you do?

There’s the book again. And, uh, it’s life saving sleep, um, new horizons and mental health treatment. It’s available wherever books are sold, obviously on Amazon, any online bookstores. It’s also available as the, uh, Kindle. Um, on my website, barrycracomd. com. Um, we have a number of resources. That, uh, your listeners I think could be interested in.

Um, one is my coaching services for people, for example, who are struggling with nightmares, insomnia, or learning how to use a pap machine. So I’m innovating in that way. I’m trying to move a little bit beyond. the medical encounter approach and more of a coaching because I think that education is very underdeveloped when it comes to sleep medicine.

When I talk to patients all over the world about their sleep issues and I say, well, what did you learn at your sleep center? [00:47:00] And they’ll go, well, pretty much nothing compared to what we’re talking about in this conversation. And so that, that’s very problematic. We also have resources regarding the nightmare treatment.

Uh, we have a video introductory video on IRT. That is very good for therapists and they have used that. It’s a two hour video that they can use to learn about IRT. We have another program my wife and I, um, produced 20 years ago called Conquering Bad Dreams. I got the title wrong. That’s a book I wrote in the 1990s, Conquering Bad Dreams and Nightmares.

By the way, that book you can get online for 32 cents. Okay. Um, my wife and I did Turning Nightmares Into Dreams. It’s a, uh, audiobook, uh, and workbook. Uh, and so it’s got 20 lessons in it. And this is interesting in that many therapists buy that to also teach themselves how to do i r [00:48:00] t. But many patients who are kind of self-starters, self motivators, they can get that program, this audio series workbook and go through the whole program in like four to 12 weeks.

to treat their nightmares using that technique. There’s also a few other, um, videos on there, uh, talks about, you know, different areas about, you know, why people move towards sleeping pills as their answer when they really should be moving towards sleeping tests. And that’s, that’s a model that, you know, that we’re trying to approach.

I have other books for sale as well, um, that are on there. I do want to say it’s been great having this kind of conversation and I really appreciate it because there’s, So much going on in the military. environment that just needs upgrading to be able to enhance the sleep care. And it’s just not happening yet.

It’s happening in isolated spots, but not in a general way. Um, as far as I can see. And then the last thing [00:49:00] I’ll mention is that, um, here in Savannah, I’ve had a great opportunity where, I’m working with a psychiatry residency program who wants their psychiatry residents to learn about sleep disorders. So we’re actually training them directly in the sleep dynamic therapy model so that they can evaluate their patients for nightmares, insomnia, sleep apnea, instead of simply pulling out the prescription pad.

Sure. Determining something, you know, far beyond just, you know, pills as a solution.

Scott DeLuzio: Well, and that’s great. And I’ll have links to everything that you mentioned here in the show notes for anyone who’s interested and wants to take a look, um, to get a copy of the books or, um, you know, check out the, the videos or anything else that you, you mentioned.

Um, at this point in the show, I like to add a little bit of humor. Um, sometimes some of the episodes are a little bit heavy and I like to lighten things up at the end. Um, so. Uh, some of the jokes I’ve told have been pretty corny and I know this and that’s okay. I’m, I’m willing to make a fool of myself as [00:50:00] long as it gets someone to laugh.

Um, but in honor of the, the sleep topic, uh, for this episode, uh, the joke I have is a, you know, kind of around the sleep, uh, sleep area here, but, uh, scientists have finally discovered exactly how much sleep a human needs. You know how much that is? I’d like to know just five minutes more.

Dr. Barry Krakow: That’s a good one.


Scott DeLuzio: like that. So thank you again for taking the time to join us. I really do appreciate it. Um, and again, all those links will be in the show notes.

Dr. Barry Krakow: Thanks again.

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