An Interview With Dr. Barry Krakow, Author of ‘Life Saving Sleep: New Horizons in Mental Health Treatment:’ Part III

Poor sleep quality can lead to poor mental health, Dr. Barry Krakow says. And poor sleep quality often stems misunderstood, difficult-to-detect, sleep breathing issues. His mission is to improve patient lives and sleep quality.

This is the last article in a trilogy on life-saving sleep. Read The Critical Role of Sleep in Mental Health—And Why Your Doctor is Getting it Wrong: Part I And Why Poor Quality Sleep Can Be the Critical Factor Behind Any Number of Conditions: Part II. 

Barry Krakow, M.D. is an internist and specialist in sleep medicine. He has been working in the field for over 30 years as a sleep medicine specialist and researcher. He pioneered innovative approaches and techniques for treating chronic nightmares, complex insomnia and upper airway resistance syndrome.

His forthcoming book “Life Saving Sleep: New Horizons in Mental Health Treatment” describes how to fix your sleep and improve anxiety, depression, and post-traumatic stress while decreasing sleeping pill use, destructive thinking, self-harm, chronic pain—and nighttime trips to the bathroom.

This interview has been edited for clarity and length.

Susan C. Olmstead You write “All sleep disorders always have a physical factor—always—because sleep itself is a measurable physiological activity originating in your brain.”

What does the physical aspect of sleep disorders relate to psychological factors?

Dr. Barry Krakow A sleep problem that is physical refers to the fact that your brain produces electrical activity during sleep, which is similar to electrical impulses coming from your heart. This brain activity can tell you how well or poorly you sleep. This physiological dimension of sleep is often overlooked by most health care professionals. They instead focus on the psychological aspects.

This measurement will tell you if your sleeping brainwaves (indicating good quality sleep) are normal or abnormal.

This part is simple, but tricky because we don’t measure sleep very well—indeed we don’t even measure sleep breathing very well. While our measurements provide more information, the good news is that this information is extremely revealing and can help us understand the physical issues that must be addressed by poor sleepers.

High-quality sleep, for example, is known to be consistent, deep and consolidated throughout the night. This doesn’t necessarily mean that every stage of sleep is super deep and super consolidated. This means that there is something going on in your brain during the night.

Poor sleepers often have brain waves that look disorganized. It means that after 20 seconds of sleep, you wake up and go back to sleep. After 60 seconds, you fall asleep again and you wake up every 45 seconds. It happens so fast and often that a person doesn’t even notice it.

Individuals who wake up every night can’t go to sleep. They remember the one awakening because now they’re wide awake—but they don’t have awareness of all the other brief awakenings occurring as well. They aren’t even aware that they were awakened from sleep before the big awakening.

This phenomenon was discovered to be 90% of all awakenings. This is called sleep fragmentation and it’s the key to understanding and treating sleep disorders. Sleep fragmentation can be defined as inconsistent, unconsolidated and lighter sleep. A person may say: “There’s something wrong with my sleep, I don’t feel rested when I wake up, I’m tired or sleepy during the day,” Chances are that sleep fragmentation of 90 percent or more is the reason. My book uses the term “sleep fragmentation”. “bad and broken sleep.”

The question is, would anyone think that this is purely psychological? We don’t minimize the psychological aspects. We recognize that anxiety, depression and PTSD can all be present. [post-traumatic stress disorder] can also cause some of this fragmentation—but keep this singular point in mind—the fragmentation is still physical, which means if a drug doesn’t solve the brainwave problem, then the drug is not the correct treatment.

It’s all about the brain waves. Your brain waves are physical and intended to help you get healthy sleep.

This research is from the field of Sleep Medicine, and mental health patients are completely sold once they hear it. They claim, “Oh, my goodness, you’re saying all this time, I’ve had this physiological sleep condition with my mental health problem, and you’re saying we could do something about it?”

Olmstead: This means that patients need to be offered physiological treatments instead of psychological ones for their sleep issues.

Krakow: Because sleep is in your brain, physical sleep disorders often have a psychological component. So even patients suffering from sleep apnea can experience many insomnia symptoms. Some insomnia cases are more psychologically driven that others. For all my patients and clients, I believe in a personal-tailored medicine approach to their care.

It is important to understand the psychology behind sleep. One of the most worrying places in which the mental side of sleeping is concerned is the “problem of insomnia”. “losing sleep over losing sleep.”

When your mind ratchets up the anxiety, the worries, and the rumination, your racing thoughts go beyond your finances or relationships—rather, now you’re getting upset by the loss of sleep itself. You may think if you don’t sleep you’re going to go insane, or you’re going to harm yourself, or that it’s dangerous to not sleep—once you go down this pathway, unfortunately, you’re right—it can become dangerous.

Suicidal ideation is often triggered by losing sleep. Patients can get so caught up in the fact they can’t fall asleep that they make their own sleep worse and worse. That’s when medication is crucial.

Olmstead: Reverting to physiology, we write. “Just as kidneys and liver filter your blood, healthy sleep detoxifies and eliminates waste matter generated in your nervous system during wakefulness.” Can you give us a detailed explanation of this elimination process?

Krakow: There are two reasons why you sleep. How do you reenergize? What is the source of your energy for the next day, and where does it come from? It all comes from sleep. When you sleep well, your body is an extremely powerful internal generator of energy. When you get up, you should feel good. Sleep is undoubtedly the most natural rejuvenating experience for our bodies and minds. The human organism uses oxygen and water as powerful, but external resources. The organism works by sleeping.

But the second part—to detoxify—should also be obvious, presumably even before science discovered this connection. Dr. Maiken Nydergaard has been in the medical field since 2015. [M.D., neurology–University of Copenhagen (1983), Ph.D., neuroscience–University of Copenhagen (1989)] Has done work on glymphatic system “the brain-washing system.” Why shouldn’t the brain have its own system of cleansing?

The brain is just as important for detoxification as the liver and kidneys. Most likely, some of these capabilities are already present. “waste matter” is eliminated to help you gain energy, some to alleviate your sleepiness the next day, and some appears to remove metabolic toxins—possibly related to neurodegenerative diseases like dementia.

We will be able to find different treatments for sleep disorders once we know more about the glymphatic systems. We do know that brain-washing works best in deep sleep. Therefore, we once again see why sleep-quality problems are so important for many sleep disorders.

Why is it that some people develop memory problems sooner than others? It’s most likely that their sleep is not good enough. It’s as simple as that. Poor sleep makes you age faster. And when you fix poor sleep, you’re coming close—literally—to reversing some of the brain damage that has occurred from poor sleep.

Olmstead: There are many connections made in your book about sleep disordered breathing. [SDB] and how it affects sleep quality and depth. Could you please tell us more?

Krakow: Sleep-disordered respiration is the elephant in this room. It can be connected to many conditions. The insides of your blood vessels are destroyed by sleep-disordered breath. It triggers an oxidative stress problem by releasing what is known as pro-inflammatory chemicals. These conditions, which involve the release of harmful biomolecules, can cause damage to the inner linings your blood vessels. Endothelial dysfunction, which is the result of this cumulative damage, is also known.

The blood stops flowing properly because of this trifecta of inflammation and oxidative stress. Are there blood vessels anywhere? Everywhere. This gives you a global explanation of how you can end up with cognitive problems, heart problems and kidney dysfunction, diabetes, and many other conditions.

Contrary to conventional wisdom, the largest determinant of a sleep breathing disorder is not your weight—but your facial structure, your throat, all the anatomy inside your throat involving your upper airway—things like your palate, tonsils, tongue, even your bite. A square-shaped head tends to have a bigger airway than a narrow-shaped one, which would indicate a smaller airway. This has been known for decades. A crowded mouth could indicate that the airway is more congested in the back of your throat. This is the most important determinant.

Obese patients with sleep apnea often have very crowded airways. It wasn’t because they were obese. It was their anatomy. Many patients suffering from sleep breathing disorders are either normal or underweight. This is the reason why doctors and therapists often don’t recognize such a significant physical difference. This is because they look at patients and immediately dismiss any suspicions of a sleep disorder. Unfortunately, many sleep doctors make the same mistake.

“Sleep apnea” It suggests that you stop breathing. But “sleep-disordered breathing” The difficulty in breathing during sleep can mean that you are experiencing a variety of difficulties. This makes it harder to spot. Even minor changes in the volume of the air you breathe can disrupt your sleep throughout the night.

Olmstead: What can individuals do at home to improve their quality of sleep?

Krakow: My path has been called “Sleep Coaching” over the many years I have worked in sleep medicine. “early, conservative sleep-breathing treatment strategies.” The majority of them are primarily focused on the nose.

You can find a video series free of charge on my website, called The Nose Knows. It is the process of normalizing our breathing. You can live with what you have, even if you are experiencing congestion, stuffiness, or runny nostrils. Sleep medicine teaches us to intervene early and say: “Why don’t you squirt some nasal saline rinses in your nose three times a day, for two weeks and tell us what happens?”

In follow-ups, this person frequently stated that they were sorry. “You know what? I’m already sleeping better. Wow.”

We have at least two other strategies. Nasal strips are one option. One is nasal dilators. A study was done 20 years ago and found that 75 percent of insomniacs experienced improvements in their sleep after using nasal strips every night for just one month.

The nasal strip increased airflow and decreased arousal, which could have led to sleep fragmentation. Some nasal dilators are more effective than others, according to us.

Many new innovations are appearing on the market that attempt to ease or simplify SDB treatment. There are many options for treating SDB with oral devices and positive airway pressure (PAP), machines that hold the jaw forward. It is great that there are more options available, as continuous positive airwaypressure (CPAP), can be difficult for some patients. We discontinued CPAP use in 2005 and recommend that patients only use the more advanced PAP devices, auto-bilevel or adaptive servo-ventilation (APV). These devices deliver pressure much more gently, which makes adaptation easier and improves the response.

Olmstead: Can people resist saying, “This can’t work. It has to be a drug?” Many people believe that they don’t have much control over their sleep.

Krakow: We know that many patients and health care providers have never been trained to understand and treat sleep disorders. This is why it’s no surprise that many troubled sleepers turn to pills. A lot of patients have been told by health care professionals about their sleep problems. “sleep problems are all in your head.” This point can sometimes be very discrediting.

Most health care professionals try to be diplomatic when they say, “Well, you’ve got a lot of anxiety, let’s try these medications.” Their sincerity is often eclipsed by their profound ignorance about sleep. They aren’t aware of how small and out-of-date their toolboxes are and what tools they don’t have.

The good news is that patients are open to new ideas and thinking. “Well, wait, you’re telling me there’s another way to deal with sleep? And you’re saying if I breathe better or I get better sleep quality, that’s going to make a difference?”

It will make a huge difference. Try these new methods of sleeping. These new approaches to sleep will be a hit for you for a long time.

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