I was given a very exciting opportunity to speak at a TEDx event in Albuquerque, covering my favorite topic “complex insomnia,” the term we use to designate the intricate link between insomnia and OSA/UARS. I knew the process to prepare was going to be intense, but it prove even more so than I had imagined. Two aspects proved the most labor intensive, the first in finding the right content and the second in practicing the talk in way to deliver it in a more natural conversational style to avoid sounding like a canned talk.
Despite my expertise in this area, the preparation process was extremely team-oriented, because you receive (and need) the advice of TEDx experts who have already gone through the process and given their performances in years past. Their coaching proved invaluable in actually discovering the best, most succinct and most interesting content for me to deliver to an audience of 2000 people. Right from the start, their first criticisms were that I sounded like a doctor (imagine that?) giving a lecture.
My early drafts were stuck with the opening question: “Ever wonder why you wake up a night?” I still think it’s a great opening because so many people report awakenings at night yet the vast majority of adults assume awakenings are normal. The narrative then proceeded through all the essential concepts of why awakenings are not often normal and instead frequently reflect a telltale sign of chronic insomnia. In other words, this first iteration built a foundation of information about sleep in general and insomnia in particular until it reached the climax where our research explained how awakenings are commonly caused by sleep breathing events. This model of narrative built suspense, but requires waiting until more than halfway through the talk to discover the secret to the mystery of why people wake up at night.
The immediate feedback was that the talk would be too “suspenseful” and the audience would likely find it more difficult to follow the narrative, because it was taking too long to reach the climax. Instead, I was offered the analogy of a modern day crime thriller, where you see the “murder” in the opening scene and then the rest of drama plays out over time. The analogy here is the audience is better served when the target of the story is revealed from the get-go even if they do not fully understand all its intricacies. A related complaint was the lack of personal involvement in the story and the need for a “hero” who is not the same person as the speaker, that is, not me!
Because truth is always more interesting than fiction, I was able to switch the introduction to a personal story, an anecdote I was imagining to appear later in the talk. That is, I assumed the need to explain complex insomnia’s linking of the two disorders—insomnia and OSA/UARs much later after all the essential sleep background. In the new narrative, I now had a personal story, a prop and a hero as I began with this line: “Twenty years ago, this little purple box (containing one of Dr. Thomas Meade’s early oral appliance inventions to treat sleep-disordered breathing) saved my life.”
The anecdote delved into a chance encounter with Dr. Meade at a local sleep journal club where I was belaboring him with my troubles dealing with insomnia from 1996 to 1998. Back then, Tom always carried around an oversized briefcase with samples of his Therasnore device, and at the end of journal club he whipped out the purple box and walked me over to the sleep center’s kitchenette, where he put the moldable plastic into a mug of water and boiled it in a microwave. In other words, he conducted an on the spot OAT fitting, and the very first time I used the device (that night), I experienced a dramatic change in my sleep for the better that radically influenced my personal health, mentally and physically, as well as my career in sleep medicine, because I literally recognized what it meant to sleep normally for the first time in my life.
The remainder of the talk then moved into more traditional areas where the following components of essential knowledge are conveyed through a series of questions, directly or inferred, all of which ultimately converge to answer the question, “why do you wake up at night?”
- Why awakenings at night are often not normal.
- What defines the problem of chronic insomnia.
- How earlier research uncovered the link between insomnia and OSA/UARS and yet remained under the radar for so long.
- How much money, measured in billions, is consumed, lost or spent due to chronic insomnia.
- How drugs are the most common approach to treating chronic insomnia.
- How mental health patients suffer the worst insomnia.
- Noting that insomnia can be so bad in some mental health patients it causes suicidal ideation.
- How cognitive-behavioral therapy for insomnia (CBT-I) is an empowering tool, compared to drug therapy, because it teaches insomniacs how to stop losing sleep over losing sleep.
- How neither CBT-I nor drug therapy answer our main question, “why to do you wake up at night?”
- Why most insomniacs actually know they don’t know why they wake up.
- How our research showed 90% of insomniac awakenings were caused by OSA/UAR events.
- How this information represents a radical paradigm shift in knowledge that demands a new term to convey the complexity of the problem, thus we use the term, “complex insomnia.”
- The remainder of the talk lays out the various treatment strategies for OSA/UARS:
- Nasal hygiene
- Prescription nasal sprays
- Nasal dilator strips
- Oral appliance therapy aka mandibular advancement devices
- Positive airway pressure (PAP) and how CPAP is not tolerated by many mental health and insomnia patients due to the discomfort breathing out against constant pressure
- Use of BPAP, ABPAP, and ASV devices as more comfortable and effective modes of treatment.
- Last, summing up described the three main points of the talk:
- Insomnia is common but treatment is usually not considered until the individual stops normalizing night time awakenings.
- Insomnia and sleep apnea are joined at the hip, and therefore using the term complex insomnia encourages treatment of both the mental and physical aspects of this disorder.
- Plenty of treatment options are available for OSA/UARS, and all of them provide good to great results.
In my final words, I encouraged listeners to work with their doctors, dentists and sleep medicine professionals to conquer insomnia and discover the REST of your life.
Due to previously planned travel, my TEDx talk was videotaped and scheduled to appear on the night of the other live performances on September 9th. One value to videotaping was the ease with which we were able to film various props described above for the treatment of OSA/UARS. When the video is available publicly on the internet I will update it here.
About the author
Dr Barry Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr. Krakow started in sleep research in 1988 and helped pioneer innovative therapies for chronic nightmare patients. Since 1995, he has practiced sleep medicine full-time and currently operates Maimonides Sleep Arts & Sciences, Ltd., a private sleep medical center specializing in the treatment of sleep disorders such as insomnia and sleep apnea in mental health patients. He is also principal investigator of the Sleep & Human Health Institute, a non-profit research center that focuses on the complex interplay between physiological and psychological sleep disorders.