Why do you wake up at night? What causes these awakenings that prevent sleeping through the night? How do these middle of the night interruptions lead to insomnia, the prolonged episodes where you desperately desire sleep yet cannot catch one wink let alone forty? Most insomniacs imagine stress, an overactive mind, or a genetic background causes this vexing sleep loss. Remarkably, these questions had never been researched until Dr. Barry Krakow and his colleagues conducted a study on 20 classic insomniacs, all of whom believed their problems were due to stress, racing thoughts, or a genetic predisposition. In a landmark study, published in the journal SLEEP, they demonstrated 90% of awakenings experienced by these insomniacs were preceded by a disruption in their breathing while asleep. In effect, they found a major, and likely primary, cause for why people wake up at night and have continued to research and demonstrate this physiological breathing problem in thousands of insomnia patients.
A lifelong insomniac, Barry Krakow was fortunate to gain seven years of blessed relief—four years in medical school and three at UNM School of Medicine, completing an internal medicine residency. Soon after, divine providence guided him to a sleep medicine career as a clinical specialist and sleep researcher, studying and treating chronic nightmare and insomnia patients at Maimonides Sleep Arts & Sciences, sleep medical center, and Sleep & Human Health Institute, sleep research facility. In the 1990s, Dr. Krakow learned first-hand how unwanted bouts of sleeplessness (insomnia) were not caused solely by the standard explanations found in nearly all medical and psychological textbooks. Insomnia was far more complex and ultimately proved to be intricately linked to sleep breathing problems. Since then, his quarter of a century quest to map out connections between insomnia and sleep-disordered breathing yielded results beyond anything he would have dreamed possible.
This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at https://www.ted.com/tedx
Twenty years ago, this little purple box saved my life. It all happened in one night, a night of the most restful sleep I’d ever known. Earlier that day I was talking with my friend and colleague, Dr. Thomas Mead, a pioneer in dental sleep medicine.
I was belaboring Tom, with my two-year running battle with chronic insomnia. Frequent awakenings, trips to the bathroom, struggling to get back to sleep. Exhausted in the morning, and tired and sleepy throughout the day. Plus, two car accidents tied to sleep deprivation. Tom’s Cheshire cat grin told me he’d heard this story before, as he pulled this magic box out of his oversized briefcase. He pulled it open, took out this piece of plastic, plopped it in a mug of water, boiled it in a microwave, and then he handed it to me and said, “bite this.” After clenching my teeth into the warm plastic mold, I handed it back. He smoothed the surface, handed it back to me, and he said, “let’s see if you breathe any easier tonight.” Which was a strange thought to someone who was complaining about insomnia.
That night was so memorable. I can still picture in my mind’s eye, waking up, turning over and asking my wife, “Jessica! What happened?” Nothing happened that night. There were no awakenings, no trips to the bathroom. I felt incredibly rested from the best sleep I’d had in two years, really 35 years, as the true nature of my sleep disorder finally dawned on me.
This exact moment changed my life dramatically because that day I experienced an enormous burst of energy in my mind and in my body, the likes of which I never dreamed possible for my own health. This moment also revolutionized my thinking, practice, and research in the field of sleep medicine.
The irony is, Dr. Christian Guilleminault made this discovery linking sleep breathing and insomnia in 1973. Nearly 50 years later, we’re here discussing how something physical could cause insomnia. An idea that has flown so far below the radar of the general medical profession and even portions of the sleep medical community all because of the failure to ask this singular question: why do you wake up at night? Why DO you wake up? How common are awakenings? In this audience, at minimum, probably one third of you struggle with sleep or make trips to the bathroom. Yet, because so many of us wake up we think it’s normal.
Well here’s snoozeflash number one, if you wake up and suffer from broken sleep, trips to the bathroom, you’re tired and sleepy the next day, you suffer from a serious sleep disorder: chronic insomnia. A devastating and costly condition, chronic insomnia damages your brain and your heart. It worsens anxiety and depression; it even inhibits your ability to fight off infections.
Billions of healthcare dollars are used up through the ravages of sleepless nights on your mental and physical health. Billions more are lost economically from sick days, workplace accidents, and decreased productivity. And of course billions more are spent in the desperate search for sleep aids – over-the-counter drugs, prescription sedatives, vitamins, minerals, supplements, herbal remedies – yet few find truly lasting relief.
Mental health patients suffer the most from insomnia, yet more drugs are prescribed. Tranquilizers, antidepressants, antipsychotics, anti-seizure drugs; they may help mental health but these drugs cause side effects to worsen your sleep. Millions more insomniacs believe or are lead to believe, that the only solution to sleepless nights are drugs. And yet they suffer for years, without finding a cure, and often never hearing of any other options.
So if drugs are not the answer to this very vexing condition that drives some people so crazy they become suicidal or make some people feel crazy out of the embarrassment, shame and fear from not being able to sleep, what is the answer?
For these psychological problems, cognitive behavioral therapy for insomnia, CBT-I, is a potent tool because so many insomniacs frustrate themselves – lying awake in bed, tossing and turning, checking the clock, trying to force sleep – all of which just aggravates their sleeplessness. CBT-I is empowering to you far beyond drug therapy because it teaches you to stop losing sleep over losing sleep. Yet neither CBT-I, nor drugs, answer our question: why do you get up at night?
Normal sleepers wake up and go right back to sleep. Why? Because they’re sleepy! Insomniacs wake up and go from zero to sixty in about two seconds. Not only are they wide awake but they may suffer racing thoughts, heart palpitations, anxiety, stress, worries, all because they’ve been jarred out of their sleep to being fully alert. Normally we gradually ascend from slumber into waking consciousness in the morning, with or without coffee.
So why would you suddenly wake up at night? Unless something was waking you up. This clue would have explained insomnia but was ignored for a long time. Research does show that insomniacs line up the usual list of suspects to explain awakenings – anxiety, stress, worries, racing thoughts – but even insomniacs know they are asleep before they wake up. So they don’t know with certainty why they’re waking up and they remain perplexed about being fully alert in the middle of the night.
We researched insomniacs in the sleep lab and monitored them before, during, and after these awakenings. And the results were breathtaking. Not only did they wake up more times than normal sleepers, but they suffered hundred of mini-awakenings, what we call arousals that were fracturing their sleep and destroying their sleep quality.
And if you’re ready for snoozeflash number two: 90% of their awakenings and arousals were caused by… please take a deep breath… because that’s what they didn’t do! Their breathing was compromised and obstructed because they suffered from obstructive sleep apnea, the same condition that fueled my insomnia 20 years ago.
On this graphic you will see the three main breathing events of sleep apnea.
At the top is normal breathing, smooth rounded curves up and down suggesting breathing in and out. At the bottom is an apnea. A flatline complete suffocation as your throat collapses obviously anyone would awaken from that blockage. Next are the hypopneas, a 50% reduction and then the flow limitation, a 25% reduction. All these breathing events can awaken you. Insomniacs have more of the moderate types so perhaps you’re asking – would a 25% reduction in your breathing wake you up?
Well, let’s try this experiment. Go ahead and let’s put your hands out in front of you, just take a moment, now bring them up to your throat and start choking yourself for about 25…ok you get the picture. Breathing is good. Not breathing is life threatening. Which explains where all the skepticism comes about this theory, because how could you possibly wake up all night long from a breathing problem and not know about it?
Consider the case of severe sleep apnea. They suffer hundreds of suffocations all night long. Complete loss of their breathing… When do they seek help at a sleep center? Only after someone from their bedroom freaks out watching and listening to them not breathe, and afterwards do they seek help a few months later? No. How about a few years later? No. Only after suffering a life-threatening disorder for about a decade might they seek help – so if the worst case doesn’t get it, then how would insomniacs detect the problem when they only suffer this more moderate breathing disruption that still wakes them up? This recognition gap caused us to delay our understanding in the link between insomnia and sleep breathing problems.
Now we comprehend that so many insomniacs suffer two disorders in one! The psychological side is easy to see you’re awake, but the physiological side is hidden from you because you are asleep. This radical paradigm shift and knowledge demands a new term to designate the complexity of this problem. So we call it complex insomnia. Which indicates the need for in-depth physiological testing – an overnight sleep study to identify and diagnose what’s waking you up.
For any diehard skeptics still out there we’ve got one final and astonishing piece to the puzzle. Remember, insomniacs make trips to the bathroom and complain about it. That’s called nocturia. Snoozeflash #3: Who would have thought it? Sleep apnea causes nocturia. Sleep apnea pushes excess blood flow into your heart all night long. The heart responds by releasing a natural diuretic making the kidneys work overtime throughout the night. So sleep apnea causes insomnia and nocturia – actually a very nice two-for-one deal when it comes to treatment.
There are three levels of therapy to treat sleep breathing. First, focus on nasal breathing. Nasal saline rinses, neti-pot washes, prescription nasal sprays will eradicate chronic congestion. We strongly recommend nasal strips because we studied insomniacs with moderate sleep breathing symptoms and 75% of them reported a decrease in insomnia just by using the nasal strip on a nightly basis. Next are mandibular advancement devices or oral appliance therapy like the ones provided to me by Dr. Mead. These are becoming first line therapy. They gently anchor onto your dental arches and thrust the jaw forward opening the airway permitting more air through and eradicating the majority of your breathing events. Last is PAP therapy, positive airway pressure the gold standard. Most know it as CPAP. The C stands for continuous, or constant pressure breathing in and breathing out. And that’s the problem. You probably know someone who has failed CPAP because they couldn’t tolerate breathing out against that constant pressure.
Mental health patients and insomnia patients can’t tolerate CPAP. They develop panic attacks, claustrophobia and even traumatizing experiences so harmful to them they will drop out of care for a few years just after a brief exposure to CPAP. Unfortunately, some insurance carriers and even some sleep centers, do not recognize these side effects and instead blame patients for not using CPAP. Fortunately, technology has found a better way. In 2005 we switched all of our patients over to bilevel devices, dual pressure… high pressure when you breath in and low pressure when you breath out. This matches your natural breathing patterns. There are even advanced bilevel devices which monitor your breathing and adjust pressures all night long. Last, sleep technology is expanding. With numerous masks that can fit into your nose, over your nose, or as full-face mask. And there are mask liners that enhance comfort. Virtually anyone can learn to use the gold standard breathing treatment. If they are prescribed the right PAP device, accurate pressure settings, and the best mask fit.
Are you ready to put this to bed? I trust you’ve learned three things. Insomnia is a common disorder, with serious consequences to your mental and physical health. But you probably won’t seek treatment until you realize that frequent awakenings and broken sleep are not normal. Second, insomnia and sleep apnea are joined at the hip. Using this term complex insomnia will encourage you and your providers to attack the mental and physical part of your sleepless nights. For so many of you that suffer, as incredible as it sounds, insomnia is not only in your mind. It is also in your airway. Last, there are plenty of treatment options available and all of them produce good to great results. I would like to close by saying, I sincerely believe, sincerely, that if you apply this information with the aid of your doctors, dentists, and sleep medicine professionals, you will conquer insomnia and discover and experience the rest of your life. Thank you.
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.