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An Interview with Barry Krakow, M.D., on PTSD and Sleep

David Van Nuys, Ph.D.

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Barry Krakow, MD

Initially trained as an internist and emergency room physician, Dr. Krakow's interest in treatment of sleep disturbances developed after he pursued an interest in medication side effects related to sleep problems. He has since become a sleep researcher, and runs a sleep clinic in Albuquerque, NM specialized in the treatment of sleep problems co-occurring with PTSD and other psychiatric disorders. Though PTSD is associated with nightmares, successful treatment of these nightmares does not necessarily improve sleep. Instead, PTSD (particularly long-term PTSD) often co-occurs with independently diagnosable and treatable sleep disorders including insomnia and apnea. His research suggests that many chronic insomnia patients also have undiagnosed apnea like conditions they are not aware of. He frequently prescribes an imagery technique for treatment of nightmares called Imagery Rehearsal Therapy or IRT. In IRT, patients are taught that nightmares are habitual learned behaviors and therefore modifiable. Patients are then instructed to change their nightmares however they wish and to practice this between sessions. The technique is associated with symptom relief. IRT has no exposure therapy component, but Dr. Krakow does think incorporating one might be helpful. Other sleep disorders are treated using appropriate techniques including use of breathing assistance machines such as adaptive servo-ventilation (ASV), which PTSD patients more readily tolerate than CPAP. Imagery techniques are taught as distraction devices to help patients cope with the discomfort associated with breathing machines. Addressing co-occurring sleep disorders helps PTSD patients rally and cope better during waking hours.

David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.

On today's show, we'll be talking with Dr. Barry Krakow about his work with PTSD and sleep. Barry Krakow, M.D., is a board-certified internist and sleep disorder specialist who has spent over 30 years in medicine in the fields of internal, emergency, addiction, and sleep medicine. He's conducted more than two decades of research in the treatment of chronic nightmares and disturbing dreams, at the University of New Mexico School of Medicine and the Sleep and Human Health Institute.

Dr. Krakow graduated magna cum laude from the University of Maryland School of Medicine. He was residency trained and board certified in internal medicine and also has 10 years of clinical work in emergency medicine. He is a member of the American Academy of Sleep Medicine and the Sleep Research Society, and is the former medical director of University Hospital Sleep Disorders Center.

Dr. Krakow has published two books: Insomnia Cures and his most recent, Sound Sleep, Sound Mind, which is the first book of its kind to focus on mental, emotional, and physical causes to sleep disturbances. Dr. Krakow and his wife Jessica Kohr Krakow have also published Turning Nightmares Into Dreams, an innovative self-help audio series and workbook to eliminate bad dreams. Dr. Krakow is the medical director of Maimonides Sleep Arts and Sciences, Limited, in Albuquerque, New Mexico, as well as the principal investigator of the Sleep and Human Health Institute, a nonprofit research facility.

Now, here's the interview.

Dr. Barry Krakow, welcome to Wise Counsel.

Barry Krakow: How are you? Thanks for having me on.

David: I am great, and I'm glad to have you on. And you and I have both been members and presenters at the International Association for the Study of Dreams, their annual conference, and we might have even met a few years back.

Barry Krakow: I'm sure we did. I'm sure we certainly heard each other speak and talk.

David: Yes, well it'll be good to reconnect now. Now, you trained originally as an internist and later worked as an emergency room physician. How did you come to be interested in sleep and dreams?

Barry Krakow: I saw lots of nightmares in those two practices.

David: Really?

Barry Krakow: Well, in a way, but the kind of nightmares are, of course, of a different sort. What happened was, late in the 1980s, I was approached by a family member who asked me to do some investigation into his nightmares, and it turned out it was a medication side effect, but in terms of serendipity I ended up interacting with two psychiatrists a the University of New Mexico, where I was working in the emergency room. And those two psychiatrists, Joseph Neidhardt and Robert Kellner, were conducting research on nightmares; and they in fact were comparing the imagery rehearsal therapy technique with a desensitization approach, and this was back in 1988.

I ended up writing an article about them for the Albuquerque Journal, which then recruited more than half of their subjects into the research project; and within a few weeks I joined their research team, and then subsequently Dr. Neidhardt asked me to co-write a book on nightmare treatment with him, which was published in 1992, Conquering Bad Dreams and Nightmares.

David: And then eventually you opened up your own sleep clinic, which you've titled Maimonides Sleep Clinic. At what point did you decide to open up your own clinic?

Barry Krakow: Well, I started at the university to get involved with sleep medicine, and that lasted through the '90s. I did a lot of my research on the imagery rehersal therapy at that time. But I also was receiving board certification in sleep medicine, so I was learning a lot more about insomnia, sleep apnea, leg jerks, restless legs disorders, circadian rhythm problems for people with sleep.

And so, all through that period I was learning a great deal and applying a lot of skills and beginning to develop our theories about PTSD, where we would see many of these patients not just with the nightmares, but with these other sleep disorders. In fact that's what tipped our hand, so to speak: that we treated patients for their nightmares; they got a decrease, a substantial decrease, in the nightmares; yet they continued to have sleep problems, and we began investigating that, and that's when we realized there was more to it in terms of the insomnia, the sleep apnea, and so forth.

And so in the year 2000 I left the university, and I started a nonprofit - the Sleep and Human Health Institute, which is a nonprofit research center - and then in 2002 we started Maimonides Sleep Arts and Sciences, our private, for profit commercial sleep center.

David: Well, one of my colleagues referred me to a couple of stories in the New York Times website about work you've been doing with nightmares in connection with PTSD.

Barry Krakow: Right.

David: And I think they talked about what you were just - what was the phrase? Image rehearsal therapy? Is that what it's called?

Barry Krakow: Right. Imagery -- imagery rehearsal therapy, and that is what led us to this whole - and this is basically 20 years of work, where we are seeing that you can work with someone's nightmares directly using a technique that helps them to modify the dream, and then this is all, of course, done during the waking state.

But, as we were talking about at another time, what's so interesting is that in doing that work and focusing so much on the nightmares, we've been so surprised to see this greater complexity of the sleep disturbances in these PTSD patients. In fact, as I described to the New York Times reporter, there seems to be almost a crisis in the field of PTSD treatment because there's so little attention paid to these sleep problems. People are treating PTSD with good treatment such as the exposure therapy, the MDR, and a variety of other techniques, but yet we see patients in our sleep center consistently, patients who come in, who've had PTSD treatment, but yet still have sleep problems.

And so this is an area where I'm very concerned about, and I think other people are beginning to get very concerned about; that we're wondering whether or not the people with PTSD that are not doing as well in their treatments - maybe what's missing, what maybe might be a missing link so to speak, is that they're just not paying attention to the complexity of sleep disturbance that these people truly suffer from.

David: Well, that's interesting because I've always thought of nightmares in particular, and I guess more generally sleep disturbance, as one of the hallmarks of PTSD, as kind of one of the main presenting symptoms that tends to bring people into treatment.

Barry Krakow: Exactly, and yet the question is what are nightmares. Are nightmares only a psychological process? Or is it possible that nightmares are a marker or a reflection of physiological processes as well. Interestingly, a lot of people don't seek treatment because of their nightmares; it's relatively uncommon for people to do that at a sleep center. It's much more likely at a mental health center; they might bring that up for discussion.

But nightmares do influence sleep, and that's one of the things that we figured out early on; that it was amazing how many people who had nightmares did not connect that to how it was disrupting the quality of their sleep. And it was even more remarkable how many nightmare patients did not make any connection between their fear of having a bad dream and then their desire to prolong their bed time until eventually they had insomnia.

In explaining that to them, it opened up a whole new window of understanding of their problems; and of course talked about things like psycho-physiological conditioning and learned behaviors, and how the fear was actually started by having had so many nightmares at night. But they were not making these connections, and we were focused on the nightmares at first and only later did we begin to see that there was a much broader range of problems associated with the nightmares, involving, in general, the concept of very poor sleep quality.

David: Well, do you think that PTSD nightmares are different from other sorts of nightmares? And the reason I ask this is because depth oriented therapists - Jungians and psychoanalysts and so on - would tend to say that our nightmares contain important information that we need to attend to and learn from, but maybe that's not true for "normal" nightmares - I mean maybe that's true for "normal" nightmares but not for PTSD-related nightmares. Do you think there's a difference?

Barry Krakow: Well, I think it's a great question because in all of mental and physical health there's always a spectrum. There's always a spectrum of ways of looking at things. There's no question there's a spectrum of how we look at nightmares. As you know from your earlier comment about our working with ASD and our interest in dreams, I'm an avid supporter of dream interpretation techniques. Dr. Neidhardt trained me in this area; we wrote an entire section in our book Conquering Bad Dreams and Nightmares about dream interpretation techniques for the treatment of nightmares.

But the distinction is, and the one that became very apparent to us early on, was that the big difference that you're alluding to is that there are people who, when they are first traumatized and they have the potential for PTSD, that would be a very opportune moment for them to do the dream interpretation work because it's so obvious that the nightmares are providing valuable information. In fact we talk about that in our treatment groups all the time so that people recognize that the nightmares are trying to help in some way; they're trying to provide warnings or information or something that allows a person to move forward and evolve from this very difficult experience.

But the other end of the spectrum are these people who've had these disturbing dreams not for a couple of months, but who've had them for 5 years, for 10 years, for 20 or 30 years. Many of whom have already been in many sessions of psychotherapy, some of who have done their own dream interpretation work. It's very rare for me to meet a nightmare patient nowadays who has only had them for a few months. It's rare to meet somebody who's had them for less than a year. The average nightmare patient I meet has had them for between 10 and 15 years, and most of them have post-traumatic stress.

So the question you're raising is a great one because you could ask the question could this person benefit from dream interpretation work, and my answer would still be probably yes, but it would be also nice for that patient to be able to sleep. And that's what's happening, and that's what a lot of people I think are not recognizing. These nightmares are very destructive to somebody's sleep and making it very difficult for them to function the next day. And as we'll talk about later on, not only are the nightmares a great destroyer of the patient's sleep quality, but the nightmares appear to be a marker for a co-occurring event with other sleep disorders that are happening with these patients.

David: Well, we've learned so much about the plasticity of the brain, and I have to think that, after 10 or 15 years of nightmares, that something is getting changed in the brain, that something is being written, if you will, on the brain; and that maybe it really does become a different sort of issue at that point.

Barry Krakow: Right. It's almost as if the brain circuitry has now been programmed to respond to a nonspecific stressor where the individual simply has nightmares instead of something else. In other words, something happens during the day, and maybe their emotional processing skills are weak or nonexistent, or something is going on where the brain is just wired to repeat disturbing dreams whether they happen to be of the same content or different. So I agree with that.

We often use the word "learned behavior" or "bad dreams become bad habits." And part of the proof, if we can call it that, for that theory is that when you do use a technique such as imagery rehearsal therapy, IRT, then it doesn't take a long time to undo that circuitry and the patient's nightmares go away. So I think that does support the idea that this end of the spectrum of the chronic nightmare patient may be a different - or have certain distinctions compared to the initial onslaught of nightmares.

David: Yes, I really like that conceptualization. It makes sense to me. Well, maybe you can give us more detail on IRT, image rehearsal therapy. Take us through those steps. Maybe you can give us a case example even.

Barry Krakow: Sure, sure. Imagery rehearsal therapy has variations to it having to do with two big issues: that is, how much you want the patient dealing with the old nightmare versus just moving on to this new dream that I'll describe in a moment. And also whether or not, when you ask somebody to re-script or revise or change their nightmares, how much influence do you want the therapist to have versus how much do you want to empower the patient.

The simple technique is select the nightmare - we often tell patients don't pick one of the worst ones because that's probably too distressing, and the goal is just to learn the technique at the outset. So you say, select a bad dream, change the bad dream any way you wish - which is Joe Neidhardt's original instruction that we've followed now for 22 years. Change the nightmare, change the bad dream any way you wish, without giving any further guidance. And then the individual makes those changes. They can do them on paper. They can preferably just learn to do it in their mind's eye, and most people will do that.

And then that individual rehearses that new dream. Could be a few minutes a day. In research we've noted that successful users practice between 5 and 20 minutes every other day. That was the average that we documented in one of our studies. So it's not as if you even have to do it every day, but once a person gets the hang of it, it's very easy. You can certainly do it in your mind's eye for as little as minute or two a day to get the hang of it, which is where you're simply changing imagery. You're taking it from one set of very, very negative and difficult or traumatic or troublesome images, and you're changing it - and notice I'm going to say here you're changing it to something else. I'm not saying that you're changing it to something better; I'm not saying you're changing it to something triumphant; I'm saying you're changing it to something else.

And I think this is the beauty of Neidhardt's instruction, which is that it's very intuitive and it's almost potentially psychodynamic, where the individual is empowered to take the old dream and, for whatever reasons, change it to something, not necessarily out of some fantasy, but rather something comes to them. Something comes into their consciousness that tells them this is how they want to change it.

David: Now, what if they're not a good visualizer? Is that an important thing, to be a good visualizer?

Barry Krakow: Well, it is and it isn't, in that the question sort of begs the problem of people self-identifying that problem. It turns out - and I'll give you a quick test here - it turns out most people are more than adequate in doing imagery. For example, if I said to you, David, close your eyes right now and take eight seconds to picture how to go from where you're sitting now and get in a car and drive to your favorite restaurant, I'm assuming it would only take you about eight seconds to be able to see the landmarks that you're going to be cruising along, and that, in effect, is your imagery ability. That's very natural to people; it's the mind's eye. We all have that skill. It's an incredibly powerful and underrated skill, and yet we all have that. So that's all you need.

It's not like some Zen meditation or some hypnotic trance, so I believe most people have the capacity. And we've met very severe PTSD patients who definitely have this skill. We were surprised when we first realized that that was the case. The area of concern is more about the patient who has so many waking negative and unpleasant images, such as flashbacks, daymares, or in other ways they seem unstable. That patient may not be ideally suited for doing the IRT program.

David: Oh, that's interesting. So, when you're doing the IRT - say, the initial session or when they come in - do you have them say out loud their dream with the new ending that they've made up?

Barry Krakow: Well, it can go in all manner of ways. In fact, if I can give a small plug here: on our website, nightmaretreatment.com, we sell a workbook and audio series so that someone can do IRT themselves and often in conjunction with a therapist. It's called Turning Nightmares Into Dreams. It's a 100 page workbook, plus it's got 20 audio sessions with it. And what we find is that there are some patients who just get that on their own and they do it. We actually find a lot more therapists who purchase the workbook, and they use that as their own training for IRT.

And what you'll see in the workbook and what we'll be talking about here is that there's just so much variation on the way things can be done, but the key feature - and the reason that the IRT program can take a little bit longer than what we've just described here - is that the average PTSD patient with nightmares is not going to resonate with the idea immediately about, well, pick a nightmare, change it, rehearse the new dream, and we're done. That's just not going to happen. The psychology is not there for that to happen, and we often go in a much different direction in the beginning, which hearkens back to what I said about sleep problems in general.

For example, in the first hour of a 10-hour program that we've constructed for groups - it's 4 sessions, about 2.5 hours apiece - the first hour is solely related to a discussion about insomnia problems and how nightmares and insomnia are related. And we do that because we know that most people who've come into treatment for nightmares do not think there is a treatment. They may attend a research protocol, they may be coming into clinic, but when you tell them there's something called nightmare treatment, they look very confused. It doesn't make any sense to them that there could be a nightmare treatment unless it's some kind of advanced psychotherapy or some medication or something of the sort.

So, we really do spend a long time with them talking about nightmares. You know how we were speaking a little bit ago about nightmares as a learned behavior. Well, that process can take up to three hours of discussion, with patients in a group, to get them on the same page with you, where they will accept the idea that nightmares might be a learned behavior.

David: So you are doing group sessions, then, and this sort of psycho-educational discussion is happening in the context of a group?

Barry Krakow: It can be that way or it can be individual. There's no reason it can't be done with both. Originally we liked the group format better because it was obvious that you would again see a spectrum of nightmare sufferers. For example, one of the key factors that comes up in our discussions about half-way through the program is we ask everybody to consider what they've learned so far and then rate whether or not they believe that their nightmares have persisted for all these years because of the original trauma, or whether or not there's a possibility that this is some kind of habit formation, some kind of learned behavior.

And what's interesting is, if you ask that question at the very beginning of a session - I'm sorry, of a group - in the very first session, you'll have people saying the words like, "Well, what do you even mean by the nightmares are a habit or a learned behavior?" And if they rate it, they'll rate it something like "from 90 to 100% of the reason why I have nightmares is because of trauma."

David: Sure.

Barry Krakow: But then half-way through, which is now about two or three weeks into the program of four sessions - you know, once weekly - more than half of the people will now actually say, "I think about 50% of my nightmares are due to trauma, and I think 50% are actually due to it being a learned behavior." And of course by the time they get through the program, a lot of people are saying, "I want to switch my percentages. I think, now that I really see how this all is unfolding, I think my nightmares might be 90% learned behavior."

So we feel that's a very important component of our training because we know, from other people who have perhaps misused the technique of IRT, or from just our discussions of their own patients, if you give IRT too quickly, before the table is set, so to speak, you can really cause a tremendous amount of indigestion to the patient that will drop them out of treatment very quickly, and could actually do them some harm because they're just not ready for that kind of paradigm shift.

Think about this key point: as you mentioned earlier about the dream interpretation, or the Jungians, most people who've been in psychotherapy are not exposed to the idea that nightmares are a learned behavior. They're told repeatedly, well, the nightmares represent important things here, and we're going to do some psychotherapy, and maybe the nightmares will go away. Maybe we'll even work on some dream interpretation work in the nightmares. All these things they're told - and/or they're being given all this medication for their PTSD - and so they've built up a belief system for at least 5, 10, 20 years about how they're supposed to approach their problems; and those problems are not about, well, your nightmares are a learned behavior and we can help you to unlearn them.

So that's one of the reasons why, even though IRT is a very short treatment program compared to other psychotherapies, it's still long in terms of the fact that the simplistic steps that come at the end of the program do require a fair amount of introductory and preparatory work to get the patient feeling comfortable with that treatment model.

David: Well, I can see that I've latched onto the simplistic piece of it, the IRT part of it; and you've really shown that there's a lot of spade work that needs to be done before you can really use that technique. But I'm still curious if you could maybe give us a case example or two of how IRT was used, what the beginning nightmare was, and how the person changed it. Are there any examples the come to mind that you could share with us?

Barry Krakow: Yes, there are always examples that often come across with a similar theme of being chased or being attacked or being in some kind of environment that's very fearful. And I remember one woman often described that she'd grown up in a time during the duck-and-cover drills with the atomic age, and this was a recurrence of her - I'm sorry: in her dreams she would have episodes like this where she would be concerned about large explosions, overwhelming devastation, and so forth.

And when someone like this has these dreams, we don't say to them here's how you're supposed to do it. They have to come up with something else of their own. And the something else of their own can be something as simple as instead of duck-and-cover, they were able to transform it into, well, we went under our desks because we were looking at these very interesting insects that were roaming around on the floor, and we were following them making these intricate patterns in the dust. And you can see how there's not necessarily anything there that relates to the atomic age or atom bombs or nuclear devastation, whatever, but for whatever reason, the patient didn't say, "I don't want to be under the desk anymore." Whereas somebody else might have had just the opposite: they might have said, "Well, we never went under the desk."

And this is the key thing that comes up in our discussions with the patients, which are, it's not for us - the therapists, the doctors - to tell you how you are supposed to change your dreams. In our group sessions, people will go around and describe various things that they did so others can hear, and they can say, "Oh, yeah, this particular person changed the entire dream. This other person changed such a small part of it."

We're really interested in empowering the patient to realize that they have so much more control of their own imagery, just as you learned to do that with your mind's eye during the day. If you do want to get to your favorite restaurant, you do recall those images, and you remember the different landmarks that you need to go driving. Well, if you can do that during the day to go to a restaurant, there's a whole lot of other things you can use imagery for during the day to help you solve problems. And if that's the case, why not have that power over your disturbing dreams?

David: I think it's interesting that you've made that choice of having the patient construct their own fantasy, because there are, I would guess, a fairly substantial number of therapists who would attempt to use some kind of guided imagery. I'm thinking particularly hypnotherapy people might use more of a guided imagery approach, where the therapist would assume maybe that they could construct something that would be a really healthy fantasy for the person. But you've really chosen not to go down that path.

Barry Krakow: Yes, you're absolutely correct. And as I said earlier that the two issues that come up here are that there are therapists who've researched and written about imagery rehearsal therapy, and they do do a more active role in it, or they give the patient more specific instructions; like they'll say change the ending. And we never do that. We never do that, and we're not clear that you have to do that. We're not saying that the people who do it the other way are wrong; we're simply saying we don't do it that way; and of course it will be interesting to try to compare those to find out at some point.

In fact, Joe and I did a study on this many, many years ago that we never published in its particular form because we didn't really have as many people in the sample as we wanted. But there was something of a trend which suggested - and it's just a suggestion - that telling people to change it any way they wanted to was more powerful in terms of the results than telling people to change the ending, because we had done two different groups.

The other part I just wanted to mention again was this issue of exposure therapy. Right now there are a number of groups that practice IRT by not necessarily discarding the bad dream so quickly as we do. We want the patient to forget about the bad dream. We're just trying to move on to the new dream, and many people - there are some groups in Australia and Philadelphia, I believe, that are doing work where they're looking at combining some aspects of exposure to the bad dream in addition to changing that. And I think that's very interesting work. I think it's more difficult on the patient, but nonetheless we have a very good - I mean there's a very good scientific literature on exposure therapy - how powerful it is - and there's no reason for someone not to try that. That will be very interesting as that research comes out, to find out if the combination of exposure brings up even a better response than simply doing IRT alone.

David: Well, when you say exposure, are you talking about then revisiting the traumatic situation in their imagination? Or are you talking about having them remember the nightmare, recall that vividly? Or are you talking about taking them in vivo to the place where the trauma occurred, which I know is done sometimes?

Barry Krakow: Right. My understanding of those who are doing the nightmare treatment with IRT and exposure combined - my understanding is they're doing it with the nightmare. They're trying to do what I guess Joe Neidhardt and Robert Kellner initially did when I joined them, where they were doing a desensitization; and I assume there doing some elements of that with the disturbing dream as well as then changing it. I don't know the full protocols, but I image that's their point, because they're interested in nightmare treatment as a vehicle for improving PTSD.

In fact, that leads me to - I didn't want to forget to say that that's how we got so interested in moving into the PTSD realm; because when we first did nightmare treatment, it was on non-nightmare - I'm sorry, non-PTSD patients, who may have had some traumatic exposure, but there wasn't much to think that they had post-traumatic stress disorders. Whereas in the mid-1990s, we did research projects, several of them, on trauma survivors with diagnosable and scorable levels of post-traumatic stress in the moderate to moderately severe to severe range. And if I might segue here, that's how in fact, over the period from around 1995 to 2005, I was motivated to write my most recent book, which is called Sound Sleep, Sound Mind, which is really geared towards a patient who would enter into something like a PTSD sleep clinic.

The book obviously can work for anybody who's got a host of sleep problems such as nightmares, insomnia, sleep apnea, restless legs, leg jerks, and so forth. But the work was specifically written with this understanding of what we had finally begun to realize, that nightmares were truly just a tip of an iceberg; that these people have horrendous sleep quality problems. There's something just fundamentally wrong with their ability to consolidate their sleep, whether it's non-REM sleep, whether it's rapid-eye-movement sleep. These individuals with PTSD sleep disturbances often get mislabeled, in my opinion, with the phrase PTSD sleep disturbances. What they really have is PTSD coupled with a number of sleep disorders, and the two other most common ones are insomnia and sleep disorder breathing.

David: Okay, now, on your website and in other materials, you make reference to sleep dynamic therapy.

Barry Krakow: Right.

David: Is that what we've been talking about here all along? Or is that -?

Barry Krakow: Well, IRT was the initial terminology for the treatment specific to nightmares, but starting in 2000, we took on the moniker sleep dynamic therapy to imply that there is much greater complexity in the sleep disturbances of these patients and wanted to get across the idea that it really requires psychological and physiological treatment for patients when they report the problem of PTSD. And I'll give you the specific example that occurred.

There was fire in Los Alamos, New Mexico, around 2000, and 2001 we did a research project in treating these individuals. And we did a very intriguing protocol where we just gave group treatment to about 60 people who had come to a local church once a week for six consecutive weeks. And in evaluating these patients, it was amazing; these were all people who had suffered and survived the fire. Many of them had had their homes burned down; many of them had other forms of problems arising because of the fire or just the outright fear of being close to the fire; and the vast majority of these people had nightmares, insomnia, and sleep disordered breathing. A fair amount of them also had restless leg syndrome and leg jerks.

And in doing the research we learned some very interesting things about them, where some of them clearly had these sleep problems before the trauma, but yet the trauma now had made them much worse. Other patients did not have sleep problems before the trauma, but now they did have them. But throughout the entire group, there was a large number of people with sleep breathing problems; a large number with insomnia; a large number with nightmares. And that's really when it hit home for us that we had to create something that would address this, where people would say, okay, you don't just think PTSD, and you don't just think PTSD sleep disturbance; you think diagnosable, treatable sleep disorders that are co-occurring with the PTSD.

David: That's fascinating. And one of the things that came to mind as you were describing this was I was thinking, gee, maybe you should be training disaster-relief teams. I mean isn't there a lot of evidence that early intervention is best, and maybe if you had teams going into places where there'd been an earthquake or a flood or war - other kinds of disasters - that maybe there are early interventions that could be made based on the work that you've been doing.

Barry Krakow: From your lips to God's ears. We got a grant to do that Los Alamos study from the NIMH, that has something called the Rapid Award Program for Disasters. And at that time, it took more than eight months just to get this thing funded. I think their program is now more rapid than that, but I've had discussions with so many people.

I used to be a member of the disaster medical team at the University of New Mexico and repeatedly recommended that we could put something together in that realm, but just like a lot of stuff with PTSD in general, there's not a lot of interest in sleep yet. It's burgeoning now because of the issue about the nightmares, and recently I did a workshop in San Antonio that met with - we met with about 65 practitioners, mostly therapists and military-related organizations, and they were very, very enthusiastic about the workshop because we delved into training them on the imagery rehearsal therapy for the nightmares, but we spent the other half of the day on the PTSD sleep clinic, going over all of these other aspects about the insomnia, the sleep apnea, and how these patients, when they get a full menu of treatments - as opposed to something that is narrow because somebody things that, well, it's PTSD; we should just stick with nightmares - when we give them the full menu, these therapists could realize how much more powerful the treatment will be, and how it's likely to overlap and help the patients with their PTSD. That's what it should all be about.

You know, if you help somebody sleep better, what do you expect to happen to their PTSD? Well, my own experiences with sleep disorders tell me that if you're not as tired and sleepy during the day, then your ability to cope is much greater.

David: Sure. So, tell us a bit about how you approach sleep apnea and insomnia.

Barry Krakow: Well, interestingly, it was IRT that led us to some of the aspects of how we will help these patients. For example, with respect to insomnia, we now treat almost all of our insomniacs with imagery training because, in terms of the way the human mind works, a person often falls asleep in the following sequence: they will think about a few things, which tend to drift; they will have a few feelings, such as being comfortable in their bed and getting a little drowsy; but one of the last things that occurs before an individual falls asleep is they have little emotion pictures or dreamlets that come across the mind's eye. And if you're as obsessed with sleep as I have been much of my life, you get to actually watch that experience, and you can see yourself falling asleep; because you know that once those little dreamlets take hold, that you're going to fall asleep next.

Well, we teach our patients that. And what's so amazing about imagery work is that imagery, once it's adopted by an insomnia patient, they will report that it's more powerful than sleeping pills, because it is: it's natural; it has no side effects, so to speak; and once you start to use it, most people start falling asleep within a very few minutes, which in many cases is much faster than a sleeping pill. So that's how we started off with insomnia patients, although we use all the standard cognitive-behavioral therapies as well, sleep restriction therapy, stimulus control.

Another area that we're very excited about, that we're trying to submit papers on now, is time monitoring behavior. Many people with insomnia watch the clock. And just by helping them to undo that behavior, they can decrease some of their psycho-physiological conditioning and already they will get some improvement in the insomnia.

With respect to the sleep apnea - and I'll go into these in more detail, but just to give you an introduction. On the sleep apnea, again, we use the imagery technique, and it's remarkable how the imagery technique is so powerful here. Because what we've learned about sleep apnea is that, if you're a PTSD patient, it is not easy to use something like CPAP - and CPAP stands for Continuous, Positive, Airway Pressure therapy, and the Continuous means it's one pressure.

A person has a mask on their face; it's hooked to a tube; it goes to an air compressor. This air flow is opening up the airways so the person doesn't have any sleep apneas. But this airflow is not something that is pleasurable when you first start to use it. It's actually quite uncomfortable, and it's most uncomfortable when you're trying to breathe out when this air is coming in. And what we learned was that if you give somebody a distraction with imagery, that sensation starts to improve and become less of a problem because it's the patient's attention to it that made it worse in the first place. But once you do that, many of these patients now can at least start to wear the mask and start to use the pressure device.

So imagery has been quite useful to us both for insomnia and the sleep disordered breathing.

David: Now, are you feeding them the imagery or are they generating it on their own?

Barry Krakow: We can do it either way. When we have the cases in our sleep lab at night where a patient comes in, we will always inquire first as to how well they can image things on their own. And we'll ask that simple question, can you picture driving from here to your home, and how easily did you do that? We might ask them a few other questions, and then that patient it will be determined can do it on their own. Another patient may still feel somewhat in the dark, and if they do, then we can say, "Well, would you like to try a guided imagery session for a little bit here to get you started?" And we'll do a lot of that in clinic, and we'll do a lot of that in the sleep lab, depending upon what we're specifically trying to treat in that patient.

David: Well, this is all really fascinating. Now, you also run a research program. Can you tell us about some of the research findings you've generated? I think you've already alluded to some. Is there anything going on currently, or do you have some future research that you're planning?

Barry Krakow: No, there's some very good projects that we're doing right now, we're in the midst of. We've published aspects on them, so I can talk about them, and I'll mention a few. And we're also trying to publish them in the scientific literature and the major journals.

One of them refers to the sleep apnea connection that's very exciting, and that is that what we know on this topic of people being uncomfortable using CPAP is that the PTSD patient is a prime example of an anxiety patient who literally will show up on the airflow tracing that we're looking at an irregularity that actually confirms that they're uncomfortable. And when we see that we realize that a lot of patients, even beyond PTSD patients, are getting CPAP and they have the same problem. They can't easily breathe out against the air coming in.

It turns out there's all these newer technologies in the field of sleep medicine. They are called BiLevel or Auto-BiLevel, and another one's called adaptive servo-ventilation. And these devices, the basic thing about them is that they give one pressure when you breathe in, but a lower pressure when you breathe out. And they also have these highly advanced scientific algorithms that measure somebody's breathing as you're breathing through the night, and then the machine changes the pressure setting through the night.

Well, the reason this is so exciting for us is that we're just finishing up a paper where we had - it has already appeared in a recent sleep conference - where we looked at a group of about 50 insomnia patients or anxiety patients who had sleep breathing problems, and these people had failed everything. They couldn't use CPAP; they couldn't use auto-CPAP; they couldn't use BiLevel devices. They could use nothing but this one device that's been on the market a few years. It's called ASV, again - adaptive servo-ventilation - and it just has this incredibly comfortable way of helping a patient to breathe, which is different than the traditional CPAP device. And what we found was that these insomnia patients and these anxiety patients could use the ASV device. They could use it all night long, and they could actually get the benefit.

And so now we're beginning to think this is good because at Maimonides we spend a lot of our time working with mental help patients with sleep disorders. That's our specialty, and that makes it of course easy to do research there as well. And what we're seeing now then is we don't put mental health patients with sleep disorders on CPAP any more. We've stopped doing that. We don't think it works for them anywhere near as well as these more advanced devices. So that's one of the major projects we've been doing, and hopefully we'll have it published by next year.

And a second one that I think you would find interesting is this whole relationship between insomnia and sleep disordered breathing. That's an area we've been publishing on now for several years. And, again, here's another abstract we just finished up and a paper we're working on. When we looked at 20 patients who walked in the door of the sleep center and they said, "I've got insomnia; I'm on sleeping pills; they're not working," what we found was almost all these people have breathing problems and they don't know it. And when we examine the specific awakenings that these individuals had on their sleep studies, the awakenings on their sleep studies were all preceded by breathing events, but yet these patients don't know it.

And when you ask people questions about why do you wake up at night, the answers are usually something like "I don't know why I wake up at night," or they'll give some psychological explanation like "I guess I'm stressed out," or "I had a nightmare," or a physical reason - "I had to use the bathroom." But none of them imagine that they have a breathing thing that's going on; and that's the part that really triggered our curiosity when we kept seeing all these nightmare patients back in the 1990s having both insomnia and sleep disordered breathing.

And it's as if all three of these conditions are overlapping in some way to the point there's actually a belief that if - I'm sorry, not a belief; there's a theory now - that insomnia, by causing so much fragmentation in your sleep, may predispose somebody to having compromised respiratory function so that the breathing actually gets worse and eventually may be some type of trigger or risk for developing sleep apnea.

David: Boy, this is all very interesting. But we're kind of running out of time here, so as we wind down, I wonder if there's anything else that you'd like to add, or a thought that you'd like to leave our audience with.

Barry Krakow: Well, I hope people will have a look at my book, Sound Sleep, Sound Mind, because it's got so much in their on sleep dynamic therapy and so many new ways to look at mental health patients with sleep disorders. I think it's a very informative work. It's really the pinnacle of my writing at this point in terms of putting stuff together, in terms of a mental, physical treatment program for people that have sleep disorders. And I'd also say we've got a lot of information on our other websites - sleeptreatment.com, PTSDsleepclinic.com. So we're really out there trying to get new information so that therapists and doctors will realize that there is so much more that can be done in the sleep angle to help PTSD patients. And, in fact, I think this coming November we'll be having another workshop on IRT, and PTSD sleep clinic here in Albuquerque in I think it's the second week of November.

David: Well, it has been delightful speaking with you. Dr. Barry Krakow, thanks so much for being my guest on Wise Counsel.

Barry Krakow: Oh, David, thank you very much for having me.

David: I hope you enjoyed this conversation with Dr. Barry Krakow. I'm especially impressed by his devotion to both research and clinical practice. It would be easy enough for him to be content with running a successful sleep clinic, but it's clear that he's also driven to verify and continually improve his techniques, and that's a good thing. If you or someone you know is suffering from PTSD, nightmares, insomnia, or sleep apnea, a good place to start might be his two websites: www.sleeptreatment.com and www.nightmaretreatment.com; and/or the audio course that he and his wife developed, which I'm sure you can order from one or both of the aforementioned websites.

You've been listening to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net. If you found today's show interesting, we encourage you to visit Mentalhelp.net, where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show's page and show archive information via the podcast box on the Mentalhelp.net home page.

If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at www.shrinkrapradio.com. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.

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About Barry Krakow, MD

Barry Krakow, MD Barry Krakow, MD is a board certified internist and sleep disorders specialist who has spent over 30 years in medicine in the fields of internal, emergency, addiction and sleep medicine. He has conducted more than two decades of research in the treatment of chronic nightmares and disturbing dreams at the University of New Mexico School of Medicine (1988-1999) and the Sleep & Human Health Institute (2000-current).

Dr. Krakow graduated magna cum laude from the University of Maryland School of Medicine. He was residency trained and board certified in internal medicine and also has ten years of clinical work in emergency medicine. He is a member of the American Academy of Sleep Medicine and the Sleep Research Society and is the former medical director of University Hospital Sleep Disorders Center.

Dr. Krakow has published two books, Insomnia Cures and his most recent, Sound Sleep, Sound Mind, is the first book of its kind to focus on mental, emotional and physical causes to sleep disturbances. Dr. Krakow and his wife, Jessica Kohr-Krakow have also published Turning Nightmares into Dreams, an innovated self-help, audio series and workbook to eliminate bad dreams.

Dr. Krakow is the medical director of Maimonides Sleep Arts & Sciences, Ltd, in Albuquerque, NM as well as the principle investigator of the Sleep and Human Health Institute, a non-profit research facility.