Dr. Krakow's book

[BarryKrakowMD]

Human Intelligence

Human intelligence, as everyone knows, is a complex dimension to measure, and I am no expert in measuring it. However, as a sleep doc, I’ve formed some fairly clear perceptions about patients with insomnia, who I believe often “suffer” from a higher than average level of “intellectual” intelligence, for lack of a better term.

TFI System

This insight emerged in my own thinking once I realized that most human behavior is coupled to a fairly prominent system of consciousness called the TFI System. (T = Thoughts; F = Feelings; and I = Images.) I write extensively about this system in my book, Sound Sleep, Sound Mind, because the balance within any individual’s TFI system predicts who is most likely to suffer insomnia, who is most likely to have difficulty adjusting to PAP therapy, and who has the capacity to engage in sufficient, self-generated cognitive restructuring (“changing your mind”) to overcome or adapt to either of these difficulties (insomnia or PAP issues).

To simplify, before you eat, you THINK about the need or desire for food, FEEL hungry for food, or PICTURE (IMAGE) in your mind’s eye the sumptuous Caesar salad you crave. Each of these three activities represents the unique and overlapping components of the TFI System. If you spend time “observing yourself” throughout the day, you will notice you spend at least some time with each component preceding, during or after various behaviors.

In unusually well-adjusted individuals, great awareness of all 3 components is the norm, leading to a balanced system in which the individual freely moves through all components at any given time as needed to adapt to and interact with their environment and the people in it. Having said that, you can no doubt imagine a hundred interpretations of what a “balanced system” entails or feels like. Without wishing to be cryptic, however, let me just say that tasting the experience of a balanced TFI System is a much easier way to know it than someone trying to explain it to you.

Lacking Balance in the TFI System

It’s much easier to explain the opposite—a lack of balance, in which one component of the system tends to predominate or one component tends to be relatively absent. Most of us learn to keep our TFI systems out of balance, and we usually adopt this jaded system some time in childhood or adolescence. As the most classic and relevant example to our discussion, many insomniacs show a high intellect that arguably developed out of a desire (usually unplanned) to adopt an imbalanced system dominated by thoughts and lacking in emotion, which turns out to be a perfect setup for insomnia.

Let’s assume you are a smart person, and your intelligence is obvious to those around you as early as childhood. More importantly, let’s suppose you begin to notice in school or elsewhere that your mind is sharper or quicker than many others at certain intellectual tasks: solving math problems, remembering grammar rules, knowing more words, how to spell them and what they mean and so on. In a short time, you would receive a great deal of reinforcement (grades, praise, requests for advice/answers, etc.) buttressing the belief that your “thinking capacity” is more advanced than others. Very soon, you will turn repeatedly to your powers of intellect to solve the problems you face. So far so good; this example describes a fair number of people who end up with graduate degrees in engineering, physics, medicine, other sciences and so on. In these individuals, “Thoughts” are the predominant component of the TFI system and up to a point have served them well in society.

The question or problem arises at some point as to what happens to the other two components of the system: Feelings and Images. The answer for a lot of individuals is the person grows far too comfortable solving life’s problems with thoughts and conversely grows more uncomfortable attempting to manage emotions or mental imagery. Why so? Because the latter two components of the TFI system seem or feel chaotic; whereas, thoughts seem more controllable.

Over time, some individuals who go down the intellectual path will see a decay in their innate capacity to work effectively with feelings and mental imagery. In the single most classic example of this phenomenon, individuals no longer readily access their own emotions in direct fashion. Instead of “feeling their feelings,” they “think about their feelings.” If you describe this distinction to someone with a healthy and balanced TFI system, they immediately and fully understand the difference. If you make this point to an insomniac, they often need much more explanation (still more intellectual discussion) just to come close to understanding the distinction between “thinking about vs. feeling an emotion.”

Insomnia and the TFI System

And, therein lies the basis of my observations and theories. In my clinical and personal experience, people with balanced TFI systems rarely have trouble closing out the day at bedtime. Because they’ve spent much of the day processing a wide array of thoughts, feelings, and images, they fall asleep faster than you can say “lights out.” But, for the individual with too much reliance on intellect, the lack of balance throughout the day means that emotional or imaginative residue probably lingers at bedtime and prevents the necessary closure that leads to the Land of Nod. In fact, among the majority of insomniacs, the single most common complaint is “I cannot turn off my mind,” which means racing thoughts or other ruminations actively fuel the mind with too much alertness to permit sleep.

Returning now to the balance concept, the intellectually inclined individual has spent far too much time in life developing their “thinking smarts” but now they pay for it with insomnia. Why would too much thinking lead to insomnia? Because thinking represents a very active component of consciousness within the TFI System, whereas feelings and imagery represent more receptive components.

When you fall asleep, can you guess which components are closer to the final point of wakefulness where sleep onset begins? The answer appears to be feelings as in feelings of comfort and sleepiness, followed by mental imagery as in little dreamlets that flash across your mental landscape just as you fall asleep.

In other words, active thinking is antithetical to sleep; but if you spend more of your day in the world of thought, there is no easy way to turn off the spigot of thoughts at bedtime. In my book, I describe at length how excess thinking in most insomniacs has actually become a “defense” mechanism, which individuals use to avoid feelings and imagery. But, as I’ve just pointed out above, sleep does not follow from an active and ruminating mind; it follows from a receptive mind based on comfortable feelings and dreamy images.

Summing Up

Most insomniacs I’ve treated have a marked imbalance of the TFI System. The thinking system is so powerful it blocks most feelings and some images throughout the day. Eventually, it prevents the individual from fully processing the day’s experiences, because the system directs the person to think and self-talk about the day without processing deeper emotions or clearer images about the actual experiences during the day.

Finally, SDB patients with similar or other imbalances of the TFI System tend to have greater difficulty adjusting to PAP therapy, because the imbalance makes their personality somewhat more rigid. Their ability to “change their minds” and adapt to the foreign nature of PAP therapy is less than it could be if their minds were more balanced.

In sum, in a large proportion of insomnia patients and some proportion of poorly adapting PAP therapy patients, I routinely see this highly intellectualized intellect, which in fact frequently correlates with a higher IQ. In my opinion, these patients “suffer” a great deal from this lack of balance as they try to solve their sleep problems.

[roster]

Dr. Krakow, before you explained it this way, I could not get a feel for it or an image of it. But now your explanation has allowed me to think about it and understand it.

Now I am really going to have trouble closing out the day and going to sleep.

[Guest]

Hi Dr.Krakow,

Very good explalanation and exploration of TGI. In my opinion, there is one more little thing that many forget. This is "Smell".......any comment welcome.

Mckooi

[Jmark]

Interesting --

Dr. Krakow, is this related in some manner to right/left brain hemisphere processing and communication? I'm not a scientist, but I understand left brain = thinking functions and right brain = feeling functions.

Mark

[jskinner]

1. Early Retitration. ... Given all the variables we are talking about as well as the difficulty adapting to this foreign physiological process, the odds are actually against finding the best pressure the first time. This has been described in a variety of papers showing or implying how far off the first titration was in many cases.

I think anyone that has been on this forum for any length of time realizes that the first titration is often not correct. For me I was titrated to 6cm but I barley slept not making it past stage 2. After a month or two I was still waking up abruptly which what felt to me like apneas. So I went back and asked for a retitration. My AHI was about 10-14 at the time and the sleep lab said no, that it was good enough (down from AHI 55) and would have to wait a year. At that point I was not happy so I had to do something and got myself a data capable machine and worked on it myself. Eventually I moved to Nova Scotia where my new ENT wanted to retest me to see how things where. The sleep lab here said there was a 1-2 year waiting period but they eventually booked me for July 2008 (referal was in July 2007)

I think many of us agree with you that retitrations would be the best option. My feeling is that maybe since you work so closely in the sleep field you may not realize how hard it is for some of us to get them. So instead we do what we can and use the limited data that comes from our machines.

I wish all sleep professionals where as well informed as you but sadly they are not.

that Dr. Krakow write another book focusing on sleep apnea and its treatments, an expansion of the last few chapters of his current book - or that he puts this information on his website http://sleeptreatment.com/

I agree completely!


PS I just ordered your current book from Amazon... your viral marketing is working

[roster]

Dr. Krakow,

You are making some excellent contributions here. I have been reading bits and pieces of the book.

My inclination was to read the book completely through, studying it very hard. My TFI is predominantly focused on T for many years. So maybe an intense study of the book will push me more towards T and away from F & I. So it will continue to be bits and pieces of this excellent book for me.

I am trying some of the things in the book for imagery (I). The weather is tough here presently and the daylight hours are short so time to get out into nature is limited. As you stated, looking at picture books for some time before bed seems to help and luckily we have a good collection.

You suggest in the book to watch a PBS nature show with minimal narration. Last night I watched part of a DVD about tigers in India. It was quite relaxing.

Around three a.m. this morning I awoke from a vivid dream about India (I have traveled there). It was an adventurous but pleasant dream.

I don't know whether this is good or not: to have such a dream and then awaken. But I did not mind the dream and took it as a good sign of REM sleep. Maybe there will be more about this in tomorrow's bits and pieces of your book.

I recognized a few years back that my F was low. Well, I thought of it as relationships and have been trying to work on that with some success.

Well before bed, off to some picture books, a nature video or maybe even a travel show or a cooking show will provide material for Imagery.

[BarryKrakowMD]

About writing another book, please see my latest post on the "Bilevel PAP Therapy Pearls" Topic. I sincerely believe this group has the expertise and drive to write the book you are seeking or at least much of it...

About right/left brain, yes this is very much related to the TFI System and how we access our intelligence. A very useful way to look at right/left brain is the concept of active vs. receptive. The right brain seems to be much more receptive, makes you a better listener, and virtually all people learn faster, remember more, and arguably raise their intelligence or certainly knowledge base by perfecting their listening skills. By listening without feeling the pressure to respond, you tend not only to take in more information but you also take in more components of intelligence, that is, when you are receptive, you can more easily notice feelings in your body and images in your mind's eye as well as observe your thoughts. Talking and thinking tend to be more active and left brain; however, you can train yourself by talking or thinking just a tad slower and suddenly gain awareness of feelings and images that might supplement your thinking.

Regarding smell, I just know that this sense is probably tied into memory, images, and emotions, because we often meet trauma survivors who can be overwhelmed by unpleasant smells, that is, a bad smell seems to trigger strong and unpleasant emotions and memories.

About TFI Balance, most of us are brought up to emphasize Thoughts and minimize Feelings and in some cases minimize Images. So, the "bits and pieces" approach is ideal, because you do not want to bite off more than you can chew let alone cause indigestion. Nonetheless, I always like to point out that virtually all of us had an extremely active TFI System from birth through the first few years of life. Therefore, it's not really a new thing to develop; rather, it's an old thing to re-embrace, which I think should add some confidence to your efforts.

[krousseau]

It isn't just bad smells, trauma survivors' memories and unpleasant feelings can be triggered by many odors, good or bad. Some people seem to be triggered by specific odors (perhaps related to something present at the time of the trauma), and some people react to a very wide variety of odors unrelated to anything in the environment at the original traumatic event.

[JeffH]

I finished the book a couple of days ago. There are some good points in it and I am using them. It is defiantly a book that requires going back and referencing. I'm using mostly the simple things at the beginning of the book for now. I pretty much locked up at the BEACON part. As of right now, not willing to go without coffee as soon as I get up.


JeffH

[Guest]

Hi Dr.K & Krousseau,

Krousseau, you are right on the matter of smell...much more than just memory....good, bad, normal, uncommon, irregular smells are much more than just memories of events. This sensory is the mot powerful of all since from the born of the baby. intultively, this smell sensory creates unlimited intellectual right from the begining to the end of a person. The smell itself is much more than that......Dr.Krakow .....I recommend you try this ot....go to a quet place with air breezely.....light a essences stick that you like to smell the most, close you eyes and smell it for 10-20mins.......then try the others......you be able to tell more after that.

Mckooi

[BarryKrakowMD]

I rarely recommend anyone go off coffee or other caffeine products unless or until they have fully evaluated and treated their sleep disorders. Caffeine is the miracle drug of modern civilization, probably having saved more lives, enhanced more productivity, and treated more mild to moderate cases of depression than probably any other drug out there.

If one wishes to experiment with reduced caffeine to find out how truly sleepy or tired they are and how much caffeine is helping to combat those problems, by all means consider experimenting in these ways WHEN IT'S SAFE TO DO SO.

The BEACON system (simply an acronym for times of day to check in with your self-assessments) is really a small subset of a much larger paradigm, known as your "Observing Self." The point in the book that discusses fatigue, tiredness and sleepiness attempts to help the reader see how easily we tend to normalize these feelings, but if we learn to develop a "healthy self-consciousness" about what's going on in our mind and body, we can usually tease apart these feelings.

Knowing the difference between fatigue, tiredness, and sleepiness makes for much easier treatment for virtually all sleep disorders' patients, ranging from insomnia to sleep apnea and everything in between. As a testament to the power of this skill, consider how most insomniacs do not believe there is a difference between tiredness and sleepiness, which explains in no small way why they suffer from insomnia.

[JeffH]

So Doc, are you off coffee?

Just curious.


JeffH

[BarryKrakowMD]

I drink one cup of cocoa about 10 to 15 mg (max) of caffeine most afternoons and have 1 piece of chocolate around dinner time (about 5 mg). Both products are dark chocolate, and I'm impressed that I seem to notice a definite boost from both ingestions.

My goal would be to need no caffeine whatsoever, but 20 mg per day in the scheme of things is quite low. And, I'm impressed with some of the interesting data on dark chocolate (not to mention the taste). Then again, I don't consider myself a normal sleeper by my standards. I'm more of a 90 to 95 percenter.

When I hit a 100% night of sleep, I sometimes forget to drink cocoa or eat chocolate.

I was never a big caffeine user prior to diagnosing my sleep disorders, but it's fairly clear from my history that I could have averaged 4 caffeine drinks per day to get me over humps at 10:30, 1:30, 4:30 and 7:30. I used to use behavioral influences instead as a matter of pride, but I was rather stupid about the whole thing because I was clearly impaired when I was driving.

Now, I have 2 mini-dips at 3 pm and 6 pm, which almost never generate the type of sleepiness or drowsiness I used to experience and which required daily napping from age 13 to 48. Even if I didn't drink hot cocoa or eat chocolate, I might nap once every 3 months, and the dip nowadays feels more like a relaxing break, and I never have to fight the feelings; they just fade away and my energy returns.

I began using the cocoa as an experiment along with trials of 15 mg of green tea to learn about caffeine effects a few years back, because I wanted to speak from experience when discussing this issue with patients.

Caffeine is an amazing drug, and I have many theories about how and why people use it, and I think it's a very important drug for sleep patients because in many ways it mimics the way you should feel if you are cognitively on track most of the day. For example, it would never occur to me to use caffeine in the morning or until well after lunch, because my level of concentration is very high, I presume, from sleeping at the 90 to 95% level most nights. Still, I'm betting that there is more improvement to be gained in the treatment of my SDB, and I suspect that with more advanced technology in the coming years, that my caffeine intake would probably drop to an even lower level.

[JeffH]

I have two or three cups in the morning, and then 90% of the time, that's it for the day. Maybe three days a year I'll make coffee in the afternoon if I get tired or sleepy.

I also have type 2 diabetes, and read yesterday that coffee tends to raise blood sugar levels, so between better sleep and lower blood sugar levels I might get motivated to get off caffeine.

[Wulfman]

I have two or three cups in the morning, and then 90% of the time, that's it for the day. Maybe three days a year I'll make coffee in the afternoon if I get tired or sleepy.

I also have type 2 diabetes, and read yesterday that coffee tends to raise blood sugar levels, so between better sleep and lower blood sugar levels I might get motivated to get off caffeine.

I read that, too.

http://news.yahoo.com/s/nm/20080128/hl_ ... jNshEQ.3QA

And, I just found this one while looking up the link for the previous one......

http://news.yahoo.com/s/nm/20080128/hl_ ... 8M1O0Q.3QA

Oh, Hell, we're gonna die of something someday!

Den