WASHINGTON, DC—Returning servicemembers are among the some 40 million Americans who suffer from chronic long term sleep disorders, and, for reasons ranging from disrupted sleep during deployment, battlefield stress or even hyper vigilance, their sleep problems can be especially challenging to treat. That is even more the case when post-traumatic stress disorder (PTSD), depression, pain and traumatic brain injury (TBI) are involved.
“Addressing sleep problems can really have a significant impact on a person’s medical condition,” said Louis French, PsyD, chief of the TBI Service and DVBIC Site Director at the Walter Reed Army Medical Center. French spoke at a day-long conference held by the Defense and Veterans Brain Injury Center (DVBIC) and Walter Reed Army Medical Center’s Traumatic Brain Injury Service to educate providers on sleep dysfunction and how they can help servicemembers who are suffering from sleep issues.
Insufficient sleep is not an uncommon problem, particularly among troops who have deployed. A study published in the Dec 1 issue of SLEEP found that servicemembers who completed a follow-up survey during deployment to Iraq or Afghanistan were 28% more likely to report having trouble falling asleep or staying asleep than those who had not yet been deployed. Servicemembers who completed a follow-up survey after deployment also were 21% more likely to report having trouble sleeping, according to the researchers. The study included 41,225 personnel who completed a baseline survey between 2001 and 2003 as well as a follow-up survey between 2004 and 2006.
In all groups surveyed—during deployment, post deployment and those who had not deployed—there was an even greater likelihood of sleep difficulties with baseline symptoms of mental health problems such as PTSD or depression.
In many cases, those problems may be rooted in their deployment experience. For example, they may have done shift work at night or may have been located near an air base where airplane noise routinely disrupted their sleep.
“If people are having problems post deployment with their sleep, there is probably a reason for it,” said Suzanne Lesage, MD, a staff physician in the sleep clinic at WRAMC. “You have to really look at what happens during deployment as to why they may have developed difficulties post-deployment.”
Some servicemembers anticipate that once they head home from a deployment, they will sleep much better, only to be disappointed when new stresses and a new schedule keep them from sleeping very well. Add an injury to the mix, and sleeping problems can be greatly exacerbated, with some prescription drugs contributing to the problem.
“For all of these conditions people are given many, many medications,” Lesage said. “The medications that they are given can impact sleep.”
Getting to Sleep
Paul Savage, MD, an internal medicine and sleep specialist in the TBI Program at Madigan Army Medical Center, said that a unique element in dealing with military sleep problems is that servicemembers sometimes tend to be hyper vigilant and have a “Battle Mind” in which they cannot stop scanning for danger. This mindset, which can impede sleep, might be present whether or not they have experienced combat, he said.
In 2009, Savage started a sleep workshop at Madigan to teach patients sleep essentials and to help them improve their sleep. Using a calendar or diary to track sleep patterns is important in determining how patients are sleeping, the quality of their sleep and whether their sleep improves or not, Savage said. Patients are also encouraged to set a consistent bedtime and wake up time.
If patients cannot fall asleep within 30 minutes of their bedtimes, they are told to get out of bed and engage in other activities. That helps “turn off” the mind so it can recognize that it is exhausted, according to Savage. Sometimes, he said he even encourages patients to do necessary activities they really don’t want to do, such as cleaning, in order to become sleepy.
He also recommends using background noise for servicemembers who cannot sleep because they are always listening for danger.
Another effective technique is Cognitive Behavioral Therapy (CBT), a form of therapy that emphasizes observing and changing negative thoughts about sleep, Savage said. One type of CBT is sleep restriction therapy in which patients who have difficulty nodding off are asked to limit their time in bed to the actual amount of time they actually sleep in order to increase sleep efficiency. The time spent in bed is slowly increased as the patient’s sleep improves.
Currently, he said Madigan has an ongoing study examining the use of classic CBT for sleep problems in returning servicemembers from Iraq and Afghanistan who have mild TBI. The study consists of an eight-week program in which patients participate in seven 30 to 60 minute CBT sessions. Preliminary findings indicate that servicemembers experienced improvements in sleep, and that about half dropped out of the study early, suggesting that CBT can be effective with an even shorter program.
Addressing Dreams and Nightmares
The relationship of dreams and nightmares to restful sleep also was discussed at the conference. Rubin Naiman, PhD, sleep specialist and clinical assistant professor of medicine at the University of Arizona Center for Integrative Medicine, said that recurrent dreams after a traumatic event can continue many years after the event.
Dreams, and particularly nightmares, are very personal experiences that can be deeply moving, he said. “The temptation to reduce them to machinations of molecules in our brain is very tempting because it offers us a certain amount of distance from them,” he said.
REM and dreaming is critical for learning and memory and plays a key role in emotional healing, according to Naiman, who noted that the attitude of clinicians towards a patient’s dream is important because it has an impact on what the patient believes about their dreams. “These dreams can be unbelievably personally meaningful, frighteningly beyond belief…” he said. “If we come at somebody with even an unspoken belief that this is merely a clinical symptom, it creates a profound disconnect.”
He recommended a resource to clinicians by Alan Siegel, PhD, called a “A Mini-Course for Clinicians and Trauma Workers on Post Traumatic Nightmares” that can help clinicians deal with patients who are disturbed by dreams. Among Siegel’s recommendations, found at www.dreamwisdom.info, are encouraging the patient to verbalize their dreams; encouraging the therapist to welcome, reassure, witness, and empathize with the emotions of the trauma survivor’s dream; and helping the dreamer break the spell of the nightmares.