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Tackling Combat Trauma Head On Helps Resolve Sleep Disorders

by U.S. Medicine

January 10, 2012

BETHESDA, MD —A problem with insomnia, one of the shared symptoms of TBI and PTSD, sometimes can be overshadowed by what seem to be more serious, immediate symptoms. For those suffering from sleep disorders, however, exhaustion can quickly take over their lives.

At the National Intrepid Center of Excellence (NICoE), which brings patients in for weeks at a time in order to tackle all of their symptoms comprehensively and holistically, sleep problems are taken very seriously. The treatment for those disorders frequently takes into account the combat trauma at the heart of the PTSD or TBI.

Earlier in the war, an Oregon National Guard soldier takes a few moments to catch up on some sleep on the hood of a Humvee in the north side of Fallujah. – Photo courtesy of the Defense Imagery and Video Distribution Center.

A good sleeper is someone who spends most of the night quietly asleep, awakens physically and mentally refreshed, has no great desire to nap during the day, wakes easily, dreams regularly and looks forward to going to bed. Someone with a sleep disorder sleeps in short, shallow spurts, awakens exhausted and can even dread going to sleep. Many patients suffering from PTSD and TBI resemble the latter more than the former.

In May, physicians at NICoE began testing returning veterans experiencing sleep disorders. Among patients who arrived at NICoE suffering from a TBI, 46% also were suffering from sleep disorders and 25% from excessive sleepiness.

Patients and, when applicable, their spouses were interviewed and given a polysomnogram — a one-night sleep study that gives NICoE physicians a picture of how the patient sleeps, Anthony Panettiere, MD, told an auditorium of physicians, researchers and veterans’ family members at the recent Trauma Spectrum Conference held at NIH.

“Insomnia is very present in the population we see at NICoE, but it’s almost never a problem for the sleep study. [The patients say], it’s because the technician was watching out for [them]. They’re safe in a locked building. They have someone watching them like a sleep-tech sentry. And, because of that, they’re able to relax better than normal and fall asleep.”

Constructing a Sleep Architecture

Panettiere, a neurology and sleep-medicine physician, uses that one night study to help construct a patient’s sleep architecture, which shows how much deep, restful sleep a patient gets.

“It’s possible to only get three hours of sleep, but if you get all that deep sleep done, then you can wake up and go out and be in combat and be relatively effective,” Panettiere said.

He also has patients wear a wrist monitor that tracks physical movement. Some patients complain that they get as little as an hour of sleep during a night, but the monitor shows that they are getting six or seven. If the patient is waking up frequently, however, they might not realize they are sleeping, or reap many benefits.

“If [they] keep waking up due to pain or hypervigilance, they’ll perceive that they’re not asleep,” Panettiere said. “It’s the equivalent of 40 naps. It’s not good. They’re very tired. But, they’re getting more sleep than they think they are.”

Tackling Combat Trauma Head On Helps Resolve Sleep Disorders Cont.

Factoring In Combat Experiences

Since May 1994, Panettiere and his colleagues at NICoE have studied patients with sleep disorders. Most were male, and all were people who had no complaints before being injured.

Approximately 41% had sleep-disordered breathing, such as sleep apnea, which is nearly double the rate in this group as seen in the average population. With sleep apnea, patients can actually stop breathing in the middle of the night and wake themselves up. This can cause significant fluctuations in heart rate and blood pressure. 

“In normal sleep your heart rate drops about 20%, and in this condition it goes up about 20%,” Panettiere said. “So when a patient says they feel like they’re worse in the morning than when they went to bed, they’re probably right, at least physiologically.”

The most common treatment is positive airway pressure (PAP) therapy, also widely used in the general population.

For other sleep-disorder symptoms, such as nightmares and insomnia, Panettiere has developed more veteran-specific solutions.

“If you had PTSD and TBI together, your chance of having insomnia is 92.9%,” Panettiere said. “Insomnia is not an area of medicine a lot of doctors are interested in doing. It takes a lot of time, a lot of visits, and there’s not a procedure tied to it. But I’ve always had an interest in it, and there’s a time in everyone’s life when they’ll suffer from insomnia.”

One of the common ways a person tries to combat insomnia — staying in bed for as long as necessary until they fall asleep — is doubly ineffective for a veteran suffering from combat-related trauma and stress. “For our troops, all that quiet with nothing to do but ruminate. Instantly, they’re back in Iraq, thinking about what could have, should have, all those things,” Panettiere said.

Instead of having these memories and thoughts creep up on them when they are at their most vulnerable, Panettiere advises veterans to tackle them head-on.

“I tell soldiers to write it down in a journal,” he said. “Don’t do it in bed. Do it in the family room. You know you’re going to think about it. It’s not going away. It’s going to be there. You have unprocessed feelings. You’re taking it out of your head that day, closing that day down and setting up a perimeter of sleep to start the next day.”

The treatment for recurring nightmares — image-rehearsal therapy — is also proactive. Panettiere has veterans record the dream in detail.

“That can be tough for them, particularly if it’s combat-related,” he said. “I tell them to write it down, then change the beginning, the middle or the end of the story to something less emotional.”

The veterans are told to read over the dream sometime during the day, so it is fresh in their memory. Soon, the veteran is dreaming that scenario regularly, rather than the previous nightmare.

“Then I have them change it again,” Panettiere said. “To something even less [disturbing].”

Eventually, the dream no longer resembles the event that spawned the original nightmare. This is particularly effective in combination with the mental healthcare the patient receives from other physicians at NICoE.

“The psychologist and psychiatrists are a huge benefit for me,” Panettiere said. “I could not treat these [sleep disorders] without the veterans working on other issues.”

National Intrepid Center of Excellence (NICoE)

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