Sleep Soundly Every Night, Feel Fantastic Every Day (32 page)

A.
 
No, not yet. Your husband is evidencing what we call VBS—violent behavior associated with sleep. There are numerous causes such as sleepwalking, RSBD (a disorder of dream enactment), and nocturnal seizures, to name a few. It is very important that your husband undergoes a thorough sleep evaluation, including a sleep study. That should pinpoint the cause and result in appropriate treatment.

Q.
 
Recently, I saw a doctor about my insomnia since I have trouble staying asleep. Sometimes I have vivid dreams and actually act them out. He suggested that I get a sleep study at home. He has a new device they call a WatchPAT. Can you tell me about it?

A.
 
The WatchPAT and other portable home devices are good only for diagnosing sleep apnea. They monitor arterial tone, body movement, and drops in oxygen. Unfortunately, they are useless in diagnosing myriad other sleep-related conditions. These devices are unable to detect in what stage of sleep you are. They cannot detect problems such as periodic limb movement disorder, which frequently accompanies restless legs syndrome, or adverse medication effects on sleep. In your case, it sounds as if you may have REM behavior disorder. This condition results in abnormal movement during dream sleep. I recommend that you discuss with your health care provider a fully attended diagnostic sleep study in a sleep lab.

Q.
 
Recently, my wife underwent a sleep study because of her chronic insomnia. She wakes up frequently throughout the night and does not know why. During the test, they noted that she moved a lot while in dream sleep. Her doctor said this could be due to a sleep abnormality called RSBD. I looked this up and it says these people act out their dreams. We have been married for over 30 years and I can definitely say she does not. What do you think?

A.
 
Increased movement during dream sleep is needed to make a diagnosis of RSBD. However, it also requires a history of dream-enacting behavior. Without that, one cannot call it RSBD. Still, about 25% of people that present with this finding in a sleep lab will go on to develop the full-blown disorder.

 

 

Sleep disorders coexist with other medical problems that disrupt sleep, such as post-traumatic stress disorder (PTSD) and attention deficit hyperactivity disorder (ADHD). It is essential to treat both issues.

 

 

The pain and the memories will never go away. I wish I could sleep one night without nightmares.

—PATIENT WITH PTSD

Could sound, long sleep be a health solution for those diagnosed with post-traumatic stress disorder (PTSD)? In short, yes. Recent studies reveal that treatment focusing on sleep alleviates both sleep disturbances and the severity of PTSD symptoms.

Gina attended a private high school in an Atlanta suburb and was approaching her sixteenth birthday in the middle of a very active junior year. She stayed after school for a cheerleading meeting with the squad's sponsor to plan for
the next semester after Christmas break. She entered the bathroom before heading to the meeting. Two high school boys in the empty hallway followed her into the bathroom. They attacked her from the back and threw her to the floor; they pinned her down, slapped her around, and raped her several times.

Gina and her parents reported the incident to the school and the police. The boys were charged, and a trial date would be set eventually.

Meantime, Gina withdrew from her social activities and could not muster the courage to return to classes at the high school. Rather, she focused her time and attention on accelerated high school courses for the gifted via an online portal. Her gifted mind kept her busy in exploring, learning, and creating, but the rape was not distant. She relived the experiences but she never told her parents. She appeared to be studying and working hard, but she had to force her effort, and sometimes do the same task several times, like trying to see through fog.

Her resilience amazed me as I came to know Gina better during her first appointment at the sleep disorders clinic to discuss her medical history.

“Welcome, Gina. I'm so glad that you decided to explore getting more help. Your therapist indicated she thought your sleeping issues should be addressed before continuing in more depth with her. I understand the trauma you went through from your therapist's input and medical records. Can you tell me more about what you have been experiencing?”

“Yes, I can, and thank you for seeing me. I know I need help, and I try to control everything that comes up with me so my parents don't freak out any more than they already do. My new therapist is great, but she says I need more help from you, and she gave me some tools to get started. First of all, I am having nightmares, like replays of the rape. The
memories seem to creep in when they want to, not like they have a schedule, and usually it is at night. My therapist said the experience could come any time, day or night, but …”

“Gina, does that happen every night? Or maybe several times a week?”

“Oh! Thanks for reminding me. My therapist said to keep a journal, like a log.” Gina pulled out a spiral-bound journal with attractive pink roses. She caught me looking at the roses.

“Pretty, aren't they? They make me smile, so I sketch roses and doodle flowers.” She laughed as she explained to me that her doodling was her art therapy, and then opened the journal, and reported that within the last 14 days, she had nightmares 10 times. The nightmares were not always long dream episodes.

“Dr. Rosenberg, there are a few other things going on. Some nights, I cannot go to sleep at all. If I am exhausted and sleep a little when my head hits the pillow, it feels like I am still awake and going through the nightmare. I try to be cheerful around my parents, but I feel like I am sinking into a hole. Sometimes at night I get headaches, and just crying seems to help when a headache hits. Other times my heart beats fast, and I feel like I can't breathe, but I walk around outside, or just be still until it passes. My therapist says to stay present with it and the symptoms aren't as bad.”

“Thanks, Gina. You did a wonderful job of documenting everything, and it helps me to understand how best to help you.”

Gina's lack of sleep, that is, sleep deprivation, triggered the emotional processing part of her brain and set in motion brain wave patterns similar to people who worry too much, are anxious, or are prone to panic. As her sleep specialist, I saw clearly how vulnerable she was, and likely would become more so without sleep therapy. The insomnia prevents the appropriate emotional processing.

“Gina,” I said, “I believe we can develop a helpful program for you. You have had a truly traumatic experience, and you have a temperament sensitive to stressors.

“You are so lucky that sleep medicine can offer you treatments, and coordinate it with your counselor when necessary to help you have the best first year of college you possibly can have!”

She looked up directly at my face and nodded again, this time with a wide smile and a bit of a sparkle in her eye.

I explained that her counselor would use some strategies from cognitive behavioral therapy such as imagery rehearsal therapy. I explained to Gina that the imagery she remembered of her event could continue to be distressing. To take charge of her toxic internal imagery and to reduce this distress, Gina and her therapist would rescript the images and create a new story. Imagery scripts follow a sequence like first finding a safe place, then relaxing, and then following the script the therapist voices for Gina to experience. The safe place is always an internal safe place, and then Gina can follow the script again at home. After rehearsing this rescripting of the nightmare, the disturbing dream begins to transform and lose its distressing properties.

Other techniques her therapist might use are journaling or a stress reduction program, which she knew about already. I further directed Gina to continue her sleep journal and check back with me about every three to four weeks as pharmacology also offered her some options.

PTSD is a medically recognized anxiety condition that occurs after witnessing or directly experiencing a life-threatening event. People have certainly been suffering from PTSD since humans walked the earth. However, the syndrome was not formally named until 1980, largely in response to the
high numbers of Vietnam veterans who continued to suffer from battle fatigue long after they had returned home. “The estimated rate of lifetime PTSD among American Vietnam Veterans is about 30% for men and 27% for women.”

Later, the definition expanded to include a delayed response to any traumatic event that continues to haunt the person and affect his or her life. PTSD is the only psychological disorder that does not originate within the patient, but from without. In fact, no one is diagnosed with PTSD unless he or she has experienced a highly traumatic event.

The types of recognized trauma are results of war, terrorism, violence and abuse, and natural disasters. An estimated two-thirds of the population is exposed to at least one such traumatic event in their lifetime. These experiences include the following:

1.
 
Developmental trauma
is a childhood experience of multiple or chronic exposures to interpersonal, adverse trauma, which could start at home with maltreatment or abuse. Children's trauma also includes medical procedures, community violence, and accidents.

2.
 
Acute trauma
is the result of the experiencer's subjective interpretation, the psychological state, in response to a terrifying event such as rape or other physical assault.

3.
 
Near-death experiences
include a dissociated state in which the experiencer feels disconnected from the body. Positive perceptions, such as the incident being spiritual, help, but do not mitigate the eventual appearance of PTSD symptoms, especially if the NDE occurs through a traumatic event such as an auto accident or surgery.

4.
 
Natural disasters
of late include Hurricane Katrina, the massive Sandy Hook storm, and the powerful tornadoes in Oklahoma.

5.
 
Long-term, chronic stress
is a condition of sustained, high levels of stress hormones, which eventually affect sleep, the cardiovascular and respiratory systems, as well as physically changing portions of the brain.

People from all walks of life can have PTSD and therefore PTSD-related sleep disorders, of which the highest prevalence is those who have experienced military combat. Recent studies show high rates of sleep disorders in military personnel, who may receive a co-existing diagnosis of a specific sleep disorder like insomnia or sleep apnea. An estimated one out of nine soldiers returning from Afghanistan and one out of six returning from Iraq have exhibited symptoms of PSTD.

A person with PTSD may relive the trauma through nightmares or intrusive thoughts. Persistent daytime recollections intrude into daytime consciousness. Such thoughts can be absent for a period and then savagely return at any time. Most persons with PTSD re-experience the trauma within the first year after the event.

PTSD sufferers tend to withdraw emotionally and avoid situations, places, and people, even thoughts perceived to be trauma triggers. Persons with PTSD show increased arousal, which can present as a range of symptoms from general irritability to hyperarousal as manifested by being sleepless. The fight-or-flight alert condition of the nervous system and metabolism contributes to nightmares and insomnia, and results in symptoms while both asleep and awake.

During waking hours, PTSD sufferers can continue to re-experience the trauma and remain hypersensitive to stimuli, particularly those that trigger memories of the event. Most likely, each of us has watched a television show where a combat veteran hears a car backfire and drops to the ground reliving a memory of combat gunfire or an explosion. Yet, a memory of trauma can include a car driver shaking and
sweating with heart palpitations when approaching an intersection where she was involved in a severe car accident. Whatever the event, people feel a lingering sense of dread and fear, helplessness, and even horror long after the event has occurred.