Sleep Soundly Every Night, Feel Fantastic Every Day (33 page)

The re-experience symptoms are also problematic during sleep. People may show complex motor behaviors and vocalizations as if reliving the event or acting out the incident. The sleeper can experience nightmares, nocturnal anxiety, panic attacks, hyperarousal, and sleeping difficulties.

The more common, self-reported sleep complaints by PTSD sufferers are

1.
 
That 70% to 91% of patients with PTSD have difficulty falling or staying asleep

2.
 
Inability to go to sleep

3.
 
Frequent awakenings and then difficulty returning to sleep

4.
 
Shorter sleep time

5.
 
Nightmares

6.
 
Anxiety dreams

7.
 
Restless sleep

8.
 
Daytime sleepiness

A research review correlated that insomnia and nightmares were the most prominent reported sleep issues of PTSD. The overall evidence of the hyperarousal mechanism in PTSD patients contributing to the listed sleep disruptions is strong. Recent studies have shown that patients with PTSD have elevated levels of a neurotransmitter called norepinephrine and that high levels following emotional trauma is a significant contributor to both daytime and nighttime problems. Norepinephrine, a stress hormone, is like adrenaline, in that it makes available to the body and brain the energy to be awake,
alert, and ready for … whatever! This causes hyperarousal and disrupts rapid eye movement (REM) sleep.

In addition to the above symptoms, PTSD can also lead to a host of secondary problems, which contribute to sleep problems in going to sleep and maintaining sleep, including:

1.
 
Panic attacks, social anxiety, conduct disorders, dissociation, and eating disorders

2.
 
Low self-esteem, alcohol and substance abuse, problems at work, even arrest

3.
 
Self-destructiveness, including risky sexual behavior, self-injury, and attempted suicide

4.
 
Chronic physical ailments, including headaches, digestive problems, pain in the chest or other areas of the body

 

 

To treat PTSD-related sleep disorders, a professional must first diagnose the disorder. If you believe that you or someone you know is suffering from PTSD, this checklist may help you decide to get a diagnosis immediately. Sleep disorders, insomnia, and excessive daytime sleepiness, even within a month after a traumatic event, are important predictors for the development of PTSD.

1.
 
Have you suffered a traumatic experience that you keep reliving?

2.
 
Do you feel a sense of numbness or emotional detachment?

3.
 
Do you find yourself avoiding situations or activities that remind you of the trauma?

4.
 
Are you suffering from insomnia or any other sleep disturbances, such as apnea?

5.
 
Do you have frequent nightmares?

6.
 
Do you have marital or other relationship difficulties?

7.
 
Do you experience emotional instability?

 

 

Because sleep complaints are high in deployed soldiers, one group of researchers set out to determine the prevalence of sleep disorders in combat-related PTSD and traumatic brain injury (TBI). The conclusion was that soldiers with combat-related PTSD and TBI did have high rates of sleep disorders and these were considered critical due to the chronic nature and high incidence rates.

1.
 
In soldiers with blunt trauma, higher rates of obstructive sleep apnea were noted.

2.
 
Soldiers with blast trauma had higher rates of insomnia.

3.
 
Soldiers with PTSD, but without injuries, had higher rates of obstructive sleep apnea. This provided further possibility that sleep apnea was a preexisting disorder to PTSD in the combat soldiers.

Some people may have difficulty understanding the important significance of the rejuvenation and healing that occurs during sleep for patients with PTSD. Normal dreaming REM sleep is needed to cope with emotional trauma and is integrally involved in a process called fear extinction. In fear extinction, the brain uncouples the traumatic feelings associated with the original event from events common in everyday life.

We process the events of our day during sleep mainly through the limbic system. The amygdala are almond-shaped clusters of nuclei located in the medial temporal lobes of the brain and are responsible for memory consolidation,
including forming long-term memories and processing emotional responses. The amygdala receives data about the day's events, and then sends it to the hippocampus for processing. The hippocampus checks these events against prior memories, and if it finds them similarly stressful, it tells the sympathetic nervous system to deal with the perceived threat. This initiates release of more stress hormones and more arousal, resulting in disrupted sleep.

It's imperative to resolve sleep disorders in those with PTSD for the purpose of healing the emotional trauma patterns that can occur during healthy sleep. Moreover, continued lack of sleep exacerbates stressors and leads to other health issues, as well making the sleep–wake cycle more problematic.

John was a 25-year-old combat veteran of Afghanistan sent to me for sleep apnea by the local VA hospital. He was withdrawn and unemotional. As we spoke I discovered he had severe insomnia and recurrent nightmares. He was becoming progressively more withdrawn, and he absolutely refused to go to certain places such as shopping malls. Large crowds and incessant noise brought back stressful emotions and even flashbacks of the war. John had PTSD.

The VA physician had prescribed some anti-anxiety medications, but John's sleep-related problems were not being addressed until he came to the Sleep Disorders Clinic. Because of John's loud snoring, I scheduled him for a sleep study. The sleep study revealed that John had sleep apnea. Interestingly, it also showed a pattern during REM sleep called fragmentation, during which there were numerous arousals, reducing the total amount of time spent in REM sleep. This is a pattern I frequently observe in PTSD patients. In fact, it may explain their inability to reconcile
negative emotions because this fragmentation interrupts the duration of the REM sleep cycle.

John started on CPAP, and there was improvement in his daily functioning. He was less irritable and able to go out more often. However, his nightmares continued with little improvement. At that point, I elected to start him on a medication called prazosin. His response was excellent, and he stopped having nightmares after four weeks of treatment.

A high incidence of sleep apnea occurs in people with anxiety disorders, such as PTSD, generalized anxiety disorder and panic disorder, as well as obsessive–compulsive disorder. Sleep apnea has been noted most often in PTSD in returning veterans as well as in women who have suffered sexual trauma. This fact is not coincidental because the percent with sleep apnea in those groups with PTSD, especially the veterans, far exceeds what would be expected in a control group of similar sex and age. Sleep experts have learned that sleep apnea may be a preexisting condition, and, in many cases, treating the sleep disorder results in significant improvement in the anxiety disorders. Sleep apnea may actually intensify symptoms of PTSD.

Several recent studies have confirmed what sleep experts already thought to be true. Treating sleep apnea in PTSD with CPAP decreases and can even eliminate recurrent nightmares. Most likely, this can happen because untreated sleep apnea fragments REM sleep more than any other stage of sleep. This fragmenting inhibits the individual's ability to process and reconcile the trauma and results in continued nightmares.

The first large-scale study (published 2010) of sleep patterns in 41,225 military personnel deployed to Iraq and
Afghanistan revealed that deployment definitely affected the veterans' sleep patterns. Results showed 25% reported sleep problems before deployment and a majority developed them during or after deployment.

Average reported sleep time was six and one-half hours, which the authors felt was restricted sleep time with a lasting impact on performance and mental health. A subgroup of post-deployed women, pregnant or new mothers, and moms of young children, was less than six hours. When compared to civilian pregnant mothers, the military moms slept less.

More recently, the results of later large-scale research provided a very different viewpoint about how lack of sleep affected mental health in military personnel. The findings of this study were part of a larger epidemiological investigation called the Millennium Cohort Study that included 15,204 servicemen and woman prior to first deployment. According to the study, military members who have insomnia symptoms before they deploy are more likely to develop mental health issues, which include depression, PTSD, panic, and anxiety. The odds to which insomnia predisposes service personnel to PTSD was described as equal to combat exposure. The conclusion was that insomnia itself is a risk factor for mental health problems, as well as being a symptom. This is more than a significant result, as it now sets the standard for further studies in determining if the chicken or the egg came first in terms of insomnia effects.

Moreover, researchers found that short sleep duration, defined as less than six hours per night, also increased the likelihood of developing PTSD. If you remember from the insomnia section, this sleep disorder is characterized by difficulty falling asleep and staying asleep. Short duration
of sleep does not allow the sleeper to move through the necessary sleep cycles in order to restore balance, hormones, and other benefits of seven to nine hours of sleep. Think of the high school student Gina during the assault. Her physiological responses to the event included high levels of the brain neurotransmitter norepinephrine, causing hyperarousal and disrupting REM sleep.

Nightmares disturb sleep, which disrupts the REM sleep that stimulates the areas of the brain used in emotional processing. The consideration of nightmares and insomnia as hallmarks of PTSD is that sleep disruptions and shorter sleep durations develop into a cycle that exacerbates trauma and the ability to function well on a daily basis. Normal, uninterrupted REM sleep also enables the strengthening of fear extinction memory. Consistently disrupted REM sleep compromises fear extinction and recovery from PTSD.

Until recently, most therapies for PTSD were aimed at the daytime experience but ignored sleep problems. We now know that sleep problems must be addressed. When diagnosed with PTSD, there are a number of courses for treatment.

1.
 
Treating sleep apnea, which appears to be present in higher-than-expected numbers with PTSD, can decrease sleep disruption and nightmares.

2.
 
Treating insomnia and other sleep-disorder symptoms does help alleviate the waking symptoms of PTSD.

3.
 
A technique called imagery rehearsal therapy has been very effective. The person with PTSD writes down the nightmare and then rewrites the script to be an unthreatening scenario that he or she rehearses during the day.

4.
 
Cognitive behavioral therapy used to help those with insomnia without PTSD has proven to be beneficial.

5.
 
Finally, several medications have been used to improve sleep and reduce nightmares. One in particular called
prazosin,
which blocks the effects of norepinephrine, has been effective.

The take home message for those with PTSD and for friends and family members is that the sleep issues associated with the disorder need to be addressed. The good news is that we are gaining better understanding into the mechanisms and effects of dysfunctional sleep in PTSD sufferers, and as a result, are developing new and effective treatments.

Q.
 
My son returned from Iraq a few years ago, and the VA diagnosed him with PTSD. He snores and the doctor was concerned he may have sleep apnea. They want him studied and treated if he has it. The VA doctor told him that sleep apnea seems to be very common in veterans with PTSD. Why would that be?

A.
 
We are not sure, but in most studies, the incidence of sleep apnea is much higher than it is in men and women of a similar age and weight. One theory is that the sleep apnea was present before the PTSD. It is felt that by disrupting sleep repeatedly, sleep apnea makes it more
difficult to deal with the emotional trauma associated with the PTSD. As a result, people with sleep apnea are more likely to go on to develop PTSD.

Q.
 
My husband is a Vietnam war veteran. It has been over 40 years since he returned from the war, but he still has weekly nightmares. He goes for counseling, but it has not helped. Do you have any ideas?

A.
 
Yes, several medications have been used to treat nightmare disorder in PTSD. The newer atypical antipsychotics such as Seroquel have been used with some success. However, ironically, an older blood pressure medication called prazosin has been the most successful. I would discuss this with your health care provider.

Q.
 
I am a 61-year-old Vietnam veteran. I have PTSD. I am a very light sleeper and always feel fatigued. The VA wants me to get a sleep study. What is the point, since most of us vets with PTSD sleep poorly?

A.
 
Recent studies have shown that people with PTSD have a higher incidence of sleep-disordered breathing than normal. Most importantly, these studies demonstrated that spending much of the night in lighter stages of sleep—as is common in PTSD—can predispose one to sleep apnea. I would advise you to get the study done. At our sleep center, we have seen dramatic improvements in patients with PTSD after they are treated for their sleep-disordered breathing.