Sleep Soundly Every Night, Feel Fantastic Every Day (34 page)

Q.
 
My husband is a Vietnam veteran. He was diagnosed with PTSD more than 20 years ago. He still has the same
recurrent nightmare a few times a week. How long can this go on?

A.
 
Actually, for a lifetime. A study done several years ago on World War II veterans showed recurrent nightmares in 60% of the subjects after 40 years. The good news is that there are some new pharmaceuticals and behavioral techniques available.

Q.
 
I am an Iraq war veteran with PTSD. I am on a drug called sertraline and have done well. I no longer have flashbacks and feel calmer. However, my sleep problems such as insomnia and nightmares are still a problem. Shouldn't the sertraline have cured that as well?

A.
 
Actually, that is not always the case. Many patients with PTSD have a high incidence of sleep disorders predating the PTSD. Sleep apnea, insomnia, and nightmare disorders seem to be higher in those with PTSD before it occurs. The theory is that poor sleep quality impairs emotional coping and may make these folks more susceptible to PTSD following severe emotional trauma. Recent studies have shown that sleep disorders may persist well after the PTSD has resolved. The trend in sleep medicine is to address the sleep issues as independent problems and not to automatically expect them to resolve when the PTSD improves. If this continues, consult with your health care provider. You may need a referral to someone familiar with these problems and its treatment, such as a sleep medicine specialist or psychiatrist.

Q.
 
I am a Vietnam veteran. I was diagnosed with PTSD several years ago and attend a support group at the local VA hospital. It has helped, but I am still having trouble
sleeping. It is difficult to fall and stay asleep. Worst of all, I have recurrent nightmares that have plagued me since the war. These group sessions do not seem to be helping me with my sleep. Do you have any suggestions for me?

A.
 
Yes, I do. We know that people with PTSD have sleep-related problems. Recurrent nightmares are a major issue. Recent studies have shown that patients with PTSD have elevated levels of a neurotransmitter called norepinephrine. We have found that a blood pressure medication called prazosin that blocks norepinephrine in the brain has been effective in eliminating sleep problems in PTSD. You should discuss this with your health care provider.

Q.
 
My brother lives with us. He came back from Iraq with PTSD. He is having trouble falling and staying asleep, which is making him increasingly irritable. I am trying to get him to seek help. Do you think it would make a difference?

A.
 
The answer is yes. Insomnia is an integral problem associated with PTSD. If untreated, it interferes with emotional adaptation and further contributes to the increased irritability associated with PTSD. The good news is that there are now treatment options, both behavioral and pharmacological. To help with the sleep disorders associated with PTSD, I would urge your brother to seek help from the Veterans Administration or your family physician.

Q.
 
My husband was in a terrible car accident several years ago. He was diagnosed with PTSD about a year later. Unfortunately, he still wakes up in a panic with
nightmares about the accident. Is there anything that can be done about this? He has undergone therapy and most of the other symptoms have resolved.

A:
 
Yes, there is hope for those with recurrent nightmares in PTSD. The nightmares are the re-experiencing of the event during sleep. There are both pharmaceutical and behavioral treatments available. Among the medications, an older blood pressure medication called prazosin seems to be the best. Imagery rehearsal therapy is a cognitive treatment. In this therapy, the person alters the disturbing content of the dream to a more pleasant one and rehearses the change in their mind during the day. It has been shown to be very effective in studies done with military veterans.

 

 

Sleep is the golden chain that ties health and our bodies together.

—THOMAS DEKKER

The estimated percentage of children and adolescents in the United States diagnosed with attention deficit hyperactivity disorder (ADHD) is 5.9% to 7.1%, and the numbers continue to rise. Symptoms, including difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (overactivity), often continue into adulthood. A long-term study following young children (three to four years old) diagnosed early with ADHD and treated through educational and pharmaceutical methods found that from 30% to 70% still experienced symptoms as adults. Their symptoms persisted because there is a significant, deeper issue at play. Many kids and adults with ADHD have an underlying sleep disorder. Sleep problems
can exacerbate ADHD symptoms and treating the sleep disorder will improve the ADHD symptoms. Conversely, some children are misdiagnosed with ADHD when the cause of their symptoms is an untreated sleep disorder, like sleep apnea, restless legs syndrome (RLS), or inadequate sleep.

In my sleep practice, I see many caring parents who are unaware of how much sleep children require. It is estimated that 30% of children demonstrate symptoms of sleep disorders. Children need 11 to 12 hours of sleep every night. Deprived these hours, they become irritable, have difficulty sitting still, and have a hard time concentrating. One sleep study involving 2,463 children of 6 to 15 years old, showed

  
Sleep problems are more likely to cause children to be inattentive, hyperactive, impulsive, and display oppositional behaviors.

  
As a result of being sleepy, children may be moody, emotionally explosive, and/or aggressive.

Lack of sleep also affects their cognitive development. In a study reported in the British
Journal of Epidemiology and Community Health,
children who demonstrated irregular bedtimes up to the age of three were the most negatively affected when it came to reading, math skills, and spatial awareness. When followed over time, the same children continued to lag developmentally, even at the age of seven—and girls more than boys. The authors concluded that the first three years of life seem to be a particularly sensitive time for sleep and its relationship to cognitive development.

A more recent study published in the
Journal of Pediatric Psychology
further verified the impact of lack of sleep on children's emotions and cognitive performance. In the study, 32 children (8 to 12 years old) wore devices that could detect sleep, called actigraphs. These were worn on the wrist, similarly to a watch. They detected motion or its absence and could differentiate between being asleep and being awake. The children were initially studied under their usual sleep habits for one week. Then during week two, half were deprived of one hour of sleep and the other half had their sleep lengthened by one hour. During week three, each group was exposed to the opposite condition.

The study period ended on a Friday. The following morning the children were put through a number of tests of cognitive function such as short-term and working memory. They were also tested for emotional responses to positive and negative images. The parents filled out detailed questionnaires about their children's cognitive ability and emotional responses during the test period.

The results were quite impressive. Parents reported that their children had more difficulty regulating their emotions when they were in the short-sleep compared to the long-sleep duration group. In addition, the children, when tested, expressed far fewer positive responses to various stimuli when they were in the short-sleep group.

Additionally, short-term and working memory, as well as math fluency, were found to be negatively affected in the short-sleep group. Both parental observations and testing demonstrated significant problems with attention as well.

As you can see from the previously mentioned studies, many of these symptoms that children exhibited due to lack of sleep were similar to symptoms for ADHD, and could complicate an accurate ADHD diagnosis. The following table compares symptoms of children with ADHD to children with sleep disorders.

 

Some researchers believe that the presence of sleep problems can be a predictor for ADHD. A recently published comprehensive study investigated sleep duration and disturbance as predictors of ADHD diagnoses in children from birth through age 11. Of the assessed 8,195 children, 173 children (2.1%) met the criteria for ADHD. According to the study, ADHD children had more night awakenings than their peers at every age. Shorter sleep durations and disruptions appeared early andare a significant predictor of ADHD between ages three and five.

A child diagnosed with ADHD is likely to have a sleep disorder. The most common issues include excessive daytime sleepiness, trouble falling asleep, difficulties awakening, restless legs syndrome, and sleep apnea. In a vicious cycle, the sleep problem aggravates the ADHD symptoms and ADHD behaviors in children can reinforce sleep issues. The good news is that when the children's sleep disorders received treatment, the ADHD symptoms improved. For example, attention deficits were reported in up to 95% of obstructive sleep apnea (OSA) patients. In patients with the full ADHD syndrome, 20% to 30% showed incidence
of OSA. After treatment for the sleep apnea, behavior and attention improved.

The most common sleep disorders that coexist with ADHD in children are:

1.
 
Higher daytime sleepiness.

2.
 
More movements in sleep.

3.
 
Sleep-disordered breathing, sleep apnea, and sleep hypopnea, which is a partial obstruction to breathing resulting in at least a 3% drop in oxygen saturation. It is considered just as deleterious as an apnea.