Sleep Guide for Veterans Sleep Disorders

Veteran sleep disorders are different than that of civilians.  Many times, finding a solution or treatment is more complicated for service personnel.  Due to insufficient sleep and physiological stress, medical conditions outside of sleep issues can also develop.  These may increase the likelihood of acquiring one or more sleep problems and also muddle treatment options.  Veteran sleep disorders are well documented, but more research needs to be done to understand the full scope of the relationship.  What we do know is that the risk for trouble sleeping is more prevalent for those in the military.  Statistics show that service men and women are at an increasing risk for experiencing sleep issues.  Affected US Veterans are urged to integrate management of sleep disorders within their medical care.

Military: Culture of Deficient Sleep

The ability to perform at high levels on little sleep is all too often considered a sign of strength.  However, in the long-term, sleep deprivation can cause irreparable harm.  Continuously not getting enough uninterrupted sleep can put a person at higher risk for accidents.  It can also increase risk for high blood pressure, heart attack and stroke.  The cumulative effect can worsen anxiety which a soldier may already experience.  Almost 42% experience short sleep duration compared to non-military reports of 9.3%.  The shortened sleep schedule may start as a result of long work hours during deployment but it continues after returning home.

Veterans Sleep Disorders

Veteran sleep disorders can include conditions that impact quality and quantity of sleep.  Some people may have more than one of these sleep problems.  Some of these conditions can worsen others.  For example, obstructive sleep apnea can create or worsen depression that leads to insomnia.  These are highly common Veteran Sleep Disorders.

• • Circadian Rhythm Disorder: Vets can undergo a shift in their natural wake and sleep patterns.
  • Insomnia: Sleeplessness can follow difficulty falling asleep or even abbreviated periods of sleep.
  • Pain Syndromes: Injuries and back or joint pain can keep you from getting necessary sleep.
  • Movement Disorders: Medical issues can cause physical movements that result in sleeplessness including restless leg syndrome.
  • Hypersomnia: Not all sleep disorders reduce sleep time, this one actually means you sleep too much during the day.
  • Sleep Apnea: Sleep related breathing disorders may be caused by physical trauma – but not always.

• Sleep Deprivation: Whether it was out of need or a show of mental toughness, sleep deprivation can happen with devastating effects on health and wellness.
• Parasomnia: REM behavior disorder and sleep paralysis are common parasomnias seen in combat Veterans with PTSD.
• Nightmares and/or Night Terrors: Combat related nightmares can cause sleep disruptions. Night terrors are different, they occur during sleep but the sleeper is in an awakened state where they are able to move which is more dangerous.  Content of these episodes center around emotions of guilt, anger and helplessness with moments of intense terror.
• Paradoxical Insomnia: A more rare form of insomnia where sleep duration is not short but perception of it is.

Sleep with Service-Related Illnesses or PTSD

Service connectable or not, many medical concerns have significant associations with Veteran sleep disorders.  Medical circumstances that can influence sleep difficulties include anxiety, depression, and pain or movement syndromes.  Additionally, mild TBIs (Traumatic Brain Injuries) can bring complexity to sleep outcomes.  PTSD (Post Traumatic Stress Disorder), previously known as battle fatigue, and sleep problems are tied together in several ways.  In a study of 116 Vietnam Veterans with PTSD, 91% also reported sleep struggles.  In other research it was found that 80% of patients with PTSD also encounter paradoxical insomnia.  Illnesses that seem to corelate with combat operations and accompany a diagnosis of PTSD include the following:

PTSD and Sleep Terrors – These go together so often that often times night terrors are misdiagnosed as PTSD.  PTSD and sleep disorders that cause nightmares or terrors can dominate the nighttime, reducing sleep quality.  The combination of PTSD and night terrors can produce a variety of symptoms.  Some symptoms include panic attacks, hyperventilation, rapid heart rate, aggressive behavior and many more.  Cognitive Behavior Therapy or Cognitive Processing Therapy works to train your brain to think differently.  The idea is to replace the negative thoughts and memories so that they don’t become the foundation of your dream state.

PTSD and Sleep Deprivation – Due to other sleep inhibiting hurdles, sleep deprivation and PTSD are deeply connected.  Up to 90% of PTSD sufferers also experience sleep deprivation.  As many sleep disorders are connected with PTSD, sleep deprivation can stem from any one of them.  Anything that prevents a person from getting to sleep or maintaining sleep can be the root cause of sleep deprivation; guilt, fear, nightmares, pain or substance abuse included.  Solutions for sleep deprivation are about treating the cause in hopes that it will improve the sum of sleep and its overall quality.

PTSD and Sleep Apnea – It’s still not clear why PTSD and sleep apnea are connected, but they are.  An evaluation of Afghanistan and Iraq Vets with PTSD found over 69% were also at risk for sleep apnea.  With sleep apnea, breathing halts during sleep.  It can be for brief periods of time or longer ones.  Those with sleep apnea may snore loudly.  The dangerous part of sleep apnea is that because you partially wake during occurrences, sleep cycles are interrupted.  This prevents your body from performing key functions that happen as you sleep normally.  This increases your chances of developing heart or liver conditions and a bunch of other health-related problems.  To help, your doctor may suggest using a CPAP machine, making lifestyle changes or even undergoing surgery.

PTSD and Sleeping Too Much – This is called Hypersomnia.  PTSD and sleeping too much could be linked but may simply correlate due to shared causes.  Typical causes can be medical issues, medication, substance abuse, or psychiatric disorders.  The exhaustion of depression may also be at play.  Whatever the cause, the fact is, hypersomnia directly impacts quality of life.  Sufferers miss out on activities during the day and excessive sleepiness reduces the enjoyment of what they do experience.  Eliminating caffeine and alcohol while practicing good sleep hygiene is a good place to start if you want to rid yourself of oversleeping.  Though your doctor might prescribe medications to help.

PTSD and Insomnia – When assessing military personnel returning from Iraq and Afghanistan combat zones for PTSD, insomnia was the most common symptom.  Not only that, but those returning from non-combat zones in Kuwait and Shipboard, also had insomnia as the number one symptom.  The link is undeniable.  The onset of insomnia could be a response to a change in the environment, feelings of isolation or depression, pain, nightmares or alcohol abuse.  Cognitive Behavior Therapy helps many deployed soldiers with sleep issues such as insomnia and sleep disruption.

Why Veterans Experience Sleep Problems

The reason for Veteran Sleep Disorders can be any number of things.  Perhaps previous sleep deprivation has left long-term effects on sleep habits.  Maybe the sudden change from a dangerous high-risk environment to the suburbs is to blame.  It is possible that coping mechanisms used to forget or manage negative experiences during combat bring about substance abuse.  The fact is that when soldiers first go into the military, they sustain evaluations to ensure their mental and physical health.  If they don’t pass to a certain degree, they aren’t accepted.  So, it’s safe to say veterans sleep disorders are connected to some aspect of being involved in the military.  Whether it is training, combat exposure, a pre-disposition, or deployment in general, that is yet to be discovered.

Possible Reasons for Veteran Sleep Disorders:

• • Stress, Anxiety and Hypervigilance: The need to be on high alert in a war situation can create chronic stress that simply does not go away upon returning home.
  • Emotional Trauma: Being witness to combat operations may traumatize making it difficult to sleep.
  • Depression: A predominating factor for many Veteran sleep disorders is feelings of guilt. Sadness for friends lost, and survivor guilt.
  • Tinnitus: Ringing in the ears or other effects can make it hard to sleep. The noise is there preventing sleep even though it’s only heard by the person with the condition.

• Side Effects of Coping Mechanisms: Alcohol affects sleep so when it is used to manage internal stress, it can block progression through sleep cycles.
• Unnatural Sleep Schedule: The after effects of shift work can require adjustments in your sleep schedule. This does not happen overnight which can bring on abnormal sleep patterns like sleeping during the day versus at night.
• Brain Injuries: Sleep disturbances are reported by half of mTBI patients with about 30% meeting specified criteria for sleep disorders. Mild traumatic brain injuries are among the most common psychologic and neurologic injuries in the military workforce.
• Pain: Intense or chronic physical pain can make it all but impossible to fall asleep.
• Military Related Stressor: For women at least, a probable precursor for problematic sleep is a stressful event. It could begin because of an incident of sexual harassment, abuse, rape, trauma or even the act of deploying itself.

Veterans Sleep Treatments

What it all comes down to is veterans like you are looking for a way to make these symptoms go away.  Please remember that you are not alone.  If you are suffering from Veterans Sleep Disorders or are experiencing other trauma-related symptoms, seek help.  Medical professionals will be able to best assist you when coping with combat exposure and the disorder that can follow.  When meeting with health professionals it is imperative that you provide information about your service experience.  This can help with pinpointing what your issues are and how best to go about finding a treatment.  This is especially important if you seek care outside of the VA system.

Some Methods of Treating Veteran Sleep Disorders:

• • Talk Therapy: This may consist of Eye Movement Desensitization and Reprocessing, Prolonged Exposure, Interpersonal Psychotherapy, Stress Inoculation Training, and/or Cognitive Processing Therapy. Cognitive behavior Therapy includes managing stimulus while incorporating good sleep hygiene and relaxation methods.  It can reduce the impact of inconsistent sleep schedules, lesson insomnia and help with sleep deprivation.
  • Yoga, Meditation, Relaxation Therapy: Reducing sensitivity to pain, lessoning anxiety and reducing anger for a state closer to calm can help initiate sleep.
  • Light Therapy: This may be used in the correction of Circadian Rhythm Disorders.

• Refine Sleep Hygiene Practices: There are many ways to improve sleep hygiene. Create a routine, go to sleep at the same time daily, wake up at the same time daily.  Adjust the bedroom environment to be conducive to better sleep using lighting and eliminating distractions.
• Medical Equipment: Devices such as a CPAP machine can work against sleep apnea.
• Medications: Physicians may prescribe one of several medications; antidepressants, Levodopa, Clonidine, MAO inhibiters, Bromocriptine, and SSRIs.
• Lifestyle Changes: Identify patterns of substance abuse and find a treatment plan that helps you quit. This can include therapy, detox, rehabilitation programs and more.  Other lifestyle changes that may help include exercising more and cutting out caffeine.

Important Resources for Veterans

This compilation of resources may help you find the care you need for Veteran’s sleep disorders and more.

Veterans Crisis Line (US Dept. of Veterans Affairs): 1-800-273-8255 (Select #1)

VA Locations by State: https://www.va.gov/directory/guide/allstate.asp

Wounded Warrior Project: https://www.woundedwarriorproject.org/programs

Sleep Diary Intake for Health Care Provider: http://www.veteranshealthlibrary.org/SleepChartVHL.pdf

Veterans of Foreign Wars: https://www.vfw.org/about-us

The list here directs you to who to contact with concerns about homelessness, mental health, and caregiver support:

https://www.mentalhealth.va.gov/MENTALHEALTH/get-help/index.asp

Make the Connection (Connects Veterans to Area Resources): https://maketheconnection.net/resources

American Sleep Apnea Association: 1-888-293-3650

American Academy of Sleep Medicine: 1-630-737-9700

Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4909622/

https://www.everydayhealth.com/sleep/health-risks-of-long-term-sleep-deprivation.aspx

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3543057/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4967368/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3543067/#B5

https://www.ncbi.nlm.nih.gov/pubmed/2030013

http://sleepdisorders.com/qa/what-difference-between-night-terrors-and-nightmares

https://www.verywellhealth.com/the-causes-and-treatment-of-ptsd-nightmares-3014688

https://www.sleepfoundation.org/articles/connection-between-ptsd-and-sleep-apnea

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3832138/

http://www.veteranshealthlibrary.org/Encyclopedia/142,41442_VA

https://www.ncbi.nlm.nih.gov/pubmed/22705246/

https://www.ncbi.nlm.nih.gov/pubmed/23205531/

http://www.veteranshealthlibrary.org/Search/142,HW184263_VA

http://www.ptsdtraumasurvivors.com/night-terrors/nightmares-night-terrors-ptsdc-ptsd /