John, a 25-year-old combat veteran of Afghanistan, was sent to me for sleep apnea by the local VA hospital. He was somewhat withdrawn and unemotional. As we spoke, I discovered that he had severe insomnia and recurrent nightmares. He was becoming progressively more withdrawn and there were certain places like shopping malls that he absolutely refused to go to as crowds and noise brought back stressful emotions and even flashbacks of the war. John had PTSD (Post Traumatic Stress Disorder). He was being treated with some anti-anxiety medications but his sleep-related problems were not being addressed. I knew that if they were not, it was unlikely he would ever improve.
Seven percent of all Americans and 15 to 20% of our returning veterans suffer from PTSD. Their sleep-related issues including insomnia, recurrent nightmares, and a high incidence of sleep apnea, must be addressed in order for there to be improvement in their daytime functioning.
Recent studies have shown that high levels of the brain neurotransmitter norepinephrine following emotional trauma is a significant contributor to both daytime and nighttime problems. Norepinephrine not only causes hyperarousal but it disrupts REM sleep. Normal 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. An example would be an accident victim who now re-experiences the feelings of the original event every time they drive down a particular street or hear a horn.
Until recently, most therapies were aimed at the daytime experience but ignored the sleep problems. We now know that we need to address the sleep problems as well if we are to help these people. Treating sleep apnea, which appears to be present in higher than expected numbers of these individuals, can decrease sleep disruption and nightmares. A technique called Imagery Rehearsal Therapy, where the person is asked to write down the nightmare and change it to something unthreatening, and then rehearse it during the day, has been very effective. Cognitive Behavioral Therapy, which is used to help those with insomnia without PTSD, has also been beneficial. Finally, several medications have been utilized to improve sleep and reduce nightmares. One called Prazosin, which blocks the effects of norepinephrine, has been very 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 a better understanding of the mechanisms and effects of dysfunctional sleep in these people and as a result are developing successful new treatments.
By Robert Rosenberg