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Everyone knows about the importance of sleep and its role in our physical, mental, and emotional well-being. Unfortunately, though, getting the sleep we need is not always an easy task, and it can be an especially vexing problem for our veterans.
Research shows that veterans face heightened challenges when it comes to sleep. In one study, a significant percentage of veterans and current service members — over 74% — reported symptoms consistent with insomnia, and this figure is even higher in veterans diagnosed with Post Traumatic Stress Disorder (PTSD).
Lack of sleep can cause or contribute to a wide range of health issues. For example, it can exacerbate mental health problems like PTSD and depression, reinforcing sleeping problems. A sleep deficit can affect the cardiovascular and metabolic systems in complex ways. It can also disrupt cognitive function, create risks when driving, and lead to problems in the workplace.
To understand more about this issue, we’ll review the current research about sleep disturbances for veterans, their possible causes and effects, and some of the treatments that may be helpful in addressing them.
While sleep disturbances and insomnia certainly affect people in the general population, they occur at a higher rate in current and former service members. Not only is the frequency of these disturbances higher, but in some veterans, the intensity may be greater than in the civilian population.
Sleep problems are multifaceted, and at times it can be hard to pinpoint exactly why someone may have difficulties falling or staying asleep. But research has identified some reasons why these issues are more common in veterans.
This condition is a mental health problem that occurs in many people who are exposed to traumatic events such as those in combat. PTSD can vary in intensity and frequency: it may arise soon after a difficult experience, or it may come about months or even years later. It can be a regular experience or marked by occasional episodes.
Symptoms of PTSD can be diverse. Often, they include reliving the event (through triggers, flashbacks, or nightmares), feeling the need to avoid situations that may involve triggers, negative feelings, and hyperarousal (feeling constantly “on alert”).
Because everyone faces trauma at some point, PTSD can occur in anyone and at any age; however, it is more common in veterans. In the U.S. population as a whole, PTSD affects about 7-8% of people. Estimates from the Department of Veterans Affairs indicate that PTSD affects around 15% of veterans who served in Vietnam, 12% of those who served in the Gulf War, and 11-20% of those who have served in Operation Iraqi Freedom and Operation Enduring Freedom.
Insomnia and sleep problems are common in people with PTSD. This can be the result of nightmares, fears of going to sleep, anxiety, persistent mental alertness, depression, and other negative thoughts. Insomnia has been reported in 90-100% of veterans with PTSD who served in Vietnam, Iraq, and Afghanistan. In fact, insomnia is one of the most frequently reported symptoms of PTSD and may make the condition more difficult to treat.
TBI happens when there is a blow or other impact to the head. Like PTSD, it can occur in the civilian population, but service members are at higher risk.
The impact from blasts, gunfire, falls, vehicle crashes, and other assaults can cause TBI. TBI can occur both in combat situations and in military training environments. TBI has been increasing during wars in Iraq and Afghanistan and has even been called the “signature wound” of these wars.
Injury to the brain can come about because of contusions to the brain (from shaking of the skull), swelling of the brain, and /or damage to nearby connecting fibers, nerves, and blood vessels.
The symptoms of this damage are numerous and are also referred to as post-concussive syndrome (PCS). These can include headaches, nausea, cognitive problems, mood changes, and many others. Sleep disturbances are also reported by a majority — as high as 80% — of people with TBI.
The severity and duration of symptoms can depend in large part on the intensity of the TBI. Symptoms go away within a few months for many people but may persist for others.
Even in veterans who have not been diagnosed with PTSD, they may experience heightened levels of stress or anxiety. Racing thoughts and mental alertness can interrupt a person’s ability to fall asleep or may cause them to wake in the night. The psychological stress of combat and of reintegration to civilian life can take a major toll and can be a significant cause of sleep problems.
Injuries sustained during combat may cause physical pain even well after a veteran has returned from war. Chronic or acute pain can prevent someone from being comfortable in bed or may cause a person to wake up numerous times during the night. Pain medications can also affect quantity and quality of sleep.
In military life, sleep schedules are often much different from those in civilian life. Circadian rhythms may be maladjusted in service members, and some veterans may have difficulty readjusting when they finish service. This can cause difficulties in going to bed and can lead to daytime fatigue and sleepiness.
In attempting to deal with PTSD, stress, anxiety, depression, pain, or other physical and emotional challenges, some veterans, like members of the civilian population, use alcohol or other drugs. Alcohol and many drugs, both legal and illegal, can interfere with sleep patterns and affect sleep quality.
Sleep problems in veterans can take many forms and can be influenced by factors beyond just their time in military service. As a result of the numerous obstacles to good sleep that veterans face, it should come as no surprise that many suffer from sleep disorders.
Insomnia is marked by frequent difficulties in falling asleep or staying asleep. It can be a long-term (chronic) or short-term problem. Insomnia is considered chronic when it persists beyond one month.
The symptoms of insomnia are familiar to most people who’ve experienced their fair share of sleepless nights; except in insomnia, these symptoms can be more regular and pronounced. For example, excessive daytime sleepiness (EDS) and fatigue are common symptoms. Problems with attention, concentration, and balance can arise, creating risks when driving. Insomnia can be related to depression and other emotional issues. And finally, insomnia is linked with weight gain and cardiovascular problems.
Insomnia is a significant problem for veterans because of the myriad of ways that their sleep can be interrupted. Up to 74% of service members in general report symptoms that correlate with insomnia, and this percentage is likely higher in those suffering from PTSD and TBI.
Treatment for insomnia depends on the individual and underlying cause. Cognitive behavioral therapy for insomnia (CBT-I) is one treatment that may help. It involves talk therapy to try to identify and address underlying anxiety or mental health concerns that can disrupt sleep. It can involve focused exercises to draw out and scrutinize these concerns and as a result typically requires sustained counseling over a period of several weeks or more.
Improvements to sleep hygiene and changes to a daily schedule may also be used as treatments for insomnia. Depending on the cause, medications — both prescription and over-the-counter — can be used to try and address insomnia.
Apneas are temporary pauses in breathing that occur during sleep. Sleep apnea can cause poor sleep, leading to daytime sleepiness, fatigue, cognitive deficits, and cardiovascular problems.
In obstructive sleep apnea (OSA), the airway in the back of the throat becomes blocked. In central sleep apnea (CSA), the messaging from the brain to the muscles that control breathing becomes disrupted.
OSA is more common than CSA. The risk factors for OSA include obesity, family history, certain physical features (relating to the narrowing of the airway), use of opiates or alcohol, smoking, and sleeping on your back. Risk factors for CSA include use of sedatives, heart problems, and injury to the central nervous system.
While definitive estimates of the rates of OSA and CSA in veterans do not exist, there are indications that these conditions affect veterans at a higher rate than the general population. In one small study, nearly 70% of veterans with PTSD were at heightened risk of OSA. TBI and injury to the nervous system may put service members at higher risk of CSA as well.
To diagnose sleep apnea, patients take part in a sleep study where they spend the night in a sleep clinic where professionals monitor their breathing.
If OSA or CSA is diagnosed, treatment usually involves a device like a CPAP (continuous positive airway pressure) or BiPAP (bi-level positive airway pressure) machine. These machines pump pressurized air through a hose and mask, into the airway to support effective breathing through the night.
Other treatments include lifestyle changes, such as losing weight, reducing use of sedatives and alcohol, and/or changing sleeping positions. In rare cases, surgery may be considered.
Our Circadian Rhythm is our sleep-wake cycle, and it is normally aligned with the pattern of daylight during the day. As we are exposed to light, our bodies produce hormones to ramp up our energy and wakefulness, and as night sets in, our bodies prepare to sleep.
When a person’s life or work obligations cause them to be awake contrary to this normal cycle, it can create serious sleep difficulties. While exact estimates of the prevalence of these disorders in veterans are limited, the nature of combat can lead to these disorders in service members.
Members of the armed forces who are required to be awake during the night in combat or training environments often have sleep interrupted and may find it hard to adjust to a regular daily routine when they return to civilian life. Issues like mental alertness or anxiety may also prevent someone’s effective alignment with a standard Circadian Rhythm.
The symptoms of these sleep-wake disorders can include significant daytime fatigue and tiredness and other symptoms similar to those of insomnia. Treatment may include changes to sleep hygiene, use of CBT-I, or other methods to work to realign a person’s Circadian Rhythm.
Vivid and terrifying dreams can cause significant sleep disturbances. They may cause someone to wake up in the middle of the night and may also make someone fearful of falling asleep in the first place. This can lead to insomnia and all of the symptoms associated with that condition.
Nightmares have been found to be quite common in veterans suffering from PTSD. Studies indicate that 50-70% of veterans with PTSD report having nightmares.
Treatment for nightmares is difficult. A medication called prazosin helps some people already dealing with regular nightmares. Some types of therapy related to CBT-I may be helpful but are still being studied to better understand their overall effectiveness.
RLS is a disorder of movement during sleep in which people feel the urge or need to move the lower limbs and often involves a numb, “pins and needles” feeling. It can cause poor sleep, daytime fatigue, and sleepiness.
The exact causes of RLS are not fully understood, but there are some indications that it may be more common among veterans.
Treatment for RLS usually begins with changes to sleep habits and hygiene and may involve medications if the condition persists.
Parasomnias represent a range of different disorders related to abnormal behavior during sleep.
Two parasomnias associated with PTSD include REM behavior sleep disorder (RBD) and sleep paralysis. RBD involves vigorous activity (physical and vocal) during rapid eye movement sleep, which is the deepest part of sleep. Sleep paralysis involves waking up and being unable to move for several minutes.
Prevalence of these can be difficult to ascertain in civilians and in veterans, and episodes may be rare. However, both of these parasomnias can be quite disturbing.
The exact cause of these parasomnias is not always certain. Treatments vary based on the specific circumstances but may include medications and changes to sleep hygiene.
PTSD is a central issue for veterans suffering from sleep disorders. In this section, we’ll take a deeper look at the relationship between PTSD and insomnia.
Insomnia and other sleep disorders are among the most common complaints of people who have PTSD. There are several reasons why this can be the case.
More than half of people with PTSD describe having issues with nightmares. These nightmares can involve a reliving of a traumatic event or may just be otherwise disturbing (and in many cases related to other negative thoughts).
Nightmares can cause abrupt awakenings and difficulties in falling back asleep. They can also exacerbate PTSD by serving as a trigger for recollection of trauma during periods of wakefulness. As a result, PTSD-associated nightmares can be a source of insomnia, daytime sleepiness, and daytime distress.
Hyperarousal is another common symptom of PTSD. This state makes it extremely difficult for a person to relax.
Worries and anxieties, often related to a traumatic event, can keep someone’s mind running to an extent that they cannot fall asleep in the first place. Or if they wake up in the night, they are again on alert and unable to fall back to sleep.
As with nightmares, this can provoke insomnia, fatigue, and distress.
For people with PTSD who are suffering from nightmares or have fears about what may happen at night or when they are sleeping, this can make going to bed a profoundly uncomfortable experience. Instead of being a time to relax and recharge, bedtime can become something to be feared and avoided.
Depression and sadness can occur with PTSD and may not necessarily be directly related to thoughts about a specific trauma. Insomnia may reinforce these negative thoughts. Depression is commonly linked to insomnia, and these conditions can be mutually reinforcing.
Some people with PTSD turn to frequent alcohol or drug use to try to help induce sleep, blunt emotions, or cope with negative thoughts. Unfortunately, these can have profound effects on sleep which may contribute to the cycle of insomnia and negative thoughts.
Other problems like chronic pain may afflict people struggling with PTSD. Sleep apnea also appears to be more common in patients with PTSD.
Combined with PTSD, these different health issues can pose further barriers to the kind of restorative sleep that could help people with this condition.
While sleep problems can be a serious issue for veterans, treatment options are available.
Cognitive behavioral therapy for insomnia (CBT-I) is a method proven effective for many people. It involves frequent counseling sessions to discuss sleep problems and devise strategies for managing them. This type of talk therapy can delve into the relationship between insomnia and other mental health issues (such as PTSD).
This is also a form of talk therapy, but is not focused specifically on the issue of sleep. For example, psychotherapy to work through trauma or anxiety itself may have a secondary effect of reducing insomnia. Research is still ongoing about how to optimally combine and/or sequence psychotherapy with CBT-I.
In people who have issues with Circadian Rhythm Disorders, light therapy uses specialized lights to help address the misalignment of the Circadian Rhythm. This may be especially important for veterans who do shift work or who had roles doing work at night during their time in service.
Since anxiety and alertness can be impediments to falling asleep, relaxation therapy works to help a person find a sense of calm at night. This can take regular practice but may help a person fall asleep when they get into bed and/or get back to bed if they wake up in the night.
This approach works by trying to routinize sleep and by restricting time in bed that is not spent actually sleeping. It tends to involve strict times for going to bed and getting out of bed each day.
Depending on the underlying cause of sleep problems, a medication or medical device may be able to help. For example, if a veteran has sleep apnea, a CPAP or BiPAP device has a high likelihood of improving their breathing and sleep quality. For other conditions, a medication may be able to help.
Medications should always be taken with the guidance of a doctor even if they are over-the-counter.
Sleep hygiene is a broad term used to refer to your sleep environment and the habits surrounding your sleep. Having good sleep hygiene means having practices that make it easier and more natural to get comfortable and fall asleep.
One aspect of sleep hygiene is the sleep environment. This means having a bedroom with a comfortable mattress and pillows, limited noise (which may involve using a white noise machine or earplugs), limited light (which can be achieved with blackout curtains or an eye mask), and a cool to moderate temperature. Overall, your bedroom should be a calm and comforting place.
Another aspect of sleep hygiene is all of your routines leading up to falling asleep. Having a standard routine, including a standard bedtime and wake-up time even on weekends, can bring a sense of normalcy to your evening. Following the same set of steps (such as washing your face, brushing your teeth, etc.) before getting in bed can help prepare your mind and body to sleep.
Many people also incorporate activities to relax the mind and/or body (such as stretches, meditation, or deep breathing), into nighttime routines. An important part of these routines is also avoiding things that may disrupt sleep like caffeine, alcohol, and spicy food close to bedtime.
Many veterans receive care in community medical settings outside of the VA system. In these cases, a doctor or nurse may not know of a person’s military history and may not inquire about issues like PTSD, TBI, or sleep-related issues.
As a result, it’s important for anyone who is concerned that they may have PTSD or insomnia to raise this issue with a doctor. Bringing this issue up with a health professional is an important first step for trying to get help in managing PTSD and/or insomnia.
Military Health System: Mental Health Home Page. This page offers descriptive pages and videos covering a large range of mental health issues as they relate to veterans.
U.S. Department of Veterans Affairs: Sleep Training. This page introduces key topics about sleep and has links to CBT-I programs for veterans.
National Center for PTSD: Finding Help. This website lists a range of different resources for finding help and support if you have PTSD. It includes links for finding a therapist and self-help and coping among others.
National Veterans Foundation. This non-profit organization offers a range of services and programs to provide direct help to veterans.
Defense and Veterans Brain Injury Center (DVBIC). This organization, part of the Military Health System, works to enhance knowledge and quality of care for veterans who have suffered traumatic brain injuries.
Harvard University Sleep Health and Education Program. This interactive website from Harvard Medical School’s Division of Sleep Medicine provides useful information about healthy sleep, sleep apnea, and other related topics.