Dr. Williams is the chief of sleep medicine at the Womack Army Medical Center in Fort Bragg, North Carolina, and an assistant professor in the Department of Medicine at the Uniformed Services University in Bethesda, Maryland. Dr. Collen is a staff pulmonologist, intensivist, and sleep disorders physician at the San Antonio Military Medical Center in Fort Sam Houston, Texas, and an assistant professor in the Department of Medicine at the Uniformed Services University. Dr. Mysliwiec is chief of pulmonary, critical care, and sleep disorders in the Medical Specialties Clinic at the 121 Combat Support Hospital in Korea. Dr. Wickwire is an assistant professor for the departments of psychiatry and medicine at the University of Maryland School of Medicine in Baltimore. Ms. Ryan is a health strategist and lead communicator and Dr. Lim is a psychologist, both in the Office of the United States Army Surgeon General in Falls Church, Virginia.
Empirically supported and evidence-based treatment options exist. Further, a robust evidence base supports the conclusion that treating insomnia improves not only sleep and quality of life (QOL), but also health-related outcomes in comorbid conditions, including depression, PTSD, chronic pain, and alcohol dependence.21-24 One historical barrier to effective treatment has been poor recognition of the scope of the problem. The army is looking to implement a more robust assessment of sleep in the primary care setting as part of the Army Performance Triad in order to intervene as early as possible. Other government organizations may also follow suit.
Although several FDA-approved medications for insomnia exist, the gold standard treatment for insomnia is cognitive behavioral therapy (CBT).25 Specific behavioral patient preferences that can be used to tailor treatment have been identified within a military population.26 Unfortunately, the most commonly used treatment for chronic insomnia in the military remains sedative- hypnotic medication. Multiple estimates suggest that 15% to 20% of all deployed service members have been prescribed a sedative-hypnotic to aid with sleep initiation, including many off-label antidepressants, antipsychotics, and antihistamines. Indeed, within VA, the use of quetiapine (an antipsychotic used off-label to treat insomnia) increased > 7-fold between 2001 and 2010, making it the second largest single drug expenditure in 2010. Many off-label medications have questionable risk-benefit ratios when used for sleep, and adverse effects can include infection,27 motor vehicle accidents,28 falls,29 and mortality.30 Further, some medications can limit deployability.
There are substantial challenges to incorporating behavioral approaches into the military armamentarium. There is a shortage of behavioral sleep specialists, although training initiatives seem promising.31 Most military facilities now have a medical home model of care with behavioral health providers as intrinsic team members. Their presence makes it easier to refer patients while reducing the stigma associated with behavioral health care. Leveraging technology will also facilitate the provision of quality, physician-directed insomnia treatment to an increasing number of military beneficiaries.
Nightmare Disorder
When patients with PTSD are able to get sleep, nightmares are a frequent occurrence and have been seen in up to 80% of individuals with this disorder.32 Nightmares usually occur during rapid eye movement (REM) sleep and are characterized by distressing dreams that threaten survival or security. They are often well remembered.33 After the nightmare, individuals typically wake up rapidly and report symptoms of distress, which can result in avoiding sleep (thereby perpetuating comorbid insomnia), daytime sleepiness, and fatigue.
Posttraumatic nightmares may have different dream mentation than do other disturbing dreams. The nightmare theme may involve actual events or reliving a prior traumatic experience. Most nightmares, however, have no associated movements or other complex behaviors, because during REM sleep, normal individuals are paralyzed, and thus do not move or act out their dreams.
Trauma-Associated Sleep Disorder
In some cases though, nightmares are accompanied by parasomnia activity.34 Parasomnias are abnormal and unintentional activities that occur during incomplete transitions between sleep stages and are seen more often in military personnel returning from deployment than in the general population. There is limited data regarding parasomnia activity in military personnel and veterans, although a study assessing sleep in 24 OIF/OEF veterans reported that 38% had either non-REM or REM parasomnia.34 Although in some instances these behaviors are simply a combination of genetics and insufficient sleep, in the majority of cases the clinical presentation is more complex.
In the authors’ clinical experience, patients described disruptive nocturnal behaviors (DNBs) which consisted of abnormal vocalizations (screaming, yelling), abnormal movements (tossing, turning, thrashing, sleep walking), or combative behaviors (striking the bed partner). These behaviors were strongly linked to symptoms of autonomic hyperarousal (night sweats, increased heart rate, or fast breathing). The DNBs often mimicked the content of the nightmares. The bed partner or spouse reported many of the cases after they had sustained unintended physical trauma from the combative behaviors.
Initially, REM behavior disorder (RBD) or nightmare disorder were considered potential diagnoses. However, RBD tends to occur in elderly males with neurodegenerative disorders (such as Parkinson disease). Dreams are relatively similar among patients with this disorder.35 Non-REM parasomnias are more common in young children and usually resolve prior to adolescence, although individuals who experienced parasomnias as children may see a reemergence during adulthood as a result of sleep fragmentation, medications, sleep-disordered breathing (SDB), recovery from sleep debt, or recreational drug or alcohol use.36,37
Since these posttraumatic nocturnal behaviors are not formally classified, a condition termed trauma-associated sleep disorder (TSD) was recently proposed.38 Trauma-associated sleep disorder is distinct from other parasomnias, because the onset must relate to a potentially traumatic event. On an overnight polysomnogram, increased muscle activity is seen during REM, and nightmares are almost invariably reported. Trauma-associated sleep disorder seems to involve not only DNB and traumatic dream enactment, but also insomnia and obstructive sleep apnea (OSA).
