Management of Comorbid Sleep Disorders in Patients With PTSD
Patients with posttraumatic stress disorder have unique barriers to restful sleep, which may result in chronic conditions and decreased mental performance.
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.
[This article originally published online ahead of print April 23, 2015.]
Sleep in the military has traditionally been thought of as a luxury and is sometimes considered at odds with optimal productivity. Every minute that a service member is asleep, he or she is not performing a primary duty, and getting a minimal amount of sleep is often seen as a badge of honor and strength. Research has recently been conducted, underscoring the importance of sleep management as an operational variable that must be accounted for in order to achieve optimal performance and promote resiliency. Both the quality and the duration of sleep must be considered, particularly given the increasingly complicated tasks that every service member must perform during both war and peace.
It has been well established that higher order mental tasks are the most vulnerable to sleep loss, as are those with little mental or physical stimulation, such as guard duty.1,2 Because service members are expected not only to perform in combat, but also to behave and operate ethically in spite of the challenges of war, the importance of adequate sleep must be considered. Many challenges are commonly encountered by service members when attempting to get adequate sleep (Table).3 This review highlights the recent diagnostic and treatment advances with respect to the overlap of sleep disorders and posttraumatic stress disorder (PTSD).
Culture of Sleep Loss
At the United States Military Academy in West Point, New York, a culture of poor sleep is instilled during initial military training; students typically get less than the recommended 7 to 8 hours of sleep per 24 hours.4,5 This sleep restriction continues for most of the time served on active duty: Military members get less sleep on average than does the rest of the U.S. population.6
Studies performed on pilots and during deployment have consistently shown a trend toward inadequate sleep, but only recently has inadequate sleep gained the attention of senior leadership.7,8 The Army Performance Triad, a public health campaign launched in 2013 by the Office of the U.S. Army Surgeon General, equally values sleep, nutrition, and activity. The goal of the Army Performance Triad is to influence behaviors by promoting healthy sleep, activity, and nutrition. Sleep is the apex of the Army Performance Triad.8
Those with chronic sleep restriction may not understand how impaired they are until objective testing is performed.9 In the civilian population, fatal sleep-related traffic accidents have been shown to exceed fatalities due to alcohol and illicit drug use combined.10 When poor sleep is combined with the trauma of war, symptoms exponentially worsen, and treatment becomes more complicated.11 Therefore, even before a formal sleep disorder or psychiatric condition develops, service members put themselves at risk by practicing poor sleep behaviors.11
Once insomnia develops, however, the potential negative health consequences are much more significant. Chronic insomnia, characterized by difficulty initiating or maintaining sleep or by waking too early, is the most common sleep disorder among adults. Thirty percent of adults experience occasional or transient insomnia, and between 9% and 12% of adults have severe chronic insomnia.12,13 This number is likely higher in the military and is much higher in those with PTSD.13
The etiology of chronic insomnia is multifactorial and is best conceptualized within a biopsychosocial framework. Physiologic abnormalities, such as increased activity in the central nervous system, hyperarousal of the hypothalamic-pituitary axis, and activation of proinflammatory cytokines, predispose individuals to developing insomnia. In addition, personality traits, such as anxious temperament or an internalizing stress-management style, make it more likely for individuals to respond negatively to stress, the most common precipitating cause of chronic insomnia.
Behavioral factors are also paramount. For example, individuals who experience acute sleep disturbance during deployment might develop maladaptive compensatory behaviors, such as spending excessive time in bed, “trying harder” to sleep, or overusing stimulants. These sleep behaviors can become a chronic condition.14
Comorbidities
Patients with insomnia are at increased risk for medical consequences, such as cardiovascular disease and mortality as well as psychiatric sequelae.15,16 Insomnia is also common among people who have attempted suicide.17 In the military, there was nearly a 20-fold increase in the rate of chronic insomnia among service members between 2000 and 2009, coincident with the dramatic uptick in operations tempo.18
Insomnia is one of the most common reports of returning Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans and is associated with the development of PTSD.19 Soldiers who reported symptoms of insomnia predeployment were more likely to develop anxiety, depression, and PTSD during deployment than were soldiers who did not report these symptoms.20
