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RETURNING
TROOPS,
POST-TRAUMATIC
SLEEP DISORDERS
ARE THE
NEW PTSD
PETER S. GREEN
A special report from
THROUGH
THE LONG
SUMMER
OF 2008,
U.S. ARMY CORPORAL SEAN BEDINGFIELD
led a fire team at a dust-choked combat operations post
in the craggy terrain of Kunar province in northeastern
Afghanistan. His platoon was five men short of its full
32-person complement, and would catch incoming fire
several times a day from Taliban insurgents in the surrounding hills.
1
interview from his home in Fitzwilliam, New Hampshire. With constant incoming rocket, mortar and
small-arms fire, the result was a platoon always on edge,
always groggy. If I could get three, four hours [of sleep]
a night, thatd be the most Id ever see, Bedingfield, now
discharged, said.
The toll on his body and brain was steep. Coming
home with a traumatic brain injury, shrapnel wounds
and knee pains, Bedingfield found himself on a laundry list of drugs. He said he was taking Clonidine for
blood pressure and suffering residual effects from the
antimalaria drug Mefloquine, which can cause horrific nightmares, delusions and sleepwalking. He was also
on antipsychotic medication and two different amphetamines to wake him up every morning.
It was terrible, absolutely terrible, Bedingfield said.
Sleep isnt very much regarded by the Army. He was
discharged with a 70 percent disability in 2012, and the
local Veterans Affairs hospital, he says, was unable to
help him restore his mental health.
As the longest war in U.S. history drags through its
13th year, Americas armed services are discharging an
increasing number of soldiers with serious sleep problems. Exact numbers are hard to lock down, but the
RAND Corporation found earlier this year that 48.5
percent of servicemembers reported such poor sleep
quality, it would qualify as a clinically significant sleep
disturbance on the Pittsburgh Sleep Quality Index.
With roughly two million U.S. veterans of the wars in
Iran and Afghanistan, that means some 900,000 active
or retired servicemembers may have significant sleep
disturbances or sleep disorders.
According to Dr. Vincent Mysliwiec, the Armys top
sleep specialist at Fort Hood, Texas, the Army alone
While the military recognizes that sleep is mission-critical in 2012, the Armys top health official,
Surgeon-General Patricia Horoho, unveiled a new set
of health priorities that she dubbed the performance
triad of sleep, activity and nutrition changes have
been slow to come for boots-on-the-ground serviceThe root of veterans chronic insomnia, and the PTSD men and -women.
In fact, sleep deprivation is so widespread in the
that often develops alongside it, isnt a disorder that can
Navy
that Shattuck says its as though a giant scientific
be cured as part of their post-discharge adjustment.
Its a symptom of larger problems that begin during experiment is being staged in front of her.
If we
dont
treat
sleep
disorders,
we cant
treat
PTSD.
We have
to attack
them
together.
Occasionally hed see soldiers using cocaine or homebrewed crystal meth to stay awake. (See Drug Use in
the Military, below.)
Youre always on guard, always suspicious of anyone coming up to you or next to you, said Steve Young,
a now-retired Army staff sergeant who served in Iraq
SLEEP IS FOR THE LOSERS
from 2005 to 2006. He served on guard and escort duty,
and as a trainer for Iraqi troops, at Camp Cedar 2, a
rmies have been going without proper rest since 20-square-mile air base at Ur, the mythical birthplace of
the beginning of time, many adhering to the man- the biblical patriarch Abraham.
tra that tough guys dont need sleep.
Even when youre trying to sleep or on rest days, you
As an infantryman, not being able to stay awake is a were always on alert, he explained.
weakness, said Bedingfield, the sleepless corporal. Its
Bedingfield says some soldiers in his unit were preinherently ingrained in our little societys hard wiring. scribed zolpidem, the sleeping aid commonly known as
To stay awake despite the arduous patrols and Ambien. Others used the muscle-strain reliever Flexconstant incoming fire Bedingfield and his fellow eril, which packs a hefty knockout punch.
soldiers had access to plenty of options to keep them
But medics in Iraq were loath to prescribe sleeping
awake, including Rip Its, a canned energy drink. If that pills, which can lead to depression and leave soldiers
he Army is fully aware of the dangers of chronic sleep deprivation. In fact, the Armys 1992 field
manual for interrogation (known as document FM
34-52, Intelligence Interrogation) specifies that, Examples of mental torture include...abnormal sleep deprivation alongside mock executions and chemically
induced psychosis.
Fatigue may also have been a factor in the 2012 collision between the U.S.S. Porter, a guided-missile cruiser,
and a Japanese supertanker near the Strait of Hormuz,
according to the Navys Dr. Shattuck.
said Davenport. The problem, he noted, is that sleep-deprived sailors are significantly more accident-prone.
A study by Shattuck showed that one-third of the
time, the response speed for sailors on an 18-hour watch
bill (six hours on, 12 hours off) was the same as if they
were legally drunk.
In the wake of the Port Royal grounding, Carroll was
demoted and eventually left the Navy. The service began
taking a closer look at how it could avoid fatigue-driven
accidents. In the past five years, five of the 31 so-called
Class A incidents in the Navy (where damage totaled
more than $2 million or a life was lost) cited fatigue as
a contributing factor, according to data collected by the
Naval Safety Center in Norfolk, Virginia, and obtained
by Van Winkles.
Curiously, the Port Royal was a subject of a 2008
study of shipboard fatigue by Navy Lt. Derek Mason,
who found its officers and crew were not getting the
sleep they required. Mason found that the Navys watch
patterns were wreaking havoc on sailors, whose bodies were naturally fighting to stay awake and maintain
alertness during daytime sleep periods, and he noted
they often failed to reach rejuvenating, mission-critical
REM sleep stages.
This break in routine leaves a person feeling fatigued and tired, despite sleeping for six to eight hours,
he wrote.
ASLEEP AT THE KEEL
Sleep
problems
can predict
the onset of
downstream
mental health
problems,
including
PTSD,
depression
and
suicide.
We are trying to convince the Navy senior leaderof running aground. All I could do was order a full stop
ship that they need to stop doing this, Shattuck said of
until we figured out where we were.
The near collision woke Cordle up to the real threat the irregular watch schedules that disturb sailors circasleeplessness could pose to a ship and its crew. A ships dian rhythms. She noted that most of the worlds navies
commander has a great deal of autonomy; on his next keep their sailors on a watch system of four hours on,
command nine years later, helming the guided-missile eight hours off.
9
I never had
any of these
problems
when I was
growing up.
Now its been
two or three
years without
proper sleep,
they are
still trying
to figure
out whats
wrong.
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youve been doing starts to hit you and you feel the effect of it.
Jacob Hansel is a Marine Corps weather forecaster who deployed to Iraq twice, in 2010 and 2011. His
12-person unit had just four trained forecasters, leaving
Hansel and his three colleagues to pull long shifts, analyzing floods of raw data, then telling helicopter pilots if
Compounding the problem even further, soldiers it was safe to fly and generals and platoon leaders how
are, by and large, kids, Shattuck noted. For example, the to avoid sandstorms.
average Marine Corps recruit is 20-years-old, according
The pressure was intense. If we get a forecast wrong,
to the Corps Recruitment Command. Thats an age at someone dies, and we can go to jail. We cant mess up,
which most men and women are still establishing their Hansel said. But his understaffed unit was often pulling
sleep patterns. The militarys skewed sleep schedules 24-hour shifts, then unable to get a decent nights sleep
leaves them open to worse circadian scarring.
before the next duty.
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ight bulbs and hormones wont work for many seWhether its CBTI or another technique, behaviorrious cases. As an alternative to traditional drug
therapies, the VA is training social workers and al therapy might have helped Jacob Hansel, the Marine
psychologists in a behavioral treatment known as Cog- Corps weather forecaster. After returning from his last
deployment, he spent months unable to sleep. At his
nitive Behavioral Therapy for Insomnia, or CBTI.
wifes urging he visited a Veterans Affairs hospital in
The CBTI treatment shows promise for some chronNew Hampshire, where he was given a two-week trial
ic insomniacs, said Dr. Wilfred Pigeon, a psychologist
of Ambien. It didnt help.
with the Veterans Affairs suicide prevention center in
Id fall asleep and wake up after two hours, Hansel
Canandaigua, New York. In CBTI, patients are guided
through mindfulness exercises in an effort to retrain said. His doctor sent him for a psychological evaluation,
where he was diagnosed with major depression, and
their brains to accept restful sleep.
adjustment disorder not uncommon for returning
Pigeons research also shows that veterans with sleep
veterans. After a few months, a civilian doctor diagproblems are more likely to commit suicide. PTSD and
nosed him with ADHD and put him on an antidepressleep problems have what Pigeon calls a bidirectional
sant prescribed off-label as a sleep aid.
relationship. If Im not sleeping well, then my PTSD
They put me on Trazidone for sleep, and I was on
symptoms might be more severe, and if I have PTSD,
Prozac and all that happy SSRI crap for a while, he said,
that cant help but affect my sleep.
referring to another kind of antidepressant, Selective
The treatment is controversial, with some psycholoSerotonin Reuptake Inhibitors (SSRIs). After a couple
gists saying that it merely masks the symptoms by trainmonths, I had a reaction to the Trazidone, so I couldnt
ing patients to ignore them, creating a ticking bomb of
breathe through my nose and was waking up at night.
stress that will eventually explode.
On the Prozac, he gained 30 pounds in a month, a
Patients with chronic insomnia develop a variety of
weight gain that could have forced him out of the serwhat psychologist and CBTI proponent Simon Rego
vice. Ditching the SSRIs, he was put into psychotherapy
calls unhelpful thoughts and behaviors, which rev up
and prescribed Adderall to stay focused on work and
emotions and actually maintain the insomnia theyre
Tamzipan to help sleep.
trying to get rid of. With CBTI, psychologists use a fiveAs long as I did a lot of work during the day, I was
part treatment that includes relaxation training and
okay. But if not, my mind wouldnt fall asleep, he said.
sleep hygiene to treat patients.
The drugs took a toll and, when he tried to extend his
If we know that people develop problematic behavioral patterns dysfunctional beliefs and attitudes enlistment, the Corps turned him down, he said. Devabout their sleep then maybe we can have a systemat- astated, for several months again he couldnt sleep, findic set of procedures that one-by-one counter these per- ing his whole world had fallen apart. By the time hed
petuating behaviors and bring the cycle back on track, retired and sorted out his medical insurance and care,
said Rego, director of the cognitive behavioral training he was diagnosed with atypical psychosis.
Hansel was put into therapy again, and prescribed an
SNRI, or serotoninnorepinephrine reuptake inhibitor,
When its successful, CBTI can replace many drug another class of antidepressant thats also used for anxitherapies for insomnia. Its not as easy as prescribing a ety and ADHD. Yet another cycle of sleeplessness forced
medication, said Rego, and there are many more peo- Hansel to be hospitalized and taken off his medication.
program at Montefiore Medical Center/Albert Einstein
College of Medicine in New York.
13
It should be common sense that chronic sleep deprivation will lead to insomnia, which will exacerbate, or
even cause, post-traumatic stress for our returning vetWhen Im not being bipolar, Im schizophrenic, he erans. As Troxel put it, Anyone whos experienced sleep
said. Once, suffering from a delusion, he nearly beat up disruption for extended periods of time your frustration tolerance is lower, and youre more likely to snap.
his younger brother.
At the Armys Medical Research and Materiel ComI never had any of these problems when I was growing up. Now its been two or three years without proper mand at Fort Detrick, Maryland, Jaques Reifman, a senior research scientist, and his team have developed a
sleep, they are still trying to figure out whats wrong.
smartphone app, called 2BAlert, that can measure soldiers alertness based on how much sleep theyve had
DESTRUCTIVE BEDFELLOWS
and their caffeine consumption.
We came up with formulae that allow us to matheor a long time, sleep problems were thought of matically capture how individuals perform when they
as something that went along with mental health are sleep-deprived, and when they take some kind of
symptoms, said RANDs Dr. Troxel. We now countermeasures such as caffeine, Reifman said.
know that sleep problems can predict the onset of
The app runs soldiers through a series of 25 tests that
downstream mental health problems, including PTSD, measure reaction time in order to establish a baseline
depression and suicide.
for each soldier. He says his team hopes to have it ready
Speaking at the 2015 SLEEP conference in Seattle, Dr. for beta-testing by the end of the year, and soon thereMysliwiec said, plainly, If we dont treat sleep disorders, after ready for the frontlines with Lieutenant Colonel
Lims help.
we cant treat PTSD. We have to attack them together.
14
RESOURCES
Naval Postgraduate Schools Crew Endurance
http://my.nps.edu/web/crewendurance
Navy Sleepiness Quiz
https://my.nps.edu/web/crewendurance/sleepiness-quiz
University of Pittsburgh Military Sleep Tactics & Resilience Research Team
http://www.veteranssleep.pitt.edu
University of Pittsburgh: Sleep Disturbances and Sleep Disorders
https://www.veteranssleep.pitt.edu/resources/sleep-disorders/
Pittsburgh Sleep Quality Index Questionnaire
http://consultgerirn.org/uploads/File/trythis/try_this_6_1.pdf
U.S. Department of Veterans Affairs
http://www.va.gov
National Center for PTSD
http://www.ptsd.va.gov/public/problems/sleep-and-ptsd.asp
Help with PTSD
http://www.ptsd.va.gov/public/where-to-get-help.asp
PTSD Coach for Veterans
http://www.ptsd.va.gov/public/treatment/cope/
PTSD Coach Mobile App
http://www.ptsd.va.gov/public/materials/apps/PTSDCoach.asp
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Not during
the past
month (0)
Less than
once a
week (1)
Once or
twice a
week (2)
Three or
more times
week (3)
Very
good (0)
Fairly
good (1)
Fairly
bad (2)
Very
bad (3)
9. During the past month, how would you rate your sleep
quality overall?
Component 1
Component 2
Component 3
Component 4
Component 5
Component 6
Component 7
#9 Score.................................................................................................................................................. C1_______
#2 Score (15min=0; 16-30 min=1; 31-60 min=2, >60 min=3) + #5a Score
(if sum is equal 0=0; 1-2=1; 3-4=2; 5-6=3) ........................................................................................ C2_______
#4 Score (>7=0; 6-7=1; 5-6=2; <5=3) ............................................................................................. C3_______
(total # of hours asleep)/(total # of hours in bed) x 100
>85%=0, 75%-84%=1, 65%-74%=2, <65%=3 ................................................................................... C4_______
Sum of Scores #5b to #5j (0=0; 1-9=1; 10-18=2; 19-27=3)............................................................. C5_______
#6 Score ................................................................................................................................................. C6_______
#7 Score + #8 Score (0=0; 1-2=1; 3-4=2; 5-6=3) ............................................................................ C7_______
Add the seven component scores together ________ Global PSQI Score ________
Buysse, D.J., Reynolds III, C.F., Monk, T.H., Berman, S.R., & Kupfer, D.J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric
practice and research. Journal of Psychiatric Research, 28(2), 193-213.
Reprinted with permission from copyright holder for educational purposes per the University of Pittsburgh, Sleep Medicine Institute, Pittsburgh Sleep
Quality Index (PSQI) website at http://www.sleep.pitt.edu/content.asp?id=1484&subid=2316.
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