Treating combat-related sleeping disorders in veterans of Afghanistan and Iraq will require drawing on knowledge from veterans of previous conflicts.

As of the fall of 2005, more than 433,000 men and women in the armed forces have served in Afghanistan and Iraq.1 As they have returned home, vestiges of their time on active duty have remained. For many, the stress has left a scar that will take a long time to heal. If you practice sleep medicine, it is likely that you may see returning veterans in your clinic as disturbed sleep is one of the most prominent problems that occurs in response to stressors, such as war-zone military service. The aim of this article is to review current knowledge of the normal response to exposure to severe stress and trauma and to provide an overview of treatment options.

Active military duty is inherently stressful, particularly during times of war. Stress is considered to be traumatic when an event involves actual or threatened death or serious injury and a person’s response is one of intense fear, helplessness, or horror. Stress, both traumatic and nontraumatic, can leave lasting effects that range from days to many years. There are three broad categories of traumatic stress symptoms: reexperiencing of the trauma, avoidance of trauma-related stimuli, and hyperarousal.2

Symptoms of Traumatic Stress Reactions
Reexperiencing symptoms, as the name implies, involves a replay of the traumatic events in some form. The reexperiencing may occur as repetitive memories of the event, or in more severe cases the individual may experience flashbacks in which it feels as if the event is actually happening again. Of primary interest to sleep clinicians is the reexperiencing symptom of nightmares. These nightmares can range in content from an actual replay of the event to images that are more symbolic in nature. In most cases, the nightmare terminates in an awakening followed by difficulty falling back to sleep. In cases where the nightmares are frequent and chronic, individuals may fear going to sleep because of the possibility of having a nightmare.

The second category of symptoms is avoidance of trauma-related stimuli. Following traumatic exposure, there may be an active avoidance of situations that might remind the individual of the event. For veterans, this may mean avoiding conversations and staying away from places, activities, or people that remind them of the trauma (eg, avoiding media reports related to the conflict). In extreme cases, there may be complete seclusion at home because there is a fear that leaving the house will involve encountering reminders and an inability to cope with trauma cues.

The third category involves symptoms of excessive arousal. The hyperarousal can take the form of a heightened startle response or constant vigilance. One of the most common types of hyperarousal is disturbed sleep. The excessive arousal interferes with sleep onset and can make it difficult to fall back to sleep after nocturnal awakenings. Disturbed sleep is such a prominent symptom that it has been considered to be the hallmark symptom of traumatic stress reactions.3 In one study of Vietnam veterans, the prevalence of sleeping disturbance in those with post traumatic stress disorder (PTSD) was 44% for difficulty falling asleep and 91% for problems maintaining sleep.4 Despite the impact that all stress-related symptoms can have on daily functioning, it is surmised that poor sleep contributes to the greatest distress.

Stress-Related Diagnoses
Individuals who have mild reactions to stress experience some combination of these symptoms on a short-term basis. The symptoms fade on their own and do not typically require treatment. The diagnostic label given to these individuals is likely to be an adjustment reaction and may involve symptoms of depression and anxiety.

More severe reactions that persist for less than 1 month are given the diagnostic label of acute stress disorder (ASD), and severe reactions lasting greater than 1 month are labeled as PTSD.5 Although the symptoms experienced in each disorder are similar, patients with PTSD typically have a more severe constellation of symptoms than in cases of ASD. Patients with these types of stress reactions are likely to present to the sleep clinic with complaints of difficulty falling asleep or staying asleep and repetitive nightmares.

Sleep disturbance during this acute phase should not be ignored with the assumption that it will likely resolve. Individuals who experience nightmares and/or disturbed sleep during the initial period following the trauma are at increased risk of later development of PTSD. In a study conducted by Harvey and Bryant, 33% of individuals with nightmares within 1 month of the trauma, compared to 9% without nightmares, went on to develop PTSD.6 Similarly, 72% of those with sleep disturbance in the first month, compared to 36% without, developed PTSD. Clearly, nightmares and sleep disturbance in the early stages following exposure to severe stress warrant clinical attention. It is not currently known whether successful pharmacological or psychological treatment of these difficulties can reduce the likelihood of later development of PTSD, although work in this area is currently under way.

Treatment Options
A variety of psychotherapeutic and pharmacologic treatment options are available for post-trauma symptoms. The overwhelming majority of investigations have attempted to address the constellation of symptoms in PTSD and are not specific to disturbed sleep and nightmares, despite evidence that sleep disturbance often persists as a residual symptom even after successful treatment.7 A review of these treatment approaches is beyond the scope of this article, and the reader is referred to current practice guidelines.2,8-10 Rather, this article will focus on those interventions specific to sleep.

Psychological Treatment of Sleep Disturbance
One approach to treating disturbed sleep in PTSD is to use interventions designed for the treatment of insomnia. The typical “package” treatment currently in use consists of a combination of behavioral (ie, sleep hygiene, relaxation techniques, stimulus control, and sleep restriction) and cognitive components.11

This combination of behavioral and cognitive interventions is the mainstay of psychological treatment of insomnia. It stands to reason that they may also be useful for disturbed sleep in patients with PTSD. A survey of PTSD practice patterns in six VA medical centers in the western United States found that roughly 40% to 50% of practitioners used behavioral interventions for sleep in their patients with PTSD,12 indicating that a large number of providers are already utilizing these approaches.

Psychological Treatment of Nightmares
In recent years there have been increased efforts to develop efficacious treatments for chronic nightmares associated with PTSD. Forbes and colleagues13 and Krakow and colleagues14 have developed a treatment called Imagery Rehearsal Therapy (IRT) or simply Imagery Rehearsal (IR), respectively, to address this issue. IRT/IR is a psychotherapeutic intervention predicated on the idea that waking mental activity can influence the content of nighttime dreams and nightmares. Patients are taught to examine the content of a recurrent nightmare from which they suffer and to use imagery to alter or reduce aspects of the nightmare. This new dream is then mentally rehearsed prior to going to sleep.

Often with practice, the nightmare content changes to incorporate this new imagery. Alterations in the content of the nightmare are further purported to promote mastery and control. An example is a veteran who was a medic in Vietnam and had a recurrent replay nightmare of a combat experience in which he was the only medic tending to wounded soldiers. The nightmare was very vivid and the veteran could hear other soldiers screaming out for his help. Over time and with practice, he learned to insert a change in the nightmare so that a helicopter landed bringing other medics to help him. Preliminary evidence supports the efficacy of IRT/IR in reducing the frequency, intensity, and/or distress associated with PTSD-related nightmares.13,14

Our group at the Philadelphia VA Medical Center and the University of Pennsylvania is currently conducting a randomized controlled trial of IR specifically in Vietnam-era combat veterans with PTSD. Based on the existing data, this treatment approach appears promising as an intervention for traumatic nightmares in veterans returning from Afghanistan and Iraq.

Nightmares and disturbed sleep usually go hand in hand. In recognition of this fact, Krakow and colleagues have extended IRT to include behavioral interventions for insomnia.15 Their data thus far suggest that this combined approach can produce improvements in both nightmares and sleep disturbance in patients with PTSD.

Pharmacologic Treatments
Guidelines specific for treating the sleep disturbance in PTSD have not been developed. However, management of the sleep-related symptoms, recurrent nightmares, and insomnia has been addressed within broader algorithms for the treatment of PTSD. There is a consensus that selective serotonin reuptake inhibitors (SSRIs), including sertraline, paroxetine, and fluoxetine, are the first-line pharmacological treatments for PTSD.16 There is some evidence that the serotonin-norepinephrine reuptake inhibitor venlafaxine may have comparable efficacy. However, these medications often produce only a partial response, and insomnia and frequent nightmares can persist even when the entire PTSD symptom complex shows signs of remission. The potential of SSRIs to increase psychological activation, and thereby worsen insomnia, needs also to be recognized. Clinicians often attempt to augment the therapeutic action of an SSRI by adding a member of a different class of drugs. Medications that have been recommended include trazodone,9 nefazodone,17 the sedating tricyclic antidepressants imipramine and amitriptyline, and atypical antipsychotic drugs with sedative side effects, including quetiapine and olanzapine. Recently, the alpha-1 adrenergic antagonist prazosin, otherwise employed as an antihypertensive agent, has been found to relieve the sleep disturbance in some military veterans with PTSD.18,19 It might be predicted that the sedating new generation antidepressant mirtazapine will have usefulness in treating insomnia associated with PTSD. The role of the benzodiazepines in managing the sleep disturbance in PTSD remains unclear; while these medications may have some usefulness, attention needs to be paid to their addictive properties, particularly in patients with a history of substance abuse or dependence.8 Nonbenzodiazepine drugs that act at the benzodiazepine receptor may be less likely to produce daytime sedation. In all cases, physicians will want to consider the risk of side effects and drug interactions when choosing a pharmacological agent to ameliorate the sleep problems in PTSD.

Conclusions
Veterans returning from Afghanistan and Iraq are likely presenting to sleep clinics in ever-increasing numbers complaining of poor sleep and nightmares. These symptoms may occur in isolation or as part of a larger traumatic stress syndrome. There are a growing number of treatment options available, including both psychotherapeutic and pharmacologic approaches. Incorporation of these treatments into routine clinical practice should provide sleep clinics with the tools needed to help veterans get the rest they need.

Philip Gehrman, PhD, is assistant professor of psychology at the social sciences department of the University of the Sciences in Philadelphia. Joan M. Cook, PhD, is assistant professor of psychology in psychiatry at Columbia University. Richard Ross, MD, PhD, is professor of psychiatry at the Philadelphia VA Medical Center and the University of Pennsylvania School of Medicine.

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