Post-traumatic stress disorder and its Effects on Sleep in Military Veterans
Post-traumatic stress disorder has been related to a number of health difficulties, including psychological and physiological impacts, as well as sleep disorders and disruptions. Sleep problems raise patients' anxiety and diminish their ability to perform. Despite the fact that current research has found a link between sleep disruptions and PTSD, there is still a void in the literature about the effects of PTSD on sleep in military veterans. As a result, this review of the literature will discuss the available information on the psychological and physiological consequences of PTSD on sleep in veterans. Sleep issues in military veterans with PTSD symptoms are an important area that needs more research. Keywords: nightmares, sleep apnea, insomnia, CBT, health outcomes, functional impairment.
The Physiological and Psychological Effects of PTSD on Sleep in Military Veterans
Introduction
Individual experience or exposure to traumatizing events, for instance, war, is linked to the onset of post-traumatic stress disorder (PTSD) and poor health outcomes. PTSD with relation to combat trauma among veterans has been researched on for many decades (Xue et al., 2015). Nonetheless, the impact of PTSD on veterans is a topic that raises much concern among policymakers, leaders, and even the public. PTSD is associated with severe distress and may impact the personal and social functioning of veterans. Furthermore, according to Khazaie, Ghadami, Nasoori, and Paveh (2015) patients with PTSD symptoms frequently complain of sleep disturbances among other sleep disorders. In addition, Khazaie, Ghadami, and Masoudi (2016) argue that 87% of patients diagnosed with PTSD have reported sleep disruptions. Different researchers have conducted studies on the effects of PTSD on sleep, however, little research has been done among military veterans. Due to the gap in knowledge, analyzing the psychological and physiological effects of PTSD on sleep among veterans becomes essential. Therefore, this paper will present an analysis of the current literature on the topic.
Sleep Variability among Veterans with PTSD
The interplay between distress and sleep is mirrored in the diagnostic measures for PTSD, which includes sleep disruptions. Sleep disruptions include effects such as insomnia (inability to fall asleep), snoring, nightmares, rapid leg movements, sleep deprivation and sleeping sickness (irregularity in sleep cycles), as illustrated in figure 1. As Koffel, Khawaja, and Germain, (2016) report, persons with PTSD symptoms and subjective sleep disruptions have an increased probability of functional impairment when compared to patients with regular sleep patterns. Furthermore, the presence of comorbidities may exacerbate greater sleep inconsistencies among veterans .Comorbidity is the occurrence of two or more conditions at the same time. For instance, an experimental research conducted by Brown et al. (2017) examines sleep variations among veterans with PTSD and mental illness. The research which was conducted among 53 subjects revealed that both groups experienced severe sleep difficulties. Regardless, subjects with both PTSD and mental illness (comorbid conditions) had worse sleep quality as compared to veterans who had PTSD or mental illness in isolation (Brown et al. 2017).
Sleep Disturbances Associated with PTSD
Insomnia
Sleep Apnea
Nightmares
Sleeping Sickness
Rapid leg movements
Disruptive nocturnal behaviors
Major Disturbances
Figure 1: PTSD-related sleep disturbances
In addition, a different study also examined sleep variability among veterans with different conditions, PTSD and insomnia. Straus, Drummond, Nappi, Jenkins, and Norman (2015) conducted a case control study among three groups, 45 veterans diagnosed with PTSD, 25 with primary insomnia and 27 healthy veterans to identify differences in sleep patterns. The researchers assessed both the objective and subjective measures of sleep. The study findings revealed that veterans with PTSD symptoms reported worse fragmentation of sleep and greater sleep unpredictability than to the other groups. Furthermore, objective sleep effectiveness was considerably worse among subjects with PTSD than the normal subjects and the participants with insomnia (Straus et al., 2016). The findings imply that there are differences in sleep patterns among veterans, with reference to the occurrence of PTSD and comorbid conditions.
Sleep Nightmares as an Effect of PTSD among Veterans
A military veteran will definitely be changed by the experiences of the battlefield (Fogger, Moore, & Pickett, 2016). Even though not all soldiers coming back from war develop PTSD, it is reported that veterans with PTSD symptoms may have ongoing nightmares, thereby affecting their sleep (Fogger et al., 2016). Many researchers have acknowledged sleep nightmares as a psychological and physiological effect of PTSD among military veterans. For instance, in their study, Campbell and Germain (2016) recognized nightmare as a symptom of PTSD that affects most trauma-exposed veterans. According to their findings, experiencing nightmares is a core feature of PTSD that affect sleep among military veterans. The results have been supported by other studies that reported a correlation between PTSD and nightmare among military veterans (Khazaie et al., 2016). For instance, the research by Khazaie et al. (2016) reported that 52% of veterans suffering from PTSD registered complaints regarding experiencing nightmares compared to a small percentage (4.8%) of military veterans not diagnosed with PTSD.
Existing literature have also sought to investigate nightmare content experienced by PTSD veterans in a bid to ascertain the correlation between the two. One study revealed that as much as though veterans diagnosed with PTSD and even those without the symptoms had distressing dreams, only subjects with PTSD recounted that their dreams were related to the experiences witnessed in the period of war (Khazaie et al., 2016). A study conducted by Pigeon, Campbell, Possemato, and Ouimette, (2013) also concluded that there was a strong association between nightmare and severity of PTSD among recent combat veterans. A similar investigation by Sandman et al., (2013) likewise demonstrated that nightmares, characterized by negative intense dreams were a prevalent sleep problem among Finnish war veterans. The study concluded that nightmare was common among Finnish adults, with war experiences being one of the main occurrences (Sandman et al., 2013). In other words, numerous studies have supported the correlation between nightmare and PTSD among combat veterans. The studies confirm that experiencing nightmares is a psychological effect of PTSD common to military veterans.
Insomnia as a Physiological and Psychological Effect of PTSD among Veterans
Insomnia is also a common complaint among military veterans and has been identified as major effect of PTSD (Crawford, 2013). According to existing, complaints of insomnia are normally registered after traumatic events and leads to significant subjective distress among those affected (Martin et al., 2017). Recent studies on insomnia among veterans have concluded that around 44% of participants diagnosed with PTSD presented self-reports of sleep problems with sleep inception occurring irregularly or recurrently as compared to 6% of veterans not with PTSD symptoms (Khazaie et al., 2016). In another study, 90 percent of examined veterans reported that in certain occasions or most of the time, they experienced difficulty in sustaining sleep (Khazaie et al., 2016). The results were different among veterans without PTSD as only 63 percent stated that they had trouble maintaining sleep. In their study, Bramoweth and Germain (2013) also supported the findings as they revealed that insomnia was a common complaint among U.S. servicemen and women coming back from battlegrounds and non-combat zones. Furthermore, more complains were registered from those who were returning from combat zones.
In addition, Pigeon et al. (2013) also found a positive correlation between insomnia and veterans diagnosed with PTSD. Among the combat veterans with PTSD that were recruited for the study, 74% met the medical limit point for persistence insomnia (Pigeon et al. 2013). To ascertain further the effects of PTSD on sleep, Martin et al., (2017) conducted a study involving 660 women veterans. The investigation revealed that the indicators of insomnia were recognized by over 50% of the female veterans. These studies support previous findings reported a consistent relationship between veterans with PTSD and insomnia. In summary, even though there are controversies regarding the objectivity and generalizability of some investigation, there is still enough evidence that insomnia is one of the physiological effects of PTSD among war veterans.
Sleep Apnea
Sleep apnea is a condition characterized by frequent and episodic breathing particularly at night, loud snoring, and restlessness during sleep. It is a potentially serious disorder. As much as the exact link between PTSD and sleep apnea has not yet been established, researchers suggest that disrupted sleep, long periods of sleep deprivation, physical and psychological distress among veterans, may be associated factors (Colvonen at al., 2015). Colvonen at al. (2015) reported that veterans with PTSD had an elevated risk of experiencing sleep apnea. The researchers examined 195 young veterans attending an outpatient PTSD clinic. Based on the quantitative analysis of the data, Colvonen at al. (2015) reported that 69.2% of the subjects had sleep apnea. Furthermore, the researchers also reported that the probability rose with as PTSD symptoms became more severe. Based on the analysis, a considerable rise in the PTSD symptoms was linked to a 40% likelihood of developing sleep apnea (Colvonen at al., 2015). In addition, similar findings were reported from a non-interventional study by Yesavage et al. (2012). The research on 105 veterans revealed that 69% of the subjects presented with mild obstructive sleep apnea. The researchers concluded that there is a relatively higher prevalence of sleep-disordered breathing such as sleep apnea among veterans with PTSD symptoms (Yesavage et al., 2012).
In addition, a research conducted by Williams, Collen, Orr, Holley, and Lettieri, (2014) also revealed that the prevalence of sleep apnea was quite high (67.3%) among veterans diagnosed with PTSD. The sleep study was conducted among 130 veterans. The researchers also reported that the probability of experiencing sleep apnea was higher in veterans who had no physical injuries. Such findings may be explained by the veterans' exposure to stressors and consequent sleep deprivation that could have reduced their ability to cope with the stressors, resulting in the presentation of PTSD symptoms and the subsequent development of obstructive sleep apnea (Yesavage et al., 2014). Understanding the interplay between PTSD and sleep apnea is essential, as it is a predisposing factor to psychological impairment among veterans. On that note, further research should be conducted to fill the gap in knowledge on the mediating factors between PTSD and sleep apnea.
Treatment of PTSD-related Sleep Problems in Military
Sleep problems among veterans with PTSD can be treated by either pharmacology or psychotherapy (Table 1). Cognitive behavioral therapy has been presented as an ideal treatment option for sleep disorders such as insomnia (Talbot et al., 2014). Cognitive behavioral therapy (CBT) is a short-term psychological and interactive form of treatment. CBT aims at modifying the patients' thought processes and behavior. The therapy incorporates a range of strategies that focus on sleep hygiene, restriction, stimulus control and psychological reorganization. Talbot et al. (2014) did a study to determine the efficiency of CBT in improving sleep outcomes among veterans with PTSD. The researchers stated that CBT was linked to better psychosocial functioning, sleep, and disruptive sleep-related habits in veterans with PTSD (Talbot et al., 2014). Furthermore, the reported improvements were sustained for six months, strengthening the evidence on the efficiency of CBT as a strategy towards the treatment of sleep problems. Similarly, other studies have also revealed large improvements in sleep patterns following the initiation of CBT (Karlin, Trockel, Taylor, Gimeno, & Manber, 2013; Trockel, Karlin, Taylor, & Manber, 2014). According to Koffel, Koffel, and Gehrman (2015), CBT can be administered to both individual patients as well as groups. However, research on the effectiveness of group psychotherapy revealed that as much as they are effective, individual therapy is more efficient (Koffel at al., 2015).
Many literatures propose pharmacological treatment of PTSD among war veterans (Steckler & Risbrough, 2012). A number of studies point out that in some cases, patients might not respond well to non-pharmacological treatments such as CBT (Schoenfeld, DeViva, & Manber, 2012). In such situations, drugs play a crucial role in treating sleep problems such as insomnia and nightmares (Schoenfeld et al., 2012). For instance, certain medications have large positive effects on reducing PTSD sleep related symptoms (Hoskins et al., 2015). Drugs such as fluoxetine, paroxetine, prazosin, and venlafaxine have been identified as potential medications for alleviating PTSD symptoms (Hoskins et al., 2015). A study on pharmaco-therapeutic treatment of nightmares revealed that the drug, prazosin, is quite effective in decreasing nightmares and results in better sleep among veterans with PTSD symptoms (Raskind et al., 2013). However, there is still inadequate research and evidence as regards the efficacy of most drugs. As a result, it points out to the need for more research in this area.
Conclusion
In summary, military veterans present with different sleep problems that may impact their physiological and psychological functioning. The major sleep problems discussed in the literature review are sleep apnea, insomnia and nightmares. The sleep disorders are associated with poor health outcomes and an overall reduction in the quality of life. It is also important to note that there are differences in sleep patterns among veterans, with reference to the occurrence of PTSD and comorbid conditions. Fortunately, different researchers have provided evidence to the efficacy of therapeutic approaches such as medications and psychotherapy. For example, studies on the effectiveness of cognitive behavioral therapy have revealed that is vital to improving sleep problems more so for conditions such as insomnia and nightmares. Therefore, to ensure better health outcomes among veterans with PTSD symptoms, it is essential to incorporate sleep-focused treatments.
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