U.S. Army Pfc. Brent Dawkins (left) and U.S. Air Force Tech. Sgt. Efren Lopez sleep on the ground beside a mine-resistant, ambush-protected vehicle while snow falls in Wam Valley, Kandahar province, Afghanistan, on Dec. 22, 2009. DoD photo by Tech. Sgt. Efren Lopez, U.S. Air Force.
Service members and veterans have a unique relationship with sleep. On one hand, troops can fall asleep at the drop of a hat. Standing up, leaning against each other, airplane, ship or tank…we could catch Z’s any time we wanted. The old joke in the motor pool was that you could snatch a few if you crawl up under a vehicle and hook your hands into the undercarriage…it looks like you’re working, while you’re not.
On the other hand, we didn’t do enough of it, and what we did get was not very restful. You’re not getting a lot of stage three deep sleep bouncing along on the inside of an aircraft, waiting to jump out of it. We often prided ourselves on being able to function on minimal amounts of sleep, field by caffeine and edgy irritation.
The complicated relationship that we have to sleep carries over into our post-military lives.
One of the most universal challenges that I see in veterans I work with are sleep problems. As in, they don’t. Insomnia is a common condition that many veterans experience, for a variety of reasons, and it can wreak havoc on our psychological wellbeing as well as our physical health. Insomnia and mood disorders can go hand in hand, and particular symptoms of PTSD are sleep-disrupting as well. There are treatments and supports, however, and if we can figure out the sleep issues we have, we’re ahead of the game when it comes to managing our moods.
Anxiety and Depression
For starters, many don’t realize that insomnia doesn’t just mean “I can’t sleep.” There are different forms of it. In this research study looking at the intersection of insomnia, depression, or anxiety, the three kinds of insomnia are Onset (can’t get to sleep), Maintenance (can’t stay asleep) and Terminal (wake up early and can’t get back to sleep). Anxiety disorders are associated with onset insomnia; “I can’t get to sleep because I’m worrying about tomorrow” or “my mind just won’t shut up.” Depression is more related to terminal insomnia; you can get to sleep pretty well, but wake up at two or three or four in the morning. Maybe waking up at four was the norm when you were in the military, but when you’ve been out for ten years? Different habits should have taken over.
The problem is that there is a chicken-and-the-egg thing going on with insomnia and mood disorders. Studies have shown that service members with greater levels of insomnia before they deployed are more likely to develop depression and anxiety, and that insomnia four months after deployment was a predictor of depression twelve months after deployment. And it doesn’t just go away; a study in 2015 found that depression, PTSD, and insomnia were closely linked in Vietnam veterans…forty years after they left the military. It also becomes a cycle. You can’t sleep because you’re anxious or depressed, which leads to an inability to manage your anxiety and depression, so you’re more anxious and depressed. So you can’t sleep. The mood disorders become associated with the bed and the bedroom, so that the two are as linked as standing at attention when Reveille sounds off.
Hypervigilance and Nightmares
On top of the impact of depression and anxiety on sleep, veterans also experience sleep disturbances specifically related to traumatic stress reaction. Hyperarousal, increased responsiveness to things that happen in our environment, is a primary symptom of Posttrauamtic Stress Disorder. The perpetually keyed-up state that our bodies are in as a result of hyperarousal make it hard to rest and down-regulate our nervous system…which makes it hard to sleep. This is more of the chicken-and-the-egg…is the insomnia make the hyperarousal worse, or does the hyperarousal make the insomnia worse? Studies indicate that both could be true. I’ve had veterans say that every little noise wakes them up, and they’re up and around the house, ready to go. Sound like the troop sleeping on the ship, vehicle or aircraft? Old habits are hard to break.
And then there’s the nightmares. You ain’t getting to sleep if there’s a horror movie on every time you close your eyes. Specifically, the nightmares that disrupt the sleep of many veterans is the vivid reexperiencing of military-related traumatic events. This is a constant re-exposure to the distressing events, which perpetuates the traumatic stress reaction symptoms, but it also disrupts sleep to a significant degree. This review of evidence and studies on insomnia and nightmares in 2012 shows that insomnia and nightmares for veterans experiencing PTSD are linked.
Treatment and Support
I’ve found that insomnia is one of the things that can really get a veteran to engage in treatment for their psychological distress. There are less beneficial ways to address this…I’ve heard a veteran say a twelve-pack a night is what was able to get them to sleep. Effective, sure but helpful? Absolutely not. Eventually, the cure becomes a curse. There are a number of different types of treatment specifically designed to address insomnia.
Cognitive Behavioral Therapy for Insomnia (CBT-I) is an intervention that has been used with success, is recognized by the VA, and is considered a primary intervention for insomnia by the National Institute of Health. It has been shown to improve symptoms of anxiety and depression, and shows promising results in reducing PTSD symptoms. Imagery Rehearsal Therapy (IRT) is another form of cognitive therapy that has been shown to be effective in reducing nightmares specifically. This is a specific set of treatments that first help the veteran to recognize that the nightmares promote learned insomnia, then to learn how to control our mind’s imagery system. IRT is essentially learning how to change a nightmare into a new dream while you’re awake, so that your mind does it automatically when you’re asleep.
Of course, there are the normal sleep hygiene things that go along with getting good sleep. Use the bed for sleep and sex. I get it, many will read before sleeping or watch TV in bed, but cognitive stimulation is the opposite of what we need when we’re trying to get to sleep. Don’t drink coffee at 8pm and expect to get to sleep later. You can see a number of different aspects of sleep hygiene in this article. And, again of course, there are medications that help reduce nightmares and induce sleep. Not everything works for everyone, but talking to your medication prescriber about the type and frequency of sleep disturbances you have can be beneficial as well.
Because we all know what it’s like to work on no sleep. It wasn’t fun when we were in the military, and it’s certainly not fun now; figuring out this part of post-military life can greatly improve the quality of everything else.
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