An evaluation of four soldiers at an Army hospital in Washington state has led researchers to propose creating a new diagnosis for a sleep disorder brought on by trauma such as combat.
The diagnosis, “Trauma-associated Sleep Disorder,” or TSD, includes a grouping of symptoms that includes screaming, thrashing, sleepwalking and nightmares, according to a paper published this month in the American Academy of Sleep Medicine’s Journal of Clinical Sleep Medicine.
“For any disease, if you can’t characterize it, then it doesn’t lend itself to appropriate diagnosis, treatment and research to improve it,” said Army Col. Vincent Mysliwiec, a doctor specializing in sleep medicine and lead author of the paper.
Researchers had previously recognized that individuals who had experienced trauma exhibited a “constellation” of “disruptive night behaviors,” Mysliwiec said. But documenting them in a controlled setting had been elusive because these patients often don’t exhibit symptoms while being viewed overnight in a sleep clinic.
Mysliwiec said researchers have theorized that, even though patients are somewhat uncomfortable while hooked up to electrodes and surrounded by monitoring devices in the sleep clinic, the change of environment somehow lets them sleep soundly without symptoms. For soldiers with combat-related trauma, knowing they’re being watched could contribute to a feeling of safety while sleeping, he said.
The team of researchers examined four active-duty soldiers who sought treatment over a nine-month period at Madigan Army Medical Center in Tacoma. Each underwent evaluation at the hospital’s sleep clinic and was given an overnight exam called a polysomnogram, during which heart rate, brain waves, movements and sounds are monitored.
They had a mix of backgrounds and experiences, the youngest was 22, the oldest 39. One of the four had been previously diagnosed with post-traumatic stress disorder, while the others had not. Three had trauma related to combat in Iraq or Afghanistan, while the fourth had trauma related to an ended relationship.
What they all had in common were sleep disturbances, in some cases so severe that their “sleep partners” were in danger, Mysliwiec said.
The 39-year-old soldier, for example, who had been deployed to Iraq in 2007, had struck his wife several times as he thrashed in his sleep as though fighting someone. This went on for several years, and the couple sought treatment only after he bruised her face one night.
Mysliwiec said doctors treating active-duty personnel and veterans saw an upswing in sleeping disturbances in the wake of combat operations in Iraq and Afghanistan.
Doctors recognized there was “this constellation of findings” involving disrupted sleep in these individuals.
“We didn’t know where they fit,” he said.
The closest diagnostic criteria listed in the International Classification of Sleep Disorders is REM Sleep Behavior Disorder, during which individuals appear to be acting out dreams. REM is the acronym for the “rapid eye movement” sleep stage, a period from which dreams can be most vividly recalled. Normally the body is “paralyzed” during REM, a state known as atonia.
Because the active-duty patients’ sleep behavior was often described as “acting out dreams” by witnesses, the Army researchers used REM Behavior Disorder, or RBD, as a basis for comparison because that’s how most non-military healthcare professionals describe this collection of symptoms, Mysliwiec said.
But his team found many features that distinguished these soldiers from typical RBD patients. RBD generally occurs in men who are over 55 and suffer from degenerative brain diseases, such as Parkinson’s. They typically dream of fighting off ferocious animals such as lions and bears. The brain disorder apparently short circuits the state of atonia paralysis during REM, and so this behavior is easily observable — even in a sleep clinic.
Trauma-associated Sleep Disorder, on the other hand, begins with an “inciting event,” such as combat, but shares many of the other symptoms of RBD. The sleep disturbances vary much more with TSD, however.
“Sometimes it’s thrashing, sometimes it’s yelling,” Mysliwiec said. “Sometimes it’s sleepwalking. So their behaviors are not as well characterized. They’re much more of a compilation, and that’s why we describe them as ‘disruptive nocturnal behaviors.’”
Although RBD is almost always linked with degenerative brain processes, researchers think that TSD is “an overdrive phenomenon,” Mysliwiec said. That could be sparking powerful surges from the sympathetic nervous system, the same mechanisms that govern the fight-or-flight reflex.
“While we think it’s very focused in REM sleep, we can’t say it’s exclusive to REM sleep at this time,” Mysliwiec said.
He estimated that 10 percent to 15 percent of trauma survivors suffer from TSD, but its actual prevalence is hard to determine because such symptoms sometimes end after several months without treatment.
Mysliwiec said that giving this cluster of symptoms a formal diagnosis is important to patients.
For the past 12 years, servicemembers have been going to doctors with such symptoms and being told, “We don’t really know what it is,” he said. “The anxiety with not having a diagnosis after seeing a medical professional … is very concerning for patients.”
And it would be of obvious help to doctors treating such cases.
RBD is normally treated with the drug clonazepam, but Mysliwiec and the group of researchers have found that TSD patients had no significant response to it.
He said that prazosin, a medication used for treating other symptoms of PTSD, has worked best for relieving symptoms of TSD.
Aside from any such treatments, however, those who suffer from TSD must institute “safe sleep practices,” he said. That could mean couples temporarily sleeping in separate beds, a safeguard that can be a hard sell, he said.
The researchers will next analyze a group of 20 to 25 patients to test whether their diagnostic criteria for TSD holds true for a larger group. From that study, the diagnosis could go on to receive a formal designation.
Doctors would then develop a “treatment algorithm” that would also take into consideration other sleep-related disorders related to trauma, such as insomnia.
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