Trauma-related nightmares and insomnia—nearly universal in people with posttraumatic stress disorder (PTSD)—rank among that disorder's most disturbing and persistent symptoms. With high prevalence rates of PTSD reported in veterans of combat in Iraq and Afghanistan, researchers are seeking ways to help these men and women avert decades of suffering (see Clinical Trials Recruiting Combat Veterans).
Among U.S. Army and National Guard veterans returning from combat in Iraq and Afghanistan who were assessed three months after deployment, the prevalence rates of PTSD and depression ranged from 8.5 percent to 31 percent, depending on the severity of functional impairment, Jeffrey Thomas, Ph.D. and colleagues at the Walter Reed Army Institute of Research Department of Military Psychiatry, reported in the June Archives of General Psychiatry. About 50 percent of soldiers who screened positive for depression or PTSD also had comorbid alcohol misuse or aggressive behavior.
Despite the military's efforts to dispel stigma, encourage treatment, and improve access to care, the researchers said, prevalence rates for PTSD and depression were even higher 12 months after deployment. "These data make clear," they wrote, "that at 12 months following deployment, many combat soldiers have not psychologically recovered."
Many veterans of combat in Iraq and Afghanistan also have mild traumatic brain injury (mTBI), often the result of one or more concussions following exposure to explosive devices. Traumatic brain injury has been associated with sleeplessness, headaches, anxiety, and memory loss.
Sleep-focused treatments include behavioral and cognitive therapies, the medication prazosin, and light therapy.
A study at the Veterans Affairs (VA) San Diego Healthcare System reviewed outcomes of imagery rehearsal therapy (IRT), a standard treatment for chronic nightmares.
IRT combines education about sleep and nightmares, instruction in devising pleasant imagery, rescripting a target nightmare by switching disturbing elements to neutral or pleasant content, and frequent rehearsals of the new dream scenario. Participants also keep daily nightmare logs.
Therapists at the VA medical center had provided IRT in accordance with a treatment manual for four to five weekly sessions lasting one hour for individuals or two hours for groups. Carla Nappi, Ph.D., associate director of the medical center's Behavioral Sleep Medicine and Cognitive Behavioral Interventions programs, and colleagues examined charts of 58 veterans—49 men and nine women—aged 22 to 83, who had attended at least one outpatient IRT session in the previous 18 months.
Eighty-five percent of the veterans had elected to focus on nightmares related to military service—mainly combat experiences. Most participants had been diagnosed with comorbid psychiatric disorders, including PTSD, mood disorders, anxiety disorders, and substance/alcohol use disorders.
Thirty-five veterans completed four or more IRT sessions, deemed a full course of treatment. Before IRT, most reported having nightmares nearly every night. Afterward, 1 in 4 reported having no or infrequent nightmares. They also said they slept better and had fewer PTSD symptoms, the researchers reported in Behavior Therapy in June.
IRT also may help short-circuit acute nightmares, a study of 11 U.S. Army combat soldiers in Iraq suggests.
The soldiers sought help for nightmares and trouble sleeping at a field combat stress control center. Study participants reported that their problems arose after they experienced a traumatic event in the preceding 30 days. Bret Moore, Psy.D., an Army psychologist, provided IRT in four weekly one-hour sessions. Moore taught himself the technique while in Iraq by studying an IRT users' manual and consulting by e-mail with the manual's author, Barry Krakow, M.D., medical director of Maimonides Sleep Arts and Sciences in Albuquerque, N.M.
After IRT, seven of the soldiers reported marked decreases in nightmares, better sleep, and diminished PTSD symptoms. Three soldiers reported no changes, and one reported a slight increase in nightmares, Moore and Krakow said in a letter to the editor of the American Journal of Psychiatry in April 2007.
"All continued with their mission, as far as I know," Moore, now a clinical research psychologist in San Antonio, told Psychiatric News. The usefulness of IRT for acute nightmares and sleep problems after traumatic exposure needs further study, he cautioned, since acute symptoms may dissipate spontaneously with time.
While psychotherapy can help if people are willing to participate in it, many combat veterans with PTSD do not want to explore their trauma nightmares, psychiatrist Murray Raskind M.D., told Psychiatric News. They prefer to take medication to relieve nightmares, said Raskind, who directs the VA's Veterans Integrated Service Network (VISN)-20 Mental Illness Research, Education, and Clinical Center in Seattle.
The drug of choice is prazosin, currently being used by 50,000 to 60,000 veterans in the VA system, Raskind said. Prazosin, a centrally active alpha-1 adrenergic receptor antagonist, is thought to reduce PTSD nightmares by normalizing rapid eye movement sleep, the state in which most nightmares occur.
In a study of 34 U.S. combat veterans from several wars—some with PTSD, nightmares, and disturbed sleep for decades—Raskind and colleagues found prazosin significantly superior to placebo in reducing trauma nightmares and improving sleep quality and global clinical status. Prazosin shifted dream characteristics from actual past horrific experiences to more normal dreamlike mentation, the researchers reported in Biological Psychiatry in April 2007.
Prazosin is not sedating, Raskind said. Although it does not speed sleep onset, it fosters sleep maintenance. Prazosin increased total sleep time by an average of 94 minutes, compared with placebo, in a study in civilians with PTSD, Raskind and colleagues reported in Biological Psychiatry in March 2008. A generic medication, prazosin is inexpensive.
Adverse effects of alpha-1 blockers, such as dizziness and postural hypotension, occur infrequently with prazosin, Raskind said, and usually can be avoided by starting treatment with a low dose (1 mg at bedtime), with slow upward titration. Patients are told to move slowly from lying down to standing up while they acclimate to the medication. Nasal congestion, headache, and sensation of increased heart rate may occur but are uncommon, Raskind said.
Bright-light therapy also may improve sleep and lessen PTSD symptom severity in combat veterans, said Shawn Youngstedt, Ph.D., an associate professor of exercise science at the University of South Carolina and a research scientist at the Dorn VA Medical Center in Columbia, S.C.
In an ongoing study, he and colleagues have treated 16 Iraq or Afghanistan veterans with combat-related PTSD. Some also had mTBI. The researchers randomized the soldiers to one of two four-week treatments: exposure to 10,000 lux of bright-light therapy for 30 minutes daily or exposure to an inactivated negative-ion generator, a sham treatment. They used standard questionnaires to assess sleep, PTSD, and depression.
Sleep and mood improved significantly with bright light compared with placebo, the researchers reported at the annual meeting of the Associated Professional Sleep Societies in June.
Light therapy is self-administered and easy to use, with few side effects. It holds potential as an alternative or adjunct to medications or psychotherapies, Youngstedt said, especially when considering the thousands of veterans with PTSD and the relative scarcity of trained psychotherapists.