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March/April 2018

Pursuing Morpheus

If there is one key to health, it may be the quality of the one-third of each day—one-third of our lives—that we spend asleep. Good sleep promotes healing—physical, mental, and emotional. Disrupted, poor-quality, or insufficient sleep can do the opposite.

Anything with that much power over our lives deserves a good deal of attention. Unfortunately, in many cases medications prescribed to treat different conditions—even PTSD—can have a negative effect on sleep.

According to Dr. Elspeth Cameron Ritchie, Chief of Mental Health at the Community Based Outpatient Clinics at the D.C. VA Medical Center, “In Vietnam veterans and other veterans of that age—usually in their seventies—sleep is nearly always an issue. And sleep becomes more fragmented as people get older.” Besides prostate enlargement in men, and other general conditions of aging, she noted other factors including PTSD and its nightmares or other intrusive thoughts.

What about the content of nightmares? “We are coming up on the 50th anniversary of the Tet Offensive,” she noted, “and I have a number of patients who have come to me who haven’t had nightmares [before] and who are developing nightmares about being overrun by enemy troops.”

When veterans see stories in the news about such events or anniversaries, “Certainly they are influenced, although sometimes they don’t know they are,” she said. “So sometimes I’ve had patients come in and say, ‘Doc, I don’t know why, but recently I’ve had more intrusive memories, more flashbacks, more nightmares.’ And then I may talk about the 50th anniversary of Tet, or the recent Ken Burns series on the Vietnam War. And then they’ll say, ‘Oh, yes!’ And then we talk about triggers, which are very common.”

Sleep Apnea

Severe obstructive sleep apnea (OSA)—difficulty breathing while asleep—can lead to brain damage. To avoid that, continuous positive airway pressure (CPAP) therapy is often prescribed. Unfortunately, there are concerns that veterans with PTSD and sleep apnea are less likely to use CPAP machines than those without PTSD. As one Vietnam veteran recalled, “I had great trouble adjusting to the CPAP mask; it reminded me of times when I was fitted with an anesthesia mask—especially after being wounded. I kept flinging off [the CPAP mask]. But it did seem to help me sleep better, so I’ve stuck to it.”

When asked whether OSA in itself is linked to PTSD in veterans, Dr. Ritchie emphasized that correlation is not the same as cause. “But I do see them coexist,” she said, and one common link she often sees is musculoskeletal problems. “In veterans who have jumped out of airplanes, or twisted their knees getting out of HumVees, or banged their heads, and so on, I find that they have knee and back pain and disability,” which often lead to “less exercise and putting on weight; and then that will contribute to sleep apnea.”

The American Academy of Sleep Medicine suggests that all veterans be screened for OSA, since even in younger, physically fit veterans, “potential factors that may connect [PTSD and OSA] include disturbed sleep in combat, prolonged sleep deprivation, sleep fragmentation, and hyperarousal due to the physical and psychological stressors of combat, the chronic stress from PTSD, or the sleep disturbances caused by OSA.” See https://aasm.org/study-finds-high-risk-of-sleep-apnea-in-young-veterans-with-ptsd/

According to a 2016 article in the journal Sleep about the National Veteran Sleep Disorder Study (2000-2010), there is “a growing need for integration of sleep disorder management with patient care and health care planning among U.S. veterans.” See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4909622/

Three Buckets of Treatment

Dr. Ritchie described what she called “three buckets of treatment” for sleep disorders related to PTSD. “The first bucket is medication; that is, as a psychiatrist, what I do the most of,” she said. “The second bucket is for therapy, individual and group, including trauma-focused therapy and supportive therapy. Bucket number three is everything else, which includes yoga, acupuncture, meditation, exercise, working with dogs and horses, and some of the new treatments such as TMS and Alpha Sim [which the VA does not offer]. Everybody is different, so what we want to do is pick from each bucket what will work for you.”

This may involve navigating between side effects, such as those of antidepressants that are often used to treat PTSD. “Some are sedating and some are activating,” said Dr. Ritchie. “We might use buproprion in the morning, which may increase energy, and then Trazodone at night.”

In addition, she said, “I always recommend exercise, because I find it helps with weight, self-esteem, and motivation. But sometimes people can’t do it alone; sometimes you need a physical therapist.”

Sleep Interupted

Virtually every medication has some side effect. A drug prescribed to treat one illness may require another to treat its side effects, and so on, creating a cascade of medications.

In too many instances, those side effects include a negative impact on sleep. AARP Magazine listed ten categories of medication, the reasons they are prescribed, and the ways they interfere with sleep. The meds are: alpha-blockers, beta-blockers, corticosteroids, SSRI antidepressants, ACE inhibitors, ARBs, cholinesterase inhibitors, nonsedating antihistamines, glucosamine and chondroitin, and statins. See https://www.aarp.org/health/drugs-supplements/info-04-2013/medications-that-can-cause-insomnia.html

Ambien, which was once widely prescribed as a sleep aid, is “a problematic medication,” Dr. Ritchie said. “It has led to sleepwalking. It can also be addicting. People can develop tolerance to it; it is now a controlled substance. So I try to use it very sparingly.”

The Mayo Clinic lists certain medications that can cause or aggravate tinnitus, which in turn can disturb sleep. Among these are antibiotics such as polymyxin B, erythromycin, vancomycin, and neomycin; cancer medications, including mechlorethamine and vincristine; water pills (diuretics) such as bumetanide, ethacrynic acid, and furosemide; quinine medications used for malaria or other health conditions; some antidepressants; and high-dose aspirin (twelve or more per day). See https://www.mayoclinic.org/diseases-conditions/tinnitus/symptoms-causes/syc-20350156

Improving Sleep

For all of the above reasons, it is often recommended that individuals and physicians first try a non-drug approach to sleep disorders. Some studies have found that Cognitive Behavioral Therapy for Insomnia has better long-term results than sleep medication, possibly because CBT-I addresses underlying causes of insomnia and teaches skills that can be used whenever needed.

The Mayo Clinic lists seven CBT-I techniques recommended by sleep therapists: stimulus control therapy (to remove factors that condition the mind to resist sleep); sleep restriction (to avoid the habit of lying in bed awake and improve “sleep efficiency”); sleep hygiene (changing lifestyle habits that affect sleep, such as avoiding coffee, cigarettes, and alcohol); sleep environment improvement (making the sleep environment more comfortable and restful); relaxation training (techniques to calm the mind and body); remaining passively awake (learning not to stay awake worrying about insomnia); and biofeedback (using a device to observe signs such as heart rate and muscle tension, and learning how to adjust those signs). See https://www.mayoclinic.org/diseases-conditions/insomnia/in-depth/insomnia-treatment/art-20046677

And don’t forget exercise. “One of the interventions I do with just about everybody with PTSD,” Dr. Ritchie said, “is that I talk about exercise. And they often say, ‘I can’t, Doc, because my knees hurt.’ And I’ll say, “Well, let’s work on something you can do: swimming or walking or sometimes physical therapy. What can you do that can help?”





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chapter 301Wreath-Laying In Paradise:
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chapter 301Mission of Honor: Bordentown,
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