veterans can't sleep suicide PTSD combat fatigue asaa

Our military service corps (Air Force, Army, Coast Guard, Marines, National Guard, and Navy) are valued for their sacrifices— while on the ground, in the air, seagoing, or behind the computer at a command center during tense encounters.

They face combat, sleep deprivation, stress over the fate of peers, worries about companions and family members, and a host of other challenges.

When they come home, however, these challenges follow them all the way to their beds. Our veterans can’t sleep, and here are some reasons why.

What keeps our veterans up at night

The root causes of many veterans’ sleep problems are the result of experiences unique to their work overseas (or in the case of national disasters, as first responders here at home).

Post-traumatic Stress Disorder (PTSD)

PTSD is commonly associated with combat stress (though it can be experienced in all kinds of traumatic situations not related to the military). This complex array of symptoms merges emotional, physical, even chemical stresses into a singular ongoing state of being for many returning troops. PTSD is difficult to diagnose, difficult to treat, and difficult to live (and sleep) with.

Traumatic Brain Injury (TBI)

This could mean something as simple as a concussion or something far worse. The more extreme and severe the impact is to the head, the more damaging it can be to the brain. TBI can alter behavior and brain chemistry. It can also lead to ongoing pain for months or even years following injury.

Emotional trauma, chronic stress, depression, anxiety

Most Americans are familiar (if only through its enactment in movies or books) with the extreme toll that combat stress can exact on military personnel. The loss of both peers on the job and loved ones back home. Hypervigilance and paranoia caused by relentless stress and sleep deprivation. The overwhelming uncertainty of combat. The witnessing of violence and atrocity. These can heap psychological burdens on our veterans.

Pain

For those who return home with physical wounds, pain management becomes a challenge. Even after injuries are treated, there are still other issues: headaches, neurological pain in ghost limbs, long-term painful conditions like arthritis. The term “painsomnia” refers to pain so intense it prevents one from falling asleep. Many veterans have to deal with painsomnia.

Tinnitus

When soldiers come under fire, they experience the noise of explosions from incoming missiles, mines, or other destructive efforts. This leads to chronic problems with ringing ears. For some, tinnitus is so omnipresent, so loud, and so distracting that it can completely alter their ability to live normally once they’ve returned stateside.

Substance abuse

Legal substances, like cigarettes, energy drinks, and alcohol, can have a negative impact on the quality of life for both civilians and members of our military.

Prescription drugs for sleeping, alertness, or pain management also have side effects and can be abused.

While we hope our soldiers aren’t turning to illicit drugs—such as heroin, marijuana, or psychoactives—they often do. Usually this effort is out of a need to self medicate against the many stresses they experience while in service. Once they come home, these habits and addictions come with them.

Substance withdrawal

Once returned to civilian life, our veterans may be proactive about addressing substance abuse. And that is a positive thing! But the act of treating one’s addiction is rife with other kinds of side effects, especially during periods of withdrawal. Addiction treatment isn’t easy, and can be devastating, at least temporarily, both during the day and at night.

Sleep problems common to veterans

Military forces have unique experiences that can change individual service members in ways both positive and negative. One of the worst outcomes? Veterans can’t sleep. This loss or disruption of sleep is usually caused by a sleep disorder.

Sleep disorders

Nightmares and Night Terrors

Nightmares are considered a diagnostic marker of PTSD in combat veterans. More than half of them report a significant nightmare problem several times a week. This means they are facing recurrent nightmarish dreams. These often come to them in sleep as flashbacks of traumatic experiences from their service work abroad.

Sometimes, veterans can also experience something known as night terrors. These anxious moments in the middle of the night are terrifying, not only for those going through them, but for their bed partners, roommates, or families.

The difference between a nightmare and a night terror is twofold: Nightmare content is generally remembered the next day, whereas a person who suffers a night terror will seem awake and inconsolable during an episode, but have no memory of it the next day. Also, nightmares are actually vivid dreams with frightening content, whereas night terrors occur between stages of sleep during periods of arousal.

Insomnia

Over 90 percent of active duty personnel with PTSD suffer from insomnia that is considered “clinically significant.” By comparison, those without PTSD suffering from insomnia only constitute 28 percent.

Insomnia is typically viewed as a symptom, rather than as a full-fledged sleep disorder. Acute insomnia is temporary but disruptive. Chronic insomnia occurs with regularity over long periods of time (three months or more) and adds to sleep debt.

Deployment-related insomnia is a form of sleeplessness that’s distinct among military personnel. New troops are fearful of combat exposure and injury. Immediately, they are forced into irregular sleep-wake schedules. Those who complete their service must then re-adjust to home life. When deployment-related insomnia not treated immediately and proactively, it can become a major risk factor for the development of PTSD, depression, and suicide.

Sleep Apnea

All forms of sleep apnea can be problematic for veterans. Many cases are not related to obesity, poor health, or aging. Instead, they are related to neurological or physical damage suffered during service. They could also be the result of substance abuse.

Restless Legs Syndrome

Cases of restless leg syndrome (RLS) have been reported among veterans. In some cases, the condition is so severe as to be deemed a contributor to disability, for which the VA compensates. For veterans, RLS is often diagnosed as a neurological dysfunction under the larger spectrum of PTSD.

With RLS, one’s legs develop uncomfortable sensations and an urgent need to move at or near bedtime. The legs could become “jumpy,” itchy, or have an otherwise unpleasant feeling to them. This makes it difficult to fall asleep. The best method for immediate relief is a warm shower or mild exercise or massage. However, medications have evolved to help keep these sensations at bay.

Parasomnias

Parasomnias constitute sleep disorders in which the central nervous system activates during sleep, often around arousals or transitions between sleep stages. Two forms of parasomnias that often occur in veterans with PTSD include REM behavior disorder (RBD) and sleep paralysis.

REM Behavior Disorder (RBD)

As we sleep, we eventually reach a state of rapid-eye movement, or REM, sleep. This is commonly known as the “dream” stage of sleep, though dreaming can occur during other stages as well. During REM sleep, the brain shuts down all muscle function in the body except for the diaphragm. It continues to work to support breathing. However, all other muscle groups during REM maintain a (temporary) mode of paralysis.

When someone experiences RBD, the paralysis of muscle movement in the body does not take place. The result? The dreamer begins to act out their dreams.

Small studies of RBD in veterans suggest more than half of those with PTSD may experience RBD. For veterans, these dreams may also be nightmares or flashbacks of traumatic events their memories are still processing. These physical manifestations of their internalized trauma can become a danger to themselves or to anyone around them.

Sleep paralysis

This strange sleep-related symptom is terrifying. It may make those who suffer from it fearful they will be labeled as insane if they report it. Sleep paralysis occurs either while falling asleep or waking up. Someone suffering from sleep paralysis may be awake and alert but unable to move their arms or legs. Panic can ensue, especially if the experience of being unable to move is enhanced by scary visual or auditory hallucinations.

Research suggests that as much as 85 percent of PTSD patients experience sleep paralysis, while in the general population, the rate of frequency is only as high as 40 percent.

Enuresis

Also known as bedwetting, enuresis is a form of night-time urinary incontinence. For adults, enuresis is typically linked to untreated sleep apnea, diabetes, or other medical conditions.

However, enuresis can happen to veterans for other reasons. Female military personnel have been found to experience bedwetting at a higher rate than the population. Researchers suggest this is related to the long-lasting psychological and psychiatric stresses of military service.

When poor sleep and PTSD collide

When veterans can’t sleep and have sleep disorders that are left untreated, a host of problems can occur.

Excessive Daytime Sleepiness

Poor sleep at night by any cause will result in daytime fatigue, the need to take naps, unrelenting sleepiness, and a dullness to daytime thinking and focus known as “cognitive fog.”

Suicidal ideation

Research shows that those with PTSD who experience disrupted sleep are at higher risk for developing suicidal ideation. This can lead to self harm and the taking of one’s life.

Anxiety/chronic stress

Prolonged or intense stress—experienced before, during, and after deployment—is associated with lower levels of serotonin in the brain. Serotonin is a hormone which regulates your ability to manage fear and anxiety. Lower levels of serotonin in the system are known to disrupt sleep. This can eventually lead to insomnia and mood disorders (which can also lead to insomnia).

Other changes to brain chemistry (especially with the regulation of adrenaline) that are related to military service may leave some veterans with feelings of hypervigilance or paranoia. Veterans who experience these symptoms are on edge at night and incapable of relaxation.

In addition, anxiety-related increases in the hormone cortisol, another stress hormone, can lead to changes in the sleep architecture of veterans. It robs them of certain kinds of sleep and fragments their stages all night long.

Substance Abuse

As mentioned earlier, substance use may occur as part of a soldier’s lifestyle or as a method for self medication. Either case can ultimately lead to its abuse. But for some, the use of substances doesn’t occur until after they’ve returned home, and for many of the same reasons.

Poor quality of life

It’s fairly obvious that veterans leave their stint of service with even the slightest damage—physically, mentally, or emotionally—are likely to experience problems with sleep.

Many of these problems may be stubborn and difficult to treat. Therapy success may also hinge on completed treatment and recovery of worse situations, such as TBI, before quality sleep can return.

Without good sleep, anyone is destined to live a less fulfilling life marked by fatigue, mental health disturbances, and other problems.

How to treat poor sleep in veterans

The first step is always to recognize the need for help. When veterans can’t sleep, consulting a primary care physician and getting referrals for specialists, including sleep practitioners, is necessary. This is how sleep problems are identified, diagnosed, and treated. These issues are not likely to go away on their own.

Possible treatments

Treatments for sleep problems among veterans are many. The trick is to confirm a diagnosis and get the proper therapy for each individual who suffers. Treatment options include one or more of the following:

  • psychotherapy
  • cognitive behavioral therapy
  • relaxation techniques
  • light therapy
  • positive airway pressure (PAP) therapy
  • sleep restriction to reset circadian rhythms
  • recreational or occupational therapy
  • medications
  • improved sleep hygiene
  • lifestyle changes (smoking cessation, daily exercise, healthy diet)
  • therapy dogs
  • addiction rehabilitation
  • treatment for drug withdrawal

Further Reading
Deployment-Related Insomnia in Military Personnel and Veterans.” Bramoweth AD, Germain A. Current Psychiatry Reports. 2013 Oct; 15(10). Publication accessed online on November 8, 2017.
Diagnosis and Management of Sleep Disorders in Posttraumatic Stress Disorder: A Review of the Literature.” Mohsenin S and Mohsenin V. The Primary Care Companion for Sleep Disorders, 2014;16(6). Publication accessed online on November 7, 2017.
Obstructive Sleep Apnea and Posttraumatic Stress Disorder among OEF/OIF/OND Veterans.” Colvonen PJ, Masino T, Drummond SPA, Myers UM, Angkaw AC, Norman SB. Journal of Clinical Sleep Medicine, 2015 May 15; 11(5): 513–518. Publication accessed online on November 7, 2017.
One and the Same? Nocturnal Enuresis and Overactive Bladder in the Female Veteran Population: Evaluation of a Large National Database.” Ninivaggio C, Riese H, Dunivan GC, Jeppson PC, Komesu YM, Murata A, Murata G, Rogers RG, Cichowski SB. Female Pelvic Medicine and Reconstructive Surgery, 2017, Jun. Publication accessed online on November 8, 2017.
Sleep apnea found in 57% of veterans with PTSD.” Kilgore C. CHEST Physician, 2016 March 4. Publication accessed online on November 7, 2017.
Sleep Disorders in Substance Abusers: How Common Are They?” Mahfoud Y, Talih F, Streem D, Budur K. Psychiatry (Edgmont), 2009 Sep; 6(9): 38–42. Publication accessed online on November 7, 2017.
Sleep disturbances in veterans with chronic war-induced PTSD.” Khazaie H, Ghadami MR, Masoudi M. Journal of Injury and Violence Research, 2016 July; 8(2): 99–107. Publication accessed online on November 8, 2017.
Treating Sleep Problems of People in Recovery From Substance Use Disorders.” In Brief (Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2014 Fall; 8(2). PDF accessed online on November 7, 2017.