Normally, after a long night on guard duty at Fort Drum in upstate New York, Melanie Pote would have been first on line for breakfast at 07:00. But that morning in March 2002 was anything but normal. Pote, 18 months into her U.S. Army service, had lingered at her post a bit before heading for the mess tent, where several others had already assembled for chow.
The beginnings of PTSD
That’s when it happened: During military exercises, two artillery shells—each one capable of destroying a tank—fell short of their target and came hurtling toward the tent. They hit, sending a storm of searing shrapnel everywhere.
The soldier at the front of the line—Pote’s usual spot—was killed instantly, while she was thrown through the air. Still conscious, she spied a sergeant contorting in pain and came his way, trying to help. She hadn’t realized that she, too, had been hit, with two pieces of shrapnel in her left leg.
After being treated for her wounds, Pote healed physically. But Post Traumatic Stress Disorder (PTSD) soon set in, interfering with Pote’s daily life—and her nightly life as well, wreaking havoc on her sleep.
“I had a constant feeling of dread, walking around with tightness in my chest and heart palpitations,” Pote recalls. “I’d go to bed and wake up every hour on the hour, never able to rest soundly. There were horrible nightmares—I’d be having flashbacks in my sleep.” It was as if Pote might never feel normal again.
The link between PTSD and sleep problems
Way back when, veterans struggling with symptoms similar to Pote’s would be said to have “shell shock” or “combat fatigue.” But in 1980, PTSD was officially recognized by the medical establishment as a mental disorder with specific, reliably diagnosable symptoms.
According to the National Institutes of Health, PTSD is associated with changes in brain function and structure. The symptoms may be subtle at first, with more severe symptoms not emerging until months after the traumatic event.
Veterans are by no means the only ones to experience PTSD; the condition has been associated with survivors of sexual abuse and other violent attacks, as well as severe weather events such as hurricanes, for example.
Those in the military, however, may be less likely than others to seek treatment. “The first thing I heard after the event was ‘drive on,'” Pote says. “So I stuffed it down. But I wasn’t really able to do that, and that started my trouble.”
Pote was hardly alone in her attempts to ignore her pain.
“Veterans with PTSD have difficulty letting go of the ‘soldier mode,'” says Daniella David, MD, chief, psychiatry service, and PTSD program medical director at the Bruce W. Carter VA Medical Center and professor of clinical psychiatry at the University of Miami Miller School of Medicine.
“Their brains—and specifically the limbic system—are consistently on alert for danger,” she explains, adding that while “most of us are able to decrease alertness in order to fall asleep, veterans with PTSD—many of whom experienced disturbing situations at night—have difficulty doing that as their brain tells them this is not a time to relax.”
As a result, veterans with PTSD often experience a host of sleep-disrupting symptoms. “Insomnia, delayed sleep onset, and difficulty falling back to sleep upon waking are all related to the hyperarousal symptom cluster—not being able to relax enough to fall asleep,” David says.
And when sleep does come, it can be anything but restful. “Trauma-related nightmares are a form of intrusive re-experiencing of the event and can lead to startled awakenings—suddenly waking up with heart racing and feeling sweaty, shaky, and disoriented—and full-blown nocturnal panic attacks,” says David. “Patients with PTSD may experience sleep paralysis [the inability to move upon waking from a nightmare] or REM Behavior Disorder, where they act out on their dreams, possibly attacking a partner as they dream they are fighting the enemy.”
Related: Exploding Head Syndrome and other lesser-known sleep conditions
Treatments for PTSD and sleep issues
Fortunately, there are various treatment options for PTSD—including two specific sleep-focused therapeutic interventions:
- Cognitive Behavioral Therapy for Insomnia (CBT-I), a structured program to identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep, according to the Mayo Clinic.
- Imagery Rehearsal Therapy (IRT), which may involve writing and practicing a nightmare narrative that changes the original disturbing scenario. “An IRT meta-analysis published in 2012 showed that IRT had positive effects on nightmare frequency, sleep quality, and other PTSD symptoms, that were sustained at six- to12-month follow-ups,” David says.
Some medications prescribed for PTSD are not without side effects or controversy:
- Trazodone, an antidepressant that has been used for sleep in PTSD, has proven effective based on clinical experience, but there have not been randomized controlled trials to substantiate it, David says.
- The antidepressant nefazodone has proven effective for PTSD and sleep, but it has “fallen out of favor due to a black box warning regarding liver problems,” David warns.
- The selective serotonin reuptake inhibitors (SSRIs) paroxetine and sertraline may alleviate some PTSD symptoms but “are not especially helpful with sleep,” David notes.
- Prazosin, originally used as a blood pressure medication, has been shown in several small clinical trials to improve sleep and nightmares in those with PTSD. However, a recent large Veterans’ Administrative cooperative study published in the New England Journal of Medicine concluded: “In this trial involving military veterans who had chronic PTSD, prazosin did not alleviate distressing dreams or improve sleep quality.”
PTSD and sleep: finding what works for you
Clearly, there is no single treatment path for a condition as complex as PTSD and its sleep problems, but sufferers are encouraged to try different techniques and therapies. For Pote, who “stuffed it” for more than a dozen years, a combination of approaches—one traditional, one alternative—was the charm.
“I started seeing a counselor who wanted me to talk about the event and how it affected me,” she says. “When I finally did, she had to kneel next to me while I spoke about it; I was so shaken up.”
Talk therapy was helpful, she says, because “I could look at it instead of let it simmer, and that took some of the weight off my shoulders.” But her symptoms persisted—until she heard about Transcendental Meditation (TM).
Though skeptical initially, Pote began practicing the form of silent mantra meditation daily, and after just two weeks, “it came at me in a flood: The sense of dread and chest tightness were gone, and I was actually able to sleep,” she says. “TM gives you a sense of calm that lasts past the meditation activity into your regular life.”
Now a tattoo artist based in Atlanta, Pote says, “sometimes I work crazy hours, but when I sleep, I sleep soundly at last.”
Having come out on the other side of PTSD, her perspective may help those still in its grip. “When you’re ready, talk about what happened,” she suggests. “And don’t brush off something like meditation because it sounds strange.” An open mind can lead to a whole new normal of peaceful days and restful nights.
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