The waking wounded

When wounded veterans began returning from Iraq and Afghanistan several years ago, their doctors quickly observed that many patients suffered from a mix of traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), and one or more orthopedic injuries — a combination referred to as polytrauma. As clinicians tried to untangle the damage and devise treatments for these complex patients, some have discovered that more often than not, the physical ravages of war were accompanied by pernicious sleep problems.

"Sleep was always the number one symptom complaint, no matter what the injury context was," says neuropsychologist Tracy Kretzmer, PhD, clinical director of the Post-deployment Rehabilitation and Evaluation Program (PREP) at the James A. Haley Veterans Hospital in Tampa, Fla. The program was developed to treat the ever-increasing population of veterans with mild TBI and post-deployment stress.

For many individuals, sleep disturbance is multifactorial, including mood disturbances, medications, poor sleep habits and medical/neurological issues. Kretzmer and her colleagues knew that for patients who had suffered physical or psychological trauma, too little sleep could make matters worse in myriad ways, such as by inhibiting their muscle recovery and compromising their immune health. Sleep loss also increased patients' fatigue and irritability, disrupted their ability to focus and increased the incidence of their headaches, all of which made it harder for patients to cope with their injuries.

Kretzmer and her colleagues hoped that if they could reliably assess and treat patients' sleep problems, their physical and psychiatric symptoms might also improve. Because sleep problems can be so complex, they've used multiple methods, including sleep logs, self-report questionnaires, actigraphy (which uses a wristwatch-like sensor to measure movement during sleep) and polysomnography (which measures physiological changes, such as brain activity, heart rhythm, eye movement, muscle movement and more). Actigraphy is a particularly valuable tool because it is a cost-effective way to gather objective data on sleep patterns, as well as to measure treatment outcomes. Actigraphy can also be used as an intervention tool because it allows patients to view data in a way they can easily understand, Kretzmer says. "For many patients, seeing objective data that suggests they are sleeping better than they think or that they are engaging in poor sleep habits can be very helpful in providing reassurance or getting them to engage in better sleep behaviors."

Sleep specialists in the PREP program also use actigraphy to tailor sleep interventions for veterans with PTSD. A key lesson, Kretzmer says, is that sleep interventions are not one size fits all. While sleep hygiene training is immensely valuable for addressing poor sleep habits, she says, sleep disturbances due to PTSD require a different intervention because at the core of such disturbances are not bad sleep habits but rather a level of hypervigilance and fear structure that requires a different intervention. "In such cases, PTSD interventions, especially those with an exposure component, are more appropriate for addressing the underlying etiology causing the sleep disturbance," Kretzmer says. Until then, she says, "PTSD treatment trumps sleep hygiene treatment." Garden-variety sleep hygiene training cannot, on its own, overcome the powerful instinct telling a veteran that it is not safe to sleep.

"Telling them to restrict their [daytime] sleep or to go to bed earlier or not drink caffeine — they don't fall for it," Kretzmer says. "They want to stay awake, because their need to be on guard is driving their insomnia."

Once patients are willing to entertain the idea that sleep is a good — not dangerous — thing, then sleep hygiene training can tackle bad sleep habits, if they are still present. For Kretzmer, treating sleep complaints as a primary symptom rather than a secondary issue has proven to be an important factor in improving outcomes in this patient population.

Kretzmer's colleague, neuropsychologist Risa Nakase-Richardson, PhD, who works with severe TBI patients, has found that sleep disturbance is a common problem following acute brain injury, more so than previously recognized. In moderate to severe cases of TBI, it can often be difficult to ascertain a patient's self-report of sleep. However, using actigraphy and behavioral observations, Nakase-Richardson demonstrated that poor sleep is a ubiquitous problem that adversely affects patients' functioning and participation in rehabilitation care. Recent research demonstrated that poor sleep following brain injury negatively impacts neural recovery. Nakase-Richardson and others' research suggests that targeted interventions for brain injury should include characterization of sleep.

—Siri Carpenter