The symptoms were common, but until this month, Army doctors did not have a good definition for the mix of nightmares and nighttime outbursts troops sometimes report after living through traumatic events at war.
Unlike civilians who have general nightmares, combat veterans would relive critical moments in their dreams. Soldiers who’d been trapped in burning vehicles, for instance, would feel their terror again.
And those nightmares would be accompanied by physical outbursts, such as punching, kicking or choking, that could endanger the veterans’ sleeping partners.
In the morning, the combat veteran would not remember anything.
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“We would have this constellation of disorders and we didn’t know what to call it,” said Col. Vincent Mysliwiec, an Army doctor who has led several sleep studies at Madigan Army Medical Center.
He’s one of four doctors who are making a case in a recently published paper that soldiers’ trauma-related sleep disturbances should be regarded as a distinct medical condition.
They call it “trauma associated sleep disorder,” and they’re advocating for a deeper study that would determine whether it should be diagnosed differently from other sleep conditions. Their initial study in the Journal of Clinical Sleep Medicine published this month was based on case studies of four veterans who sought treatment at the Army hospital at Joint Base Lewis-McChord.
It’s important to get the diagnosis right, Mysliwiec said, so patients and their spouses can take care of each other with a good understanding of what’s happening.
“If your spouse deployed, this is likely a clinical disorder and at this time you can still help each other,” he said.
Mysliwiec, who’s now assigned to an Army hospital in South Korea, said sleep doctors treating veterans with behavioral health conditions tended to diagnose them with one of two other medical conditions: nightmare disorder or rapid eye movement (REM) behavior disorder.
Neither was a good fit, he said.
People with nightmare disorder remember their dreams later and do not move at night.
And REM behavior disorder usually affects older people. That condition is not associated with a traumatic event in a person’s past, and it does not trigger the “flight or fight” response that veterans reported to sleep doctors at Madigan.
“We weren’t able to classify (the veterans’ experience) from a clinical perspective because we didn’t know what it was,” he said.
The four case studies describe:
• A 29-year-old soldier diagnosed with post-traumatic stress disorder following a 6-month deployment to Afghanistan in 2010. He’d scream and kick at night as he dreamed of attackers pursuing him. He’s one of few people who’ve demonstrated this behavior while being monitored for a clinical sleep study at a hospital. While sleeping, he repeatedly swore and said “leave me alone!”
• A 34-year-old veteran diagnosed with adjustment disorder, anxiety and sleep apnea. He started having nightmares after an Iraq deployment in 2003. He deployed twice more and developed other symptoms, such as thrashing in bed and once choking his wife.
• A 39-year-old soldier who deployed to Iraq in 2007 and developed a snoring problem as well as combative nighttime behaviors, such as kicking and punching. “His wife described he looked like he was fighting someone.” He hit her on several occasions, which caused her to sleep in a different room.
• A 22-year-old soldier who started showing disruptive nocturnal behavior after a bad breakup with his fiancée. Roommates told him he’d scream, cry, throw pillows and once shouted “I am going to kill you.”
Doctors treated the patients with several different techniques. They administered prazosin, a drug developed to treat high blood pressure, to reduce nightmares. prazosin is considered an effective drug in limiting nightmares among patients with post-traumatic stress disorder.
Patients with sleep apnea also received devices to clear their breathing. All four reported progress, including the one who drove his wife from their bedroom with his nighttime punching.
The doctors are expanding their study to document 20 cases at different hospitals. The larger sample will help determine whether their suggested diagnosis will hold up.
In the meantime, Mysliwiec recommended that patients who show symptoms like the ones described in the study consider sleeping apart from their bed partners.
“A lot of times they do that, but it’s a touchy subject,” Mysliwiec said. “It’s not safe for them. We’ve seen it where people come in with black eyes.”