Veterans and Sleep

Veterans and Sleep

The average veteran sleeps a full hour less than the average civilian, only getting 5.6 hours of sleep per night. This is well below the 7 hour minimum recommended by the CDC.

That’s concerning enough, but for many veterans, it’s even more troubling. The sleep they do get is often restless, plagued by sleep disorders like sleep apnea, insomnia, and nightmarish flashbacks of their combat experience.

Problematically, many veterans don’t seek help for their sleep problems. They attempt to self-medicate with dangerous substances and over-the-counter sleep aids, worsening their sleep problems and causing other health issues. Others leave their sleep issues untreated altogether.

Sleep problems don’t resolve on their own. The cost of ignoring them is high. Studies show sleep issues significantly increase the suicide risk for veterans.

What causes sleep problems for veterans, and what can they do to find relief?

Causes of veteran sleep problems

During their combat experience, veterans face a set of uniquely harrowing and intense circumstances on a daily basis. When they return home, they may be removed from those circumstances, but their effects still linger for a long time - creating physical and psychological trauma that make restful sleep difficult to achieve.

Physical trauma describes an injury resulting in bodily harm, whereas psychological trauma describes psychological damage to an individual’s psyche. Often times, physical and psychological trauma co-occur.

Traumatic events can include domestic violence, abusive relationships, car accidents, natural disasters, death of a loved one, military combat, and more. During combat, soldiers may experience multiple instances of traumatic events like these.

Upon returning home, veterans may be coping with one or more of the following conditions. Individually, any of these can contribute to sleep problems:

PTSD

After someone experiences a traumatic event, it’s common for them to experience anxiety, nightmares, mood swings, or an inability to focus during the day. They may have difficulty concentrating on tasks, going about their lives as usual, and communicating with each others.

When the person is safely removed from the harm originating the trauma, and conditions still persist over a period of months, as opposed to days or weeks, it’s likely post-traumatic stress disorder (PTSD).

Although anyone can develop PTSD after living through a trauma, PTSD is extremely common among veterans and survivors of assault or rape. Between 7 to 8% of Americans will experience PTSD at some point in their lives, with the likelihood being twice as high for women than men. For veterans, that number increases to somewhere between 11% to 30%.

Additionally, a large number of veterans, both male and female, suffer sexual assault during deployment. Nearly a quarter of female veterans report sexual assault, according to the VA.

PTSD is diagnosed alternately as acute or chronic. With acute PTSD, the individual usually recovers within six months. With chronic PTSD, the condition is long-term, and the individual may take years to recover fully, if they do at all. To be diagnosed with PTSD, a person must experience all four of the following symptoms for at least a month’s length of time:

  1. Re-experiencing events: Through flashbacks, nightmares, or disruptive thoughts, the individual relives the trauma in a way that interferes with their quality of life. Words or sounds can trigger a re-experiencing event.
  2. Avoidance symptoms: The individual pointedly avoids people, places, or activities that remind them of the traumatic event. This can impair their ability to live a normal life.
  3. Arousal and reactivity symptoms: Unrelated to avoidance symptoms, the individual generally displays at least two of these types of symptoms throughout the day. They may have trouble sleeping, be on edge, or be easily scared when there are no triggers present.
  4. Mood and cognition symptoms: Similar to arousal and reactivity symptoms, the individual likewise displays changes to their overall mood and cognition. They may have trouble remembering the traumatic event, or experience symptoms of depression including lowered self-worth, feelings of guilt or blame (“survivor's guilt”), or lack of enthusiasm for activities and people they used to enjoy.

Veterans who experienced combat report a higher amount of PTSD-related symptoms compared to veterans who didn’t experience combat - particularly nightmares, re-experiencing events, and feelings of being “on guard”:

TBI

One of the top traumatic events veterans experience, which can also lead to PTSD, is a traumatic brain injury (TBI). 22% of Iraq and Afghanistan war veterans have TBIs.

The brain controls a significant amount of our daily functions, including sleep. When someone incurs a TBI, the damage to their brain affects various parts of their overall functioning. Depending on the location or severity of the TBI, the impacts to their sleep can be more or less worse.

Common sleep issues for individuals with TBIs include narcolepsy, insomnia, and excessive daytime sleepiness. As we’ll go into in the following section, veterans with TBIs, PTSD, both, or neither, suffer from many of the same sleep disorders. However, individuals with TBI are less likely to have the psychological sleep problems associated with PTSD, such as nightmares, night terrors, and night sweats.

Other trauma, pain, and injury

Even when it doesn’t result in a TBI or PTSD, veterans experience trauma at a significantly higher rate than the civilian population. As a result, they can develop anxiety, depression, or other adverse mental health conditions that impact their ability to sleep well:

Another common experience veterans return home with is pain. 10% of veterans are seriously injured during deployment. The treatment, pain, and management of those injuries lasts long after the injury. Individuals who lost a limb may experience ghost pain that makes it difficult to fall asleep. Others may have headaches or accompanying symptoms that make it challenging for their body to relax sufficiently to fall asleep.

Tinnitus

Tinnitus, which describes a persistent ringing, buzzing, or whistling sound in the ears, is the number one disability affecting veterans. According to the U.S. Department of Veterans Affairs, tinnitus affects 10% of adults.

Exposure to the sounds of machine guns, tanks, helicopters, and more during war can result in tinnitus. This constant sound is extremely irritating and unrelenting, causing distress for individuals who have it who have difficulty ignoring it in order to fall asleep.

Substance abuse

To deal with the symptoms of PTSD, TBI, trauma, and pain, many veterans turn to substances like alcohol, nicotine, and other drugs to help them cope.

Unfortunately, all of these substances impact sleep. Depressants like alcohol shorten REM sleep, lower the overall quality of sleep, and cause night sweats. Stimulants like nicotine cause alertness that activates the nervous system and make it difficult to fall asleep. Over time, continued abuse of these substances can lead to addiction, causing further disruptions to the individual’s daily life and their ability to sleep well.

Because they’re not sleeping well, veterans may then come to rely on other substances, like energy drinks and supplements, to help them stay awake during the day. This constant up and down from various substances sends their nervous system into overdrive, making it challenging for their brain to recognize when it’s time to sleep and when it’s time to be awake.

“Safe” prescription drugs can also lead to abuse. Veterans who are prescribed medication for their TBI, injuries, or PTSD can also overuse these drugs. Even with safe use, these drugs may have side effects that interfere with sleep.

Common sleep disorders affecting veterans

Unfortunately, sleep disorders are on the rise among veterans. A 2016 study of nearly 10 million veterans published in the journal SLEEP found that between 2000 and 2010, the percentage of veterans with sleep disorders increased from below 1% to almost 6%. Veterans with PTSD were the most likely to have a comorbid sleep disorder.

Although the most common diagnoses were sleep apnea, at 47%, and insomnia, at 26%, veterans were also likely to suffer from hypersomnia, parasomnias, sleep-related movement disorders, and circadian rhythm disorders. We’ll review each of these below.

Sleep apnea

Sleep apnea is a sleep-related breathing disorder where the individual stops breathing momentarily during sleep, resulting in snoring-like sounds and lowered oxygen levels in their blood. The interruption to their breathing disrupts the quality of their sleep, resulting in daytime fatigue and a lack of feeling refreshed, even after spending a sufficient amount of time asleep.

War veterans are four times as likely to be diagnosed with sleep apnea than their civilian peers.

Insomnia

Insomnia describes a difficulty falling or staying asleep.

People with insomnia may suffer from anxiety-inducing or worrisome thoughts that keep them up at night, similar to the thoughts experienced by individuals with PTSD. PTSD-related nightmares can also cause insomnia, interrupting sleep. Individuals wake up in a state of extreme fear and panic, with their heart racing, and it takes a long time for them to relax enough again to fall back asleep. Worse, they may start to fear falling asleep and experiencing another nightmare.

The lack of sleep insomniacs experience results in sleep deprivation. Individuals have difficulty focusing during the day, remembering things, and feeling emotionally balanced. Sleep-deprived individuals are also more likely to make irrational decisions, have poor judgment, and experience mood swings.

Insomnia affects up to 75% of veterans, as opposed to only 10% to 15% of civilians. For veterans with PTSD, the percentage is even higher at 92%.

Hypersomnia

The opposite of insomnia, hypersomnia describes oversleeping. People with hypersomnia may regularly sleep longer than “normal”, for 9 hours or more, but they won’t feel refreshed upon waking, even with longer sleep. They have trouble waking up, they sleep in later than others, and they experience excessive daytime sleepiness that negatively affects their quality of life during the day.

Hypersomnia is often associated with other sleep disorders affecting veterans, like sleep apnea and narcolepsy.

Narcolepsy

Narcolepsy is a common sleep disorder among veterans with a TBI, as well as PTSD. Individuals with narcolepsy uncontrollably fall asleep during the day, no matter how well-rested they are or what they’re doing.  

In addition to narcolepsy, veterans with a TBI are more likely to engage in excessive napping during the day, longer than 20 minutes. This length increases their likelihood of entering deep sleep, which makes it more difficult for them to fall asleep later at night.

Sleep-related movement disorders

Common sleep-related movement disorders affecting veterans include restless legs syndrome and periodic limb movement disorder.

  • Restless legs syndrome (RLS) describes a condition where the individual experiences an uncomfortable tingling or numbing sensation in their lower limbs, often when lying down. The only way for them to find relief is to give in to an irresistible urge to move their legs, which prevents them from falling asleep.
  • Periodic limb movement disorder (PLMD) describes a condition where the individual uncontrollably moves their arms or legs during sleep, often in a jerking movement.

One study found PLMD co-existed with three-quarters of veterans with PTSD, compared to 2 to 15% of the general population. PLMD often co-exists with RLS.

Parasomnias

Parasomnias describe abnormal behaviors during sleep. Parasomnias commonly affecting veterans include:

  • Sleep walking describes when an individual gets up and walks out of bed during sleep, performing activities as if they are awake, but while asleep, and with no awareness of the activity once woken up.
  • Night terrors occur in the first half of the night, where the individual may sit up in bed and scream, move around, or otherwise appear panicked during sleep. Upon waking, the individual won’t recall the episode.
  • Nightmares are distinct from night terrors, taking place in REM vs nREM sleep. Also, typically an individual will remember their nightmares. Over half of veterans with PTSD report nightmares, and veterans with PTSD are more likely than non-veterans with PTSD to experience nightmares comprising flashbacks of their traumatic event.
  • Night sweats describe extreme sweating episode during sleep. They can accompany anxiety, PTSD, and nightmares.
  • REM behavior disorder (RBD) describes a condition where, instead of remaining paralyzed during REM sleep, the individual is able to physically act out their dreams. RBD dreams are often violent and intense, similar to those experienced by those with PTSD.
  • Sleep bruxism describes a condition where the individual grinds their teeth during sleep, causing daytime headaches, jaw pain, and damage to their tooth enamel.

Parasomnias affect between 15 to 40% of the general population, compared with up to 85% of those with PTSD.

Circadian rhythm disorders

Circadian rhythm disorders describe individuals who have a shifted, irregular, or otherwise abnormal circadian rhythm.

Our circadian rhythm, or sleep-wake cycle, roughly follows the day-night cycle, and describes our body’s natural timing for sleep, wake, and other bodily functions. A common circadian rhythm disorder is jet lag, which we experience when we travel across several time zones and feel out of synch with our environment.

Delayed sleep phase syndrome (DSPS) is a circadian rhythm disorder reported by veterans. DSPS often results from the irregular work schedules veterans follow during their deployment. They may be working at night, at different times on a day-to-day basis, or on a different schedule than in the civilian world. As a result, their body’s circadian rhythm shifts in accordance with their new schedule.

When they return home, veterans may have difficulty resetting their circadian rhythm back to normal, experiencing a sort of chronic jet lag where they naturally fall asleep and wake up later than others.

Sleep tips for veterans

Better sleep can help veterans cope with the trauma and experience of deployment. Veterans who have a good emotional support system, maintain a positive mindset, and take care of their physical health with exercise and diet, are more likely to be resilient and recover more quickly from PTSD. All of these are easier to achieve with better sleep.

Behavioral approaches to better sleep

  • Turn your bedroom into a sleep-promoting environment. Reserve it for sleep and sex only. Do not do work or practice other hobbies in there; you want your brain to associate it as a place of calm and sleep. Remove clutter and any reminders of combat, even positive ones like awards or medals, to prevent triggering yourself before sleep.
  • Set and follow a firm sleep schedule. Set a firm bedtime and wake up time, and ensure there is enough room for you to conceivably get at least 7 hours of sleep between those times. During the day, avoid napping altogether if possible, to make you more tired by bedtime. Otherwise, limit it to a nap of 20 minutes or less.
  • Establish a calming bedtime routine. In the 30 to 60 minutes before bed each night, perform a consistent routine of calming activities. The goal is to get your brain to recognize these activities as preparation for sleep, while your body naturally begins to relax. Consider practicing aromatherapy, meditation, or deep breathing exercises.
  • Eat well and exercise. Eating well will make you feel better, but it will also help you sleep better. Although, take care to avoid heavy meals late at night. These can cause indigestion and make it challenging to fall asleep. Also avoid caffeine, alcohol, and other drugs, especially past the early afternoon. Exercise every day, and do so outdoors in the morning if possible, so you can get a natural energy boost from the sunlight.
  • Find ways to relieve stress during the day. The more you can reduce your stress levels during the day, the less anxious you’ll be overall, and the easier it will be for your body to calm down at night. Try practicing yoga, writing in a diary, reading a relaxing book, or listening to guided meditation.

Therapeutic options for veterans with sleep problems

  • Cognitive behavioral therapy (CBT) is an effective treatment for both insomnia as well as many of the psychological disorders experienced by veterans, including PTSD. Over a period of sessions, the patient works with their therapist to recognize the negative or harmful behaviors and thoughts they have around sleep or their trauma. Then they learn to interrupt those reactions and replace them with healthier ones.
  • Other forms of psychotherapy recommended for veterans with PTSD include cognitive processing therapy (CPT) and prolonged exposure (PE) psychotherapy. With CPT, the individual reworks their story of the trauma, learning to accept it, reframe it in a healthy way, and adjust to coping with it. On the other side of the spectrum, PE involves the patient reliving the trauma in a supervised manner with their therapist, eventually becoming desensitized to it over time. Both of these therapies often result in better sleep as the patient starts recovering from PTSD.
  • Sleep restriction therapy, sometimes practiced as part of CBT, encourages individuals to follow a strict sleep schedule. They are only allowed to spend time in bed during that time frame, and cannot sleep outside of that schedule, whether or not they received their full 7 hours. The idea is that eventually the brain learns to adjust to the new sleep schedule.
  • Light therapy helps individuals with offset circadian rhythms, like veterans with DSPS, reset their biological clock. Individuals sit in front of a specialized light box, designed to mimic the strength of sunlight, for a short period of time in the morning or early afternoon to help their brain and body feel more awake at “normal” hours.

Sleep products for veterans

  • CPAP therapy is the most effective treatment for individuals with sleep apnea. CPAP (continuous positive airway pressure) machines deliver a steady stream of air pressure to the individual through a facial mask they wear while sleeping. One recent study found that consistent use of CPAP not only improved sleep apnea symptoms, but also severe symptoms of PTSD, for veterans with comorbid PTSD.
  • Padded bed rails and floor pads can be placed around the perimeter of the bed to prevent individuals with night terrors, RBD, and PLMD from injuring themselves during sleep.
  • Weighted blankets primarily relieve the uncomfortable sensation of RLS, but research shows they can also reduce symptoms of anxiety. The recommended measurement is 10% of one’s body weight plus 1 pound.

Additional resources for veterans

  • The Veterans Sleep Studies lab at the University of Pittsburgh conducts research studies with the goal of improving sleep for veterans. Veterans and civilians can both sign up for current studies, as well as browse the site to read additional information on common symptoms of veteran sleep disorders and locate additional programs and resources.
  • Make The Connection is an online community operated by the U.S. Department of Veterans Affairs. Veterans and their loved ones can connect with each other through online forums, find local resources for healthcare and support, and read self-help resources for better sleep.
  • The National Center for PTSD, also managed by the U.S. Department of Veterans Affairs, provides an overview of the sleep problems affecting veterans, along with links to find local care providers and apply for benefits or disability claims.
  • There are many free 24/7 confidential resources and hotlines availability for veterans, including:
    • Veterans Crisis Line: Support available on the website, Live Chat, text message at 838-255, or toll-free at 800-273-8255 x1.
    • Military OneSource: Support available on the website or toll-free at 800-342-9647.
    • The National Veterans Foundation: Support available on the website or toll-free at 888-777-4443.
    • Vets4Warriors: Support available on the website, Live Chat, email at [email protected], text message at 732-333-3634, or toll-free at 855-838-8255.
    • Marine Corps DSTRESS Line: Support available on the website, Live Chat, or toll-free at 877-476-7734.