PTSD & Sleep
Sleep is the enemy
By Jia-Rui Chong
Los Angeles Times Staff Writer
August 5, 2008
SAN DIEGO — By the time the sun began to rise one recent Friday over his Mira Mesa neighborhood, Mitch Hood had been up for about 18 hours.
He punched a caffeine tablet out of a blister pack and washed it down with two cans of Red Bull. He finished it off with a gulp of Pepsi.
He figured this would keep him awake four more hours. Then, he jumped back into his video game.
Hood, 25, spent two tours with the Marines in Iraq. Now, like many other veterans and millions of civilians, he faces a new enemy: sleep.
“I’m afraid I’m going to have nightmares and I’m going to get stuck there,” he said. “I try with all my strength not to sleep.”
When he eventually crashes and sleep overtakes him, Hood relives combat, or sometimes his mind creates new horror-filled scenarios. Once, he punched his fiancee, Natalya Gibson, while having a nightmare. She insisted it didn’t hurt, but Hood has not stopped apologizing.
Sleep and wakefulness issues were the most common health problems described by recently returned soldiers, researchers at Walter Reed Army Medical Center found in a study published last year.
About 36% of Army troops who have been back from Iraq for a year said they struggled nearly every day with feeling tired. About 34% said they had difficulty falling asleep, staying asleep or sleeping too much nearly every day. About one-third of the total U.S. adult population report sleep problems, but studies have shown that such problems are much more common in combat veterans than in other young adults, said Steve Woodward, a sleep expert at the Department of Veterans Affairs center on post-traumatic stress disorder. About 70% of veterans being treated for the disorder have sleep problems, he said.
Sleep is a vulnerable state, Woodward said. “When animals are exposed to a severe threat . . . the basic adaptation is to wake up more frequently,” he said.
Bill Rider, a 63-year-old Vietnam veteran, knows the signs. He’s seen Hood and others like him in group meetings he helps organize in Oceanside for combat veterans of different generations.
Some veterans have told him of how they long for sleep, bingeing on alcohol for sedation. Others, like Hood, fear it. Rider has seen veterans stay up for 72 hours and work themselves into a delirious, manic state.
“I gave up my tranquillity, as many of the other warriors did, so the rest of America can have theirs,” he said.
Thinking about Hood, he said, “That was me 30 years ago.”
During his tours in Iraq in 2003 and 2004, Hood dug trenches and hauled 100-pound cables as a field wireman in Marine Wing Communications Squadron 38 out of Marine Corps Air Station Miramar. The pressure was always on during those assignments, he said, because the communication lines were essential for airstrikes and medical evacuations.
There were days when “I’d be lucky to get four hours of sleep,” said Hood, who still wears his dog tags and has a Grim Reaper tattoo. “It got to the point where we had to choose between bathing ourselves and sleep, between sleeping or eating.”
During his first tour, he was worried about a chemical attack. On the second, he was always scanning for roadside bombs.
In 2004, Hood returned to San Diego from Iraq and left the Marines two years later with an honorable discharge. He is now an online student, studying computer science. A few months ago, he found out he had a herniated spinal disc and sciatica, forcing him to use a cane. Hood thinks the pain probably makes his sleep less restful, but the main problems are the terrifying dreams that begin almost immediately after he closes his eyes.
A doctor has prescribed a low-dose antidepressant called trazodone, which has a sedative effect. “I use it here and there,” Hood said. But “it basically sticks me in an eight-hour nightmare fest, so that’s not a solution for me.”
Doctors know it can also be risky to prescribe sleeping pills to veterans with post-traumatic stress disorder because up to 60% of them struggle with substance abuse, said Dr. Tasha Souter, medical director of the Trauma Recovery Program at the VA Palo Alto Health Care System. Some doctors have had some good results prescribing Ambien, which is less addictive, and the hypertension drug prazosin, which can reduce nightmares.
But there is no panacea. “Sleep problems are one of the most difficult symptoms of PTSD to treat,” Souter said. “It’s not uncommon for veteran patients to have 20, 30 years of difficulty sleeping.”
When Hood first came back to Miramar, he didn’t notice his sleep problems.
“We’d party until 2 a.m., stay up until 4 and then get up for reveille at 5:30,” he said. Once they started cutting back on the partying, “we were in the barracks staring at the wall because we couldn’t sleep.”
In time, he tried to avoid sleep, like this recent Friday. This period of wakefulness began the day before, when he rose at noon Thursday after about three hours of bad sleep. He dreamed he was in the middle of a chemical attack and awoke wondering why he wasn’t wearing his chemical suit. It took a few minutes of looking around the bedroom and hearing Gibson’s voice to bring him back.
The dream was veined with the fear he felt during one incident in Iraq. Sirens went off indicating a possible chemical attack. Hood couldn’t make it back to the bunker, so he lay face-down in a gutter. He couldn’t get his gas mask to seal. Twenty minutes later, the all-clear siren finally sounded.
He was trying to banish the chemical attack nightmare from his thoughts when he showed up at the 7 p.m. weekly meeting of the American Combat Veterans of War in Oceanside. As members of the group went around the conference table describing various work and medical issues, Rider, the Vietnam veteran, looked over at Hood. “You look great, by the way,” Rider said. “Do you feel better?”
Hood wondered whether it was his new haircut. No, he told Rider. “No, not really.”
Ray Metcalf, a 74-year-old Korean War veteran with a Santa Claus beard, approached Hood and another young Iraq War veteran during a smoke break and asked, “Do you have bad dreams?”
As the young men nodded, Metcalf recounted a nightmare he had a few weeks ago about getting shot down in a helicopter in Korea. Metcalf told them he read in a booklet on post-traumatic stress disorder that it’s best to get out of bed if you can’t sleep. He recommended going into the living room to watch a movie.
Hood listened intently.
“Sleep deprivation . . . is an ongoing discussion,” said Rider, who helped found the combat group in 2001.
Rider, who wears a Vietnam campaign medal and a Buddha on a chain around his neck to symbolize war and peace, has seen doctors to deal with his combat trauma and sleep issues. He has prescriptions for anti-anxiety medications and sleeping pills.
But still, even 40 years after Vietnam, he usually wakes up every two or three hours. Sometimes he thinks he hears a noise outside his house in a well-to-do San Diego suburb. Sometimes he has a nightmare. The nightmares tend to center on April 16, 1968, when he was ordered to take Hill 689 outside Khe Sanh.
“The repeating sequence is always about particular people killed in front of me, in my squad,” he said. “It’s just as troubling in the dream as when it happened in reality.”
When he wakes up, he has to go around the house, checking the windows. Sometimes he goes out to the front gate to make sure it’s locked.
“I understand it’s not a rational thing to do,” Rider said. “Nonetheless the imprinting just becomes too much. You have to get up and take a look.”
But Rider says his sleep has improved in recent years because working with other veterans has helped his mind grapple with the trauma. His dreams were once lifelike, but now “some quirky thing” appears in his dreams, such as an out-of-place character, which shows him the dream is not real.
“I think there might be some tranquillity waiting for me,” he said.
Rider knows that Hood’s strategy isn’t going to work. Avoiding sleep makes the nightmares more horrific, thinking more difficult and anger more difficult to control. “If you avoid sleep, it only gets worse,” Rider said quietly.
Hood left the veterans meeting about 9 p.m. and drove back to the house he rents with Gibson. He took a shower and then they went to rent some DVDs. They spent a few hours talking about an argument they had earlier in the day about the care he was receiving from the Department of Veterans Affairs.
About 1:30 a.m., a migraine that had been building finally forced Hood to lie down with a pillow over his head. He didn’t think he fell asleep, but Gibson heard him mumbling incoherently. He was up again after 10 minutes.
By now the other houses in the neighborhood were dark, but light seeped through the closed blinds in Hood and Gibson’s living room. He spoke softly and more slowly than he had at the veterans meeting, but he was still fairly alert.
About 5 a.m. Hood and Gibson looked over their DVD choices. Hood was hoping he could tire out his mind so he would not have nightmares when he finally crashed. They settled on the science fiction movie “Jumper.”
“Was there something I wanted to get?” he said suddenly.
“Medicine?” Gibson offered.
“Yeah, but that’s not what it was,” Hood said, his face screwed up in frustration.
She clicked the remote control, and the 55-inch flat-screen television filled with images of World War II as one of the previews came on. The men were in uniform, carrying guns, heading inexorably to some wintry battle.
Hood covered his face with both hands. Gibson hit fast forward on the remote.
He peeled his hands away from his face a few minutes later as the opening scenes of “Jumper” began. He picked at a slice of chocolate cake on his lap and began playing a computer game in which he tried to take over spaceships.
About 5:30 a.m., Hood was starting to fade. When he took a break from the game to focus on the movie, his eyelids closed for nearly a minute. He quickly blinked them open. A few minutes later, his eyelids dropped again.
About 6 a.m., he took a smoke break and walked back into the living room triumphantly. “This is what I was looking for: caffeine tablets!”
He chugged the tablet and Red Bulls.
Gibson was struggling to keep up with Hood. He stroked her hair and told her he didn’t mind if she went to sleep. She crawled into bed at 6:10 a.m.
Hood stayed in the living room and started another video game. He began shooting down planes over a snowy mountain landscape. “Nice kill,” a voice in the game said.
At 6:50 a.m., he popped a second caffeine pill and washed it down with Pepsi. As he stood outside smoking again, he started to think about one of the most horrifying incidents of his second tour.
He closed his eyes as he talked about the time he was on a convoy and a roadside bomb blew up a Humvee in front of him. His buddy, a turret gunner, died in the blast.
The convoy stopped, but another improvised explosive device was found behind them. A civilian bus drove over the bomb before it could be disposed of.
In one recurring dream, he said, “I’m up there with my buddy. I pull him out of the Humvee. The medevac helicopter is on top of a hill. I’m carrying him. He keeps getting heavier and heavier and sinking into the ground and I drag him. Gravity is increasing. I can’t get him to the chopper.”
He paused, lost in thought. The rumble of morning traffic hung in the air.
“That’s a stupid dream.”
Hood said talking to the other soldiers about sleep problems has “really taken a load off my shoulders to know I’m not the only one.”
But he isn’t sure how to apply their advice. He was thinking about getting a dog, which he said would help him feel someone else was on watch.
“I’ll try anything,” Hood said. “I’m almost at the point where I’d be willing to give a body part for one good night’s sleep, no nightmares, the type of sleep where you wake up feeling renewed.”
In the meantime, 19 hours had passed since his nap and Hood was waiting for the caffeine to kick in. He was waiting for his second wind.