It happens night after night: Retired Staff Sgt. Spencer Milo lies in bed, unable to sleep. He tosses. He turns. His mind races. When he finally falls asleep, it’s only for two or three hours, four on a
good night. On a bad night, his precious few hours of sleep are haunted by horrific images of a young boy detonating a suicide vest – nightmares that leave him shaking and drenched in sweat and anything but rested.
It’s been like that for years, beginning in February 2008 in Iraq when Milo’s truck collided with two other vehicles after the driver maneuvered away from small-arms fire. Milo’s head smashed into the .50 machine gun, knocking him unconscious. He saw a doctor in country, but then “went back to doing what I was doing.” He began to notice problems with his sleep when he returned home, but figured “I’ll just deal with it. I’m probably wound up from combat or whatever.
“Well, it got progressively worse,” he said.
Then he deployed again, this time to Afghanistan. He suffered a second traumatic brain injury in January 2011, after being thrown 15 to 20 feet when the boy from his nightmares, who was mentally challenged, blew himself up. Doctors sent Milo — who was left with a host of symptoms from searing headaches to hearing problems to anxiety — to the National Intrepid Center of Excellence on Walter Reed’s Bethesda, Maryland, campus for traumatic brain injury and post-traumatic stress disorder treatment.
Milo tried everything to sleep, from pills to relaxing music to meditation, but nothing worked. (Well, nothing except a dog once or twice.) “Every single doctor I had,” he explained, “(sleep) was one of the biggest things they were trying to fix because you need to be able to sleep to be able to heal. I did overnight sleep studies where you’ve got all the gizmos and gadgets hooked up to your brain. We had tried it all. … It gets really frustrating.
“It completely drains you. Every morning, you get up and you’re a little more tired, a little more worn out. … It affects your mood. You’re grumpy. … The lack of energy – I wouldn’t want to go work out. I wouldn’t want to eat or I would just eat way too much. … It really makes life terrible.”
Milo is an extreme case, but experts agree that Soldiers as a whole – Americans as a whole – aren’t getting enough sleep. The average adult needs seven to eight hours of quality sleep on a nightly basis, according to Col. Vincent Mysliwiec (pronounced my-sleeve-ich), M.D., sleep medicine specialist at the 121st Combat Support Hospital in U.S. Army Garrison Yongsan, Seoul, South Korea. Most Americans get about six and three quarters. Most Soldiers get about six.
“Soldiers have a vigorous, busy lifestyle,” he said. “They (need) to prioritize sleep. … We’re looking at our Soldiers as Soldier-athletes. If you look at a professional athlete, they’re obtaining eight, eight-and-a-half, nine hours of sleep because of … what they have to do physically. For Soldiers, we have to look at how do we align their duty day and then prioritize the time for them to achieve that seven or eight hours of sleep?”
It’s a culture shift, he and other experts admit, but one that is slowly taking place (with some units even changing physical training times), thanks to education and programs like the Performance Triad, which focuses on improving health and readiness through sleep, activity and nutrition.
As Army medical experts were developing the Triad, they quickly began considering sleep the apex because of its impact on both activity and nutrition, said Sgt. 1st Class Darin Elkins, currently the noncommissioned-officer-in-charge of the executive wellness program at the U.S. Army Sergeants Major Academy, Fort Bliss, Texas. In his previous role with the Office of the Surgeon General, the physical therapy NCO spent a lot of time educating other NCOs about the Triad – especially sleep – and wellness.
“Sleep is not a planned occurrence (for Soldiers),” he said. “Soldiers and the general population don’t understand what it takes to prepare to go to sleep or how to reduce interruptions when you’re going to sleep, whether it’s lights, whether it’s music, whether it’s ambient noise, how that impacts rest versus sleep cycles.
“If you look at the Soldier’s Creed, it says that you have to maintain your weapons, you have to maintain your arms and you have to maintain yourself,” he continued. “We have (field manuals) and we have (Army regulations) that tell Soldiers how to maintain their weapons and their arms, but it’s pretty much an implied task to maintain yourself. It’s a learned process on how sleep impacts your day-to-day activity.”
Even Elkins has had his own sleep troubles. When he returned to Iraq after mid-tour leave in 2008, his body rhythms were different and he could no longer sleep. He was constantly on alert, constantly ready to respond to his radio, to take care of his Soldiers; sleep slid further and further down his priority list. When he came home and no longer had adrenaline and energy from theater, he still couldn’t sleep. Exhausted all the time, he frequently lost his temper.
Elkins had to train himself to sleep again. He moved his TV. He started turning off his phone. He uses diaphragmatic breathing. He gets up at the same time every day no matter what.
“I don’t ever want to go back there,” he said.
Chronic sleep deprivation is linked to a host of illnesses, according to Mysliwiec, including obesity, hypertension, diabetes and heart disease. “Sleep is the period in which our brain recovers. If you don’t allow your brain to recover … you don’t think as well the next day, which is on the acute level. On the chronic level, many of our neurotransmitters, our bodies’ hormones, aren’t produced in the correct levels (and) we don’t respond to insulin appropriately and those types of things. It affects all the systems of our bodies because at the end of the day, our brain controls our body.”
Everyone occasionally has bad nights, he went on to say, but acute sleep loss can lead to “sleep casualties,” a term the Army is using because commanders understand “heat casualties.” They understand how serious they are and they understand how to prevent them.
Sleep casualties can be just as serious, if not more so, he said, because they can lead to vehicle accidents or accidents on the range.
“(Soldiers are) going through the motions, but they’re not thinking through the steps,” said Elkins. “When those steps aren’t achieved, that’s where accidents happen. … We can look at a lot of situations and probably draw back and see where a lack of sleep caused a preventable situation.”
Milo’s insomnia definitely affected his job, he said, explaining that he would often zone out when people were talking to him, and his supervisors would sometimes send him home because he just wasn’t “helpful or anything.” He would even find himself dozing off at stoplights. “It wasn’t very safe.”
More than insomnia
Many Soldiers and veterans like Milo suffer from conditions that are closely associated with insomnia such as TBI, PTSD, anxiety and depression. If a Soldier is always dragging, always seems unusually tired, it’s incumbent upon his NCO to step in and ask why he isn’t sleeping instead of just telling him to wake up, said Elkins. Maybe that Soldier is just up too late playing video games and needs some advice on setting aside time for sleep, but maybe, just maybe, something is truly wrong. Maybe the Soldier is having relationship problems or financial problems. Maybe he needs to be evaluated by behavioral health. “How can I help you?” Elkins asks Soldiers. “And if I can’t help you, where do we need to go to get you that help?”
Sometimes it’s sleep problems that finally bring a troubled Soldier to the doctor, said Lt. Col. Ingrid Lim, the Performance Triad sleep lead and a clinical psychologist. “Folks will more likely make their patient appointments for insomnia than, say, if they have PTSD or depression,” she noted. “There are screenings in their appointments that will help identify those who will have other disorders.”
Sleep is so important, so life affirming that, according to Lim, simply treating insomnia often improves behavioral health symptoms, although other disorders still need to be treated as well. In fact, she added, a recent study has shown that Soldiers who are already sleep deprived when they deploy are more likely to develop mental health problems, so it’s crucial Soldiers sleep whenever the mission allows, even if they can only squeeze in short naps.
“Sleep adds to resilience,” she said. “It allows folks to consolidate what they’ve learned. We also know that when people sleep – get good, healthy sleep – their mood tends to be stable.”
And then there’s trauma sleep disorder, a new diagnosis Mysliwiec proposed in a study with several colleagues after they found some Soldiers would return from combat and not only suffer nightmares, but act out their dreams. “People who have PTSD have PTSD-associated nightmares … but nightmares don’t cause individuals to act out in their sleep,” he said, explaining that some – but not all – patients with TSD also have PTSD. “For the actual TSD aspect, they’re having the dream enactment behaviors, the tossing, turning and associated nightmares.”
The most effective treatment for insomnia, Mysliwiec and Lim explained, is also the simplest: cognitive behavior therapy for insomnia. At its core, CBT-I is about associating the bed “with sleep and sleep alone” said Mysliwiec. It’s not for watching TV or eating or listening to loud music. Even reading in bed can be tricky, although it can also be an important part of a pre-sleep routine for many people, a process that tells their brains that it’s time to wind down and get ready to sleep.
“We teach them about their sleep with focused sleep education,” explained Mysliwiec. “There’re two processes why individuals sleep: One is the homeostatic sleep drive, which sleep restriction specifically addresses, meaning we restrict our time in bed so that when we’re in bed we’re actually sleeping. The other one is understanding your circadian rhythm, whereby during certain periods of the day you’re actually sleepy. So counseling them on those things … allows them to restore their sleep over time.”
CBT-I works for about 60 percent of patients, particularly when other illnesses and injuries are also being managed, and Lim said experts are also finding meditation and deep breathing to be helpful. If patients have followed their doctors’ orders, down to banishing TVs from bedrooms and turning digital clocks around, and they still can’t sleep, providers look deeper, ordering sleep studies when appropriate. Sleep apnea (when someone stops breathing at least five times per hour) is a common culprit, for example, and usually requires a continuous positive airway pressure machine – better known as a CPAP – to regulate breathing in addition to the CBT-I. TSD, meanwhile, often benefits from a hypertension medication that has been studied in PTSD patients.
Doctors prescribe sleeping medication when Soldiers truly need it, but CBT-I still has better long-term outcomes, according to Mysliwiec. That medication comes with lots of side effects, especially the next-day grogginess Milo knows only too well. While sleeping pills might help him sleep for a few hours, the next day he can barely function, and over time, he said, the pills become less and less effective. And sometimes, he said, “you don’t want to just rely on medicine. You want to be able to do it yourself. It gets frustrating not being able to control things on your own.”
Elkins added that while medication may be right for some people, it wasn’t right for him. He tried it in Iraq, but said he never felt rested while he was taking sleeping pills, and a recent prescription for muscle relaxers left his brain sluggish. “When I woke up in the morning, my mind was not as active,” he explained. “I didn’t have those great ideas. … The synapses in my brain weren’t firing like I was used to.
“What I talk to Soldiers about is how it affects me. … Your body can be tired. Your body can be exhausted. … But your brain, that is what gives us thought and motor function and gives us emotion and all of that. When you start using medication or alcohol … you start inhibiting … brain function.”
Many Soldiers, he added, also rely too heavily on caffeine to stay awake, not one or two cups of coffee, but multiple energy drinks that inhibit their sleep the following night. “Know when to turn it off so your body can stay in a normal rhythm,” he said. Lim recommends stopping caffeine six hours before bed.
As for Milo, who is medically retired and works with several nonprofits, he doesn’t want to wake his wife up, so after he gets his three hours, he might spend part of his night working out or sketching or just watching his daughter sleep. He has learned how to work with very little rest. “Do I like it? No, but I’ve learned to adjust my lifestyle enough where I can somewhat properly function.
“Cherish the ability you have to sleep well,” he advised. “Take care of yourself and maintain a good sleeping habit. Don’t take it for granted and hope you’re never going to have an issue, because I promise, when you have a sleeping problem, every aspect of your life becomes more difficult.”
Editor’s note: Want more sleep advice? Check out “Sleep tips from the experts.”