Study will test neck injections to combat PTSD

It is interesting that a shot may be the answer to turning off intense emotions. Not sure I would want to test this new procedure out. What do you think?

By Gidget Fuentes - Staff writer
Posted : Monday Dec 26, 2011 11:41:48 EST

Top of Form

SAN DIEGO — After seeing promising results with an innovative treatment for post-traumatic stress disorder, a group of Navy doctors in San Diego hopes a new study will show a shot in the neck that quiets nerves could bring quick, lasting relief to suffering combat vets.

In a pilot study at Naval Medical Center San Diego, 42 active-duty service members will get injections to block or turn off nerves from transmitting triggers that can cause anxiety, hyperarousal or other symptoms of PTSD. Such nerve blocks, much like basic pain management treatments first done in 1925, typically bring relief in a few days, if not several hours, and in the weeks or months after the procedure.

The study, funded by the Navy Bureau of Medicine and Surgery, uses a stellate ganglion block, or SGB. The treatment involves injecting an anesthetic into the stellate ganglion — a bundle of nerves in the neck — which blocks pain signals in the sympathetic nerve system from reaching the brain.

So far, more than 20 patients diagnosed with PTSD have begun the voluntary three-month program, which involves two or three injections of either the real treatment or a placebo, said Capt. Anita Hickey, an anesthesiologist and director of Pain Research and Integrative Medicine at the medical center.

The procedure lasts a half-hour for patients, who in most cases are sedated or receive a topical anesthetic in the neck. An X-ray and, in the case of the San Diego study, an ultrasound machine guide the proper placement of the needle and direct the anesthetic to the targeted spot, Hickey said. The treatment includes checkups at one week, one month and three months after the initial shot, with possible subsequent injections of either the placebo or the anesthetic.

‘Rebooting a computer’

Research shows an SGB injection “does have an effect on the sympathetic nervous system in the brain,” said Hickey, who has used nerve blocks in pain management. She described the treatment as “rebooting a computer,” with most patients seeing reduced PTSD symptoms.

The study team hopes to present its findings in May at an American Psychiatric Association meeting and ultimately get more funding for continuing research and larger clinical studies. An article Hickey co-wrote about the effects of SGB treatment on eight combat vets will be in the February issue of Military Medicine, the Journal of the Association of Military Surgeons of the United States.

The Navy’s study takes a page from Chicago anesthesiologist Dr. Eugene Lipov, who in 2008 first used the treatment for PTSD sufferers. Lipov, who so far has used the treatment on 30 combat vets, unsuccessfully tried four times to get Defense Department funding for a larger clinical trial, but he now provides the $1,000 treatment to patients partly funded through donations.

Lipov, who with Hickey co-wrote an earlier paper about the stellate ganglion block, said the treatment eases symptoms and can reduce emotional reactions to trauma without erasing the memory.

The treatment shows promising results, a Navy psychiatrist involved in the trial said.

“We do see some benefits at one week. People are more calm, are having fewer nightmares, are able to do more things,” said Dr. Robert McLay, Naval Medical Center San Diego’s mental health research director and psychiatrist who works with troops with PTSD.

McLay, an admitted skeptic, is excited about the treatment. “I think it potentially could really change the thinking in some respects with responding to PTSD,” he said.

Popular treatments range from medication and counseling to virtual-reality exposure and even alternative therapies such as yoga and art. But as the Iraq and Afghanistan wars wind down, with as many as one-quarter to one-third of combat vets suffering from PTSD, officials expect to see larger caseloads.

However, defense health officials told a Bethesda, Md., conference this month that fewer than half of PTSD patients are helped by medications and psychotherapy. Lipov said he has seen 80 percent success among his veteran patients so far, but he acknowledged further study will refine the treatment and help doctors better learn which patients and symptoms are helped the most.

Medical experts say the complexity of PTSD, how it affects different patients, and lack of understanding about how the brain works all add to the difficulty of treating — if not curing — the disorder. Combat veterans can suffer nightmares, headaches, depression, anxiety and isolation.

PTSD patients “by their very nature are very jumpy, very hesitant to jump into things,” McLay said. “We’ve actually been getting more volunteers for a shot in the neck ... than coming in and having to meet me twice a week to talk about their trauma.”

Dr. Maryam Navaie, a San Diego research consultant who’s worked with Hickey and Lipov, said SGB treatment requires a shorter commitment, so it’s easier for the vets. “Compliance is 100 percent,” said Navaie, compared to 30 percent to 40 percent for those who are prescribed medications.

That ease and fast relief appealed to Aviation Structural Mechanic 1st Class Christopher Carlson, who retired in 2010 after multiple deployments in a 20-year career that included at-sea tours. Carlson said he subsequently was diagnosed with PTSD after getting worsening bouts of cold sweats, disrupted sleep, anxiety and severe nightmares “that seemed almost real.”

He was prescribed medications, “but really nothing seemed to be working,” he said, and his struggles sidetracked him from getting good employment after he retired in Norfolk, Va., and moved to Chicago. He drank more, was depressed and got more forgetful; he and his wife, who have four children, divorced.

On a fluke, someone told him about Lipov’s treatment. Desperate for relief, he volunteered.

“It seemed like it was a miracle cure,” he said. “It changed my life.”

After his initial improvement seemed to wane a few months after the first injection, Carlson got a second treatment and noticed “night and day” changes.

“My mind is a lot clearer, and I’m sleeping better,” he said Dec. 14. “My emotions are a lot better.”

Memorial Ceremony remarks for fallen soldiers in Mosul

Memorial Ceremony remarks for fallen soldiers in Mosul

Deuce Four Fallen Warriors

LTC Kurilla, commander of 1st Battalion, 24th Infantry Regiment, forwarded the following comments he will make during a memorial service for 1LT Aaron Sessan, SPC Tyler Creamean, and SGT Ben Morton on Saturday, May 28th in Mosul, Iraq. He said, "I offer these comments to give everyone a small glimpse into the lives and sacrifices of three incredible men."

Thank you for sharing this message.

*****
GEN Rodriguez, GEN Bergner, COL Brown, Sergeants Major, friends of Deuce Four, and most importantly the men of Deuce Four. Thank you for coming today to honor and remember three of our fallen warriors.

Forgive me if I go long but these were extraordinary men.

Again we are drawn together as a band of brothers to mourn the loss of three Deuce Four warriors and sappers. We are truly a band of brothers. The bonds of camaraderie and friendship that we share from fire team to battalion are as strong as the very bonds of marriage. These bonds are forged and bound under the stress and fire of daily combat. We are bound together in shared friendship, shared hardship, shared loss and a desire over any other to ensure you care for the man on your left and right flank.

William Shakespeare in Henry V describes the bond that we all share. At the battle of Agincourt in 1415 AD, the English were outnumbered 5 to 1 and faced a formidable French foe that blocked their return route to England. The English were certain that no one would make it out alive. Henry V turned to his men to tell them about the uncommon bond that is shared in combat. He states –

“From this day to the ending of the world. But we in it shall be remembered; We few, we happy few, we band of brothers; For he today that sheds his blood with me today shall be my brother.”

Today we mourn the loss of three brothers in arms – 1LT Aaron Sessan, SPC Tyler Creamean, and SGT Ben Morton.

Deuce Four with our Sapper brothers have done extraordinary things for one reason and one reason only. It is because of extraordinary men. There is no piece of equipment that makes us successful, there is no technological advantage that is the key to winning, there is no special training we possess that turns the tides against the enemy. It is for one reason and one reason only that we are successful – the extraordinary men that make up this organization. Men that know that leadership means just that – leading – out front, in harms way where they are at the greatest risk. Extraordinary men that would sacrifice their own lives for their fellow soldiers. Men who place the needs of others above their own. Men who accomplish every mission for no reason other than they do not want to let down their brother in arms.

LT Aaron Sessan and SPC Tyler Creamean were out front leading on a Stryker sweep. These were men that knew the cost of leadership – out front exposing themselves to risk. A Stryker IED Sweep by its very name implies great danger and risk. You are traveling the most heavily mined and bombed roads in Iraq not trying to avoid the mines and bombs but actually trying to find them. Why? So that others can travel safely without fear of attack. Stryker sweeps are not an exact science as the enemy has become very adept at hiding his mines and bombs. It requires experience, incredible skill, patience and being out in front of the other combat patrols and logistical convoys. Sappers LT Sessan and SPC Creamean were out front leading a Stryker IED sweep. They risked their lives so that others might be safe. Our brothers in arms, LT Sessan and SPC Creamean made the ultimate sacrifice for others when their vehicle was hit by one of the very IEDs they were looking for. But it did not end there, while they were mortally wounded LT Sessan and SPC Creamean kept trying to direct medical attention to each other and PFC Buck who was also wounded. That is what leaders do – they place the needs of others over their own, even when they are mortally wounded. These Sappers were incredible men that will never be forgotten.

I would now like to talk about a very special person and leader with whom I had daily interaction, someone I fought next to, and one of the finest men I have had a chance to get to know – SGT Ben “Rat” Morton.

If there was someone that defined the term quite professional it was Rat.

Rat was special and quite frankly I do not think I ever heard him called anything else. I remember one time someone said “Morton” and I said, "who?" " Rat sir". "Oh"…I didn’t now we had a Morton, but I damn sure knew we had Rat. I am not sure he even knew he had any other name. It even extended to the battlefield. I am not sure what day it was – but we were somewhere in northwest Mosul doing a cordon and search. Rat was carrying the radio – I heard the call on the net on my PRC-148 “Hunter Three Romeo, this is Hunter Seven over..there was a pause for about 3 seconds…more agitation in his voice, Hunter Three Romeo, this is Hunter Seven over…another pause of about 3 seconds. Damn it Rat answer the radio!…then came the calm response,… this is Rat over…” that was Rat.

Rat knew about leadership and courage under fire. On the night Rat fell, he was leading his team clearing a house of a terrorist cell that specialized in car bombs. They quickly detained three of the terrorists on the first floor and moved rapidly up the stairs with Rat in the lead. The house had at least three women and 5 children on the first floor, some of them infants so they decided not to use flash bangs which can kill an infant. There were two terrorists that were hiding in a back room and they moved to the balcony in the hopes they would not be caught. Rat was the #1 man into the room, followed by his team. The terrorist hiding on the balcony knew they would be certainly caught and reached around the corner and fired an AK-47 on full automatic through the window hitting Rat four times. The team returned fire and cleared the rest of the house. Rat’s sacrifice resulted in killing one terrorist, wounding one, and detaining 5 members of a car bomb cell. Rat was awarded an ARCOM with Valor device for his actions that night. Rat knew that leaders lead from the front. I also know there is not a man in Deuce Four that would not want to be the #1 man entering and clearing a room of terrorists.

Rat also showed me how to laugh in the worst of situations. It was 11 Dec and we had just been hit by a suicide car bomb followed by very heavy small arms, RPGs, and mortars from 3 directions. We now had seven wounded and a Stryker was on fire. Rat and Plum were the first ones on the scene with fire extinguishers in hand putting out the fire, caring for wounded comrades, and then rejoining the fight. Strykers with dismounted teams were holding a tight perimeter against 25 insurgents that were attacking from 3 directions. An RPG had just hit one of the Strykers and two mortars landed right behind Rat’s Stryker. We had a fix on one enemy position to the SW. We were doing out best to rubble the building with .50 cal and Mark-19 and fast movers were still 5 minutes out. Rat grabbed a SMAW-D which would certainly rubble the building. As he raised up the weapon, 2 more mortars landed in our perimeter within 20 meters of Rat’s Stryker. He fired and the SMAW-D impacted about 30 meters in front us – we even thought it was a larger enemy mortar. Rat smiled, laughed and yelled out over the fire fight – “This one was defective – what do you expect from a Marine weapon…” You see, the SMAW-D was designed by the Marines; however it has to be aimed to hit its target…

Rat did many more amazing things that day that I do not have the time to share. Rat was awarded the Bronze star for Valor for his actions on 11 Dec. He was a hero to all of us. He is now in heaven taking pictures from an incredible vantage point. He is finding and collecting things so that when we join him and go to him and ask if he has a certain item – he will smile and return with just the item you needed.

To the men of Deuce Four we now honor our 14th warrior and sapper to die defending the freedom of an oppressed people that truly do not understand the sacrifices that we make. The only words I think that can describe their sacrifice are not even my words. They are the words of Winston Churchill in WWII describing the sacrifices warriors make. He states:

“Never was so much owed by so many to so few”

You see – there are 26 million people in Iraq whose freedom we are fighting for, against terrorists and insurgents that want a return to power and oppression, or worse, a state of fundamentalist tyranny. Some of these we fight are international terrorists that hate the fact that in our way of life we can choose who will govern us, the method in which we worship, and the myriad other freedoms we have. We are fighting so that these fanatical terrorists do not enter the sacred ground of our country and we have to fight them in our own backyard. We fight for 296 million US citizens in America. We fight for the man on your left and right so that he can return home to his family and loved ones --we fight for each other. LT Aaron Sessan, SPC Tyler Creamean and SGT Ben Morton fought for all of us. Never was so much owed by so many to so few.

These three warriors joined the rest of the Deuce Four Advance Party. CPT Bill Jacobsen is in charge of the formation while 1SG Bordelon called out the names to make sure all are present. SPC Tommy Doerflinger, CPT Bill Jacobsen, SGT Robert Johnson, CPL Jonathan Castro, SPC Lionel Ayro, PFC Oscar Sanchez, SGT Nathanial Swindell, SGT Adam Plumondore, SPC Clint Gertson, SGT Anthony Davis. 1SG Mike Bordelon, SPC Tyler Creamean, 1LT Aaron Sessan, and SGT Ben “Rat” Morton. These 14 warriors now stand high above us overwatching us, providing guidance and direction in the most difficult times. Never was so much owed by so many to so few.

On this day, we ask almighty God to grant us patience and steadfast resolve in all that is to come. We ask the Master Physician to reach down and use his healing hand to heal our wounded brothers. May God Bless Deuce Four, 1st Brigade, and may God Bless America.

Mr. President: Americans Want to Welcome Home The Troops, Too

Posted by Paul Rieckhoff on February 16

My Mom , me and my Grandma after coming home from my 4th Deployment at teh Harmon in Tacoma, Wa

A White House Dinner symbolizes a grateful country—but it's only a start.

In December, after eight years of combat, 32,000 Americans wounded, and 4,400 lives lost, the President told America that the Iraq war was over. And civilians nationwide began organizing parades—most notably, one for 100,000 people in St. Louis. Now, the President and First Lady are planning a historic White House Dinner –called “A Nation’s Gratitude” –for 200 Iraq veterans and their spouses from all 50 states. It’s the First Family’s way of saying “thank you” for their service and sacrifice.
The Pentagon is billing the black-tie dinner as symbolic of a grateful country—and it is. It’s a wonderful gesture from the First Family and an incredible honor for the few invited to attend. But unfortunately, one million vets of Iraq can’t pack into the East Room on February 29th. So the question we have to ask is: what about the rest of them? And what about all the American civilians who can’t attend to say “thank you”? Shouldn’t the entire nation be included in “A Nation’s Gratitude”?
We think so. That’s why today IAVA is proposing a deadline: we’re asking President Obama to convene a meeting of mayors nationwide to organize a National Day of Action – Operation Welcome Home. The goal? To turn America’s growing goodwill toward our Iraq veterans into concrete action. The one million veterans of Iraq represent the less than one percent. And all Americans want an outlet to honor their service while raising awareness and directing critical local resources to veterans and their families for the transition home.
As history closes the chapter on Iraq, Americans from all corners of the country want to respect all those who served there, remember those who died, and respond to the challenges they’re now facing at home from record unemployment to troubling suicide rates. It’s time for all of us, from the President to the Pentagon to mayors and ordinary citizens nationwide, to work together to channel our collective goodwill, support and momentum to deliver critical resources to the veterans’ community. Instead of having scattered parades all year long, we should work together - civilians and veterans united - to create one historic day of action: parades, memorials and service fairs in cities and towns large and small.
Just a few weeks ago, St. Louis was the first city in the nation to welcome home our Iraq veterans. It set the national benchmark not simply because it turned out 100,000 Americans in support of Iraq veterans, but because it was a multifaceted coming home event. The highly impactful, grassroots, civilian-led parade gave Americans a chance to say “thank you” to the troops. It was awesome—and it went a step beyond symbolic. It opened with a sober Memorial Ceremony to honor our dead and it ended with a Veterans Resource Village to connect local St. Louis veterans with critical employment, education and mental health resources. It was smart, popular, bi-partisan and even fun.
Since then, Douglas Wilson, the Assistant Secretary of Defense for Public Affairs, has stated repeatedly that the Pentagon supports the St. Louis model. In a recent interview on The Rachel Maddow Show, Wilson said “the kinds of things that we saw in St. Louis are the kinds of things we love to see around the country.” He and the Pentagon brass also support the President’s White House Dinner. Yet, they have strongly told Mayor Bloomberg “no” to a citywide event in New York. (Insert head-scratching here.)
Like any other hometown, New York City loves its vets too. And patriotic civilian leadership from both parties is asking the question: If our NY Giants deserve a parade, don’t our Iraq vets? These leaders want to give Operation Welcome Home the national momentum it deserves too. Folks ranging from former Mayor Ed Koch to City Councilman Vincent Ignizio (R-SI) to Speaker Christine Quinn (D-3) support a citywide celebration. Councilman Ignizio started this whole push for a Big Apple Parade way back in December. As one little girl from Staten Island sums it up, people just want to connect and say thank you. So what’s the harm in that?
The idea has caught fire. And we’ve addressed almost every single argument against it. Across the country, ordinary Americans are joining the guys in St. Louis to coordinate their own events. In San Antonio, Richmond and a dozen other cities, they’re planning parades and service fairs for their local Iraq vets. Lead by civilians, not veterans themselves, this welcome home movement is gaining steam by the day – reinforcing the urgency to coordinate our efforts and resources nationally. The American people are speaking. Loudly. And it’s time for the Pentagon and the President to lead, follow or get out of the way.
At the end of the day, we all want to welcome home America’s veterans in the most positive, meaningful and impactful ways possible. We know parades and a White House Dinner are not enough. Not even close. But if we’re smart and proactive as a country, we’ll rally the goodwill that started in St. Louis to spotlight and deliver community resources nationwide now—instead of delaying until history closes the chapter on both wars. A National Day of Action for those who have already returned should pave the way for those yet to come home, while activating the country around our entire community for years to come. Americans are keenly aware of the lessons after the Vietnam War. They know that honoring and supporting our troops 10 years after a war ends is a disgrace. We need to show those that have fought for our country that we have their backs now. So if the Pentagon says a national event isn’t an option now, then they need to tell Americans when. None of us have a crystal ball—combat operations might not end until 2013--at the earliest. So we’re looking to our leaders for some productive ways to organize and activate locally in the meantime.
No matter the front they fought on, our returning veterans are coming home today to entirely new battles - against unemployment, invisible mental health injuries, and bureaucratic red tape around their hard-earned benefits. The end of the Iraq war has increased the demand within our community for services, support and understanding of the issues our veterans face. A National Day of Action could raise the standard of awareness and resources to support our veterans’ community on the scale we’ve seen for other causes like Hope for Haiti, Live 8 and America: A Tribute to Heroes after 9/11.
In a perfect world, every Iraq vet could visit the White House for a black-tie dinner and every day would be Veterans Day—but that’s not possible. But replicating St. Louis at scale, a demonstration of our entire nation’s gratitude is possible. And now is the time for the President and the Pentagon to listen to the American people who want to help. Let’s channel that unprecedented goodwill and gratitude into something practical and lasting, in a way that benefits our veterans and their families for years to come.
If we do it right, it will do more than just help our veterans. It might just help unite our divided country. And that’s a mission all veterans would be proud to be a part of.
Paul Rieckhoff is the Founder and Executive Director of Iraq and Afghanistan Veterans of America, and the author of Chasing Ghosts.

I have PTSD...so what?

I really like what he says and how he says it, don't agree completly with carry weapons around but nonetheless the message is great.....

"For those who are like me, there is help. Seek it out. You were strong enough to make it this far, don’t give up. Dig a little deeper and make that final push. If you do not know where to go or have fallen astray, contact me. I will help. We are all brothers and sisters in this battle that will rage invariably for eternity and the one constant is that we have each other."
 By RU Rob
I have PTSD. We all know what it is, Post Traumatic Stress Disorder. I am one of millions who are affected by it each and every day. Millions of men and women who have varying symptoms yet manage to maintain a normal lifestyle. I, along with my cohorts, have been classified as a potential powder keg just waiting on that spark to set us off into a murderous explosion of ire. This is not the case as I am just as normal as you.
At the end of every day I lay my head down in an attempt to sleep. That in itself is no different than you. But when my eyes close and I should be drifting off into a peaceful bliss, my mind takes over and I am tormented in my dreams with a vivid and exaggerated version of every combat encounter witnessed. There has been nary a night that I do not have this, and have not had an uninterrupted night of sleep for years. Yet in the morning, I rise with the consistency of the sun, roll out of my sweat soaked bed, and shake off the remnants of the nightly battles and start my day…just like you.
I am functional in society, but I am a little more vigilant than you, always on the look-out for danger, avoiding large crowds and loud places. But somehow, I can still manage to go out to eat, shop for my clothes and drive my car. I pay close attention to those around me, see the drug deal that just took place on my right and notice the people who just don’t belong in a certain situation. You may not have evil intentions, but I will notice nonetheless.
I have guns. As a matter of fact I just about always have one on me. You see, even though I have PTSD, I am still a Sheepdog watching out for my flock. I don’t brandish my weapon and most of the time you won’t even know I have it on my body, but it is there. I also carry a large knife in my pocket, one that could cause serious injury or death if used improperly. I have never used any of my weapons in a malicious manner and never will, but in my duties as a Sheepdog I will not hesitate to draw down on you should the circumstance warrant it. I am armed, but I am not dangerous.
There are times that I am medicated. My PTSD comes in cycles and when things get bad I need that extra chemical push to regulate me. I accept this and because of it I do not drink. I have other physical problems that could easily warrant an addiction to pain killers, but just like most of us with PTSD, I avoid it.
I have never committed violence in the workplace, just like the vast majority of those who suffer with me. My co-workers know I spent time in the military but they do not know of my daily struggles, and they won’t. I can still communicate with my subordinates and supervisors in a clear manner. I have never physically assaulted anyone out of anger or rage.
It pains me when I listen to the news and every time a veteran commits a crime (or commits suicide); it is automatically linked to and blamed on PTSD. Yes, there are some who cannot control their actions due to this imbalance in our heads, but don’t put a label on us that we are all incorrigible. Very few of us are bad. There are more of us out there that are trying harder to do good than the lesser alternative.
Do not pity me. I know who I am and recognize the journey that has shaped me into what I am. I have no regrets about anything that I have done in the past and look forward to many wonderful years in the future. I freely take every step of life during the day knowing that there is something that will haunt me at night.
For those who are like me, there is help. Seek it out. You were strong enough to make it this far, don’t give up. Dig a little deeper and make that final push. If you do not know where to go or have fallen astray, contact me. I will help. We are all brothers and sisters in this battle that will rage invariably for eternity and the one constant is that we have each other.
To the rest of society and particularly the media: I have PTSD!

This pencil illustration attempts to visualize PTSD

"Post Traumatic Stress Disorder (PTSD). This pencil illustration attempts to visualize PTSD. Those that suffer from this disorder are constantly trying to regain some sense of the normalcy they had before events that caused pieces of themselves to go missing. This illustration was created by MSgt William Vance, Medical Multimedia Manager for the 59th Public Affairs Office."

A New Home for Nightmare Treatment

by Barry Krakow, MD

A new home for nightmare treatment

Military personnel returning from wars in Afghanistan and Iraq show increasing rates of post-traumatic stress disorder (PTSD) and post-traumatic nightmares. Media coverage of these two vexing mental health conditions is also intensifying and raising public awareness about the need for more effective therapeutic options. With growing attention focused on patients with nightmares, sleep centers have an opportunity to engage these patients. Successfully doing so hinges on applying a standard of care for nightmare assessment and treatment through behavioral sleep medicine specialists.

MENTAL HEALTH VIEW OF NIGHTMARES

Traditionally, nightmares reflect emotional turmoil that needs venting through the process of dreaming. This psychological perspective fuels the entrenched and enduring focus on dream interpretation therapy as one of two core treatments for this potent sleep disrupter. The other primary approach known as exposure therapy is gaining ascendency in the mental health community because of the prevailing view that PTSD—the cause of the disturbing dreams—must be treated first. As the theory goes, the nightmares will resolve when their cause is treated. Yet, both these treatment paradigms (dream interpretation and exposure) trigger treatment avoidance among nightmare patients because of their fear of unmasking unpleasant mental health issues. Although this paradox creates an opening for nightmare patients to seek help outside of mental health facilities, it is rare for sleep medicine clinics to encounter patients seeking treatment exclusively for nightmares.

SLEEP MEDICINE PROFESSIONALS

To date, the sleep medicine profession has not applied a standard of care for nightmare assessment and treatment. While recent practice parameters published in the Journal of Clinical Sleep Medicine spell out efficacious treatment strategies for chronic nightmares, no evidence suggests these standards are widely adopted. To make treatment options more readily available, the sleep medicine community, particularly the field of behavioral sleep medicine, must embrace the emerging model of "nightmares as an independent sleep disorder," a paradigm described in the scientific literature for more than 20 years and now inferred by the new practice parameters.

In the practice parameters, imagery rehearsal therapy (IRT) is a Level A treatment and a relatively simple instruction that seems to alter the dreaming cycle by taking advantage of the fact that waking imagery influences sleeping imagery. The technique is no more complicated than asking someone to recall a recent bad dream, change this dream's content into a "new dream" while awake, and then spend a few minutes each day rehearsing the images from the new dream. For nightmare patients without complex comorbidities such as anxiety, depression, or PTSD, one clinic appointment is sufficient to teach IRT. Treatment is more involved among nightmare patients with PTSD who may require as much as 5 to 15 hours of clinical follow-up through individual appointments or group programs, primarily because they need extensive coaching to reach the point of receptivity to, interest in, and comfort with the imagery technique.

TAKING THE LEAD

In order to more firmly root sleep medicine professionals as leading care providers for this patient population, the next logical step will be facilitating and marketing the role of behavioral sleep medicine specialists as therapists for nightmare patients. The most expedient ways to develop this market include internal development and external outreach. At the most basic level, introducing a few key questions into the sleep center's intake process such as "How often do you suffer from nightmares?" and "Do your nightmares disturb your sleep?" has proven highly reliable in identifying patients likely to be interested in nightmare treatment. Outreach may be straightforward if your sleep center resides in a locale that also houses military installations.
At Maimonides Sleep Arts & Sciences, the single largest source of treatment-seeking nightmare patients is the US Air Force and US Army. The second most useful resource is outpatient mental health clinics or therapists, who routinely see patients with chronic nightmares yet often do not provide effective treatment programs for disturbing dreams. Many of these therapists are frustrated with their inability to resolve the nightmares in their patients, and therefore, they tend to be very receptive to programs such as IRT.
To maximize clinical efforts toward nightmare patients in our PTSD Sleep Clinic, we combine individual patient encounters with a self-help workbook and audio series, Turning Nightmares into Dreams (2002), developed at Maimonides Sleep Arts & Sciences. We believe the workbook not only reinforces treatment efforts, but in the majority of cases it decreases the total number of follow-up appointments.
In clinic, we have also seen that nightmares serve as a marker for much more complex sleep disturbances. Our PTSD Sleep Clinic experience demonstrates that nightmare patients almost always suffer from insomnia and a sizeable proportion (70% or greater) suffer from obstructive sleep apnea (OSA). When testing is conducted for upper airway resistance syndrome, upwards of 90% or more of our nightmare patients suffer diagnosable sleep-disordered breathing. Thus, both cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure therapy (PAP-T) for OSA are important treatments to be considered for nightmare patients seeking help at sleep medical centers.
Other nightmare treatment programs have also been tested, many of which use components of IRT: Burgess, Marks, and Gill (2001) published Self-Help for Nightmares, a manual that uses self-exposure therapy; Davis (2008) recently published Treating Post-Trauma Nightmares, which combines elements of IRT and exposure therapy. In the 1990s, Krakow and Neidhardt published Conquering Bad Dreams & Nightmares (1992), the first book on IRT; Cartwright and Lamberg published Crisis Dreaming (1992), an innovative dream interpretation approach to nightmares; and Lansky published Posttraumatic Nightmares (1995), an authoritative work on the psychodynamic approach.
By embracing and applying a standard of care for nightmare patients, sleep medicine physicians and psychologists are likely to emerge as leading care providers in offering solutions and treatments for afflicted individuals. And as military personnel return from wars in the Middle East and the media expands coverage of related mental health issues, our profession has an opportunity to serve these soldiers and others who need treatment for chronic nightmares.

Barry Krakow, MD, is the author of Sound Sleep, Sound Mind, principal investigator at Sleep & Human Health Institute, and medical director at Maimonides Sleep Arts & Sciences Ltd (www.sleeptreatment.com), and blogs at www.sleepdynamictherapy.com. He can be reached at sleepeditor@allied360.com.
We have seen that nightmares serve as a marker for much more complex sleep disturbances.