The stories are eerily similar. The patient awakens from a terrifying recurrent dream, sweating, heart beating fast, and often unable to fall asleep again that night. Some are elderly men, others are young women. Some have suffered trauma on the battlefield, others at home.
In my more than 30-year career in sleep medicine, I have treated civilians, active duty soldiers, and veterans in Canada and across the United States. For some, the trauma was recent; for others, it occurred 30 to 50 years before.
Some experienced violence directly while others simply witnessed it. Many carry a survivor’s guilt that is central to the psychic disturbance. What they all have in common is that a traumatic experience has gripped them and won’t let them sleep.
The patient stories below are disturbing to read. They are remarkable to me in that they portray an historical snapshot of the violence that people living in North America have experienced since the 1940s, from the unique perspective of a sleep physician.
I share them with you to give you a sense of how close the relationship is between traumatic events and sleep, and how powerful is the sleeping mind.
The patient in front of me was in his 60s, referred to me because of a sleep problem. Every night for about 35 years he awakened in a cold sweat, his heart beating rapidly from a dream about terrible events he witnessed in a concentration camp during the Holocaust.
The dream and the result were always the same — he could not go back to sleep because of fear. I never asked him exactly what he dreamt because it was early in my career, and I was reticent. His doctor did not know what to do with him and neither did I. It was a problem that would continue to challenge me throughout my career in sleep medicine.
Soon thereafter, another gentleman was referred to me with insomnia. The patient's sleep problem began on June 6, 1944 — D-Day. Shortly thereafter, he was hospitalized for a “nervous breakdown” for a few months. Since his discharge from the hospital, he had been awakened by a recurrent nightmare every single night. As a result, he developed a fear of falling asleep. I saw him roughly 40 years after D-Day.
This time, I asked about his recurring dream. It was that his best friend was blown up on the beach at Normandy and that the bleeding body parts of his friend landed on him, knocking him over. He told me that that is precisely what happened and that he believed that his friend’s body had protected him from the slaughter that was going on all around him. He wanted a pill to block out the nightmares so he could sleep.
The man came to our clinic because he awoke early every morning and could not get back to sleep. He would get up, go to the bathroom, and when he looked at the mirror he saw the face of a young Korean boy.
When I asked him if he recognized the face of the boy, he told me that while he was on patrol in Korea more than 50 years before, he saw in the distance a person that he assumed to be an enemy and shot him. When he went to identify the body and saw the face, he realized that it was a boy, barely 10 years old.
The patient had sleep apnea, a condition in which people stop breathing during sleep. The usual treatment is to use a continuous positive airway pressure (CPAP) machine in which the patient wears a mask connected to a blower that generates the pressure. However, the patient could not wear the mask due to severe claustrophobia that he blamed on his experiences in Vietnam a generation before.
He had been in a helicopter on a mission to evacuate some wounded troops. His helicopter was shot down, killing several of his buddies and injuring him. After the helicopter crash-landed, he and his surviving comrades hid in the jungle to await rescue.
He was terrified and in pain, and after a few hours, another helicopter arrived and evacuated him. He remembered very little about that trip except the oxygen mask.
A soldier on active duty came in complaining of insomnia, awakening from sleep with a terrifying nightmare. In his recurring dream, he saw his best friend bleeding and dead, next to a building. The soldier had been on a peacekeeping mission in Bosnia.
He was a driver. He had backed up his truck, failing to see his friend behind the truck, and crushed him. He came to the clinic for a sleeping pill to keep from waking up; he was too ashamed to be treated for posttraumatic stress disorder.
I was practicing medicine in Winnipeg, Canada, when the terrible events of 9/11 unfolded. There was a rash of patients who were referred for insomnia. Some of them reported symptoms of posttraumatic stress disorder with nightmares related to the terrible images they had seen on television.
He was a tough-looking soldier, physically fit, short-cropped hair, and neatly dressed. He came to the clinic with severe insomnia and a request for refill of his medications.
He was being actively treated for post-traumatic stress disorder, but had been referred to the sleep clinic to see whether we could do something about his nightmares. He boasted that he had killed many enemy in combat, but was not bothered by that experience, nor the fact that he had run over children after receiving orders not to stop his vehicle under any circumstances when he was part of the convoy. Rather, the dream that disturbed him was of the barrel of a pistol put next to his head and its trigger being pulled, after which he defecates in his trousers.
His dream was based on actual experience in Afghanistan. As a practical joke, his direct superior told him that he had been accused of treason, and that he was about to be executed. His superior pulled out a pistol and pulled the trigger. The gun was not loaded. “I was terrified,” he said. “It was the only time in my life that I crapped my pants.”
Sitting in front of me was a broken man. He had suffered traumatic brain injury from an improvised explosive device, had an uncontrollable twitch, and was in the sleep clinic because of severe sleep problems. His recurring dream was that he was running over a young child who had run in front of his truck, which was part of a convoy. He could have stopped his truck, but the orders were clear: he must not stop his truck under any circumstances.
There Is Much We Do Not Know-
Medical science does not yet understand why witnessing or experiencing a traumatic event sears the event into the brain and may cause symptoms decades later.
Are there actual chemical or structural changes in the brain related to fear, pain, guilt, and shame? What is the role of disrupted sleep and nightmares in perpetuating symptoms of PTSD?
We also wonder why some individuals suffer PTSD and others who witness or experience the same traumatic events do not develop symptoms of PTSD. We do not know why some people are at greater risk for developing PTSD.
First described in about 1980, “Post Traumatic Stress Disorder” has obviously been around as long as people have witnessed or suffered traumatic events. What is so distressing for care providers is that we see patients who are victims twice: once from the traumatic event itself and later from its collateral damage.
There is much work still to be done.
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