Sleep Dynamic Therapy

Archive for May, 2007

One month after the murderous rampage at Virginia Tech, should we expect a similar media frenzy to latch onto the community’s efforts at recovery? Obviously and regrettably not, as few journalists or media organizations know how or what to effectively broach when exploring the topic of recovery. Articles will appear here and there about various human interest stories, the availability of counseling, or with the media’s addiction to controversy, what the Scientologists are doing in Blacksburg. But, aside from rare instances when they cover in depth the work of an expert in the field of trauma recovery, most of what the mainstream media writes in this realm is useless.

Now at the one month mark—a critical milestone in trauma recovery—it is important to closely examine some aspects of recovery, including what is and isn’t normal and how to identify the risks that predict whether someone is heading in the wrong direction. First and foremost, from an economic and community perspective, it is useful to recognize that the vast majority of individuals directly impacted by the shootings (e.g. everyone on the campus or closely affiliated with the campus) need absolutely no interventions to recover from traumatic experiences. A large number of individuals probably need only to discuss their experiences with close friends and family members for a few days or weeks, and there are probably a sizeable number who probably need even less engagement and will do just fine.

Natural human resilience explains this process. It doesn’t mean that individuals are not scarred for life or that the imprint of the experience can be erased. Rather, it means that most humans have the ability to acknowledge terrible things, feel a wide range of distressing emotions, and then move on with their lives. Many in fact move up in a spiritual sense because the experience permits, encourages or forces them to take stock of their lives. Resilience should not be confused with callousness; resilience is the ability to engage a traumatic experience at a level that hurts but then move beyond that hurt to some form of reckoning—rational, emotional, or spiritual—that allows the individual to embrace the idea and feeling that “life goes on.”

How these resilient individuals negotiate this process takes various forms and steps, one of particular interest to the visual media is the desensitization caused by repeated exposure to the horrific images or assorted reminders of these images. This desensitization allows the person to dampen the emotional reaction to the trauma over the course of days or weeks. In this area, visual media are truly serving a valuable purpose for a very large number of survivors, although arguably most people would have recovered and coped fairly quickly with or without this added exposure.

Who then doesn’t recover quickly or recover to a reasonably healthy state? How do we identify and provide them the help they need? And, how do we match individuals with post-traumatic struggles with the best and most appropriate therapeutic interventions?

Sleep is a very useful marker to estimate when someone will recover fast, slowly, or poorly. Within days of traumatic events, most survivors describe unwanted sleeplessness, poor sleep quality, or nightmares, or a worsening of these symptoms if they already suffered from sleep disturbances. It is in fact logical to need less sleep or experience a lighter form of sleep (poor sleep quality), because adverse experiences raise a person’s threat level. A continuous threat assessment emerges after trauma, raising one’s level of alertness and vigilance to a state of hypervigilance. Consider how much more cautiously or safely you drive immediately after you suffer a very scary, near-miss with another car.

As your threat level rises, you want to reduce your vulnerability to future threats. The sensible thing is to avoid sleep, the most vulnerable state within the natural human life cycle. Sleep can be avoided in the extreme by not sleeping (insomnia), but one’s vulnerability can also be decreased by making sleep lighter (poor quality).

Nightmares play out in several ways in the recovery process. On the one hand, nightmares function acutely to remind you of events, thus insuring you keep your guard up; they also provide detailed information about what happened in ways that might stimulate you to reflect on all the circumstances surrounding the events and what you might do the next time to prevent something or respond in better ways. Nightmares also have direct therapeutic potential for some individuals by aiding their processing of emotional reactions to stressful events. It is extremely common for some survivors to report “instant replay” like dreams following traumatizing experiences, but typically in a matter of days or weeks, the nightmares change in ways that become less threatening than these original, disturbing replay images.

Research indicates that a metamorphosis occurs within the dream material. At first, the dreams resemble the actual trauma. Then, they change, becoming more symbolic or metaphorical about what occurred. During this transformation, emotions within dreams change in ways that suggest dreams are helping survivors feel more comfortable with and adapt more to their responses to the traumatizing events.

What’s remarkable about sleep symptoms is that the more and the longer you have them, the more likely you are to suffer a poor recovery or no recovery at all. In technical terms, a person with these symptoms almost always suffers from other post-traumatic stress symptoms; and, after the first month if they are still present, an acute stress disorder is diagnosed. When these stress symptoms including some of the sleep symptoms persist at three months, the individual may meet diagnostic criteria for post-traumatic stress disorder (PTSD).

In my clinical and research experience, I have found that once sleep symptoms of any type persist beyond 4 to 6 weeks, the chances are much higher that the trauma survivor’s recovery will go slower and less smoothly unless proper treatment is provided. Proper treatment would not mean treating just these sleep symptoms, because most survivors who report sleep problems one month later would also report other types of post-trauma stress indicators such as: memories of the trauma while awake, easily startled, restless or jumpy feelings, emotional numbness, difficulties with memory and concentration, irritability, increased pessimism, feelings of isolation, and behavioral avoidance in which survivors distance themselves from circumstances, locations, or discussions that might trigger memories of the traumatic experiences. Undoubtedly, these other symptoms are also useful markers in recognizing individuals who are more susceptible to a slow or poor recovery.

Sleep symptoms are particularly vexing because sleep deprivation due to insomnia, compromised sleep quality, or nightmares worsens all other symptoms by triggering chronic, daytime fatigue or sleepiness that robs survivors of the energy they need to cope effectively and move toward a health recovery. In our work, we find that sleep treatments spark a lot of curiosity among trauma survivors. It’s not to say that sleep treatment is the best approach or that it should be the first approach. Rather, as physicians, we must recognize the “opening” the patient offers and use that to initiate treatment with the hope of expanding services as needed to maximize recovery.

Trauma survivors can hear instructions about how to tackle sleep problems or how to use their dreams to help them recover; whereas, they may be less inclined in the early going to discuss the actual traumatic events. This reluctance also manifests as a disconcerting paradox in the mental health community. On the one hand, many researchers have developed state-of-the-art programs that dramatically increase rates of recovery from traumatizing events; and these treatments require that the person “re-live” some of their experiences to either become desensitized to them or to work successfully through their emotional responses (usually both goals are achieved). These techniques are known as exposure therapy, and in the space of weekly sessions, given for about 2 to 4 months, they will often reduce PTSD symptoms to negligible levels or yield an outright cure.

The paradox is that a large proportion of community-based mental health professionals outside of academic centers are often unaware of these advanced yet now standardized techniques, have never received training to provide such therapies, or have their own reluctance about using them. Ironically, this reluctance mirrors that of those survivors who are skeptical, weary, or nervous about being “exposed” to exposure therapy. Survivors and therapists alike have concerns about the “reexperiencing” model and imagine it could just as easily worsen stress levels. However, exposure therapy is conducted in a controlled environment in which traumatic memories are divided up into much smaller units to make the process more digestible. The key element occurs when individuals allow themselves to reexperience the distressing emotions, and they do so by permitting themselves to feel feelings in their bodies instead of overanalyzing their feelings in their minds. In the simplest terms, trauma survivors who are recovering slowly or poorly often fear fear, so they engage in activities to avoid having to feel fear. Through exposure therapy, the fear is reexperienced, preferably in graduated doses over several weeks of work, and the individual gradually realizes they no longer have to fight with their traumatic memories or the distressing emotions triggered by these images.

Remarkably, it is this key part of the process that seems to generate reluctance among many therapists, even among those who have received training or education on exposure therapy. They apparently fear that the patient’s reaction to the therapy will lead the patient to feel overwhelmed, even though the technique when properly administered frequently leads the survivor to much healthier, richer, and controllable forms of emotional expression.

In our practice of sleep medicine, we are not trained and do not offer exposure therapy. Instead, we see many trauma survivors in research and clinical practice eager to start treatment by focusing on their insomnia, poor sleep quality and nightmares. In my new book, Sound Sleep, Sound Mind (October, Wiley & Sons), I detail a number of techniques to solve these problems, and the book was written with many of my most complex patients in mind, particularly trauma survivors who report some of the most severe sleep disturbances. In future posts, I’ll be discussing these techniques, and our website www.sleepdynamictherapy.com will also provide practical, interactive programs to lead you through many of the steps.

Here’s a link to Dr. Krakow’s commercial Reel

This report has two interesting points. First, at the very bottom of the reporter’s story, we find quotes about resiliency and how the majority of trauma survivors don’t develop PTSD. I’ll be talking more about this next week in a post on the one month anniversary of Blacksburg. Second, while most of the reporter’s discussion is on the evaluation of PTSD, little is said about how limited the treatment options are for PTSD at many VAMCs. From our view, we are persuaded that undiagnosed sleep disorders exacerbate PTSD conditions in a large number of vets.

There have been several claims over the past few years that the positioning of the tongue at rest predicts some degree of risk for sleep-disordered breathing (SDB). The tip or front of the tongue is supposed to rest against the roof of the mouth, elevated about a half inch to an inch above the back of the front teeth, on or just above the little ridges you can feel there. When the tongue rests in the bottom of the mouth (flat position), that is, the tip is closer to the back of the lower teeth, it is said that risk increases for SDB. If you try the two positions right now, you’ll notice it’s easier to breathe through your nose when the tongue is in the elevated position. Several small research studies over the years have suggested that if you can strengthen the muscles in the oral airway including the lips, it will promote improvement of the tongue position and may reduce SDB severity. Now, there is an actual device that lets you strengthen your lip muscles and claims by doing so to reduce SDB severity. The question that goes unanswered on their website is how to buy one if you in the USA.