A 39-year-old soldier arrived at the sleep clinic at Madigan Army Medical Center with symptoms not uncommon in combat soldiers: nightmares of his war experiences and thrashing in his sleep, at one point clocking his wife hard enough to leave bruises.
For Dr. Vincent Mysliwiec and other Army doctors at Joint Base Lewis-McChord, Washington, there didn't seem to be an accurate diagnosis for the symptoms.
Unlike other nightmare disorders or night terrors, the soldier's condition developed after he was deployed, and the frightening dreams, which like most nightmares occurred during rapid eye movement, or REM, sleep, were not accompanied by body paralysis common with everyday REM sleep.
The symptoms didn't exactly match the most common diagnoses for combat-related sleep issues: nightmare disorder or REM behavior disorder. So Mysliwiec and fellow researchers are building a case for combat-related nightmares to go by a new name: Trauma-associated Sleep Disorder.
In an article published in October in the Journal of Clinical Sleep Medicine, the researchers cited four case studies of the proposed disorder and hope other physicians who have observed these unique behaviors chime in.
"In about 2006 or 2007, we started seeing soldiers come into our clinic with nocturnal disruptive behaviors" that could not be characterized, Mysliwiec said.
Four service members observed in a sleep lab were found to be re-enacting their nightmares mentally and physically while asleep, often not awaking from their dreams and not remembering the violent episodes in the morning.
With normal nightmares, most people aren't able to act them out.
"Most of our dreams occur in REM sleep and when they do, we are paralyzed and can't move. It's a safety mechanism. If we all acted out our dreams, we'd end up getting hurt," Mysliwiec said.
But these troops didn't have "atonia," or paralysis. And their spouses or significant others often suffered the consequences.
"Our patients usually end up in our clinic because their spouse says they need to get treatment. Since hurting your spouse in our society is kind of frowned upon, it's not something they are usually comfortable to admitting, or they may not even known they've done it," Mysliwiec said.
The three other cases in which the problems were observed:
■ A 29-year-old with combat-related PTSD, insomnia and depression began having sleep issues a year after deployment, experiencing nightmares in which he would yell, kick defensively and curse in his sleep.
■ A 34-year-old with sleep apnea developed sleep issues following a one-year Iraq deployment in 2003 — symptoms that caused him to thrash about and even choke his wife during one violent episode.
■ A 22-year-old cried, cursed and screamed in his sleep, and, according to a roommate once punched and kicked a wall, shouting "I am going to kill you," all while asleep.
Sleep issues are well documented in patients with post-traumatic stress disorder, but Mysliwiec said only one of the four patients presented in the paper was diagnosed with PTSD. More common in the patients were diagnoses of insomnia or mild sleep apnea.
Their symptoms were relieved with treatment for sleep apnea — a positive airway pressure mask — and/or prazosin, a drug that eases nightmares in PTSD patients.
Mysliwiec said more research is needed to understand the problem and explore its link to combat experiences, psychological disorders and physical issues.
He urged troops having sleep problems to see their doctor and, if needed, pursue an appointment with a sleep specialist.
"There still are a lot of doctors who don't believe that sleep problems are a significant medical disorder," he said. "But if you treat sleep, patients get better."
