Hello everybody, this is Doc V from Call Sign Wizard. I'd like to welcome you back to another podcast. Today we're going to be talking about sleep, insomnia, and veterans. Sleep is one of the most underrated aspects of veterans health. And yet, it's one of the first things to fall apart after service. Whether it's because of nightmares, hypervigilance, or chronic pain, sleep issues are practically epidemic among veterans. And it's not just about being tired. It's about the long term toll on their health, their relationships, and their overall mental well being. So today we're going to dive into why this happens and more importantly, what can be done about it. This is Call Sign Wizard, the podcast for therapists who work with veterans, and I'm your host, Doc V. a veteran, therapist, and your guide to understanding the unique challenges veterans face. Each week we're going to be diving into topics like PTSD, chronic pain, military culture, and evidence based treatments to help you better understand and serve those who served. Whether you're a seasoned therapist or new to working with veterans, this podcast is here to provide you the insights, tools, and supports that you need. The truth is that sleep problems among veterans are rarely just about sleep. They're about the body and mind struggling to turn off after years of being conditioned to stay alert. Imagine going through combat zones, or being in convoys driving through the desert, operating on four hours of sleep. or less, and then coming home to a world that suddenly expects you to stop or to relax. It's a massive physiological and psychological shift, and for many veterans, that shift never really fully happens. Sure, the military has a path set up for veterans to get checked out before they get their DD 214, before they get their discharge paperwork, they can go through a medical process, but many veterans, most probably, say only what they need to say to get out of there as quickly as possible to get home as quickly as possible and When they do this, they often don't give themselves the time to set up or get the care that they need for a healthy transition So Let's break this down. Okay. So first there's hypervigilance This is the brain survival mechanism and it's stuck in overdrive stuck in the sympathetic nervous system This is that fight or flight System that keeps you safe when there's a threat And veterans are trained to scan for threats, to stay alert at all times, to keep your head on a swivel to not be complacent. That doesn't just shut off because they're back home. So for some, lying down in a quiet, dark room feels less like relaxation and more like vulnerability. In response to this vulnerability, Some veterans will end up having a gun or other weapon near them when they sleep, further tainting their sleep environment. With a weapon so close, part of their brain registers that there is an ongoing threat, and that is why they need that weapon, to keep them and their family safe. Then there's trauma and PTSD. Nightmares, flashbacks, intrusive thoughts. They don't just disrupt sleep, they make the idea of sleeping itself feel dangerous. Imagine being afraid to close your eyes because you know you'll relive the worst moments of your life. And it's not just a hassle for the veteran, but also for their loved ones. I've had many veterans who have lashed out and hit their spouses while fighting off invisible enemies in their sleep. Think of it from the spouse's perspective. Could you stay in bed or go to bed with your veteran spouse if you're afraid they're going to harm you, even accidentally? This strains relationships and can cause the veteran to feel even more guilty or isolated. More like there's something wrong with them. And finally, we have the physical factors. The chronic pain, the injuries, and the health conditions like sleep apnea. These don't just make it harder to sleep, they make it feel impossible to sleep sometimes. You can't get the right position because of an injury. Even if you do find the right position, pain starts to build up as you sleep and then wakes you up and causes you to toss and turn. And what would you do when pain gets in the way of sleep? You'd probably get up and try to find some kind of medication for that. You might try a pain reliever or a muscle relaxer. Some non steroidal anti inflammatory drugs, the NSAIDs, they can reduce your body's pain, but they can also reduce your body's melatonin. And then you have opioids. They can affect REM sleep. They can affect the quality of your sleep cycle. And opioids have the effect of suppressing your respiratory system. And so if you already have sleep apnea, opioids can make your sleep apnea worse. If you develop tolerance for any of your medications, whether it's opioids or some of the muscle relaxers you may also go into a withdraw at some point during the evening when the medications start to wear off and that withdraw, those symptoms from that can start to affect your sleep cycle and your quality of sleep as well. And then there's also some medications out there that have caffeine in them, some stimulants in them, which can further interfere with your sleep. Sleep apnea is pretty common among veterans and I've found that If a veteran has nightmares, many therapists just assume it's due to their PTSD. In fact, if you look at their sleep apnea can be making their nightmares worse and more frequent. When you sleep and are dreaming and your body is starting to suffocate because you're not getting enough oxygen because you're choking, your adrenaline is going to kick up and that adrenaline can go into your brain to different areas and start to trigger those nightmares. This is where it gets tricky. A lot of people assume that these sleep issues are inevitable, that veterans just have to figure it out, tough it out. But it's not true. Sleep problems aren't a life sentence. They're a symptom and one that can be treated. And this is where therapists come in. But we have to approach it differently. You can't just hand out sleep hygiene tips and hope for the best. Veterans need tailored, evidence based interventions. There is a a VA website, VeteranTraining. va. gov. It has a bunch of little tiny classes. So if the Veteran isn't ready for a full on therapy with you and they want to try some self care there's a class online on that website that they can take that can help them with their sleep. So when the Veteran is ready, what can you do? We can start by asking the right questions during your intake. Don't just ask if your veteran is sleeping, ask how they're sleeping, why they think that they're not sleeping. And what, if anything, they've tried before to handle or get better sleep. Ask about how many hours they're sleeping. If they have nightmares, and how often. Are the nightmares repetitive and about the same thing? Perhaps combat trauma, something that actually happened to them? Or are they thematic, like someone's always chasing them? Screen for sleep apnea. Look, you might think sleep apnea is only for overweight or older veterans, but that's not the case here. You want to always screen for sleep apnea. The fact is that the veteran's insomnia will not significantly change no matter how much therapy you do if the main cause is physical, if the main cause is sleep apnea. We can use tools like the 3P model of insomnia to understand and get a bigger picture of what's happening. Predisposition the first P is what predisposed them to this. Is there some family history or a genetic predisposition or other vulnerabilities that made them more susceptible to sleep issues at the outset? What precipitated it? What was the cause for their current sleep issue? Was there something specific that happened? Were there long shifts in the military that messed this up for them? Was there some specific trauma that started this out and they just felt that they couldn't sleep at that time? And what keeps it going or perpetuates their sleep issue? What habits and behaviors have they been caught in? that has been keeping their insomnia from subsiding. And once we get all these answers, we want to focus on evidence based treatments, things that have some evidence that have been proven to have been effective for a large number of veterans. Cognitive behavioral therapy for insomnia, or CBT I, is the gold standard, right? It helps veterans retrain their brains and bodies to rest. It's known to be even better for sleep issues than medication in most cases. For trauma related sleep issues, especially nightmares, EMDR and other trauma therapies can be a game changer. Then there's also Imagery Rehearsal Therapy, or IRT, as another way that helps reduce and eliminate nightmares specifically. I love working with insomnia and nightmares. Having these issues, these sleep issues, change for a veteran can greatly improve the overall health and outlook on life. Sometimes you'll see PTSD, anxiety, or depression symptoms significantly reduce or disappear. when the veteran can finally, sleep soundly. And don't overlook the basics. We want to connect our veterans to a sleep study for apnea. We want to get them to make sure that there's no physical health related issue that's getting in the way of their sleep. We want to help them build a consistent schedule. And, educate them on the different phases of sleep and why sleep matters. There are medications out there that a veteran could get through a psychiatrist or a physician. And some of those might be Trazodone. Hydroxyzine Zolpidem or Ambien, Quietipine. Quietipine is an antipsychotic that is used often with a low dose up to 25 milligrams, I believe for sleep. And that might help the veteran as well. But CBT I remains the gold standard for sleep at this point. And again, it can be more effective than medication. So veterans deserve better than to have to fight a battle for rest every night. As therapists, we have the tools to help them. But it starts with understanding that this isn't just about sleep. It's about survival. It's about recovery. And it's about getting their lives back on track. And if we can do that, we're not just helping them sleep. We're helping them heal. Thank you for listening. This has been Doc V with Call Sign Wizard. Out.