Tracy Kretzmer, PhD

A good night’s sleep: It’s something many people take for granted.

But for some veterans returning from Iraq and Afghanistan, regular sleep remains elusive, compounding a slow recovery from war-related trauma. Some call them the “waking wounded.”

Some wounded veterans suffer from the complications of post-traumatic stress disorder (PTSD), traumatic brain injury (TBI) and physical injuries — a situation known as polytrauma. On top of this, sleep disorders are a common symptom among returning war veterans.

“Sleep was always the No. 1 symptom complaint, no matter what the injury context was,” says neuropsychologist Tracy Kretzmer, PhD, who works as the clinical director of the Post-Deployment Rehabilitation and Evaluation Program at the James A. Hartley Veterans Hospital in Tampa, Fla.

And at the core of veterans’ sleep problems, the trauma experienced — either physical, emotional or a combination of the two — is what determines how psychologists approach treatment.

Initially, Kretzmer and her team believed that traditional means of assessing and treating sleep problems could alleviate veterans’ physical and psychiatric issues. These include sleep logs, questionnaires and polysomnography — a means of measuring physiological changes during sleep, such as heart rhythm, eye movement and brain activity.

Sleep specialists also suggest using an actigraph — a sensor worn by patients — to gather data on sleep patterns and analyze treatment results.

“For many patients, seeing data that suggests they are sleeping better than they think, or that they are engaging in poor sleep habits, can be helpful in providing reassurance or getting them to engage in better sleep behaviors,” says Kretzmer.

But the team soon learned that sleep problems involving PTSD require a different kind of intervention.

“PTSD trumps sleep hygiene,” Kretzmer says, referring to the common strategies of restricting daytime sleep, going to bed earlier and avoiding caffeine.

“They don’t fall for it,” she says. “They want to stay awake, because they need to be on guard.”

In these situations, Kretzmer first focuses on the psychological element, helping veterans embrace the idea that there is nothing to fear about a good night’s rest, while showing them the benefits of sleeping well. 

Poor sleep, particularly in cases of TBI, impedes neural recovery, according to research among Kretzmer’s team. In addition, it increases fatigue and irritability, disrupts the ability to focus and increases the incidence of headaches, all of which make it harder for patients to cope with their injuries. Poor sleep also affects the immune system and muscle strength.

In this population, Kretzmer believes that treating sleep problems as a primary issue, rather than a secondary symptom, has been the right strategy for getting her patients on a path to wellness.