Trauma survivors losing less sleep than they think

HAIFA, Israel and NEW YORK, N.Y., December 20, 2001 – After September 11, requests for sleep medications had increased some 30 percent in New York City, while 23 percent of Americans nationwide said they had been suffering from insomnia. But in fact, many trauma survivors sleep much better than they think they do, according to a report in the Dec. 20 New England Journal of Medicine.

The report, "Sleep Disturbances in the Wake of Traumatic Events," by Dr. Peretz Lavie, an influential sleep researcher and head of the Sleep Laboratory at the Technion-Israel Institute of Technology, also questions the traditional treatment for traumatized patients, which is based on reliving the trauma. Dr. Lavie’s studies with Holocaust survivors suggest that learning to leave traumatic memories behind may be more effective for a good night’s sleep.

The report is based on decades of research in the U.S. and on Israel’s population, "one of the world’s best laboratories for sleep studies given the numerous traumatic experiences this population has experienced," said Dr. Lavie.

"In his report, Dr. Lavie finds that many of the sleep-related symptoms that are considered by some to be hallmarks of [post-traumatic stress] disorder (PTSD) seem to be without much basis in the laboratory and literature," said Dr. Thomas D. Hurwitz, director of the Sleep Medicine Clinic at the Minneapolis VA Medical Center and assistant professor at the University of Minnesota Medical School.

-Dr. Lavie’s studies on patients who complained about sleep problems indicate that "far fewer sleep disturbances are documented than would be expected among traumatized patients. People often confuse fear of going to sleep with inability to sleep, and also have misperceptions about the quality of their sleep," Dr. Lavie explained. "This is borne out by objective results from our sleep laboratory studies. On the other hand, many studies that show widespread sleep disturbances are based on subjective reports from patients."

Two of many studies cited bolster Dr. Lavie’s findings that reported sleep loss is exaggerated. Researchers at the Minneapolis Veterans Affairs Medical Center used polysomnography (brain wave recordings) to analyze sleep patterns of 28 Vietnam veterans, 18 of whom had PTSD. The 1998 study found that participants consistently underestimated their sleep time and overestimated how long they took to fall asleep.

Dr. Lavie’s study monitored sleep patterns among 70 adults and children in areas of Israel under attack by Iraqi missiles during the 1992 Gulf War. By fitting participants with devices that monitor movement during sleep, researchers found surprising results: on average, participants slept normally. Even those wakened by the alarms that preceded missile attacks returned to sleep within 12 minutes at most. In contrast, a nationwide telephone survey around the same time, based on participants’ own descriptions, found a significant increase in sleep disturbances.

-The vast majority of those suffering from sleep disorders following the terrorist attacks in New York and Washington will have only transient symptoms, a normal reaction to traumatic events, according to Dr. Lavie. However, since sleep disturbances are often precursors to PTSD, Dr. Lavie advocates timely treatment of sleep disorders because that can often prevent the onset of PTSD or lessen its symptoms.

-Dr. Lavie also advocates a treatment diametrically opposed to the currently popular treatment, which involves repeated recounting or reliving the traumatic event to help "master" the fear. His studies with Holocaust victims and Israeli war veterans support his argument that quickly moving beyond memories of traumatic events can actually be healthier for many people.

In a 1991 study of Holocaust survivors, Dr. Lavie found that better-adjusted survivors tended to remember fewer dreams than their less-well-adjusted peers. The dream recall rate for sleepers awoken during the rapid-eye-movement stage of sleep – commonly associated with dreaming – was 33.7 percent for survivors deemed well adjusted and 50.5 percent for those deemed less well adjusted. Among the control group it was 80 percent. Similarly, a study of 3,000 middle- and high-school students in Oklahoma City found that the amount of exposure to television coverage of the bombing was one of the predictors of scores on a scale of PTSD symptoms. The more students were exposed to television images of the bombing, the higher their score for PTSD symptoms.

Furthermore, in the Journal of the American Medical Association (286:537-45), Dr. B. Krakow et al have shown that "imagery rehearsal therapy" – in which patients practice the substitution of pleasant images for unpleasant ones – has helped reduce nightmares and improved sleep in sexual assault victims.

Regardless of the specific counseling methods used, Dr. Lavie said that real "sleep disturbances in traumatized patients should be treated as an independent clinical entity, with both behavioral and pharmacologic therapies."

Recommendations for Disaster Survivors With Sleep Difficulties
by Dr. Peretz Lavie

1. Behavioral therapies produce excellent results. These treatments commonly include progressive muscle relaxation, which works well in patients who go to bed wide awake; stimulus control, in which patients are trained to associate the bed and bedroom with rapid sleep onset; and sleep restriction, which involves curtailing the total time in bed in order to increase sleep efficiency. "Imagery rehearsal therapy" – in which patients practice the substitution of pleasant images for unpleasant ones – has proven beneficial with sexual assault victims.

2. Follow proper sleep hygiene:

• Do not spend too much time in bed. Limit the time spent in bed to sleeping. If you wake up, get out of bed. Go back to bed only when you are ready to sleep.
• Do not try to force yourself to sleep. The more you try to fall asleep, the more your arousal level will increase, and falling asleep will become more difficult.
• Remove the clock from your bedroom; a ticking or luminous clock face can easily prevent you from falling asleep.
• Avoid physical activity in the late evening hours. Exercise should be completed at least two hours before going to bed.
• Avoid drinking coffee or alcohol and smoking before going to bed.
• Do not eat a heavy meal before going to bed.
• Do not drink an excessive amount of any beverage before going to bed.
• Go to sleep and wake up at regular hours.
• Do not nap during the day.
• Make sure that your sleep environment is as comfortable as possible with respect to temperature, noise, light, etc.

3. Prescription sleep aids can be effective in combination with therapy. Talk to your doctor.

The Technion-Israel Institute of Technology is Israel's leading scientific and technological center for applied research and education. It commands a worldwide reputation for its pioneering work in computer science, biotechnology, water-resource management, materials engineering, aerospace and medicine. The majority of the founders and managers of Israel’s high-tech companies are Technion graduates. The Technion’s 19 faculties and 30 research centers and institutes in Haifa are home to 13,000 students and 700 faculty members.

Based in New York City, the American Technion Society (ATS) is the leading American organization supporting higher education in Israel. The ATS has raised $868 million since its inception in 1940, more than half of that during the last eight years. A nationwide membership organization with more than 20,000 supporters and 17 offices around the country, the ATS is driven by the belief that the economic future of Israel is in high technology and the future of high technology in Israel is at the Technion. Technion societies are located in 24 countries around the world.