Healing Combat Trauma

The Cortisol Connection: Sex and Sleep, Stress and Survival

An amusing quote from two women health experts on Oprah, back in February of 2001: "Sleep is the sex of the next century," (meaning this one that we're in, now), by Laura Berman, Ph.D. and Jennifer Berman, M.D.

Good sleep being equated in importance to good sex?  Ahhh, that's not just humorous, that's interesting!  And both topics are recent focuses of this blog, so we've got to dig in and discuss.

Recently, we've talking about sleep AND sex (though not necessarily at the same time, for obvious reasons ;-).  However, both are important to maintaining good psychological health and happiness -- and the reality is, they both have something to do with a topic we've recently mentioned: cortisol. 

According to one expert, "Elevated cortisol levels resulting from chronic stress" [PTSD is a chronic stress] have been associated with the following conditions: increased appetite and food cravings; increased body fat; decreased muscle mass; decreased bone density; increased anxiety; increased depression; mood swings (anger and irritability); reduced libido (sex drive); impaired immune response; memory and learning impairment; increased symptoms of PMS (cramps, appetite); and increased menopausal side effects (hot flashes, night sweats)." Oh, my goodness!  Is there anything that ISN'T on that list?

Remember, too, that increased cortisol levels such as exist in veterans with PTSD are also implicated in risk for heart disease, as we blogged about here, recently.

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Shawn Talbott, Ph.D., who has an interesting book called The Cortisol Connection: Why Stress Makes You Fat and Ruins Your Health -- And What You Can Do about It, has several pages devoted to the all-important topic of how cortisol from stress -- which veterans with PTSD have -- wrecks people's sex lives.  Since we've been discussing healthy sex and the combat veteran lately, it seems tailor-made to discuss what Talbott finds.  As he writes:

“You don’t need to read a book about the relationship between stress and disease to know that when we’re stressed out, we also have problems in the intimacy department.  For starters, menstrual cycles get all out of whack, erections are more difficult to achieve and maintain, and overall libido (sex drive) plummets.  Stress simply makes us lose interest in sex.  In males, this is due primarily to a dramatic fall in testosterone levels during stressful times.  In females, the stress-induced loss of sex drive is a bit more complicated, involving disruption in levels not only of testosterone, but also of estrogen, progesterone and prolactin.

 

(We're skipping over the part where he goes into biology class level details about how cortisol levels affect men's and women's sex drives, and going straight to his conclusion.  His book, which is worth getting, goes into details about what you can to do affect your own cortisol levels, apparently for better health.)

“So what to do?  Quit your job, move to the islands, and open a surf shop!  Your sex drive is guaranteed to increase.  (Ever wonder why you feel friskier when you’re on vacation? – Less stress!)  Not practical to move your family to Tahiti?  Okay, then at least do something about your cortisol levels…”

 

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Another part of Talbott's book I found interesting was when he talks about the three main factors that make a huge difference in stress levels of individuals.  Take a look at these and think about combat trauma in the lives of veterans you know, and wonder about these factors continue to play into their lives, from remembered combat:

 

“We know from studies of both animals and humans that at least three factors can make a huge difference in how the body responds to a given stressor: whether there is any outlet for the stress, whether the stressor is predictable, and whether the human or animal thinks they have any control over the stressor.  These three factors – outlet, predictability and control – emerge as modulating factors again and again in research studies of stress.”

It's safe to say, healthy sex could be an outlet for stress, intrustive memories of PTSD are relatively un-predictable; and veterans' ability to "control" their stressors, many of which arrive unbidden, is fairly sketchy.

 

Another aspect of Talbott's work I found interesting was when he talked about how even potentially stressful sitautions can eventually lose their "charge" over time, if only they become "expected" or "predictable."  Unfortunately, there's pretty much nothing about combat that's "predictable" (except that it will be unpredictable!) so it stands to reason why combat veterans struggle with both stress and high cortisol levels, implicated in various illnesses including heart disease.  This scenario, below, shows a great "de-fanging" of a potentially large trigger: but because it becomes "predictable" over time, it loses its intensity.  Unfortunately, probably VERY little of what combat veterans experienced fell in this category: 

"The scenario [of predictability] has been studied in Army rangers training at jump school to become paratroopers.  At the start of the training, the soldiers underwent enormous increases in cortisol levels during each jump, but by the end of the course, their stress responses were virtually nonexistent.  By making the stressor more predictable, the stress response of each soldier was controlled to a much greater degree (though skydiving will probably never become a completely stress-free activity)."

 

At the very least, Talbott's book is worth picking up because it gives many practical ideas (including exercise, relaxation and diet) for reducing cortisol levels, which ultimately should result in better health.  Since cortisol is implicated negatively in sleep and sex, as well as many other important categories, it's worth knowing more about how to modulate your own levels, to optimize your experience.

Racktime, Sacktime: The Importance of a Good Night's Sleep for Brain and Heart Health

Trying to pull together two seemingly unrelated concepts lately: the importance of a good night's sleep (heck, any decent sleep would be a good idea) and heart health, let's look at this longish quote from an interesting and worthwhile book, The Cortisol Connection: Why Stress Makes You Fact and Ruins Your Health -- and What You Can Do About It, by Shawn Talbott, Ph.D. 

 

Essentially the background here is that high cortisol levels are both common in veterans with PTSD, and implicated in the literature with increased risk of death from heart disease.  It's also thought that cortisol causes other problems, including weight gain, diminished libido, increased blood pressure, and other topics of interest to veterans and their families, some of whom struggle with all these issues.

 

By writing a whole book about cortisol levels and their effect on health, Talbott is able to isolate the importance of some things we might not ordinarily think about (as well as suggest improvements). Says Talbott on cortisol levels and sleep:

 

"If you’re like most people, you understand that stress management can be used effectively to help with stressful events.  After reading the previous chapters, you now know that effectively managing your stress response will help you maintain your cortisol levels within a more normal range.  What you may not know, however, is that as little as a night or two of good, sound, restful sleep may do more for controlling your cortisol levels and reducing your long-term risk for many chronic diseases than a whole lifetime of stress-management classes.  Here’s why:

 

When you were just a few months old, a mere babe, your brain had you programmed to sleep about 18 hours a day – not a very stressful existence.  Upon reaching adulthood – say, about 20 years of age – your nightly allotment of sleep had been slashed to less than seven hours (six hours and 54 minutes, according to the National Sleep Foundation.)  That’s around two hours less than the eight to nine hours recommended by sleep experts for optimal physical and mental health. 

 

Progressive changes in your body’s internal clock (the suprachiasmatic nucleus), combined with alterations in your patterns of hormone secretion, have you going to bed later, and waking up earlier with each successive decade, resulting in nearly 30 minutes less sleep per night with each passing decade. 

 

By the time we reach our thirties and forties, we’re getting 80% less time in the most restful “slow-wave” period of sleep (as compared to our teenage years), and by the time we hit our 50s and 60s, we get almost no uninterrupted deep sleep.  (We still get some deep sleep, but it tends to come in short fragments that do little in terms of recovery and repair for mind and body.)

 

What does this lack of sleep mean for your cortisol levels?  It means that the average 50-year-old has nighttime cortisol levels more than 12 times higher than the average 30-year-old – yikes!  Perhaps the worst piece of news is that not only will an inadequate quality or quantity of sleep result in elevated cortisol levels, but high cortisol will also limit both your ability to fall asleep – and the amount of time that your mind spends in the most restful stages of deep sleep.  This sets you up for a vicious cycle of poor sleep, elevated cortisol, and subtle changes in metabolism that lead you down the path toward chronic diseases.  So get some sleep!"

 

-- Source: The Cortisol Connection: Why Stress Makes You Fact and Ruins Your Health -- and What You Can Do About It, by Shawn Talbott, Ph.D.

You'd have to read Talbott's book -- and you should -- to learn more about the relationship between high stress, cortisol levels and disease (as well as his recommendations for what to do about it).  However, even several items we've got linked to this blog are possible suggestions, among others, for getting a better night's sleep.  Not to pun, but most experts' recommendations on this topic often sound like a "real snore," they're so basic (practice sleep 'hygiene,' set a regular bedtime, warm milk for tryptophan, don't exercise within several hours of bedtime, etc.)  What's of greater interest to me at least is what items can we use to de-stress or relax more completely so that we can sleep.  Some suggestions:

 

Sleep Soundly CDs, by Steven Halpern; The Delta Sleep SystemDVD, by Dr. Jeffrey Thompson; and, of course, the highly-recommended Pacific Light DVD, by Thomas Day Oates, Jr.  And of course the restful, soothing lavender sleep pillow, which you can make yourself; or if you're really lucky, a massage.

 

Happy Zzs...

Bad Moon Rising: Poor Sleep Injures Veterans Psychologically, Expert Says

Sleep and and sleep deprivation are big topics in the "Veterans with PTSD" world. In combat, servicemembers "function" despite being chronically sleep-deprived.  When they return home, veterans find that nightmares, sleep avoidance, and typically poor sleep set up difficult recovery from combat trauma.

No less an authority than Jonathan Shay, M.D., Ph.D., has weighted in on the perils of poor sleep for veterans.  (Shay is the author of Achilles in Vietnam: Combat Trauma and the Undoing of Character and of Odysseus in America: Combat Trauma and the Trials of Homecoming.) In personal correspondence with this author, he wrote:

I have become something of a nut-case on the subject of sleep in every aspect of psychological injury: sleep loss as a cause of psychological injury to others when people, especially leaders, lose emotional and ethical self-control; sleep loss as a critical intervening variable between horrible experience today and persisting psychological injury weeks/months/years later; sleep loss as a critical intervening variable in the complications of psychological injury that wreck the lives of veterans and their families; restoration of sleep as crucial to recovery even years later.  So consider yourself warned, that I will try to interest you in that subject...

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Of particular interest to combat veterans and their families, the LA Times has a live web chat planned on "Sleep Issues and PTSD" tomorrow, Tuesday, at 12 noon PST.  Click here for the link.

According to a related article coming out in Tuesday's LA Times,

Sleep and wakefulness issues are the most common health problems described by recently returned soldiers, researchers at Walter Reed Army Medical Center found in a study published last year.

A Times reporter and videographer stayed up all night with the former Marine and his fiancee to witness his struggles. (The print story will appear in Tuesday's newspaper. A video of the vigil, plus interviews with Hood and other veterans, accompany the story on the Web.)

Join us for a live Web chat at noon Tuesday to discuss the influence of war on sleep and how physicians try to treat the problems. We will be doing a question-and-answer session with Dr. Thomas C. Neylan, director of the Posttraumatic Stress Disorders (PTSD) Program at the San Francisco Veterans Affairs Medical Center, and Steve Woodward, director of the Sleep Research Laboratory at the VA's National Center for Posttraumatic Stress Disorder in Palo Alto.

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NPR recently had a program devoted to the topic of sleep (and insomnia): "Can't Sleep? Neither Can 60 Million Other Americans."  Not specific to PTSD issues, it's nonetheless a very good overview of the subject.  For that link, click here.

Editor's Note: For other blog entries and resources devoted to sleep and PTSD, click here.

Sweet Dreams Are Made of This - One Potential Coping Tool for PTSD's Nightmares

"To sleep, perchance to dream..." said Hamlet in his famous soliloquy, in the Shakespeare play of the same name.  It's not so much the dreams PTSD sufferers are worried about, it's the nightmares that bring bad memories rushing back, or otherwise destroy a night's sleep. People with PTSD can be so agitated about their nightmares that they try to put off sleeping altogether, numbing themselves first with drugs or alcohol to keep the nightmares at bay.  (Of course, that creates more problems than it solves, but it's perfectly understandable why that might happen.)  (That's an EEG diagram of healthy, uninterrupted sleep, by the way, at left.)  Now, one novel technique, publicized by a military trauma specialist, may hold out some hope to those whose experience of nightmares prevents them from getting a good night's (and restorative night's) sleep, so crucial to good health, psychologically and physiologically speaking.

In an article published in the Air Force Times of August 9, 2007, linked here, Navy Commander and combat psychologist Beverly Dexter, Ph.D. discusses a somewhat controversial concept she's developed that apparently helps some troops sleep better through the night.  The concept is called "planned dream intervention," although it might more accurately be called, "proactive nightmare intervention," because the goal is to keep a terrifying nightmare from interrupting an otherwise good night's sleep -- essentially by seeing it through to its conclusion, the very thing the sleeping person beset with nightmares usually is too terrified to let actually happen.  I have no idea what to make of this whole concept, and whether it's the concept that's confusing, or the article that describes it just not doing a good enough job of conveying how it really works.  Or, maybe the concept itself has some kinks to work through. What sort of universal applicability does it have?  Only to some types of nightmare sufferers, or does it have validity for all?  Would some types of patients benefit more from this than others?  Does it matter how long (in terms of months or years) people have had the nightmares for?  These and other questions are not really addressed in the article.  It sounds like Dr. Dexter herself says that the concept sounds too good to be true, but she claims it really works, and the article lists a number of examples of people who it's helped.  From the article, it also seems like it's generated a certain amount of buzz as a topic, among troops and military chaplains.  Dr. Dexter, whose bio is linked here, is planning a book on the subject, to come out sometime in 2008.  The book's tentative title is "No More Nightmares:  How to Use Planned Dream Intervention to End Nightmares," but it doesn't seem to be in print yet -- at least, Amazon doesn't have it listed.

According to the article, Dr. Dexter served as the chief of the Combat Stress and Readiness Clinic at Al Asad Air Base in Iraq, and works at the Naval Medical Center in Portsmouth, VA when she's not deployed.

Similarities Explored in How Cops and Troops Experience Trauma Cumulatively, Develop PTSD

Lately we've been taking a look at crucial concept in the linkage between combat trauma and PTSD -- the "dose-response relationship," which is apparently a more or less linear relationship between more combat trauma experienced and greater chance of developing PTSD.  (Earlier blog entries on that topic are linked here and here.)

On the Web, every once in a while you find a gem -- some good and useful material -- in its entirety, and one such "find" is Mary Elizabeth Claire's Ph.D. thesis at Drexel University, available online, called "The Relationship between Critical Incidents, Hostility, and PTSD Symptoms in Police Officers."  (The thesis is linked here.)

While we might prefer her thesis to be about combat veterans and PTSD (heh), the reality is, there's quite a bit of overlap or similarity in how police and veterans experience the events that contribute to PTSD, a fact she explains early on, when she writes:

...Although police officers are usually identified with emergency responders, the context in which police officers experience critical incidents is similar to situations experienced by military veterans. Violanti (1996a) identified six areas of police work that are comparable to the experiences of those that served in the Vietnam War: guerilla warfare at home, the identity of the enemy, a continual sense of insecurity, lack of support, witnessing abusive violence, and depersonalization. The first area, guerilla warfare, is similar to the current plight of many police officers. Violanti (1996a) describes police officers as serving in "peacetime combat."

In a segment entitled, Cumulative Effects of Exposure to Critical Incidents, she writes that:

Learning theory suggests that when an individual is exposed to a repeated stimulus, the person either habituates to the stimuli or becomes sensitized to it. When habituation occurs, the individual reduces their responsiveness to the stimuli while sensitization increases and heightens an individual’s responsiveness. Both behaviors are normal responses but how one reacts to a repetitive stimulus often depends on the intensity of the stimulus. A high intensity stimulus generally tends to sensitize a person to the stimulus while habituation occurs when a person is repeatedly exposed to low to moderate stimuli (Barker, 2001).

It is commonly assumed that individuals that encounter traumatic stressors frequently (e.g., police officers, firefighters) habituate to the stimuli, and therefore they are more resistant to the psychological effects of traumatic incidents. However, the opposing view, that the cumulative effect of critical incidents results in more posttraumatic stress symptoms, has become more empirically supported in recent years (Violanti, 1996b). These findings are congruent with the theories of learning since police officers experience high intensity stimuli on a routine basis thus becoming sensitized, not habituated, to the stimuli.

Several studies have investigated the cumulative effect of critical incidents and the development of PTSD symptoms. For example, Stephens and Miller (1998) conducted a study of 527 New Zealand police officers and found a positive relationship between the number of traumatic events and more PTSD symptoms. Trauma experienced prior to joining the police force was not related to PTSD symptoms while trauma experienced after joining the police force was related to more PTSD symptoms.

Martin et al. (1986) reported that 26% of the 56 police officers attending a sensitive crime seminar met criteria for PTSD. Moreover, the authors found PTSD was related to the number of incidents experienced by the officers. The most frequently endorsed symptom "Recurrent and intrusive recollection of the event" was endorsed by 47 % of the police officers. Martin et al. (1986) indicated it is not surprising that this symptom was endorsed most frequently since police officers continually place themselves in situations similar to previous traumatic incidents and have little opportunity to distance themselves from the incident. Likewise, only 11% of the officers reported in engaging in active avoidance of activities. Moreover, sensitization to the repetitive trauma appeared to occur for these police officers as evidenced by the frequent endorsement of hyperarousal and exaggerated startle response.

Mitchell (1999) reported on the qualitative descriptions of 426 officers above the rank of probationer in the United Kingdom. The officers were asked to describe the most memorable critical incident they experienced during their police career. Almost 75% of the descriptions involved death, and almost 33% of the deaths described involved traffic accidents. Although the Lockerbie Disaster and the crash of the RAF Chinook helicopter were frequently reported, traffic accidents were the largest category of memorable critical incidents described. Different occupational groups within the police department participated, however, 60% of the traffic incidents described as memorable and distressing were reported by current members of the traffic division. Thus, it appears that these officers did not habituate to the incidents in which they were commonly exposed, but instead became sensitized to such incidents. Additionally, the length of time since the accident ranged from two weeks to 25 years with a mean of 5.6 years, indicating that time did not ameliorate the impact of critical incidents in this sample.

Neylan et al. (2002) investigated the impact of critical incident exposure on the quality of sleep in 747 police officers from New York, New York, and Oakland and San Jose, California. The investigators found that cumulative critical incident exposure was associated with nightmares, a symptom of PTSD. Furthermore, sleep disturbances were strongly related to PTSD symptomatology and general psychopathology.

Sleep disturbances and how they contribute to PTSD is another well-deserved treatment that we'll have to leave, though, for another time...