Episode 32 – Understanding how trauma impacts sleep with Dr. Craig Stewart

MIND BEYOND THE MISSION EPISODE 32 — UNDERSTANDING SLEEP HEALTH WITH DR. CRAIG STEWART

Brian McKenna

You found our podcast. We are Mind Beyond the Mission. This is a podcast about Veterans and their Families, and specifically mental health, what goes on in our lives, what goes on in our heads. We’re not talking to you as doctors or professionals. We’re talking to you about living with it and what it’s like. Brian McKenna, 19 years in the Canadian Forces. I’m joined by my partner, Laryssa Lamrock.

Laryssa

Veteran Family member. I’m a proud military brat. My husband served in the military. Proud military mom. We’re really excited about this podcast to delve into issues that are important to the Veteran and Family community.

Brian

Join us as we talk about mental health from the perspective of Veterans and their Families.

Laryssa

Well, welcome back to another episode of Mind Beyond the Mission. Holy smokes, look what the cat dragged in. Brian McKenna, it’s really good to have you back in the seat. Welcome back, buddy.

Brian

Yes, it’s about time. A couple months of practicing what we preach. I needed to take some time off, get a number of things sorted out, and was dealing with some Family stuff. At the end of the day, if we’re going to tell other people that you’ve got to be able to take a knee, well, I did. We’re back at it. This is going to be an interesting one. We’re tackling something that you and I have been talking about for a while, which is sleep.

At the end of the day, I’d say for me, it was the first thing I really struggled with, whether it’s nightmares to a degree, but it was also the fact that I don’t think I felt comfortable going to bed. I felt very vulnerable letting the guard down. I think these are things that are really Familiar in the Veteran community. We are joined today by Craig Stewart, a doctor from the OSI clinic. We’re going to get a bio from Laryssa quickly. Is that how this rolls? Are there sleep experts out there?

Craig Stewart

Yes. I think the term is largely subjective, but I would call myself an expert. I have a background, obviously, in psychiatry where there’s a lot of sleep content in that. Secondary to that, I have a fellowship specifically in sleep medicine. The standards vary differently depending on what jurisdiction you’re in. The jurisdiction I’m in Ontario, I’m officially certified as a sleep medicine specialist where I practice medicine.

Brian

Alright Laryssa, I think it’s bio time.

Laryssa

I think Craig pretty much did it. Dr. Craig Stewart is a psychiatrist with the St. Joseph’s OSI Clinic where he specializes in treating operational stress injuries among Veterans. He also serves as a sleep specialist, helping patients manage complex sleep disorders through evidence-based interventions, which I’m sure we’ll touch on today. With a compassionate approach, Dr. Stewart integrates mental health and sleep science to improve overall well-being and resilience. Boy, do I know how much sleep and mental health, physical health go hand in hand.

Craig joined us, actually, at the Family Summit in 2025. Please go check that out right after this podcast to hear more. It was an hour session which went by so quickly, and it was fascinating. A lot of great information that you presented, Craig. One of the things that you mentioned during that summit that’s resonated with me is you mentioned that up to 92% of Veterans with PTSD also suffer from insomnia. That number was staggering to me.

Craig

It really is, Laryssa. I lead off a lot of talks with that just regarding the prevalence. I try not to get too number-heavy but the anecdote that I always tell is that we have that DSM-5, which is that psychiatric textbook for diagnoses. At least, let’s say for PTSD, PTSD is the only diagnosis with sleep as two of the constituent factors to it: nightmares and also disruptions in sleep.

If you look at the prevalence, as you said, the 92%, depends on the studies you look at, but it’s one of the most widely reported symptoms of mental health in general and specifically in the Veteran community and active service military, for that matter, as well. Obviously, something near and dear to my heart is something we do every day. We spend a third of our lives sleeping. It’s an incredible part of our experience as humans.

Brian

Can you maybe start with a little explanation to me as to why is it I struggle to sleep in my bed, but I can sleep just about everywhere else? It’s a soldier story. They can sleep leaning up against an armored vehicle. They can sleep in plus 40 under a tree with a root sticking in your back. Then you take us home, and there’s a place that we’re actually supposed to go to bed, and our eyes are wide open, and we’re just not getting it done. What’s that about?

Craig

It’s a great couple of anecdotes there, Brian. I hear that a lot in my clinical practice as well, too. When you’re in training, it’s sleep while you can, and then in the field as well. We hear that a lot. What you’re referring to probably is most consistent with what we call a conditioned arousal. It goes back to that very old concept of the dog ringing the bell, and it’ll salivate. Classical conditioning, that’s where this conditioning piece comes from.

Many people learn to associate their bed — get conditioned for their bed to be associated with arousal, or nightmares, or a fear actually of going to sleep. It’s that pairing of those emotions or those thoughts with that physical location that can then precipitate that response. We hear this all the time. Folks are sleepy, and they’re drowsy. Then they shut everything off, the phone, whatever it may be. Then they get to the bed, and boom, wide awake. It’s that pairing of the arousal with the physical location, whereas that arousal is not associated, let’s say, with the couch, or with the spare room, or wherever it may be.

Brian

First of all, I’d like some credit for recognizing you were just referring to Pavlov’s dogs there. I’m digging back into high school here to pull that reference out. Are you essentially saying that I’ve created a situation of sleep anxiety about going to bed in my bed?

Craig

It’s absolutely possible, Brian. We talk about habits, and how the habits form. Habits form because we do the same thing over and over again. We might not even notice we’re doing it, and then it becomes an entrenched behavior. I’d probably parse that a little bit and say, you haven’t created this necessarily on purpose, but it’s developed. I think that’s important that no one’s trying, intentionally, to create their bed as a place of arousal, unrest, or mind rumination going, but it happens because you have these intrusive thoughts, you have these nightmares that come in.

The night is a quiet time. It always has been. That’s when these thoughts tend to come in when things are quieter, there’s less disturbances. The mind is active. As I said, it’s not something intentional that I think you’re doing, but absolutely, you create that habit, and then that perpetuates.

Laryssa

I’m looking forward to unpacking some of those habits and some things that people can do to potentially help them with their sleep. I’m curious before we go completely down that road, why are so many Veterans with trauma struggling with sleep? I’m even thinking back to, what’s the connection with sleep and trauma? I’ve heard before that when someone has experienced trauma, if they’re sleep-deprived going into the trauma, and if they’re sleep-deprived following the events, that can perpetuate their experience, or how they cope with the trauma after. Is there some connection there right from ground zero, Craig?

Craig

There is, Laryssa. It’s actually incredibly complex. I’ll try to distill it down because it’s something I always struggle with too. I’ve asked people smarter than me about this as well, who work in the field. The thought is that these nightmares and intrusive memories get encoded. Sleep, what is sleep? Why do we sleep? That’s a bigger question. We don’t know exactly why. Certainly, when we have memories, part of the dreaming sleep, part of the processing of sleep helps us to encode memories, both good and bad.

We know that bad memories, these negative emotional valence memories, can actually be encoded much stronger in some cases than positive ones. There’s a little bit of an uncertainty over exactly the mechanism of what is the connection, let’s say, between this rapid eye movement sleep that’s associated with dreaming and the encoding of traumatic memories? Certainly, as you said, vulnerabilities in terms of lack of social support, stressors in your life, and lack of sleep can actually precipitate, again, this association, making you more vulnerable to have that negative encoding.

On the flip side, and this is getting a little bit down the rabbit hole, is there’ve actually been studies to show that if you actually sleep-deprive somebody selectively of that specific REM sleep after they’ve had a traumatic event, that actually that can prevent the encoding of the negative memory. This is where it gets a little bit wonky because things in the brain are not always X plus Y equals C, is that it could equal A, B, C, D, E, F, G, H, whatever it may be.

There’ve been a lot of studies about trying to figure out, “Let’s selectively deprive people of REM sleep, or let’s give them a medicine before or right after the trauma, like a beta blocker that slows the heart down, and we’ll see if PTSD progresses or the sleep is disrupted.” It’s a bit of a mess. It’s not just that simple. It’s always multifactorial. Certainly, as you said, sleep deprivation can play a role for a vulnerability, but then maybe there’s also this part that if you don’t let people sleep, maybe it ends up better, but it’s not something that we would do in clinical practice or try to do, except in an experimental situation, or it just happens naturally.

Brian

One of the things I think about when we’re talking about the Veteran experience is also the fact that Veterans are normal people and they go through everything else that people go through, including welcoming new kids into the world. I think back to when you finally get that baby home, what’s the number one goal, really, other than health and safety? Is, “I can’t wait till we’re all going to bed at the same time.”

At home, it’s just a dream for that new parent of, mom and dad sleeping and the baby asleep at the same time, but you go into the military world and that is absolutely not what we do. We would never have a unit, a functioning group of people, or even down to a section of eight people. The idea that all eight of the eight would be sleeping, it can’t happen.

I guess what I’m asking you is, do you see any circumstances both in your work life and working through the OSI with a lot of military and a lot of RCMP vets where they’ve essentially trained into themselves that someone always has to be awake?

Craig

No, I haven’t seen so much of that, Brian, necessarily. I think there’s an absolute bit of hypervigilance that’s there, and it’s not necessarily having someone be awake that I see on a regular basis. It’s more that people are very attuned to sounds, they’re very attuned to safety, they’re very attuned to making sure the sleep environment is secure. This starts with things which I’m sure you’re both Familiar with, perimeter checks before the bed, windows are done, locks are done, everything’s done. Kids are asleep, their windows are locked, everyone’s locked, maybe a double sweep. Then it’s up to bed, and the sleep tends to be very light.

It’s what we call a low arousal threshold, meaning there’s not much that it takes to wake that person up. That, I think, comes from this degree of hypervigilance that, in some cases, as you said, has been drilled into folks during training and or then gets exacerbated, or it becomes new when you have some of these well-known traumatic events and people are on guard and they’re scanning for exits and all the stuff that we hear a lot. That translates into the sleep world as well.

Brian

Do you notice a difference between your military and your RCMP cohorts of patients?

Craig

Subtly, I think I would notice some of that, and it would be subtle. The differences between the two populations are similar, but then there’s also differences. RCMP, a lot of times we hear about when they do their training, their general duties, where they, typically, are being sent to a more remote area, they end up doing a lot of shift work. Not that doesn’t happen in the military, but they’re in a remote location, underserved, two, four, six of them in the detachment, and you’re just not a lot of people power. They’re working a lot of shift work. There’s not a lot of backup, and sleep can really get disrupted up there.

In the military, in general, as you said, Brian, you’re more in a unit full of folks, and there’s a lot more backup, let’s say. Not that there can’t be shift work, but that’s probably the biggest difference that I would see. In police force, in general, talking about first responders, there’s a huge amount of shift work that goes on that it is just anathema to sleep, in general.

Laryssa

It sounds, from day 1 within policing, within military, there’s sleep disruptions. I remember my spouse telling me about QRF, quick reaction force. You weren’t really sleeping. As you mentioned, Brian, someone’s always on fire picket, from what I understand. Lack of sleep is part of the job. Then you throw trauma into the mix, and that’s perpetuating that lack of sleep. I’m curious, what are the long-term consequences of insomnia, lack of sleep, flipped circadian rhythm, all those types of things? What’s the long-term consequences of that?

Craig

Laryssa, it’s a great question. Thank you for asking that, because I talk a lot about this also in the context of treatment and medications, which we may or may not get into. More and more, we’re recognizing what the burden is of untreated insomnia and untreated sleep. It’s not just worsening mental health. It’s increased suicidal ideation. Particularly in circadian piece, actually, there’s really good studies that show that suicidal thinking peaks in the early morning when combined with this insomnia. There’s physical effects: increased cardiovascular disease, increased metabolic effects like diabetes, early all-cause mortality. It really does go back to what you were saying in the beginning there about this mind-body connection, that we’re seeing these physical downstream effects. It’s not just, you’re not sleeping, you’ll get a good sleep the next day. It really is increasing all of these physical indices across the board. That’s becoming more and more apparent.

Brian

When someone has got a significant sleep issue, what organs are the most vulnerable? What parts of the body would you start seeing negative effects in other than the fact that the person would feel sleepy, tired, and have a hard time functioning? Has my liver got some capacity to repair itself? Do my kidneys suffer more? Does this raise the chance of heart failure? Where do you see this coming through in terms of how our organs suffer due to lack of sleep?

Craig

Brian, I’m not sure we have the specific detail to get that granular talk about which organs and how it may present. It’s more like an increased risk factor for things like high blood pressure, like cardiovascular disease, coronary artery disease, and also, in terms of diabetes, which is a multi-organ system as well.

To answer your question, the organ that you notice at first is the brain. That’s both in terms of physical manifestation, such as reaction time, short-term memory. We’ve all had that experience where we don’t get a good night’s sleep, you go to the pantry, and you’re, “What was I getting?” There’s those cognitive factors that get affected, but then obviously the mental health piece, irritability, and again, lower mood, increased anxiety. Absolutely, I would say it’s brain first. The rest of the organ systems are largely, let’s say, chronic and over the time in terms of risk factors, but immediately, acutely, we’re talking about impact on the brain.

Brian

One thing I’d like to get at a little bit here, more on the myth-busting side, if I’m your patient and I have atrocious sleep hygiene, just not doing any of the things, but I commit and I’m actually going to take your advice now, how quickly do you think you could turn me around into someone that has a proper sleep regimen?

Craig

Brian, it really depends on, again, the specifics of who you are, who I’m managing in terms of how severe the sleep disturbance is. What are the comorbid pieces? PTSD, depression, anxiety? Are there substances involved? Are there other medications involved? Is there pain involved? The answer is always individual. I always say that because people are individuals. No two people are alike and everyone comes with their own presentation.

In general, these days, all treatment you can get done in 8 to 10 weeks. Perfect. You’ll be fine in 8 to 10 weeks. Obviously, it varies, but that would be the first-line guideline intervention for standard insomnia, would be cognitive behavioral therapy for insomnia, which is a scripted 8-to-10-week program where we look at your sleep habits and we change them accordingly through behavioral scheduling as well as some cognitive approaches.

That’s the general guideline that we would look for improvement. Again, what is improvement to? Working within a recovery model, we need to set goals that are reasonable. I think that’s one of the things that we encounter a lot in this work is, “What’s our outcome here?” People always say when they come to see me, a lot of times, it’s, “I just want to get back to who I was before. I just want to sleep like I was before.” It’s part of my job to work with them to recognize, “You know what? That’s probably not going to happen. Let’s get to a place where there’s some meaningful improvement that’s meaningful to you,” to the person I’m working with.

Laryssa

I’m imagining Veterans and Families listening to this and some people going, “Holy crap, I’m not sleeping.” We were talking about the mental health implications, the physical health implications. I hope that most practitioners explore the sleep habits of any clients, patients that they’re supporting with trauma or mental health, whether it’s depression or PTSD or anxiety disorders. If not, though, what are questions, or what should patients be sharing with their clinicians?

Craig

I think it’s great. This is something, Laryssa, actually, that brings up — I do some teaching within the university and I have the medical students ask very specific questions. It’s more than just, “I don’t sleep.” This is what I see in my clinical sleep practice, in the community when I do that. People come in with this chief complaint of, “I just don’t sleep.” That’s a good starter, but it’s not a really good descriptor.

It’s my role, as you said, from the patient side, to give as much detail as you can. The role of the clinician, too, and we have work to do on this front, too, obviously, I’m biased, so I ask very detailed questions about this, but it’s beyond, “What time do you go to sleep? What time do you wake up?” It’s, “What time is bedtime? What happens then?” We always say there’s bedtime at 10:00 and bedtime at 8:00, then we write down 10:00 and 8:00, but maybe the person goes to bed at 10:00 and then picks up their phone, or maybe they’re chatting with their partner, or maybe they’re watching TV. Maybe they go downstairs and have a snack. Then, after all, they shut out the lights, and then it takes another hour to go to bed. Now we’re looking at midnight, 1:00 in the morning, and that’s different from a bedtime of ten o’clock.

I think that’s the biggest piece, is asking about the bedtime routine and what does that look like? One of my biggest questions is, I tell people, “Tell me how long it takes you to fall asleep. Once everything is shut down, once the phone is gone, once you’re in bed, once the teeth are brushed, all the above, the TV’s off” — although the TV may still be on in some cases — how long does it take you to fall asleep at that point?” Again, those may be very different answers.

I think it’s helpful if you can bring forth as much detail as possible in terms of the very specifics. How long does it take you to get back to sleep once you’re up in the middle of the night? Then, what time are you getting up for good in the morning? Sometimes getting up for good also, I get up at 5:00, but I’m not out of bed until 8:00. It’s those real details that can change a lot of the behaviors for me, and those are the targets for intervention in terms of, “Okay, let’s not lie in bed for 5:00 to 8:00 in the morning for three hours. Up and out of the bed at 5:00.”

Those are the details. Whenever we’re looking as clinicians for pieces of history, we’re looking stuff that helps inform the picture, but we’re also looking for things to change and things that we can improve on.

Brian

I saw the sleep specialist at the OSI clinic in Vancouver, the operational stress injury clinic for those who aren’t Familiar with them. One of the things that he said to me was, “There’s two things you should be doing in your bed. There should be sex and sleep.” If you’re scheduling in your bed, if you’re going over the plan for tomorrow, if you’re figuring out who’s grocery shopping, who’s taking the kids to whatever — if you’re doing these other things in the bed, his advice was that try to limit it to just what’s supposed to be happening there and do those other things elsewhere.

He also was reminding me, and I had to admit guilt on this, “we’re people like everybody else, we’re as addicted to the phone as everybody else.” At the end of the day, most days when I wake up having had terrible sleep, I have to admit that there was some reels on social media or some doom scrolling that I was partaking in while I was trying to go to bed. How common is that? Has life got worse for us in the world of sleep since we started using the phone as our alarm clock and putting it right beside our bed pretending we’re not going to look at it tonight?

Craig

I think it really is, Brian. I don’t have a data or a study to reference on that, but phones are just so ubiquitous, electronics are just so ubiquitous now that we hear more about that. I’m glad that you’ve talked about the content and the physical act of doing the doom scrolling. One of the things to get around to your myth-busting is that you see a lot of articles about blue lights and, “Don’t get the blue light from your phone, and this is going to cause bad sleep.” Really, the amount of blue light that comes from your phone is minimal.

For me, it really is this association, like you said, of being awake in bed on your phone, doom scrolling, spending the time awake in bed, not doing those two S’s, the sleep or sex, and really making that conditioned arousal that you talked about earlier. You’re being awake in bed. You’re learning to be awake in bed when we want to be asleep in bed. As part of best practices for sleep, absolutely. It’s, shut off the electronics, ideally a half hour before bed, put them aside. I really would highlight the blue light piece is minimal. It’s more this association, the time spent in bed. I think that’s the biggest part.

Laryssa

I appreciate, Brian, you talking about, “We’re real people. Let’s bring up the phone. People are doom scrolling.” That’s a reality. I remember my spouse, following Afghanistan, that’s how we would go to bed every night. He was fixated on it, and I was not very happy about it because I could anticipate what was going to happen then over the night. That’s the reality of what happens. I think, Brian and I try and put the realities of what Veterans and Families are living with into our conversations.

Some place I’d like to explore, which will lean into impact on Families, is the fact that some Veterans who want to feel safe and secure might sleep with weapons beside their bed. That’s a reality and a conversation that folks need to have. It impacts Family concerns. We’ve talked about, I don’t sleep in the same room with my spouse. He has whole — they call it restless leg syndrome, and that’s an understatement. It’s his whole body, and I would want to punch him in the morning when I get up because now I wasn’t sleeping. That’s a strategy for us. We don’t sleep in the same room.

A lot of Families have described getting inadvertently and non-intentionally kicked or punched, things like that. Can we explore that a little bit? I want to talk about it because it’s a reality that happens for many Veterans and Families when we talk about sleep.

Craig

It really is, Laryssa. One of the first things that I learned as I went through my career in sleep medicine was the amount of people who sleep separately, actually, and not even just in different rooms but in different beds. These are run of the mill folk, not even part of a Veteran community or first responders or anyone who has this potential to act out at night. That was a real eye-opener for me.

I think that normalizes it a bit. I think it’s with any community. The more you get into a community and the more you learn about who’s part of that community, normalizing is important. It’s okay to sleep in different rooms. It’s okay to sleep in different beds. There really is this expectation, two people sleep in a bed together, and that’s the way it should be. It really isn’t. Again, this points to the individual and what the best practices are.

Specifically, this piece about acting out at night, a lot of different names for it, disruptive nocturnal behavior, dream enactment behavior, it really is a potential for danger. Fortunately, I haven’t had many significant bad outcomes myself, but there’s studies that are awash with these really tragic outcomes, in many cases, serious injury, death even. These are extreme and rare. It’s not uncommon for me to hear from, typically, guys who say, “I woke up and I was choking my partner.” This happens.

Ideally, as you said, it really is balancing and working with the person. Having a weapon around, if they’re going to use that in an involuntary state where they’re acting out a dream, they’re either going to hurt themselves or others, that could be a really bad outcome. It’s working to try to make the sleep environment safe enough that we can get rid of that weapon.

Even from a weapon, as opposed to a your own weapon, I’m counseling people, “Get rid of the lamp that’s beside the bed. Get rid of the alarm clock. Get rid of anything that could be used as a weapon,” because even something as simple as a lamp, that’s going to end up badly as well. Really, it’s scanning your sleep environment and making it as safe as possible, balancing that need for safety for the person.

Brian

I think one of the things that I’ve struggled with is you look at what you go through on your own, but you also look at what you put your Family through. For the first couple of years, while I was still very highly reactive, my kids actually were trained by their mom how to wake Dad up. Very similar to the inside parliament of being two sword lengths away. That was the idea, was she made a joke of it and taught it to them in a child-appropriate way, but at the end of the day, the moral of the story was, “You wake him up by touching his foot from as far away as you could possibly stand so you don’t get hit.”

Realizing that your five and three-year-old are being trained on how not to get hit by Dad when he wakes up, that’s a hard piece to live with but that is the reality that we lived with.

Craig

Right. I think that’s also part of the overall treatment piece within psychotherapy, in the acceptance and the challenge for the person who’s experiencing those actions to reconcile that. Absolutely. Again, really common to hear that, specifically that piece about touching the feet and things to that effect. Part of what I counsel my patients is, this is… I wouldn’t say necessarily normal, but expected, and part of the disease process. If someone’s got PTSD, that comes along with a lot of symptoms, just like other disorders come along with a lot of symptoms. One of those is hyperarousal, actions that may not be under your control.

It really is the education piece, I think, for the person themselves and for the Family and bringing that Family piece in to say, “This is not something the person wants to be doing. There’s probably a huge amount of guilt and shame associated with that. Putting that on the person is not going to be helpful for anybody.” Balancing that, again, with, “These are practical solutions. No one wants to get clocked in the head, either at night or getting woken up. Let’s come up with a joint plan to talk about this, make a plan. This is why it’s happening.” Again, age-appropriate.

I think that’s like you said. You’re not telling the five and the three-year-old, “These are PTSD dreams from so-and-so and so-and-so. This happened.” Make it age-appropriate. Like you said, put it into that game part or whatever it may be. As they become more able to process that, you give them as much detail as they can handle, or you, as parents, think that they can handle.

Brian

The world of nightmares, one of the things I lived through, I would be scared to go to bed because — it wasn’t reliving things that had happened. A couple of bad things happened to me, but what would actually happen would be, I’d go to bed and my brain would come up with events that actually hadn’t happened to me, things where they’d happen to friends and then I’d go to bed and I’d dreamt that I was on that patrol, or I was in the vehicle beside them.

I remember waking up thinking one morning like, “I’ve got enough bad things in my mind. I don’t need a mind that’s creating more bad things. If there’s three nightmares reliving in your life, I don’t need three more.” My brain was at this point of actually making up stuff and I would wake up in the morning struggling to actually know if I’d been on that or if my brain had just created it. Is that a common thing? What’s going on when my brain is actually making new problems for me?

Craig

Absolutely, Brian. I feel like that is another one of these situations that we touched on and brings it back really nicely about, what is this role for rapid eye movement sleep or the dream sleep that we typically associate with dreaming? Part of its function, we think, is to make sense of memories that happen during the day. The classic is you watch the tennis match and you put that together and then you see people’s eyes moving left and right in the night.

With traumatic nightmares, there’s a nice model that I reference frequently that goes through a hierarchy. One of the key distinction is what we call thematic memories and replicative memories. Just as it might sound, replicative memories are a replay of specific events that happen to the person and get replayed. Those are actually a little bit easier, in some cases, to manage with treatment because you can work within a very nice model to limit those and replay them and actually script. We call it nightmare rescripting to get rid of that.

The more thematic ones are these ones that get mushed together. Why is that? This is the process that we don’t totally understand of the brain making sense of these various memories. Similar to a non-traumatic memory, we have these memories of people riding dragons and spaceships. How does that happen? It’s what the brain does. It puts things together. It just sticks things together.

There’s a lot of different models for this, scientific models, but it’s eventually making sense of the disparate threads in our head that are going around it, sticking them together. They don’t always make sense when you stick them together in a nice row. That really explains what you experienced where you had something happen to you, but there’s also something that you knew from someone else and the brain at night is cleaning this up, “Let’s stack it together.” In the morning you wake up and go, “Wow, that was weird.”

Laryssa

I’m realizing how fast our conversation is going. There’s so much to cover. I was hoping we were going to talk about sleep hygiene, but maybe that’s a teaser to send people over to the Family Summit presentation that you did, Craig. It was an hour long and you provided a really phenomenal overview. You did talk about your thoughts on sleep hygiene. Maybe that’s our teaser. I know that you have a lot of really phenomenal resources that you’ve recommended. We’ll try and link that in the show notes for the podcast, so people have someplace to go and learn a little bit more and find some helpful resources.

I think one of the last questions that I would like to ask is if you could give one piece of advice to Veterans or Families that are struggling with sleep-related issues, what piece of advice would you give them?

Craig

I think it’s talk about it. That goes for anything, any mental health concern that we’re having. Sleep is obviously one of the things that’s easier to talk about, so there’s not as much concern there.

It’s actually one of the things that the US military at one point in their part of their active treatment is, they found that people didn’t want to come in and talk about PTSD. They said, “We’re just going to talk to you about your sleep.” People were happy to talk about their sleep, and the talk about their sleep led into other pieces as well.

I think that may be one of the pieces is, if you’re not ready to go in and let everything out, have someone take all the pieces out, dig around, and all that things that we think happens doesn’t really happen in therapy quite to the extent that it’s portrayed in some of these popular depictions, talk about it. Come in and talk about your sleep and see where that leads. If that’s what you’re comfortable talking about, start with that. I would say that is one of the biggest things.

The second thing that I would say is have reasonable expectations. There’s a lot of pressure, again, put on people to get better. This is the stigma of mental health that is, “Well, why can’t you sleep?” Sleep is a process that’s incredibly complex. We don’t understand a lot about it. There’s a lot of factors that go into it. I think it is having reasonable expectations about, “Let’s try to get sleep better. What does that reality look like? It’s not going to be eight hours where we wake up feeling fresh as a daisy like we did when we were teenagers, but let’s have a realistic goal of what we can improve.”

I think that’s where providers can really add a lot of benefit to people is, “Let’s look at the nightmares. Let’s look at falling asleep. Let’s look at staying asleep. Let’s look at the sleep apnea.” It really is identifying something specific that could be worked on. Again, I think that takes a lot of the pressure too off of the person in general. Again, there’s pressure to get better and get everything perfect. Sleep is tough. It happens naturally, but to many people where it’s disturbed, it’s very unnatural and it’s hard to get back to that natural peace.

Brian

One of the things that I’ve noticed in the Veteran community, it has been said that the ailment of Vietnam was PTSD and not that it was new because it had been experienced by soldiers going back to Roman times, but it was the military medicine finally coming around to how prevalent it is.

The common discussion about the global war on terror, so the Iraq, Afghanistan, and the modern phase that we find ourselves in, is the military medical world getting its head wrapped around how much mild and medium traumatic brain injury we have, concussion, compression, the actual physical injuries of the brain. How do you find the sleep is for your patients that you suspect have had an actual physical injury to the brain?

Craig

It’s incredibly complex again, Brian. That whole area is something that is raising a lot of visibility these days, things like repetitive concussive blasts, these micro blasts as well. Sleep, like anything else, gets affected. It’s really, really challenging. With TBI in general, sleep gets disturbed. Oftentimes, the typical interventions that we have, typically medication approaches, don’t work as well or they work funny. They do opposite things that they’re supposed to do. It’s not always the case, but it becomes a very challenging subset of sleep disturbance to deal with when there is TBI.

We don’t know enough about it at this point. It’s our standard approach knowing that there is a TBI involved, but it makes it more difficult overall, is the easiest way to put it.

Brian

What are things that I can do just as an individual to have better sleep? It does go into the sleep hygiene discussion to a degree, but I find with a lot of the ailments that are out there, we don’t have the silver bullet that magically fixes it, but there are things that I can be doing to make it easier on myself and easier on my Family. What are a couple of those?

Craig

Brian, I’ll revisit the teaser to the sleep hygiene, as you said. It’s never my favorite term because there is actually no evidence to suggest that sleep hygiene actually helps with insomnia. I tend to frame my answers in the term of, let’s practice principles and practices consistent with cognitive behavioral therapy for insomnia, which is not as nice and neat, and doesn’t roll off the tongue as well as sleep hygiene.

It involves things like getting up at, basically, the same time every day. It’s not going to be exact to the minute, but generally within an hour. Getting as much sunshine as you can in the morning. Reset that circadian rhythm with this zeitgeber, this time-giver. The sun is the strongest time-giver that we have. Stay active. The body is designed to move for up to 12, 16 hours a day. That’s not running marathons. That’s just being continually active. Stay active during the day.

Go to bed when sleepy. The worst thing you can do to someone who has insomnia is tell them, “Just go to bed at the same time every day.” I think that’s one of the pieces that I have a big challenge with sleep hygiene is if you go to bed at the same time every day and you’re not sleepy, you’re just looking at the ceiling for hours. That’s right back to that piece, Brian, of that conditioned arousal. You’re learning to be awake in bed, not asleep in bed. Those are the real fundamental things that I always try to highlight with folks. Up at the same time every day, get some sunshine, get out and about, go to bed when sleepy.

Laryssa

I think those are good parting words for people to put into practice. I’m conscious, Craig, that you might have clients at the top of the hour. I want to thank you so much. I know you’re very busy for making time. We were persistent with you, and I’m so grateful that we were because this was phenomenal. I think we could talk for another full hour and still not get to sleep apnea or the sleep hygiene misnomers and such. Thank you again for joining us today. Brian, good to have you back. Was it like riding a bike?

Brian

To a degree. It’s just nice to get back in the swing of things. It’s how we’ve always wanted to do stuff on this podcast. We want to bring the experts in to hear what they can advise us and what they can tell us, but also to talk about the real-world way that this plays out. How does this actually happen in the community?

Craig, I appreciate you. The vets of this country, they’ve earned it, but they need dedicated people like you across the country working at these OSI clinics and bringing these different levels of expertise to the table. I hope that through the podcast here, that this isn’t just a resource that’s located in one specific place, or someone thinks they have to go to the Vancouver OSI and see that specific doctor. I hope that people realize that there is information out there, that this is evolving science. In five years, we’ll probably know more. Probably in a day, we’re going to have more questions for you. I appreciate you attending with us today, Craig.

Craig

Grateful for the opportunity. As I say, it’s always a pleasure to serve those who served.

Brian

This has been another episode of Mind Beyond the Mission.

Brian

We hope you enjoyed this episode of Mind Beyond the Mission.

Laryssa

If this conversation resonated with you or helped you in any way, I encourage you to subscribe to Mind Beyond the Mission wherever you listen to your podcasts, so you’ll be the first to know when our next episode comes out.

Brian

If you know someone who might relate to what we’ve shared or could find it helpful, please feel free to send it their way. We’re all on the same team.

Laryssa

Plus, we’d love to hear what other topics you’d be interested in us exploring in future episodes. Brian and I have a lot of ideas and subjects we plan to dive into, but you, the listener, have probably experienced or thought of topics that haven’t crossed our minds yet.

Brian

Please reach out if this is the case. We’re on social media, @atlasveteransca on most platforms. Please feel free to tweet at us, send us a message, or leave a review on this episode. Let us know what else you’d like to hear us talk about.

Laryssa

Brian, it’s always a pleasure having these important conversations with you. Looking forward to next time.

Brian

You bet, Laryssa. Take it easy.