Staff Perspective: The Curious Case of SGT B - Unpacking the Roles of Trauma, Insomnia, and OSA
Recently a case was shared with me in consultation that perked my ears up. He had a number of disruptions related to his sleep, including difficulty staying asleep, nightmares, a diagnosis of obstructive sleep apnea (OSA), and a history of two traumatic incidents. Worse, he had started grinding his teeth to the point of wearing through over the counter mouthguards. He was described as an “extreme case” that had failed prior evidence-based treatment and would not likely benefit from say Cognitive Behavioral Therapy for Insomnia (CBT-I).
SGT B is a married early-40s Army SGT who was screened by a behavioral health provider in primary care after a recent visit with his primary care provider. He reports sleep problems for at least several years, and is currently attempting to use continuous positive airway pressure (CPAP) after a polysomnography or sleep study confirmed a diagnosis of OSA a year ago. He falls asleep for a few hours fairly quickly, then wakes up usually between 0200 to 0300 if not sooner, increasingly, but not solely due to nightmares which also started a year ago and seem to be worsening. As he awakens, he is aware of pulling off his CPAP mask. Some nights he will lay in bed for a bit before he musters the motivation to resume, what he describes as “fighting the fight” with his sleep, putting his mask back on until he eventually returns to sleep, which sometimes doesn’t take long, but other nights is an hour or more. Other nights, he does not put the mask back on at all. Recently, he has started grinding his teeth at night, to the point that his teeth are cracked despite wearing a mouthguard. He notes he’s “tried that behavioral stuff” in the past, and is frustrated that it was not very helpful, so does not feel very interested in CBT-I. Oh, and as the appointment was about to wrap up, he admits that earlier in his career, he witnessed some events that friends have told him could be traumatic, but he was reluctant to share.
SGT B’s provider is recently trained in CBT-I, and is concerned his case is so complex and unusual he will not benefit from the protocol. Besides, even if he otherwise would, he says he has already tried behavioral treatment. His provider wants to know, isn’t this case a lost cause?
Interestingly, while SGT B himself probably feels like a lost cause, hopeless and helpless, his situation is not that atypical from what we often see with military-connected patients who have co-morbid OSA, insomnia, and trauma. Let’s unpack everything, starting with OSA as that has been previously diagnosed. He dislikes the CPAP, but denies purposefully removing it as he is half-asleep. It’s not surprising that since he’s not able to use his CPAP regularly, he would still have the associated symptoms, like excessive daytime sleepiness, attention and memory difficulties, and reduced productivity at work. There seems to be a relationship between untreated OSA and nightmares, so his report of increasing nightmares over time, despite what he believes is sufficient CPAP use isn’t too surprising. There also may be a relationship between untreated OSA and bruxism, or detrimental teeth grinding. Mostly, the challenge for SGT B is going to be using his CPAP for more time during the night – which admittedly, is a challenge, if he does not fully realize he isn't doing it.
Next, SGT B clearly has evidence of impaired sleep ability, as even on nights without using his CPAP, he has difficulty, and he will wake during the night at times even without nightmares. Although he says he has tried behavioral treatment, it turns out, he completed a sleep log for a few weeks, but did not get out of bed, as recommended by his previous therapist more than a few nights, and did not stick with a sleep schedule. It is likely his sleep inability, or insomnia, is contributing to taking his mask off as he becomes more aware of it on awakening, as well as contributing to his nightmares as we may remember nightmares more so if we awaken from them.
It also seems SGT B has a strong potential for screening positive for PTSD. Of course, sleep disruption can exacerbate symptoms of PTSD, and PTSD would, in turn, contribute to further sleep disruption and nightmares.
Take a moment to pause here before reading on. What do you think now that you know more details – is SGT B’s case treatable with behavioral interventions? What would you recommend as next steps?
Read on from here if you would like my take. In short, I don’t think SGT B is really an extreme case, even though it probably feels that way to him. He is not alone in the presence of these comorbidities. If he feels up to it, I might recommend a trial of CBT-I with motivational enhancement strategies, clearly assisting him in differentiating this from his prior attempt. I would anticipate if he can sleep more solidly, he will have fewer awakenings and thus fewer instances of pulling off his mask and nightmares. At the same time, I would encourage him to speak with his sleep medicine physician to perhaps find a more comfortable mask and setting option. After CBT-I and optimizing his CPAP comfort, his bruxism may also improve. Once his sleep is improved, he may feel he has the energy and mental resources to explore his trauma history and complete treatment for PTSD, if diagnosed. On the other hand, if he does not feel up to starting with CBT-I, he might be open to starting with a discussion of trauma; evidence-based PTSD treatment would be expected to decrease nightmare frequency, which would reduce associated awakenings and again decrease pulling off his mask. If insomnia is still clearly present, which will likely be the case, as it is one of the most common post-PTSD treatment residual symptoms, he could revisit CBT-I as an option then. Or, he could even start with addressing either the insomnia or potential PTSD and while he is working with sleep medicine, he could set up a mask desensitization protocol with his therapist and decide whether to address insomnia or potential PTSD directly down the road.
It would be easy in a case like this to worry there is too much going on for a behavioral health provider to play a role. However, in looking at the options above, behavioral interventions play a key role in all of them! SGT B’s provider felt more confident with potential options and reassurance that he would likely improve to some extent, and ultimately he chose to tackle CBT-I first. As providers, and especially if we are feeling uncertain or even overwhelmed, it can be very helpful to take a step back and think through our case conceptualization with a colleague or consultant. At CDP, we have consultation tools and resources for you. Feel free to reach out to us!
For more information about consultation options, vist the "Consultation Services" section here.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Diana Dolan, Ph.D., CBSM, DBSM, is a clinical psychologist serving as an Assistant Director of Training & Education with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland..
Recently a case was shared with me in consultation that perked my ears up. He had a number of disruptions related to his sleep, including difficulty staying asleep, nightmares, a diagnosis of obstructive sleep apnea (OSA), and a history of two traumatic incidents. Worse, he had started grinding his teeth to the point of wearing through over the counter mouthguards. He was described as an “extreme case” that had failed prior evidence-based treatment and would not likely benefit from say Cognitive Behavioral Therapy for Insomnia (CBT-I).
SGT B is a married early-40s Army SGT who was screened by a behavioral health provider in primary care after a recent visit with his primary care provider. He reports sleep problems for at least several years, and is currently attempting to use continuous positive airway pressure (CPAP) after a polysomnography or sleep study confirmed a diagnosis of OSA a year ago. He falls asleep for a few hours fairly quickly, then wakes up usually between 0200 to 0300 if not sooner, increasingly, but not solely due to nightmares which also started a year ago and seem to be worsening. As he awakens, he is aware of pulling off his CPAP mask. Some nights he will lay in bed for a bit before he musters the motivation to resume, what he describes as “fighting the fight” with his sleep, putting his mask back on until he eventually returns to sleep, which sometimes doesn’t take long, but other nights is an hour or more. Other nights, he does not put the mask back on at all. Recently, he has started grinding his teeth at night, to the point that his teeth are cracked despite wearing a mouthguard. He notes he’s “tried that behavioral stuff” in the past, and is frustrated that it was not very helpful, so does not feel very interested in CBT-I. Oh, and as the appointment was about to wrap up, he admits that earlier in his career, he witnessed some events that friends have told him could be traumatic, but he was reluctant to share.
SGT B’s provider is recently trained in CBT-I, and is concerned his case is so complex and unusual he will not benefit from the protocol. Besides, even if he otherwise would, he says he has already tried behavioral treatment. His provider wants to know, isn’t this case a lost cause?
Interestingly, while SGT B himself probably feels like a lost cause, hopeless and helpless, his situation is not that atypical from what we often see with military-connected patients who have co-morbid OSA, insomnia, and trauma. Let’s unpack everything, starting with OSA as that has been previously diagnosed. He dislikes the CPAP, but denies purposefully removing it as he is half-asleep. It’s not surprising that since he’s not able to use his CPAP regularly, he would still have the associated symptoms, like excessive daytime sleepiness, attention and memory difficulties, and reduced productivity at work. There seems to be a relationship between untreated OSA and nightmares, so his report of increasing nightmares over time, despite what he believes is sufficient CPAP use isn’t too surprising. There also may be a relationship between untreated OSA and bruxism, or detrimental teeth grinding. Mostly, the challenge for SGT B is going to be using his CPAP for more time during the night – which admittedly, is a challenge, if he does not fully realize he isn't doing it.
Next, SGT B clearly has evidence of impaired sleep ability, as even on nights without using his CPAP, he has difficulty, and he will wake during the night at times even without nightmares. Although he says he has tried behavioral treatment, it turns out, he completed a sleep log for a few weeks, but did not get out of bed, as recommended by his previous therapist more than a few nights, and did not stick with a sleep schedule. It is likely his sleep inability, or insomnia, is contributing to taking his mask off as he becomes more aware of it on awakening, as well as contributing to his nightmares as we may remember nightmares more so if we awaken from them.
It also seems SGT B has a strong potential for screening positive for PTSD. Of course, sleep disruption can exacerbate symptoms of PTSD, and PTSD would, in turn, contribute to further sleep disruption and nightmares.
Take a moment to pause here before reading on. What do you think now that you know more details – is SGT B’s case treatable with behavioral interventions? What would you recommend as next steps?
Read on from here if you would like my take. In short, I don’t think SGT B is really an extreme case, even though it probably feels that way to him. He is not alone in the presence of these comorbidities. If he feels up to it, I might recommend a trial of CBT-I with motivational enhancement strategies, clearly assisting him in differentiating this from his prior attempt. I would anticipate if he can sleep more solidly, he will have fewer awakenings and thus fewer instances of pulling off his mask and nightmares. At the same time, I would encourage him to speak with his sleep medicine physician to perhaps find a more comfortable mask and setting option. After CBT-I and optimizing his CPAP comfort, his bruxism may also improve. Once his sleep is improved, he may feel he has the energy and mental resources to explore his trauma history and complete treatment for PTSD, if diagnosed. On the other hand, if he does not feel up to starting with CBT-I, he might be open to starting with a discussion of trauma; evidence-based PTSD treatment would be expected to decrease nightmare frequency, which would reduce associated awakenings and again decrease pulling off his mask. If insomnia is still clearly present, which will likely be the case, as it is one of the most common post-PTSD treatment residual symptoms, he could revisit CBT-I as an option then. Or, he could even start with addressing either the insomnia or potential PTSD and while he is working with sleep medicine, he could set up a mask desensitization protocol with his therapist and decide whether to address insomnia or potential PTSD directly down the road.
It would be easy in a case like this to worry there is too much going on for a behavioral health provider to play a role. However, in looking at the options above, behavioral interventions play a key role in all of them! SGT B’s provider felt more confident with potential options and reassurance that he would likely improve to some extent, and ultimately he chose to tackle CBT-I first. As providers, and especially if we are feeling uncertain or even overwhelmed, it can be very helpful to take a step back and think through our case conceptualization with a colleague or consultant. At CDP, we have consultation tools and resources for you. Feel free to reach out to us!
For more information about consultation options, vist the "Consultation Services" section here.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Diana Dolan, Ph.D., CBSM, DBSM, is a clinical psychologist serving as an Assistant Director of Training & Education with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland..