For members of the military, sleep issues related to trauma can arise at any time. Most often, veterans are considered at risk for nightmares, insomnia, depression and posttraumatic stress disorder (PTSD), but servicemen and women on active duty are just as prone to these conditions. Few studies examine trauma-related nightmares in current military personnel, but research conducted by Kristi Pruiksma (PhD ’11) reveals that a form of nightmare treatment developed at The University of Tulsa can alleviate sleep problems among this particular group of military members.
Active duty personnel vs. veterans
Pruiksma is an associate professor and licensed clinical psychologist in the Department of Psychiatry and Behavioral Sciences at The University of Texas Health Science Center at San Antonio, also known as UT Health San Antonio. Her research involving cognitive behavioral treatment for trauma-related nightmares in active–duty military personnel was published in the Journal of Clinical Sleep Medicine in January. It is the first controlled trial to look at nightmare treatment in active–duty servicemen and women. “They’re seeing a lot of different things compared to veterans and civilians in terms of their work schedule,” Pruiksma explained. “There are so many factors that can impact their sleep such as overnight duties, physical training early in the morning, being exposed to trauma triggers during the day such as cannons being fired on post, and impending deployments. All of these different stressors can really add up and take a toll on sleep.”
The purpose of the study was to obtain preliminary data on the efficacy, credibility and acceptability of Exposure, Relaxation and Rescripting Therapy for active–duty military members (ERRT-M) with trauma-related nightmares. ERRT-M is a form of nightmare treatment developed in 2001 by Joanne Davis, professor of psychology and director of clinical training at TU.
“It used to be thought that sleep problems were a part of PTSD, so if PTSD was treated, the sleep problems would resolve,” Davis said. “However, we know that oftentimes, sleep problems are separate and independent problems from PTSD. Sleep problems after trauma may increase the risk of developing PTSD and often remain after other PTSD symptoms have resolved. I developed ERRT as a means of targeting post-trauma nightmares and sleep problems directly.”
Implementing ERRT for the military
ERRT-M treatment consists of four to five sessions that each run one to two hours in length. Methods of application include psychoeducation about trauma, PTSD and nightmares, relaxation training, modification of sleep habits, written and verbal exposure to the nightmare, rescription of the nightmare based on trauma-related themes and rehearsal of the rescripted dream each night prior to sleep.
“We have published three randomized clinical trials from our work at TU demonstrating that ERRT is effective in reducing the frequency and severity of nightmares, improving sleep quality and quantity and reducing symptoms of depression and PTSD. We are currently conducting four clinical trials at TU to further assess the effectiveness of this approach, including with individuals diagnosed with bipolar disorder. Dr. Cromer, TU associate professor of psychology, is conducting similar work treating nightmares in children,” Davis stated.
Pruiksma supervised the participation of 40 active–duty personnel at Fort Hood in Killeen, Texas, where they attended five 90-minute sessions. She said it can be difficult to establish a research infrastructure with active–duty members because of the complexities surrounding their schedule and changes in command. “I wasn’t sure how interested or accepting this population might be with this kind of approach, but the results showed they found it credible,” she said. “They attended sessions and didn’t drop out at a higher rate compared to other military populations.”
After assessments were completed at baseline, post–treatment/post–control and one-month follow-up intervals, participants reported reductions in nightmares and other secondary outcomes such as PTSD, depression and insomnia. Pruiksma said an additional clinical trial is now needed to confirm the initial findings, but the data is promising.
“For people who have PTSD and chronic sleep problems, we need to determine the sequence for what to treat first and what are the benefits of treating sleep first,” she stated.
Pruiksma: From TU to UT
Her ongoing research is based on similar clinical trials she conducted under the mentorship of Davis as a TU clinical psychology PhD student. Pruiksma earned her undergraduate degree at Harding University in Arkansas before joining TU’s graduate program in 2005. Initially, she enrolled in coursework for a master’s, but Davis encouraged her to apply to the PhD program and to join her lab. “If it wasn’t for that conversation when she reached out to me, my life would be very different,” Pruiksma explained. “Conducting assessments for people before and after the nightmare treatment, I received first-hand information from people about how much better they were feeling after just a few sessions focused on sleep. That made me interested in learning about behavioral sleep medicine and mental health.”
She served as a post-doctoral fellow at UT Health San Antonio and later joined the faculty there in the Department of Psychiatry and Behavioral Sciences. Her PTSD and sleep research has been affiliated with the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience, more commonly known as the STRONG STAR Consortium, and funded by a grant from the American Academy of Sleep Medicine Foundation.