A 39-year-old man with no significant medical history sleepwalks, sleep-talks, and snores loudly. He kicks and punches the air during the night -- and sometimes hits at his wife, one time bruising her face. What's the diagnosis?
Wait, one more thing: all this started after he returned from a 12-month deployment during the Iraq War in 2007. Now, what's the diagnosis?
It's not any sleep disorder that's currently in the books, according to one military sleep doctor. Col. Vincent Mysliwiec, a sleep-medicine specialist for the U.S. Army, thinks that cases like the one described comprise a new syndrome, which he calls Trauma-Associated Sleep Disorder, or TSD.
"This disorder has some similarities with both Post-Traumatic Stress Disorder (PTSD) and REM Behavior Disorder (RBD), in which people act out their dreams, but it does not respond to the characteristic treatment for either of those," he told The Huffington Post. "Most importantly, it's observed among young veterans who were deployed in active combat."
Mysliwiec, who is based at Brooke Army Medical Center in San Antonio, began observing hard-to-classify sleep disturbances among veterans returning from Operation Iraqi Freedom in Iraq and Operation Enduring Freedom in Afghanistan around 2008. He outlined the diagnostic criteria for TSD in a 2014 article in the Journal of Clinical Sleep Medicine.
Most TSD sufferers don't experience daytime symptoms, like flashbacks, which are a hallmark of PTSD. The drug Clonazepam, which treats PTSD, is ineffective on TSD symptoms. And unlike in RBD, the nightmares in this syndrome are usually replays of a traumatic combat experience, rather than generalized scary dreams.
Mysliwiec hopes that if the American Academy of Sleep Medicine accepts this diagnosis, more resources can be directed towards its study and treatment.
"Classifying something is the best way to evaluate it," he said.
Mysliwiec has observed about 20 cases firsthand so far, but he estimates there are thousands more who are undiagnosed nationwide. TSD sufferers have responded well to a drug called Prazosin, which treats hypertension. They have also seen improvements with cognitive behavioral therapy and sleep hygiene interventions, like instituting regular sleep and wake times.
After combing through the historical record, Mysliwiec suspects that veterans he served in earlier wars had the same condition. "A Civil War veteran was observed to exhibit 'dream-enacting behavior' and scrounging for food in his sleep, and there are similar reports of sleepwalking among World War II veterans," he said.
“Veterans suffer from a host of sleep disorders, so it can be tough to disentangle the symptoms of one from the other.”
If TSD is accepted as a standalone condition, its diagnosis would still be complicated. Veterans suffer from a host of sleep disorders, so it can be tough to disentangle the symptoms of one from the other. For instance, they're four times as likely as other Americans to suffer from obstructive sleep apnea. Plus, many patients never realize they have TSD, since it happens during sleep, Mysliwiec said. Spouses have generated a lot of his referrals. So single veterans may never realize they have a problem.
The study Mysliwiec conducted is also limited, with just four cases.
"This report contains a case series of just four individuals, all of whom are men and all of whom are on the younger side," said Dr. Raj Dasgupta, a USC professor and Fellow of the American Academy of Sleep Medicine. "We definitely need a broader study." He pointed out that several of the patients in the cases were on prescription medications and one had a history of alcoholism -- all of which complicates their diagnoses.
Still, Dasgupta thinks that further study may confirm the idea of a veteran-specific sleep disorder. "We already know that war can literally change the brain, so I would not be surprised if active combat uniquely affects veterans' sleep," he said.
Mysliwiec is grateful for the extent to which the military supports his research work, thanks to a renewed focus on sleep and wellness within the Army.
Soldiers used to view sleep "the enemy of productivity, the enemy of vigilance, the enemy of being able to outlast our adversaries," Maj. Gen. David Wilmot, the Deputy Surgeon General for Army National Guard told the National Sleep Foundation in 2014.
"People are more aware of sleep now, which is a good thing," Mysliwiec said. "The challenge is that, even if the culture changes, the Army's mission doesn't actually change. Combat is as stressful as ever. So when we try to square these two goals, we have to deal with the disorders that arise from the clash."