In many PTSD patients, sleep problems such as insomnia and nightmares are the most common complaint. (Photo courtesy of Flickr user <a href="http://www.flickr.com/photos/kreep" target="_blank">Kreep</a>.)

Sam Brace doesn’t want to talk about what he saw when he was a soldier in Iraq eight years ago. Brace is an inpatient at a PTSD treatment center run by the Department of Veterans Affairs in Menlo Park, and that trauma is something he’s actively trying not to dwell on. But what he can’t control are his dreams.

"When I was overseas we hit an IED, um…" he says, trailing off. "When I have a nightmare normally it’s something related to that. "

In the past, scientists who study PTSD thought of nightmares and insomnia as byproducts of the disorder, side effects that could only be targeted through daytime interventions, such as cognitive behavioral therapy. But that view is changing.

In Sam Brace and others afflicted with PTSD, nightmares and insomnia lead to alcoholism and drug abuse, and the inability to function well during the day. Doctors who treat PTSD say that sleep is central to the disorder, and that restoring it may go a long way toward helping patients return to normal lives.

"Wacky" dreams are healthy dreams

Steve Woodward, a psychiatrist with the National Center for PTSD in Menlo Park says the hallmark of a healthy dream is that it seems kind of random.

"They’re wacky," says Woodward. "They associate things that are not normally associated."

PTSD dreams, in contrast, are like a broken record: the same, real-life event, played over and over again. Woodward says he's seen patients haunted by the same true-to-life nightmare for twenty years.

The question scientists had was: why? Why can't people with PTSD sleep normally?

Healthy sleep as therapy

Matthew Walker is a sleep researcher at the University of California, Berkeley. One of his particular interests is in rapid eye movement, or REM. It’s the stage of sleep where a lot of dreaming occurs.

REM sleep is also the only time of the day that the brain stops producing a kind of adrenaline called norepinephrine. That fact struck Walker as an intriguing mystery. Why would rapid eye movement sleep suppress this neurochemical, he wondered. Is there any function to that?

What Walker and his colleagues found is that in healthy people, REM sleep is kind of like therapy. It's an adrenaline-free environment where the brain can process its memories while stripping away their sharp, emotional edges.

"When you come back the next day," says Walker, "yes, you can better recollect [the memory]. But also, it doesn’t trigger that same visceral reaction that you had at the time of learning."

Emotions are useful, says Walker, because they show us what really matters to us. But it's not useful to hold onto what he calls the "emotional blanket," that accompanied the original event. The emotions, he says, "have done their job. Now it’s time to hold on to the information of that memory, but let go of the emotion."

"Broken" REM sleep

Walker believes that in many people who have PTSD, REM sleep is broken. Something about PTSD either causes the brain to be overly sensitive to norepinephrine, or forces the brain to create too much of it. The brain's adrenaline system is effectively out of whack.

As a result, REM sleep is no longer theraputic. The PTSD brain can't process tough memories, so it just cycles through them, again and again.

Which begs a question: What if you could change that? What if you could make the adrenaline go away?

An old drug finds a new role

Murray Raskind directs Mental Health Services for the Department of Veterans Affairs Puget Sound Health Care System. About a decade ago, he became interested in a drug called Prazosin, which was traditionally used to treat high blood pressure.

Prazosin can be bought generically for about ten cents a pill. It can have the side effect of making people dizzy. For the most part, it's been supplanted by other, more recent hypertension drugs, whose effects last longer. But Prazosin turned out to have another use: It makes the PTSD brain less receptive to adrenaline.

As a result, as Raskind discovered, prazosin can change the way those patients dream.

Raskind tells the story of one of the first vets he ever treated with prazosin, a veteran Raskind calls Charles, who spent 13 months in a combat infantry unit in Vietnam.

What haunted Charles was one specific event from his service: Under an ambush by Vietcong forces, Charles and a fellow soldier, his closest friend, found themselves trapped in a landing zone in the jungle. Charles watched as his friend was killed by a mortar round. Fragments of the round pierced Charles' right knee, leaving him unable to run. Charles was saved at the last minute by troops in a Huey helicopter, just as Vietcong forces climbed through the wire to reach him.

"This near-death experience," says Raskind, "and even more distressing, the death of his best friend, whose death he felt he was unable to prevent, haunted him most nights, every week, year in and year out."

After a few weeks of Prazosin, Charles came in for a follow-up appointment. He told Raskind that he didn't think the drug was working. He was still dreaming, just about something else.

According to Raskind, the dream went like this: "I'm in my fifth-grade classroom. And there’s a test, and if I don’t pass the test, I’m not gonna be promoted to the next grade. And I never even got the assignment!”

It was the stress dream, says Raskind, of a healthy brain, trying to work things out. "I said 'Charles, that’s MY nightmare!'" Raskind recalls.

So far the studies on prazosin have been small (abstracts can be found online, here and here and here – as well as of a 2008 round-up of data, here) but promising in decreasing nightmares and helping people sleep longer.

Other small studies involving non-combat PTSD – people who had been victims of crime and sexual assault, as well as refugees – found an improvement in the quality of their dreams, and overall sleep, as well.

The Department of Veterans Affairs is undergoing its own study on prazosin in PTSD, which is taking part in 13 medical centers across the country. But is already prescribing the drug to about 15 percent of its PTSD patients — about 70,000 people.

Murray Raskind, for one, would like to see that number rise.

"For us," he says, "it's a simple thing that works."

Doug Nomura in action on the Bay Trail.

Something about San José photographer Doug Nomura’s pictures of birds in flight, or attempting to get off the ground to fly, grabs you.  I think it’s the sheer energy and effort that the photos convey.

It’s especially timely to be broadcasting our profile of Nomura as the Your Photos on QUEST 2-minute segment on our Oct. 13 television episode, since the Bay Area is inundated with migratory birds starting in October.  The Bay Area is on the Pacific Flyway, a major north-south route of travel for migratory birds in the Americas, extending from Alaska to Patagonia.  As a result, close to 700,000 ducks are usually counted in the San Francisco Bay and the Sacramento-San Joaquin River Delta during October, said John Takekawa, research wildlife biologist with the US Geological Service. Raptors like hawks and falcons also stop over in the Bay Area in fall and winter.

Doug Nomura looks forward to the beginning of the migration in October because it multiplies his opportunities to photograph birds in flight.  He stalks his subjects along the Bay Trail, a shoreline trail that will eventually hug the entire circumference of the San Francisco Bay.  When the Bay Trail is complete, it will be 500 miles long.  Currently, the public can enjoy almost 300 miles of paths.  Nomura, whose day job is as a computer network security specialist, is an avid fan.  “This allows me to turn the cell phone off and go out there for a couple of hours,” he said.  “It’s some of the best therapy one can give oneself and it doesn’t cost anything.  I’d like my photographs to inspire people to visit the Bay Trail to look at the wildlife and appreciate what we have in our backyard.”

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