The opinions expressed herein are those of the author and should not to be construed as official or as reflecting the policies of either the Department of the Army or the Department of Defence.

Posttraumatic Stress Disorder (PTSD) is defined by a protracted response to a particularly traumatic experience. The cardinal features encompass manifestations of intrusive thoughts, avoidant behaviour, negative alterations in cognition or mood, and autonomic hyperarousa [1]. Much of the PTSD knowledge base comes from studying the military. The earliest historical evidence of a post-traumatic response is from a cuneiform tablet detailing the battle-related death of King Urnamma (2111-2094 BC) [2]. In the inscription, reference was made to significant sleep problems in the survivors. Post-traumatic responses have been described in various texts to include ancient Greek and Roman accounts of war. American writers have referred to PTSD as “Soldier´s heart” during the U.S. Civil War (a reference to the autonomic hyperarousal), “shell shock” during World War I (a description of the numbing and dissociation), and “combat neurosis” during World War II [3]. The term “PTSD” was introduced for the first time during Vietnam War. In all of these descriptions, sleep complaints are a central feature.

Despite considerable advances in the treatment of PTSD, it remains an extremely pervasive and difficult problem to treat. PTSD is often comorbid with a variety of physical and psychological conditions. Musculoskeletal injuries and amputations can lead to chronic pain. Self “medication” with alcohol or illicit drugs can lead to substance abuse issues. Neurologic trauma such as Traumatic Brain Injury (TBI) can lead to decreased adherence to therapy as a result of cognitive dysfunction and poor motivation. All of the above conditions are inextricably linked to sleep disturbances which may increase the risk of nocturnal violence [4-7].

In our experience treating active duty Soldiers with co-morbid PTSD, sleep disorders, substance abuse and TBI, a cohesive and multidisciplinary approach with frequent communication amongst the treating providers has shown to be quite effective. Though prospective data is thus far scant, anecdotal outcomes have been very positive [8]. By looking at the patient in a holistic manner and synthesizing recommendations from psychiatry, neurology, addiction therapy, physical therapy, pain management and sleep medicine, the primary physician can more easily ensure that every aspect of the patient is optimally managed.

It is incredibly important for family members, particularly spouses, to be involved in the treatment plan for patients with PTSD. This is particularly critical for those suffering with combat-related PTSD since the Soldiers might feel as if their loved ones may not be able to handle the details of the traumatic event. In some cases, Soldiers may feel the need to protect others from the knowledge of their combat actions. Soldiers may even be worried that their marriage may be affected if their spouse feels that combat has irreversibly changed them. Most often, however, once the communication is improved between the Soldier and his significant other, healing is more rapid.

There is similar data in the obstructive sleep apnea (OSA) evidence base looking at the importance of spousal support to help improve adherence rates [9]. Sleep complaints have been shown to portend a worse outcome with PTSD. Given that untreated OSA can impact the treatment efficacy of PTSD therapy, it is critical to treat each condition individually and involve the family at every point in the process.

This is especially important when we consider the potential for nocturnal violence in PTSD. Untreated PTSD shows a higher risk of impulsive behaviours. There is also a higher likelihood that anxietyrelated nightmares may turn violent. Since untreated OSA, restless legs syndrome, periodic limb movement disorder and insomnia can all contribute to increased sleep fragmentation and a decrease in the quality or quantity of sleep, it is easy to see how each of these factors are additive or even synergistic. The result is a dramatic increase in the possibility for harm to self or others.

Ultimately, further research needs to be conducted in order to determine the magnitude of the impact of a holistic approach in reducing sleep-related violence as well as daytime sequelae.