Use of a Portable Biofeedback Device to Improve Insomnia in a Combat Zone, a Case Report

Article

Abstract

Insomnia is a common problem in situations of stress. Some forms of stress, however, may contraindicate the use of traditional, pharmacological interventions. Working in a combat zone is such a situation. Alternative means of improving sleep are clearly needed for Service Members. We report a case involving a medical provider who was serving in a military, emergency-services facility in Iraq, and who presented with anxiety, depressed mood, and insomnia. Symptoms were sub-threshold for major depressive disorder or acute stress disorder. Mood and anxiety symptoms responded to traditional therapy techniques, but problems with insomnia remained. The patient was given a portable biofeedback device that employs an infrared sensor photoplethysmograph to measure heart rate variability (HRV) from peripheral finger pulse. One week later, sleep was significantly improved. Symptom improvement lasted to at least 6 weeks while in theater. One year later, a check-in with the patient revealed that after returning home, he had been diagnosed with post traumatic stress disorder (PTSD). PTSD symptoms had resolved after 6 months of psychopharmacology and cognitive behavioral therapy. These results indicate that biofeedback may be a useful means of improving sleep in a combat zone, but that such improvements may not necessarily prevent the development of more serious symptoms later. No clear causality can be inferred from a single case, and further study is needed to determine if this finding have wider applicability.

Keywords

Anxiety Combat disorders Depression Post traumatic stress disorder Sleep War 

Notes

Conflict of interest statement

The authors have no financial support or conflict of interest to disclose.

References

  1. Buysse, D. J., Reynolds, C. F., III., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, 193–213.CrossRefPubMedGoogle Scholar
  2. Ebben, M. R., Kurbatov, V., & Pollak, C. P. (2009). Moderating Laboratory Adaptation with the Use of a Heart-rate Variability Biofeedback Device (StressEraser((R))). Applied Psychophysiology and Biofeedback. PMID: 19418214 2009 May 6. [Epub ahead of print].Google Scholar
  3. Hauri, P. (1981). Treating psychophysiologic insomnia with biofeedback. Archives of General Psychiatry, 38, 752–758.PubMedGoogle Scholar
  4. Heilman, K. J., Handelman, M., Lewis, G., & Porges, S. W. (2008). Accuracy of the StressEraser((R)) in the detection of cardiac rhythms. Applied Psychophysiology and Biofeedback, 33, 83–89.CrossRefPubMedGoogle Scholar
  5. Jacobs, G. D., Pace-Schott, E. F., Stickgold, R., & Otto, M. W. (2004). Cognitive behavior therapy and pharmacotherapy for insomnia: A randomized controlled trial and direct comparison. Archives of Internal Medicine, 164, 1888–1896.CrossRefPubMedGoogle Scholar
  6. Johns, M. W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, 540–545.PubMedGoogle Scholar
  7. Kahneman, D., Krueger, A. B., Schkade, D., Schwarz, N., & Stone, A. A. (2006). Would you be happier if you were richer? A focusing illusion. Science, 312, 1908–1910.CrossRefPubMedGoogle Scholar
  8. Mellman, T. A., Knorr, B. R., Pigeon, W. R., Leiter, J. C., & Akay, M. (2004). Heart rate variability during sleep and the early development of posttraumatic stress disorder. Biological Psychiatry, 55, 953–956.CrossRefPubMedGoogle Scholar
  9. Morin, C. M., Hauri, P. J., Espie, C. A., Spielman, A. J., Buysse, D. J., & Bootzin, R. R. (1999). Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep, 22, 1134–1156.PubMedGoogle Scholar
  10. Mulder-Hajonides van der Meulen, W. R. E. H., Wijnberg, J. R., Hollander, J. J., De Diana, I. P. F., & van den Hoofdakker, R. H. (1980). Measurement of subjective sleep quality. European Sleep Research Society Abstract, 5, 98.Google Scholar
  11. Ramakrishnan, K., & Scheid, D. C. (2007). Treatment options for insomnia. American Family Physician, 76, 517–526.PubMedGoogle Scholar
  12. Roberts, N. P., Kitchiner, N. J., Kenardy, J., & Bisson, J. (2009) Multiple session early psychological interventions for the prevention of post-traumatic stress disorder. Cochrane Database System Review, (3):CD006869.Google Scholar
  13. Sforza, E., Pichot, V., Cervena, K., Barthélémy, J. C., & Roche, F. (2007). Cardiac variability and heart-rate increment as a marker of sleep fragmentation in patients with a sleep disorder: A preliminary study. Sleep, 30, 43–51.PubMedGoogle Scholar
  14. Solomon, Z., Neria, Y., Ohry, A., Waysman, M., & Ginzburg, K. (1994). PTSD among Israeli former prisoners of war and soldiers with combat stress reaction: A longitudinal study. American Journal of Psychiatry, 151(4), 554–559.PubMedGoogle Scholar
  15. Watson, C. G., Tuorila, J. R., Vickers, K. S., Gearhart, L. P., & Mendez, C. M. (1997). The efficacies of three relaxation regimens in the treatment of PTSD in Vietnam War veterans. Journal of Clinical Psychology, 53(8), 917–923.CrossRefPubMedGoogle Scholar
  16. Yildiz, M., & Ider, Y. Z. (2006). Model based and experimental investigation of respiratory effect on the HRV power spectrum. Physiological Measurement, 27, 973–988.CrossRefPubMedGoogle Scholar

Copyright information

© GovernmentEmployee: United States Government Employee, Naval Medical Center San Diego 2009

Authors and Affiliations

  1. 1.Department of Mental HealthNaval Medical Center San DiegoSan DiegoUSA
  2. 2.RTI InternationalSan DiegoUSA
  3. 3.Clinical Investigation Department (KCA)Naval Medical Center San DiegoSan DiegoUSA

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