WASHINGTON – "I didn't realize that all this time I've been in a formation of drunks," the noncommissioned officer, or NCO, told Army Lt. Col. Kate E. Van Arman.

The NCO was referring to a quote Van Arman, medical director, Traumatic Brain Injury Clinic on Fort Drum, New York, repeated to him from her top boss, Surgeon General of the Army Lt. Gen. Patricia Horoho.

"If you have less than six hours of sleep for six days in a row … you are cognitively impaired as if you had a .08-percent alcohol level. … We never will allow a soldier in our formation with a .08-percent alcohol level, but we allow it [sleep deprivation] every day [in soldiers who have] to make those complex decisions."

Adding to what Horoho said, Van Arman pointed out that after being awake 17 hours, response time has been shown to be the equivalent to a person with a blood alcohol content of .05 percent and 24-hours awake translates to a blood alcohol concentration, or BAC, of .10 percent.

Van Arman spoke at the 2015 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, held at the Defense Health Headquarters in Falls Church, Virginia, Sept. 9.

Although her topic was "Sleep Disorders Among Military Mild TBI Patients," much of what she said applies to all soldiers, whether or not they have TBI.

SLEEPLESS IN THE ARMY

It's not just the soldiers who are partying all night who lack sleep, Van Arman said. Demands of Army life are responsible for a lot of it.

For instance, soldiers who misbehave can be ordered to do extra duties as punishment, up until midnight, she said. Assuming that revile is at 6 a.m., that's six or less hours of sleep.

Staff duty often requires the soldier to be awake for 24 hours, she said. When the pre- and post-briefs are added, it's closer to 30.

Overall, one-third of military members sleep less than five hours per night and two-thirds less than six, she said.

Deployed soldiers get an astonishing average of just three hours of sleep per night, she said, particularly those serving in the combat arms branches.

It's not for lack of them trying to sleep though, she said. Those deployed or on extended exercises attempt to catch winks whenever or wherever they can, on the ground or when being transported in vehicles or airplanes.

A lot of it, though, is fitful sleep which throws off their circadian rhythms, she said. The battlefield, even the peacetime "battlefield," can be a noisy place with others snoring, lights, helicopters flying and so on, not to mention weather conditions.

While being sleepless in the Army seems to be the norm, there are other professions that have sleepy people, particularly in jobs where that sort of thing would be concerning. For instance, 72 percent of U.S. commercial airline pilots reported being drowsy to the point of nearly falling asleep and 45 percent of all pilots admitted to actually dozing off on occasion, she said.

'CULTURE OF CAFFEINE'

All this sleeplessness has resulted, not surprisingly, in a "culture of caffeine," Van Arman said.

During a recent visit to the Fort Drum shoppette, Van Arman noticed "a big refrigerator of monster sodas and energy drinks popular with young soldiers."

Last year energy drinks in the United States netted $27.5 billion and energy drink consumption went up 5,000 percent since 1999, she noted.

A meta-analysis of caffeine on cognitive performance showed that 100 to 300 milligrams of caffeine results in mood improvement, she said. That's about one or two cups of coffee.

Anything greater than 400 mg, though, results in mood deterioration, she said, adding that while the extra caffeine may result in a person staying awake, it may not improve decision making.

Another thing to be careful about with caffeine, she said, is not to take it within six hours of bedtime, as it will result in fitful sleep. Also, alcohol in excess will result in disruptive sleep.

ERECTILE DYSFUNCTION

When Van Arman was stationed on Fort Bragg, North Carolina, she said she was surprised to see a lot of special forces soldiers in their 20s who stopped by the pharmacy for pills to help with erectile dysfunction, or ED.

Their testosterone levels were around 200 nanograms per deciliter, when it should have been around 500 or more. She said she'd tell them, "Your testosterone levels are that of a 60-year-old man because you're getting crappy sleep."

The brain is sensing stress so to conserve energy, it's not making testosterone, she explained. Instead, it's making the stress hormones associated with fight-or-flight survival.

"Once you get better sleep, your testosterone levels are going to go up and your ED issues will improve," she said she'd also tell them.

'QUICK REACTION FORCE BRAIN'

Soldiers in the field are expected to be able to pack up and move out on a moment's notice, even if it's in the middle of the night, Van Arman said. Often, soldiers won't know what time that will be so the training will be more realistic.

She referred to this situation as the "quick reaction force brain" that's needed for this mindset.

Dr. Robert Sapolsky, a biologist at Stanford University, conducted research along these lines, she said.

Sapolsky divided test subjects into three groups, she said. The first group went to a sleep lab where they were told they'd get a good night's sleep, but be awakened at 6 a.m.

The second group was told they'd be awakened once every three hours and the third group was told they'd be given no warning at all when they'd be woken up - similar to the quick reaction force.

All of the subjects from all the groups were hooked to an IV while they were sleeping so blood could be drawn periodically to determine cortisol levels, meaning the amount of stress hormones present in the bloodstream.

For the first group, cortisol levels spiked 30 to 60 minutes before 6 a.m. That meant, she said, that the sleepers were subconsciously anticipating being awakened and became stressed close to that time.

For the second group, the cortisol levels spiked 30 to 60 minutes before each and every one of the three-hour periods they were told they'd be awakened.

For the third group, the cortisol levels remained elevated the entire night, meaning that instead of having restful sleep, they had stressful sleep the entire night, she said.

High cortisol levels, she noted, have been associated with higher-than-average rates of cardiovascular disease.

OTHER STUDIES

A separate study done in the United Kingdom in 2012 showed more than 700 genes being adversely affected by sleep deprivation, she said.

Anecdotally, Van Arman said soldiers on Fort Drum told her that when they go to the rifle range and they're sleep deprived, it takes them three times longer to qualify. This provides a dilemma to commanders, she said. Is it better to train soldiers as they fight or save on time and ammunition by allowing soldiers adequate sleep time before live-fire training?

Other studies have shown that people who are sleep deprived have memory challenges. This could affect sleep-deprived soldiers studying for a promotion exam or learning new tactics, techniques or procedures, she said.

Another study shows that sleep deprivation intensifies pain. She said a lot of soldiers at Fort Drum are infantry and have sore backs from carrying heavy loads. Sleep deprivation intensifies that pain.

TBI SOLDIERS

Sleep problems are "the absolute No. 1 military disorder when people come back from deployments. Among TBI soldiers, it is the No. 2 problem, after headaches," Van Arman said. Sleep disorders include insomnia, sleep apnea, nightmares, fragmented sleep, restless leg syndrome and bruxism (grinding of teeth).

Some 300,000 military members have some form of TBI, so that's a pretty significant number, she said, providing a number of other facts and statistics of service members with TBI:

• 97 percent complain about some sort of sleep problem, primarily insomnia
• 34 percent have sleep apnea
• 90 percent report napping during the day
• 50 percent have fragmented sleep

Regarding fragmented sleep, the average person awakens three to five times per night, Van Arman said. An Army specialist who was treated for mild TBI was put in a sleep lab and monitoring results indicated that he awoke 529 times in a single night.

EXCITING DEVELOPMENTS

Van Arman said medical researchers are working on a host of problems relating to sleep disorders and there will most likely be effective treatments ahead.

For example, researchers are close to being able to provide imaging that shows changes to the brain resulting from TBI. Currently, TBI is largely based on self-reporting and incident reports.

For sleep apnea, a new device may soon be in the offing that will sense when sleep apnea is about to occur and prevent blockage of breathing.

Other areas in which advances are being made, she said, include therapies and pharmacological interventions.

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