Hello. Hi. I see Dr.
Well, okay. Yeah. Dr.
Thomas is on. Hello, Dr. Thomas.
Sorry. Hi there. Hi.
How are you? Good, how are you? All right. Thanks for joining us. So excited.
We’re going to make this worth your while. So that’s the plan. All right, good deal.
I’ll introduce you to our team here. We got the baby there. Okay, so Ken Rail is our director of our clinical research programs, and he has been with us well, he just joined us about a month ago.
A month and a half ago. He’s with us now. And then Matt Tucker is our commercialization officer.
He kind of manages all of the marketing and all of our sales team and doing those jobs, and Brandt helps him with those tasks. So that’s us. I know you’re by reputation already.
Do you want to introduce yourself, Dr. Thomas? Sure. And, yeah, I apologize.
My four month old assistant here is very chatty. I’m an occupational therapist over at the TBI clinic at Fort Belmore. So a lot of the people we see have, if you’re looking for a population where there’s sleep difficulties, people with TBI and people in the military, and so we get both of those.
And so we have a lot of the population that kind of would benefit from these services. And the people that I’ve worked with so far for Night Wear have said how helpful it is. So I’m excited to learn more.
Awesome. And we got Dr. Liam here.
Hello, Dr. Liam. So dr.
Liam. Andre. Well, I’ll let you introduce yourself.
Andre, go ahead. Hey, guys. I’m dr Liam.
I’m a physical medicine rehab doc working here in the SRU. I think I’m just across the street from you, Brianna. And, yeah, I’ve been ordering Nightmare for, I guess about a year ish now, maybe a little more.
And I’ve gotten really good results with it, but I also need to figure out how to order it with a new system. Brianna, I heard that you were able to do it. I don’t know what I’m doing wrong.
We can talk later. I’ll send you an email, figure it out. Yeah, that’s been a challenge.
So I do Red Cross volunteer work at Walter Reed. I was there doing sleep clinic this morning, and I finally cracked the code, though. I figured out how to get my notes done efficiently, which was the major hang up.
But, yeah, ordering DME is another process, so you got to do it a few times, I think, to kind of get the hang of it. I think the issue that’s happening right now, too, is that the DME requests are getting held up where Irmac doesn’t know where to send it. So we had somebody that contacted Irmac and found where to kind of direct it to, and once they knew where to direct it to, it was in Humana by the end of day.
Okay, so directing it to the DME company is that what it is. Okay. Yeah.
There’s multiple points of failure between you ordering it and the patient getting it. And so you got to just watch that whole system. It’s not just limited to night, where CPAP was the same way.
I had to outline the steps that had to everything had to go through so that if the patient wasn’t getting it, the patient knew where to go to fix the problem. That’s just the nature of things. I’m going to pull up the slides here real quick.
Okay. We’ll get started. I promise.
This is going to take less than an hour, so we are definitely going to stay on time. Let me find yes. Here we go.
So you should be able to see my screen. Someone confirmed that it should be a slide. Yes.
Okay, great. So I can see everybody’s faces, because I’m make sure I’m tracking everybody. All right.
There we go. Okay. So we’re doing these user meetings.
We had one at 01:00 P.m.. So this is second one of the day. It’s the same topics.
And then our plan right now is to have we have four different sessions kind of focused on different issues, but we wanted to start with this one first. Sorry. First, a few housekeeping things.
So we’re going to record the meeting only because we need to. What we’re going to do is transcribe it, and then through the magic of AI, a summary will be created, and we’ll all have that. And then we can distribute that insights that we develop in the meeting to other doctors.
So you’re not going to be named in it. It’ll just be a summary of what we’re talking about. And what we’re doing, really, is getting feedback.
So when you have a new device like this that really doesn’t have a comparable device, when you start, nobody knows anything about it. And so what we have to do is educate every doctor that starts prescribing. It’s like starting from zero.
We have to explain how it works, explain what kind of patients that’s good for, what patients that’s not good for. All those steps have to be done. And so I need to give the doctors accurate information.
The only way I can do that is to get feedback from doctors that have used it clinically to tell me, you’re right about this or you’re wrong about this, consider this, too, that kind of stuff. So getting that feedback is very important. The device is not perfect.
So it was invented by I don’t know if you know the backstory on this, but it was invented by at the time, college senior. He now has a PhD in computer science. Tyler developed this for his father.
And there were some development, of course, that happened early on, but I know that we’re obviously not at the it’s not everything it could be, right? So we could make it better. And so figuring out how we can make this device better, and as well as figuring out where we’re lacking in directions to the patients or directions to you instructions, we’ve tried to address those things, but there might be gaps there. And so if there’s something that patients keep coming to you and asking over and over again, or at least more than twice, say, then maybe that’s something we need to address with all the patients somehow up front.
And then finally, another goal we have is just raising awareness of the disease state. So when I talk about nightmare disorder, it can sometimes be an afterthought, and it may be under diagnosed, and that’s one of the things that we’re interested in talking about. So we’re going to talk about these four topics.
We’ll spend less than 15 minutes on each one, and then we’ll be done. So that’s the plan. Do we have someone else on the call, another physician? I don’t know.
Brandt, can you help me out? Yeah, it looks like oh, Ms. Dixon. Dixon, yeah.
How are you? Sorry about that. Hey, no worries. Hi, Ms.
Dixon. How are you doing? All right. Do you want to introduce yourself to the other doctors here? Yeah.
My name is Linda Dixon. I’m a nurse practitioner here at Fort Hood, or Fort Cadaves now, so yeah. Work in the sleep medicine clinic.
Yeah, the renaming, I think it’s I heard it was next week. Is that the official actually, this week, I think. This week.
Okay. Yeah. Brian dr.
Lang is on as well. Yeah. Okay.
And Dr. Lang. Hello, Dr.
Lang. I’m Jennifer Lang. I’m a psychiatrist at Fort Campbell.
And then for Ms. Dixon and Dr. Lang.
So Dr. Liam is a PM and r doctor. He is at Fort Belmore in the SRU.
And it’s Dr. Thomas, right? It’s Dr. Thomas.
She’s an occupational therapist by training, and she works at the Intrepid Spirit Center at Fort Belmore. All right. Okay.
The reason I want you to know who each other are is because you’ve all prescribed this. You all have experience with it, and I really want all to talk a lot during this meeting, if at all possible. So that’s one of my goals.
The first thing is, how do you find patients with nightmares? Right? And so there’s a few issues here. Like, one is, like, under diagnosis of nightmares, and then just straightforward, like, who do you ask? Who do you ask about nightmares? And maybe that’s a great question to start with is how do you find patients with nightmares? I don’t know if I’m on silence or not, but it’s a part of our questionnaire. It’s a part of our questionnaire, do they have nightmares? And then we evaluate them again.
If once they CPAP for a while and they’re still having frequent nightmares and they’ve tried Prazizam, then that’s kind of the open door for us to talk about the night wear. And most people are excited because they’ve tried so much other things so many other things, and they’ve failed those things, or they don’t get the relief that they want, so they’re excited about trying something extra. So that’s how we get a lot of patients with nightmares just because of that screening.
Okay, so screening tool and what kind of screening tool do you use? It’s a part of when every single solitary time they come in, they’re asked the same questions how are you doing? And what are your symptoms? Okay, yeah, our chief made up the questionnaire, so we use that. Okay. All right.
Anyone else? You can go first. I was going to say same. During my intake, I get a full assessment kind of of what the daily routines look like and then ask a full, what is your sleep hygiene routine? How frequently are you waking up at night? What can you attribute the cause to? Do you have nightmares? How frequently? And opening the dialogue early.
Sometimes I find that as we revisit, the answers become a little different, and people can sometimes be a little bit more open and honest about the kinds of dreams they’re having after they’ve known me for a little bit longer. Okay. I use my social workers to sort of screen for nightmares.
I mean, it’s sort of just like, hey, how are you doing? It’s sort of like a standard question, too. And I’m sure TBI with your BH team, they sort of do that too. And so they basically say, hey, do you think this guy would benefit from night wear? And I’d be like, yes.
I never said no to anybody who has any nightmares. And I really think psychiatry and the behavioral health folks really need to know what this thing is. Because they’ve seen behavioral health.
They come here to the SRU. I mean, they’re still seeing behavioral health, and then sometimes we find out, oh, hey, you have nightmares. And again, they sometimes open up later, and then we just prescribe it.
But even at the behavioral health level, because those are the guys, they have problems. They see behavioral health. But here, at least I don’t see a lot of well, at least my patient population.
I’m the one who’s prescribing it. They don’t come here with a night wear device. Right.
I know that sometimes these patients will have tried other treatments for nightmares. Someone else had seen them, and maybe they’re on Prazicin or they’ve tried some type of other therapy for nightmares. So know that what ends up happening is that a lot of our doctors end up using NightWare almost like a third line treatment.
Right? So you’ve tried these other two things. Okay, now we’ll try night wear, and it might be part of it that might be just sort of artifact, the fact that not everybody knows about it. But I’m wondering, do you have a lot of patients where no one’s bothered to address the issue before? I’ve had a few patients not on prezosin or anything, and they’re just like, oh, I have nightmares, and like, okay, well, how about this device? And some of them don’t even want to try medication.
So yeah, it’s almost first line, maybe second line if they tried therapy. Okay. Yeah.
Dr. Lang, I don’t know as much about your practice as everybody as the other three folks that are here on the call. What do you think? Do you do a systematic assessment on all the patients? I know there’s a database that is used in behavioral health.
I do. I’m trying to. Okay.
I couldn’t get my camera on. Yes, of course. I do a systematic assessment on every new patient, and it includes a thorough sleep assessment and a question about nightmares.
Okay. I’m trying to sort of come up with an algorithm of who I think really benefits from night wear. I feel like I have a fair population of soldiers whose trauma is malingered or embellished, and I don’t buy it.
And interestingly, so I try to be judicious in who I’m going to give prescribe this expensive treatment to. Strangely interestingly. Some of the people who I really think are pretty squirrely and are not to be.
I just flat out don’t believe their history do improve with their nightmares improve with the nightmare device, which is I don’t know what to make of that, but Tracy actually pulled some of my she was showing me my portal data, and one guy in particular has a very good both, he says, and the portal confirms that he has a very good improvement in his nightmares when he uses the device, even though I don’t buy his story at all. So I really don’t know. It’s like the more I use it, the more confused I am about who’s going to benefit.
Yeah. I always think about other disorders I treat. So I’m a sleep medicine physician, and we treat a lot of sleep apnea.
And there’s one thing with the mild sleep apnea patients that you can it’s like a predictor of who’s going to improve with our standard treatment of CPAP, which is that they’re sleepy during the day. The people that aren’t sleeping during the day, they don’t feel better, and they have trouble using this difficult to use device for long periods of time because they don’t feel in the morning, they don’t feel different than they would otherwise. I guess what I’m kind of looking for is there some patient symptom or characteristic that separates responders from non responders.
Right. Do you guys have any patients can you think about any patients that did not do well with the treatment? And I’m wondering you can think about those patients and maybe is there something about them that’s different than the other ones? Really? Mental health? Okay, so one patient wouldn’t even try it because he had privacy concerns data. Okay.
That was a total bust. And now I talk to people about that because some soldiers do have just they don’t want the world spying on them. Another soldier who really could benefit, I think won’t because he has sort of squirrely reasons.
His dog will eat it or something like that. So there’s the personality interference. I suspect that my patients who are drinking more than they say don’t get quite as much benefit.
That’s one thing I do wonder. I have had some feedback that kind of supports that idea, actually. I had one patient who had used very successfully, actually used Nightwear, but she noted that if she had drinks and I’m not talking about getting drunk, just even like a couple of drinks, her sleep was much worse and there were a lot more interventions during her sleep, and she tended to have more nightmares too.
I’m actually sort of trying to use that because people are like, well, I don’t drink too much, but it’s enough. So I’m sort of trying to use that to engage them on. Well, maybe it’s not too much, but you still need to back it down more.
Maybe it’s too much for you. Right. That’s the way to think about it.
Okay. Yeah, that’s an interesting point. I’m glad you brought that up.
Okay. Um, are there, like, health care system barriers that keep you from finding out about nightmares? How do we put this? I’ll tell you one thing that I ran into at Walter Reed is that I could do IRT. I knew how to do IRT.
I had other people that knew how to do IRT for treating nightmares, but nobody had time to do it right. So it was a systemic barrier to treatment. Not that the clinician couldn’t do it.
It’s that the clinician didn’t have time to do it right. And I’m wondering if that does that keep you from using other treatments for nightmares? Well, one does it keep you fine from finding out about nightmares? Is it, I don’t know, a difficult system to use? Like a questionnaire? Is there some way we could work around a barrier like that? You could find out about nightmares and then treat the nightmares. Dr.
Liam’s already mentioned one, which is Genesis. Yes. How do I say this? To me, so many soldiers feel like that they’re expected to have nightmares.
It’s a certain part of a common phenomenon. So they don’t mention it, don’t talk about it, because they have the perception that they’re not going to be believed anyway and that they get more people to pay attention to them if they focus on more of the other symptoms. But I guess for me, what I practice would be I do the whole person so they know I’m listening, they know I’m hearing, and they know that I’m receiving what they’re saying, so they’re more apt to talk to me.
And so when I recommend anything and I’ll try different measures, they’re like, Ms. Dixon is all in and she’s got our back, so we’re going to do everything we can to try and then they report positive measures or even if they don’t, I don’t see it. I get the reports that show that they’re doing better, but I agree with the lady also who talked about the drinking and they’re listening when I say that if you drink you can count on more and they’re more receptive just to cut it out or to cut it back.
But I think that so many peer providers are overwhelmed and so many soldiers have nightmares, but differentiating out between what’s trauma, what’s childhood, what’s just maybe a bad dream. And that’s the thing that I don’t think that everybody’s overwhelmed with all the work and so it makes it very difficult. It makes it difficult, yeah.
I would say I have kind of a similar experience of like people just don’t want to talk about it. I also think that we have a large population of people, at least over at our clinic that we’re seeing towards the end of their career who have really worked hard to avoid behavioral health for the duration of their career for fear of all of the things that could come with going to behavioral health potentially. And so I almost think that normalizing saying like, hey, if you’re having nightmares, this is an open conversation and doesn’t necessarily mean that you’re going to have to take a medication, which is also something everyone’s like, oh, they’re just going to give me a pill for that and I don’t want to take medications.
Right. Educating them that there is non medication treatments for this and that it’s not going to end your career. It sounds like I’ve heard that before.
So that seems like things we need to tell patients and communicate with them. This is my first thing, too. I guess I do have sort of a cut off.
People need to have nightmares, I think at least three times a week for it to be worth wearing a device every night. There’s no hard and fast data with that. But if it’s only happening once a week or certainly once every two weeks, it’s low yield to me.
Yeah, I agree too. I think that’s there needs to be like a cut off. I’ve heard one time a week, three times a week, I think I would have personally a hard time treating nightmares that happen less than once a week with anything because I don’t know that it’s affecting them as much as they might be saying to you, okay, good, okay.
I’d like to say that maybe not asking if they have nightmares, but just seeing Praisosin, that’s a dead giveaway. They usually have some kind of nightmares and it’s like, okay, do you have nightmares? And then, yeah, that sort of opens a conversation. Sort of look at their medication list and have they ever been prescribed Praise the sun? Right, that’s a clue shorthand way to get at it.
Another topic I kind of want to talk about was like patient selection. We already touched on this a little bit, talking about the frequency of nightmares, but what are some important characteristics the frequency of nightmares? We talked about that. I had one psychologist tell me that awakening due to nightmares was an important thing for her to be comfortable with the diagnosis of nightmare disorder.
The patient didn’t wake up from the nightmare. She didn’t feel like it warranted treatment. How do you feel about that? Is there any other characteristics you picked separating the wheat from the chaff and figuring out if you need to treat it besides frequency of nightmares? Is it daytime function issues? Like what do you use is your sort of shorthand question to the patient to get at how severe the problem is.
I’ve had people tell me that they avoid sleep because they’re concerned that they’re going to have nightmares. That’s one for me, for sure. Yeah, like a sleep anxiety kind of picture.
Right. Or if they just don’t go to sleep back to sleep, that’s a lot of big times that the nightmare wakes them up and it’s so scary that they won’t go back to sleep and it really greatly reduces the amount of hours of sleep that they get. So that’s a big one for me.
So sort of waking up at 02:00 a.m. From a nightmare and then refusing to go back to sleep, right? Yeah. Okay.
Yeah, I second those two comments. I think that’s sort of a dead giveaway. I don’t know about awakenings due to nightmares if that should be sort of like, I guess a relative contraindication or indication because sometimes they just remember the last dream or whatever.
I don’t know if that should be a hard and fast rule, I guess. Yeah, it’s an example of a person’s sort of shorthand rule for getting at the issue, but certainly doesn’t because the obstructive event could also cause that same thing. So you weed it out though that’s when you ask the more intricate questions that pinpoint it specifically to me, I also feel like there’s a population of people that will say, I am afraid that coming out of a nightmare, I’m going to be at risk for my partner in bed with me.
And so that’s one of those things too, that for me is like perhaps we should have a conversation about night wear. Yeah, so that’s actually a really good point. I heard in earlier session someone had mentioned the spouses, like when they treated patients successfully with night wear, one of the indicators of success was that the spouse was willing to sleep in the same bed with the person again, with the patient.
Again. That might be another way to kind of get at it is like where does your spouse sleep? Do they sleep in the same bed or do they make comments that they just can’t get good sleep because of the nightmares, things like that. I think that’s important too.
Okay, I think just tossing and turning at night too, is sort of a good indicator that they are having nightmares throughout, and they may not even, again, remember any of this stuff, but, like, they’re tossing and turning. I have one, actually. One of my nurses asked me about if her husband could have one because he’s got PTSD tosses and turns.
So I gave him one, and he’s like, sleeping so much better, and she’s sleeping so much better. So it’s a win win all around. Yeah.
So improving the spout bed partner’s sleep, that might be an important therapeutic treatment for them. Yeah, that’s a good point. And you have a healthier, happier, better social worker too.
Okay. Is there anything that makes a person a bad candidate for night wear? I guess not having nightmares, but the giveaway is if they don’t want to even try it, I’m not going to obviously give something to somebody who doesn’t want it. But at first I was whipping arms, and I think you should try it, and then I don’t think they were really into it, so they just don’t use it or don’t improve that much or don’t buy into it, I guess.
I have a few more questions. Anybody else have any comments on that about bad candidates? No. I really feel the same way.
If somebody’s giving me weird reasons why I can’t wear a watch while I’m sleeping, I’m like, no, I’m not writing this up. Yeah, right. Okay, that makes sense.
They’re already reluctant. Right. It’s in your office.
Then that might not be a good candidate. What about the cause of trauma? So you have patients that have different reasons for having PTSD. Is there something about the cause of trauma that influences how they would respond to this treatment? You may not have know this, and it’s okay if you say don’t know, but you haven’t noticed anything.
I’m just curious. So that would be a question that I would have, too, because to me to me, people who are combat related and they’ve had trauma out in combat, they react differently than if a person who had earlier childhood traumas or sexual trauma. To me, those are the ones that I tend to be very apprehensive about, but the ones who have more combat trauma, they’re the ones who tend to do better.
But that would be my question to even the group. Do you find the different types of traumas? And because some people have so much perceived trauma, but it is not a true trauma, that they feel like, oh, I got to have something, but it’s just something to fill the gap, and it’s not something that they’re going through that really would respond to this. Does that make sense? I think that makes sense, yeah.
I have prescribed it to patients with early childhood physical abuse, with childhood sexual abuse, with combat trauma, with military sexual trauma. Really a pretty wide spectrum of trauma. And it seems to help.
I wouldn’t say that. There’s a category of that that it’s not helpful for. It’s not helpful to everybody in all those categories, but certainly I do have patients who are benefiting from all of those.
Okay. That’s what I wanted to know. Thank you.
That’s good. Okay. What about men versus women? Do your women respond better? Do men respond better? Have you noticed a difference, anything like that? I think just a patient population.
It’s sort of biased being men, at least that I see with combat traumas than women. You like women? Combat traumas, but overwhelmingly they’re men. So I don’t know if that’s like that doesn’t really answer your question, but that’s just what I see.
Okay. I have both I do have more male patients, and I have prescribed it to more male patients. But this may be getting back to a different question before sort of like, when is it the right time? Or how do you choose a patient? Unless someone comes in complaining about sleep up front as their primary, I tend to kind of keep it in my back pocket.
A lot of times I’m seeing someone for PTSD, and they haven’t been on treatment before. So we were starting an SSRI. We’re getting into trauma therapy, and then I’d say I sort of hold it as a second or even third line.
I don’t like to start more than one or two medicines at a time. Anyway, I hold it back until I get the main treatment going and then bring it in. And I feel like that’s effective because, first of all, the patient’s not overwhelmed with we’re treating all these different modalities, but it also sort of lets them it lets working on the sleep be the only thing we’re doing, like the only change we’re making in that time period.
And they can sort of focus on a little bit better. Okay. That’s actually really helpful.
Okay. Thank you. Okay.
Dream enacting behavior. So some patients act out their dreams, and they have PTSD, and they not only have nightmares, but they act out those nightmares. Have you used nightmare in one of those patients, and if so, how do they respond? Feel like I’m talking a lot, but I was really hesitant because that’s one of the relative conduit communications.
But I do have a patient who has both childhood and combat trauma that I felt like really could benefit was on, like, 15 of Prazosin and still having nightmares. And so I did prescribe it to him. Even though he has acted out his dreams and injured his wife.
They sleep with a pillow between them. It has not made it worse. He’s the guy who I also drinks too much and has a lot of variability.
It’s not worse. And he has some pretty good response. He likes it.
He likes it. Okay. Is that patient you said they were on 15 milligrams of Prazasin.
Did you leave them on the Prasa. When you started night wear? I did leave it on it because I wanted to don’t want to make it worse before. I sort of shifting the night where he hasn’t wanted to stop.
So he’s down to ten now, but he is still taking it. Okay. Yeah.
One of the concern we had when we were first developing the device was do alpha blockers like Prazacin interfere with the function of the device? I know Dr. Liam’s used it in patients at a little bit lower doses with good success, too. I had a gentleman who similarly was starting on we gave him the night wear because he was suddenly saying, I’m acting out my dreams and I’m frightening myself and my spouse.
And I think that even just having something that was kind of a failsafe made him feel more comfortable co sleeping with his wife, because it was one of those situations where he’s like, I am removing myself from the situation. I’m going to go sleep on the couch because I’m feeling really anxious and upset that I could potentially cause her bodily harm. So once he started using NightWare, he said that he felt a lot more comfortable co sleeping, and it gave them both a little bit more peace of mind.
So I think even whether or not it was doing those interventions, they felt better about it. Okay, that’s helpful. I want to ask about sleep apnea.
Some of the symptoms of sleep apnea are very similar to the symptoms that one can have with nightmare sweating, palpitation, shortness of breath, that kind of thing. Have you used this device in patients that also had sleep apnea? And if so, how did it go with those patients? I always warn them that it may get worse, and a lot of the patients, it gets worse first. And I won’t start a night wear until after they’ve used it for at least a three month window, used a CPAP for at least a three month window, got over the hump of having an increase of nightmares.
And then if they’re still having them and they’re having all the symptoms of sweating and it’s pretty significant that’s when I would do it with them using their pat machine and they said that they do do better but with any of my I prefer people to be still seeing and working with behavioral too, because I think it’s a combination thing. It’s not just one to me. Right.
Both things need to be treated right. Exactly. And the sleep apnea, right? Yes.
So I don’t think I wish behavioral health was the one ordering them, but because a lot of times people can’t get in the way to get in to see anybody. Behavioral health is so long here. I just don’t want people to suffer if they don’t have to.
Yeah, we always had go ahead. Probably at least half of my patients with PTSD also have sleep apnea. I do a lot of referrals to evaluate for that.
I would say a lot of times I have started night wear before someone is diagnosed with sleep apnea and gets either their PAP or they’re really big here into the oral device. And the oral device can take six months to make. Usually they have the night wear device before they have the sleep apnea treated.
And I kind of feel it’s part of treating the whole person. So that would be my question. Is the night wear working with the oral appliance? Do you have positive results with that? Trying to think of what specific honestly, the oral appliance is such a problem here.
I’m always surprised when I’ve had like, four people actually end up having an appliance. So I want to reserve judgment on that because honestly, I also don’t find that nobody comes in saying the oral appliance is changing my life. They’re just not well rested with it either.
All right, that answers my question exactly. That’s what I found. It.
Okay. Ms. Dixon, you mentioned having more nightmares.
So do you think that the sensation of wearing the CPAP is like, I don’t know, causing the nightmares or making it worse somehow? So what I find is they’re able to go into a deeper level of sleep, and as they’re going more into the REM sleep, they’re bringing up more of the dreams and that’s what’s causing the increase of nightmares. Right. They’re getting into REM sleep and then they’re okay.
Other issues. So one is about acute stress disorder. This is just a question I have.
There’s been a thought that has been kicked around for the last couple of years in our company. We could use this device in acute stress disorder. So right after a trauma, either when the patients say that they’re having started having nightmares or even before that going ahead and starting the device on them to prevent the nightmares altogether or at least lessen them.
Have you ever thought about doing this with someone after an acute stressful event? And I guess I’m aiming this not so much dr. Liam, who sees people way after the event. Theoretically that sounds good, but I don’t know.
Yeah, I don’t know. I haven’t tried it. You haven’t tried that.
Okay. I almost wonder too, if something where going through a period where you know that it’s going to be high stressors would be helpful. Because I know I’ve had some people say, like, oh, I definitely need to make sure I bring this with me because I’m having some traumatic anniversaries and things like that.
I don’t know. I have talked to one night wear user, so I would never get to talk to the patients myself. I love it when they reach out to us because I can just get all kinds of information.
I had one of those patients tell me that she did not use night wear every single night. She responded very well, but she could predict her nightmares and it probably had something to do with how much stress she was under. So if she had a lot of stress, she would use it.
If she felt like it was a good day, she knew that she felt like she was not going to have nightmares that night and she skipped it, which kind of gets into the compliance issue. Right. What’s the definition of compliance? I mean, for her it’s not going to be 100% because she’s definitely skipping nights, but at the same time, we’re controlling the nightmares, so we’re doing what we’re supposed to do, right? Preventing nightmares.
It’s just the way that we’re doing it. I use EFT a lot with patients. I get them trained on doing a lot of that and they’re more apt to be calmer, to put the night wear on to help their sleep transition go a little bit more effectively.
And I’ve been doing a lot more of deep meditation, just trying to help them learn how to prepare for sleep. The whole process of everything together just tends to work better. But then again, I’m not behavioral health, so I tend to be very careful, cautious, and just do it if they’re really bad with their symptoms.
And I feel like the night wear will help them because they will use it. If you give them kind of like a reason, they will do better with it. I also think those kinds of strategies and, like, paired with some of the night wear data I had a gentleman who came in, and we were looking at his number of interventions, and I was like, you get the Sunday scaries, you have double the number of interventions on Sunday going back to work than you do literally any other day.
So maybe that’s the day that you use the EFT and you use the meditation and you use a lot of these mindful practices to help with those things, to help kind of decrease your anxiety level before you go to sleep. Right? Okay. Yeah, I think that’s fairly helpful.
That is one thing we do suggest to patients is having a wind down period where you do something relaxing before you go to bed to get you in the mindset to fall asleep and have a good night of sleep. I think people wearing the night wear too, because they have a comfort of knowing there’s something on there that’s going to help divert their nightmares. And people tend to have a level of security of knowing I got a protective blank or I have something that’s going to kind of keep me covered so that gives them the safety feeling that it’s okay to go to sleep.
Yeah. There’s one other issue, and I know we’re spending a lot of time on this, but I kind of want to talk about this too. I have talked to a couple of patients who have told me about women that have noted that during the pre menstrual period and during their Mensies, they tend to have more nightmares.
And they pointed us out because they’re using night wear. One of them was using night wear, and it was doing very well except for those few days a month. Right.
For about three or four days a month, she would have more problems with her nightmares. And I’m wondering if any of your female patients have mentioned anything about their menstrual cycle and how it relates to their nightmares. I had a female patient who did say that, and I just kept trying to figure out what the two the relationship between the two.
So it makes sense and kind of makes me feel a little better that you had heard that, so make you think twice. Yeah, I think that I volunteer at Walter Reed. I asked the librarian to pull all the data about nightmares and menstrual cycles, so I will share that with you once I get that report back from her.
Yeah, I’m very interested in that question too. I think it’s something we need to understand and also something we need to warn patients about. Right.
Like, hey, you have nightmare disorder. It is probably going to be worse at these times, so just be aware. Brian, I was thinking to improve the product, maybe you should have settings, because it sounds like those days are going to be different settings than their other 25 days or whatever.
Right? Yeah, I don’t know how to do that. They’re having your cycle or whatever. Just push a button or something like that.
Or just even for men, like, I’m more anxious today. I’m probably going to have more nightmares. So it’s like a high setting, low or high setting.
Right. The Sunday setting. Right.
For that one patient. Right. So control it better then.
Okay. Actually, with this particular patient that I talked to, that’s exactly what we did. We made it more sensitive for her because it worked better for her that way.
So she’s a patient that was getting ten or 15 interventions a night, and it wasn’t really controlling her nightmares. And we made it much more sensitive and lowered the threshold for intervention. And now she’s getting about 50 or more interventions per night, but it’s importantly not waking her up.
And her overall sleep quality is better, even though it’s vibrating quite often, but it’s controlling the nightmares. So I think that customization is going to be an important part of development of the device. Yeah, I have that in mind for sure.
I want to keep going because I don’t want to wait too long. This is a topic that’s come up a few times, and I just want to ask you about that. And I think we sort of touched on this already about patients avoiding a PTSD diagnosis.
So I guess two questions. One, have you had patients try to avoid a nightmare disorder diagnosis, and do you use that instead? One psychiatrist told me nightmare disorder plus adjustment Disorder equals PTSD. Right.
So that’s kind of how it’s shorthand for it. You haven’t done that where the patients are kind of refusing or afraid of the PTSD diagnosis and you’ll use a different diagnosis for them. Much more often.
My patients are bucking for a PTSD diagnosis, and I don’t think the trauma meets the criteria. Okay. There was a rocket, a planned EOD detonation.
That doesn’t count. And I have a lot that I run into this over and over. It doesn’t help that the DSM Five has been rewritten, so almost anything will meet the criteria, but no.
So I will use Nightmare Disorder when they’re with other anxiety disorder, basically PTSD minus trauma. Or some people just do have really bad nightmares without a trauma, and they’re getting up at three in the morning and driving to their unit and sitting in the car waiting for PT because they can’t go back to sleep. Those people benefit well from it.
Okay, great. Yeah. It’s come up a couple of times where we’ve talked, especially in the special operations community and patients that are on flight status, they’re very worried that getting a PTSD diagnosis will prevent them from getting their job, doing their job, perhaps getting them med, boarded out of the military or losing their security clearance.
That’s like a fear that they have. Maybe not well founded fear, but have you run into that sort of situation with these guys that have security clearance or in there in a special occupation? Yeah, we definitely see the population where people are trying to avoid the PTSD diagnosis. But again, I think that those are the people that are coming that are just like, I have been avoiding behavioral health, so they just don’t have it.
Okay. All right. I had an Air Force doctor, a psychiatrist, who told me that he’d like to use it for patients on flight status because it wasn’t for boaton.
Right. So for them I know Dr. Lang, you work at Port Campbell, so lots of pilots.
Have you treated pilots with night wear or people on flight status? I have not. I’m aligned to a non flight brigade, so I don’t treat pilots or people on flight status, but I think it would be an excellent use for that population. Yeah.
All right. My last section I know we got 15 minutes left is just talking about how you assess your nightmare patients. I’ve suggested to some doctors that Nightmare Disorder Index, which is this questionnaire here.
A couple of years ago, I went through all of the nightmare questionnaires that were out there that had been validated, and I learned about this one. And after looking at them, we decided to kind of promote this one, mostly because it’s really simple. Right.
It’s five questions. It’s really just four questions, because the last one is about how long you’ve had nightmares, which is not going to change with treatment. But has anybody used a tool like this or perhaps some other tool to to assess your patients sort of systematically.
Yeah. Okay. That’s fine.
So that one I’ll just show you these episke. It is a tool that was developed to find PTSD in patients by looking really just at their sleep and their sleep disturbances and how those affect how PTSD affects their sleep. So the Pisky A might be something you use.
The insomnia severity index, I think, might be another good choice. I like this one a lot because it picks up on problems with their overall sleep quality in a pretty easy way. It’s only a few questions.
It’s easy to score, easy to use clinically. We use that at Walter Reid quite that often. And then I had a psychiatrist suggest the PCL five, and not all the PCL five, but just question number two, which is repeated disturbing dreams of a stressful experience.
One question getting at how often they’re having nightmares. And that may be another tool you can use. So what about assessing for follow up? How often do you after you prescribe night wear, do you book them on appointment after a certain period of time, like, at the same time to follow up with the patients? I wish I could.
I mean, I have to see everybody in the SRU once a month, so I basically just ask them then. But I haven’t really done the index or anything. I may have my social workers do that.
Okay. I mostly have people kind of give me their report of how they think it’s going. Typically, when I’m working on sleep, I’ll either meet with people twice a week or monthly.
And of course, when you’re feeling better, that’s when you stop making appointments. So sometimes people are like, I’m now riding off into the sunset, and I just hope everything is great. But for the most part, I just use self report of, like, yeah, this is really helpful.
Okay. You never used a tool like this? Okay, that’s fine. I don’t have a tool, but I do definitely ask both before and then at every follow up when they’re on it, how often they’re having nightmares now.
So I have a number of times a week or a number of times every two weeks. One of the doctors who work here said that the people always want the tool to look worse than they really, truly feel. So he always talks to them about how do you feel and how are you doing? And if their other things are looking better, then that means that they’re probably doing better.
They just don’t want us to think that they’re doing better with the nightmares because then they feel like they’re overrating scores or we’ll downgrade them or something else, and they don’t want that. Okay. All right.
Yeah. There’s always the disability issue with secondary gain. I think we all have to deal with that.
I understand that very well, actually. Okay. I think those are all of my questions for you.
Is there any other comments on these topics that you thought about it wanted to mention? Maybe not. Okay, well, we’re going to have more of these meetings. The other meetings have different sets of topics.
There’s some one that’s devoted to product development in particular, so Dr. Liam mentioned that, and we’ll definitely hit that one very hard. And then also one about using that.
We’re going to focus on using the data that the device generates and how that can be used clinically. I’m very interested in that and how that works, and then really looking for patterns in the data. The patient that had the Sunday scaries.
Right. So that’s a pattern in the data. And finding things like that, I’m very interested in that too.
So hopefully you can join us for those too, because it would be quite helpful. Like I said, we’ll summarize everything talked about here, and we’ll distribute that out, and we’re going to try to spread the feedback that we get from you to everybody that’s using the device out there. I very much appreciate your time.
And Dr. Lang, it was very nice to meet you. I’ve heard your name several times, so it’s good to hear.
Good to put the face with the name. And I think I met your husband once too. Okay.
Yes. So I met him. All right, great.
Thank you. Thank you. Thank you.
Nice meeting everybody. See you. Bye bye.
