PTSD and Sleep: Sleepy Days and Haunted Nights

Sleep and Post Traumatic Stress Disorder (PTSD)

Post-Traumatic Stress Disorder (PTSD) is characterized by a chronically heightened state of arousal after a traumatic event. PTSD often gets worse over time or develops insidiously, so that people may not realize they have it until many months after the traumatic event. The disease is more common in women, though it can happen to anybody. An estimated seven people out of 100 will experience PTSD during their lifetime.

PTSD and sleep have a complex relationship. Though sleep problems accompany many mental health conditions, sleep problems in PTSD2 are actually considered part of the disorder. Among the symptoms used to diagnose PTSD, two are directly related to sleep: hyperarousal and intrusion, which can manifest as insomnia and nightmares. Researchers are still trying to understand whether sleep problems precede PTSD or whether PTSD causes sleep problems.

Sleep is when memories are consolidate; it helps pull together and make sense of memories—specifically emotional memories—and fits new memories into existing ones. Therefore, a person needs sleep in order to sort out and process a traumatic event.

Sleep is also important for learning; an important step in recovering from a trauma is to learn that reminders of a traumatic event are not dangerous and that it is possible to feel safe again. Arguably, it is logical to link a reduced quality of sleep to a higher risk of suffering from PTSD.

Research results, however, which have looked at the relationship between PTSD and sleep problems are inconsistent: some studies have shown improvement in PTSD symptoms after insomnia treatment, other studies have found the opposite: To date, it’s unclear whether effective treatment for sleep problems can also address PTSD symptoms.

The PTSD/Poor Sleep Cycle

What is known currently is that PTSD and poor sleep interact in a cycle, and each can make the other worse. Sleep problems such as insomnia get in the way of processing memories, which increases vulnerability to a traumatic event when it occurs.

In turn, PTSD causes the brain to become less able to manage sleep, which makes it more difficult to process the trauma memory and distinguish between safe and unsafe environments. This then maintains the symptoms of PTSD. And PTSD then contributes to continued sleep problems. Once this cycle develops, treatment of both conditions would be helpful.

The Connection Between PTSD, Sleep, and the Brain

Researchers have found evidence that multiple overlapping brain regions are implicated in both PTSD and sleep problems, most notably the hippocampus, the amygdala, the anterior cingulate cortex, and the insular cortex. These brain regions are likely responsible for causing the patient to revisit the traumatic event in flashbacks and nightmares, as well as for maintaining a state of hyperarousal.

Studies have found that individuals with PTSD have a faster heart rate while sleeping, indicating an enhanced fight-or-flight response that maintains the body in a permanent state of hypervigilance. Unsurprisingly, hallmarks of disturbed sleep in PTSD sufferers include more stage one light sleep, less restorative slow-wave sleep, and fragmented REM sleep.

 Another significant connection between sleep and PTSD may lie in the way the brain processes fear-inducing memories. During a traumatic event, the brain learns to associate a certain stimulus with a negative response. Long after the traumatic event, this association may be so strong that the person suffers a violent reaction every time they are presented with a similar stimulus.

Normally, this response is attenuated during a process called extinction memory, during which the brain gradually learns to dissociate the stimulus from the learned response. A significant amount of emotional memory processing is done during REM sleep, and researchers believe the REM sleep disruptions seen in PTSD sufferers may indicate an inability to efficiently process trauma.

Sleep loss may also cause daytime sleepiness and interfere with coping strategies, leaving people anxious and hypersensitive to triggers. The good news is that improving sleep seems to have corresponding effects on PTSD.

How Does PTSD Affect Sleep?

Individuals with PTSD frequently have trouble falling asleep and awaken easily, often waking up many times throughout the night. Many people with PTSD also have nightmares. These issues result in disrupted, non-refreshing sleep.

Among people who experience a traumatic event, those who suffer significant sleep problems appear to be more likely to develop PTSD in the future. In fact, one of the earliest signs of PTSD is sleep disturbance, which often encompasses nightmares, insomnia, and fragmented rapid eye movement (REM) sleep.

 Interestingly, sleep problems that precede the traumatic event may also play a role. One study found that people reporting nightmares before going to war were more likely to develop PTSD after coming back.

Once the disorder sets in, the presence of sleep problems appears to exacerbate PTSD symptoms. And even after treating daytime PTSD symptoms, many people find that they are still suffering from insomnia.

Sleep problems in PTSD interfere with the brain’s ability to process memories and emotions, slowing down the recovery process after a traumatic event. Moreover, many people with PTSD use alcohol or other substances to try to sleep better. Far from helping, these counterproductive coping mechanisms actually worsen sleep and can aggravate PTSD symptoms as well.

Those with are struggling with chronic pain, substance abuse, traumatic brain injury, depression, or other medical problems face an additional barrier to getting quality sleep. Certain sleep medications also interfere with REM sleep, which is the sleep stage during which we dream and an important sleep stage for dealing with traumatic memories.

 The most common sleep problems in PTSD can be summed up in three categories:

• Insomnia: An estimated nine in ten people with PTSD suffer from insomnia. This is largely due to hyperarousal, in which the individual is unable to relax. It may also be a lingering effect of having been in a situation that required constant alertness at night. Insomnia in PTSD may also be self-perpetuating, as the stress of not being able to fall asleep eventually leads to maladaptive sleep behaviours such as daytime napping or substance abuse.
• Nightmares and Night Terrors: Nightmares and night terrors plague a majority of people with PTSD, leading to nighttime awakenings and making it difficult to get back to sleep. The content of these vivid dreams is sometimes related to past trauma, with many PTSD sufferers reporting repetitive nightmares. Nightmares are sometimes treated with imagery rehearsal therapy, in which the patient “rewrites” the script of the dream with a less threatening version during waking hours.
•  Obstructive Sleep Apnea (OSA): It’s not entirely clear why there is a higher prevalence of OSA among people with PTSD, but it may be due to underlying factors such as chronic arousal or alcohol use. Studies have found that continuous positive airway pressure (CPAP) devices work well for treating OSA in people with PTSD and may even reduce nightmares. While not as effective, people who find CPAP devices triggering or claustrophobic may prefer to use a mandibular advancement device.

Treating PTSD-related sleep problems, as well as co-existing disorders such as depression or OSA, is an important part of resolving overall PTSD symptoms.

Coping and Getting Help

Sleep problems are important to address because poor sleep can lead to a number of other problems. A lack of sleep or poor sleep quality can be a factor contributing to stress and mood problems. Poor sleep can also have a negative impact on your physical health.

Pharmacologic interventions are sometimes necessary for the sleep problems that accompany PTSD, however changing sleep habits may also be helpful in improving your ability to fall asleep. Fortunately, there are a number of things you can do to improve your sleep.

• Stick to a Schedule

Sleep problems can be avoided by exercising during the day. However, make sure to avoid rigorous exercise within one hour of your bedtime because that can keep you awake late at night.14 With that in mind, it's also important to stick to a regular sleep schedule, so you're accustomed to going to bed at the same time every night.

• Pay Attention to Your Eating and Drinking Habits

Avoid eating heavy meals before going to bed; however, make sure that you do not go to bed hungry.  Either move can disrupt your sleep schedule. You should also reduce the amount of caffeine and nicotine that you consume during the day. Avoid drinking caffeine after lunchtime, and do not smoke before going to bed. Avoid consuming alcohol within a few hours of your bedtime as well.

• Healthy Sleeping Habits

According to the National Sleep Foundation, the best time to nap is between 1 and 3 p.m. when the body's circadian rhythms naturally drop.17 Forcing yourself to fall asleep will never work. If you are having a hard time falling asleep after 20 to 30 minutes, get up out of bed and try to do something relaxing (for example, drinking herbal tea, reading a book). Do not return to bed until you feel drowsy.

Try to make your bedroom a relaxing place and try to limit your activities in the bedroom. For example, do not eat, watch television, check email on your laptop or talk on the phone in bed.  Your bedroom should be associated with sleep.

Try to keep your bedroom at a cool and comfortable temperature. Use a white noise machine, earplugs, or an eye mask to help block out any distracting noises or light.

• Try to Relax

Practicing relaxation exercises before going to bed can help release muscle tension and slow down your breathing.  Many people experience worry when they go to bed at night. Learning mindfulness is helpful to learn how to separate yourself from your worries.

Use medications for sleep sparingly and only under a physician's recommendation. Find ways to express and process unpleasant emotions and thoughts. Some sleep problems may be due to a person not adequately coping with stress. Journal or seek out social support to limit the amount of stress that you carry into your sleep.

Complementary and alternative therapies can also be of assistance when it comes to relaxation  – from aromatherapy to vibrational essences, EMDR treatments (to desensitise the stress reactions of people who suffer from PTSD) and physical treatments such as shiatsu and massage[i] it’s worth exploring drug-free and gentle means of reducing symptoms and improving relaxation.

[i] Trauma is held in the body as well as in the mind – therefore, body treatments can be very powerful when it comes to releasing traumatic memories “locked in” the muscles

Sources: Verywellmind.com, Brainline.org, Sleep Foundation UK