If you want to effectively treat PTSD, it’s critical to address sleep issues, including nightmares. Currently, there is too little integration of sleep and trauma-focused therapies for the treatment of PTSD according to the authors of a comprehensive review of sleep disorders and PTSD. Weber and Wetter’s (2021) survey of the literature shows that intervening in sleep disturbances also helps daytime PTSD symptoms and may even offer a preventative effect.
Sleep problems, a core feature of PTSD, include nightmares, insomnia and nocturnal anxiety. The authors found little evidence for the long-term effectiveness of medication for insomnia and nightmares and called for a more complex and integrated approach to psychological treatment. They stress the importance of addressing sleep issues, noting that sleep problems and PTSD have a bidirectional link. Sleep issues can predispose a person to PTSD and perpetuate it.
“Interventions that enable people to sleep better are likely to be of particular therapeutic importance, as they may have immediate remedial effect on PTSD symptoms,” according to the authors. More than 90 percent of those with PTSD also have sleep problems that include post-traumatic nightmares, and difficulty falling and staying asleep. They can also ruminate at night, talk in their sleep, wake up disoriented and suffer from parasomnias.
PTSD associated with alterations in the nervous system and sleep architecture
There is much evidence to show that those with PTSD have low parasympathetic tone while awake and resting, and increased sympathetic activation during sleep, especially during REM when most dreaming occurs. It is now considered established that altered heart-rate variability (HRV), a measure often used to assess the state of the nervous system, increases the likelihood of developing PTSD after trauma.
The sleep patterns of those with PTSD differs in many measurable ways from normal, healthy sleep, indicating they sleep less deeply, and spend less time in restorative, regulating slow-wave sleep. Sleep spindles, bursts of brain activity that can be seen on EEG readouts during stage 2 non-REM sleep, are associated with memory consolidation and neuroplasticity. These are altered in those with PTSD sufferers. Similar disruptions in sleep spindle patterns were also found recently in those with nightmares associated with early childhood adversity – a finding that suggests trauma nightmares and so-called idiopathic nightmares (of unknown origin) may not be so easily differentiated (Nielsen et al. , 2019). REM sleep patterns are also altered in PTSD in ways that fragment this dream-rich phase of sleep that has been shown to help regulate emotion and attenuate fear and distress.
Sleep disturbances are linked to increased suicidality and self-harming behaviours. PTSD is also a risk factor for suicide. Weber and Wetter (2021) note that reciprocal influences of sleep, PTSD and suicide are well documented but not well understood. They do, however, cite a study that suggests “targeted treatment of sleep disorders and nightmares could contrubute to reducing the risk of suicidality in PTSD patients (Bishop et al., 2020).
Treatment of PSTD and Sleep Disorder Must Be Integrated
While PTSD treatment helps with insomnia and nightmares, and treatment of sleep problems helps with daytime PTSD symptoms, the two approaches are rarely integrated. The authors note several effective psychotherapeutic approaches to treating nightmares, including IRT, ERRT and EMDR. They also review pharmacological interventions, and the evidence is less favorable. They also studied the impact of sleep inteventions post-trauma as a way to prevent PTSD, and again the evidence was not conclusive.
In their conclusions, Webe and Wetter say there is “robust evidence” for psychotherapeutic inteventions and less evidence for medication as a treatment for PTSD. “Integrative concepts and optimized algorithms for sleep and daytime symptoms are needed.” These may also help reduce the risk of suicide, and in future, even prevent the development of PTSD following trauma.
References
Bishop T. M., Walsh P. G., Ashrafioun L., Lavigne J.E., Pigeon W. R. (2020). Sleep, suicide behaviors, and the protective role of sleep medicine. Sleep Medicine, 66, 264–70.
Nielsen T., Carr M., Picard-Deland C., Marquis L. P., Saint-Onge K., Blanchette-Carriere C., et al. (2019). Early childhood adversity associations with nightmare severity and sleep spindles. Sleep Medicine, 56, 57–65.
Weber, F. C. & Wetter, T. C. (2021). The many faces of sleep disorders in post-traumatic stress disorder: An update on clinical features and treatment. Neuropsychobiology, published online Seot. 2. DOI: 10.1159/000517329