Posttraumatic stress disorder is an often chronic and disabling psychiatric disorder. It is characterized by several core symptoms including intrusive thoughts, flashbacks, depression and hyperarousal. Many individuals suffering from PTSD also experience significant sleep problems. In fact, sleep disturbance is one of the most common issues individuals with PTSD face. Specifically, insomnia and nightmares plague the vast majority of those struggling with the disorder.
What We Know About Sleep and PTSD
Although it is assumed to be high, relatively little is known about the actual prevalence of sleep disturbances in veterans with PTSD. Estimates reach as high as 90% in some studies. Indeed, any clinician who treats veterans with PTSD will likely tell you that most, if not all, of their patients suffer from sleep problems to some degree.
And, the sleep problems are not all the same. Some suffer almost exclusively from nightmares. Over time, the disruptive nature of nightmares on sleep causes many veterans to experience extreme sleep deprivation. Nightmares also cause a host of negative feelings, which can follow the person into their waking day.
This situation leads to anxiety and depression in many cases. Then, there are problems related to initiating sleep that also lead to sleep deprivation and downstream negative emotional effects. It is like what is seen with nightmares, but by a different process.
Similarly, it is assumed that sleep disturbances improve with evidence-based PTSD treatments. However, to what degree is unclear. Some studies show significant improvements in sleep related symptoms whereas others show limited benefits. Regardless of the effects, the historical approach to addressing sleep problems in PTSD is to treat the PTSD and hope that the sleep symptoms resolve along with the other symptoms.
This approach has left many clinicians frustrated as sleep symptoms seem to continue when other PTSD symptoms remit.
A Promising Study from Texas
In an effort to gain better clarity on these issues, researchers from the University of Texas Health Science Center at San Antonio, and colleagues from several other prestigious academic institutions, asked the questions mentioned above to more than 100 active-duty service members. Their findings were published in the November issue of “Psychological Trauma” and were shocking.
Not surprisingly, insomnia was the most frequently reported PTSD symptom prior to treatment. A whopping 92 percent acknowledged some degree of difficulty falling or staying asleep.
Although not as high as insomnia, 69 percent of the same group reported suffering from nightmares. The surprising, and somewhat disheartening news, is that approximately three-fourths of service members still reported insomnia as a problem after PTSD treatment.
And, around half still struggled with nightmares.
The researchers took an even deeper look into the results and found additional important information. For those service members who no longer met criteria for PTSD after successful treatment, more than half continued to report insomnia and 13 percent continued to report problems with nightmares.
Again, this data is from those troops who made such significant improvement that they no longer had enough symptoms to retain the PTSD diagnosis.
Take Home Points
In my opinion, there are two important take-home messages from this study.
First, sleep problems will likely continue in many people with PTSD, even in those service members who benefit greatly from treatment. Therefore, it is important to manage expectations. There are, few, if any, complete “cures” in psychology and psychiatry, but this does not mean you can’t go on to lead a rewarding and fulfilling life.
Keep in mind, many people without PTSD struggle with insomnia and nightmares. Secondly, if your patient is undergoing or has completed PTSD treatment, you may want to refer him/her for a sleep-focused therapy in addition to the PTSD treatment. Treatments like Imagery Rehearsal Therapy and Cognitive-Behavioral Therapy for Insomnia have been proven successful for nightmares and insomnia.
There are numerous randomized clinical trials on both approaches indicating that they are highly effective in their own respects.
*A previous version of this article was published in Dr. Moore’s column Kevlar for the Mind in Military Times.