Sleep disturbances are commonly reported by patients with posttraumatic stress disorder (PTSD), along with associated distress and impairment during the day. The close link between trauma and sleep is reflected in the diagnostic criteria for PTSD, which include nightmares and sleep disturbances.1 Sleep disturbances exponentially increase distress and dysfunction for these patients.2 Patients with PTSD and self-reported sleep disturbances are more likely to report functional disability than those without sleep disturbances,2 and comorbid sleep problems may exacerbate existing PTSD symptoms and complicate recovery.3
Prevalence and Impact of Self-Reported Sleep Disturbances in PTSD
A large body of research has documented the significant association between self-reported sleep disturbances and PTSD,4,5 with estimates of up to 80% to 90% of patients with PTSD experiencing insomnia symptoms and 50% to 70% experiencing nightmares.6,7 The average frequency of nightmares based on retrospective measures has been estimated at more than five per week.8 In addition to nightmares and insomnia, other sleep disorders and disruptive nocturnal behaviors are prevalent among those exposed to trauma, including people with PTSD. Sleep-disordered breathing, periodic leg movement disorders, and other parasomnias are common in trauma-exposed samples.9,10 Disruptive nocturnal behaviors are also common among people with PTSD.11 These disruptive nocturnal behaviors include night sweats, dysphoric dreams, and simple and complex motor behaviors or vocalizations, including dream enactment (Table 1). More recently, Mysliwiec et al.12 described trauma-associated sleep disorder involving trauma-related nightmare enactment associated with specific polysomnographic features but distinct from rapid eye movement (REM) behavior disorder. Together, these observations suggest profound disturbances of both REM and non-REM sleep in adults with PTSD.
Sleep Disturbances Associated with PTSD
Evidence for Objective Sleep Disturbances in PTSD
Compared to the robust findings of subjectively disturbed sleep in patients with PTSD, evidence of objective sleep disturbances documented with polysomnography and actigraphy is equivocal. Although some research suggests increased sleep fragmentation and awakenings among patients with PTSD, other studies find no difference between patients with PTSD and controls.4 Meta-analytic findings suggest that PTSD is associated with more light sleep, less slow-wave sleep, and greater REM density,13 although it is unclear to what extent these abnormalities are specific to PTSD compared to other mental disorders.14 Despite REM abnormalities being conceptualized as a hallmark of PTSD, there is currently no commonly accepted profile of objectively disturbed sleep specific to PTSD.5,14 A recent study suggests that patients with PTSD experience more variable sleep and less uniform sleep disturbances compared to patients with primary insomnia,15 possibly contributing to the difficulties of defining a specific profile of sleep disturbances in PTSD.
Mechanisms for Overlap of Sleep Disturbances and PTSD
Sleep disturbances are considered a modifiable risk factor for onset and relapse of mental disorders,14,16 suggesting a neurobiologic mechanism by which disturbances in the sleep-wake cycle have downstream effects on PTSD symptoms. Sleep is often seen as crucial to healthy emotional regulation processes, including toning down the emotional charge of the memories.17 Sleep disturbances could potentially hinder this process, resulting in an over-consolidation of the emotional component of memories and potentially contributing to PTSD symptoms, intrusive thoughts and nightmares. Several studies have suggested that sleep disturbance impairs extinction learning, which may confer risk for the development of PTSD or perpetuate PTSD symptoms after a trauma.18
Diagnostic and Treatment Implications
Sleep disturbances in PTSD are sufficiently prevalent and severe to warrant routine screening and assessment in trauma-exposed populations as well as patients with PTSD. If sleep disordered breathing or parasomnias are suspected, laboratory studies can be used to document objective sleep disturbances. Insomnia or nightmares can be identified through clinical interviews and screening instruments. Once sleep problems are identified, targeted treatment planning and management are required. Sleep disturbances may be precipitated by trauma, but appear to transition into an independent condition that requires targeted treatment. A directional relationship has been found between sleep disturbances and PTSD. Sleep problems, particularly nightmares, do not remit after PTSD treatment.19 Conversely, psychologic sleep treatment appears to reduce PTSD symptoms,20 highlighting the importance of targeted sleep treatment for patients with PTSD.
There are highly efficacious behavioral interventions available for both insomnia and nightmares (Table 2). Cognitive-behavioral therapy for insomnia is effective in patients with a wide range of psychiatric and medical conditions, including PTSD.21 Imagery rehearsal therapy, a form of cognitive therapy targeting nightmares, is recommended for treatment of PTSD-related nightmares.22 Clinical trials have reported good results combining these therapies to simultaneously address nightmares and insomnia in patients with PTSD.20 There are currently no clinical guidelines for sequencing or combining PTSD and sleep treatments, but initial research suggests treating sleep could be a preparatory step for PTSD treatment.23 In addition, improved sleep may enhance the efficacy of PTSD-focused treatments that involve cognitive processing and conditioned learning.14
Targeted Treatments for Sleep Disturbance in PTSD
Antidepressant medications, including the selective serotonin reuptake inhibitors (SSRIs) and the selective norepinephrine and serotonin inhibitors (SNRIs), are used to treat daytime symptoms of PTSD.24 Two SSRIs, paroxetine and sertraline, are approved for daytime symptoms, although there is little evidence that they are better than other SSRIs. Often, SSRIs and SNRIs worsen insomnia symptoms in patients with PTSD.25
The pharmacology algorithm project at the Harvard South Shore program recommended sleep evaluation and treatment first before the use of an antidepressant medication for the daytime symptoms of PTSD.24 The authors argued that sleep disturbance is one of the core symptoms of PTSD and often a major source of distress. In addition, sleep deprivation may worsen core daytime PTSD symptoms.
Fluvoxamine is the only SSRI that showed improvement in “subjective sleep quality” in one study.26 Zolpidem was also found to be useful for insomnia in patients with PTSD in a few case reports.27 In a randomized, placebo-controlled study, eszopiclone showed greater improvement in PTSD symptoms, including sleep disturbance.28 Trazodone (an antidepressant) is often used in low doses to treat insomnia in patients with depression and PTSD. In one study of Vietnam veterans, trazodone improved sleep over a period of 2 to 3 months.29
Prazosin, an alpha-1 adrenergic receptor antagonist, has been widely used to treat nightmares in patients with PTSD.24 In the first placebo-controlled trial of prazosin in veterans with nightmares related to PTSD, there was a decrease in nightmares and an improved quality of sleep.30 Prazosin is generally well tolerated but can cause hypotension and dizziness. Prazosin must be administered regularly to avoid recurrence of nightmares. Prazosin is the only pharmacologic intervention that is recommended by the American Academy of Sleep Medicine for the use in treatment of nightmares.
The prevalence and associated distress of sleep disturbances comorbid with PTSD highlight the need for mental health providers and sleep clinicians to collaboratively provide evidence-based treatment for trauma-exposed populations. Continuing to educate providers about the effect of trauma on sleep and best-practice guidelines for treatment of sleep disturbances in PTSD will be crucial for improving sleep in trauma-exposed populations and potentially improving non–sleep-related symptoms.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
- Giosan C, Malta LS, Wyka K, et al. Sleep disturbance, disability, and posttraumatic stress disorder in utility workers. J Clin Psychol. 2015;71(1):72–84. doi:10.1002/jclp.22116 [CrossRef]
- Smith MT, Huang MI, Manber R. Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders. Clin Psychol Rev. 2005;25(5):559–592. doi:10.1016/j.cpr.2005.04.004 [CrossRef]
- Harvey AG, Jones C, Schmidt DA. Sleep and posttraumatic stress disorder: a review. Clin Psychol Rev. 2003;23(3):377–407. doi:10.1016/S0272-7358(03)00032-1 [CrossRef]
- Spoormaker VI, Montgomery P. Disturbed sleep in post-traumatic stress disorder: secondary symptom or core feature?Sleep Med Rev. 2008;12(3):169–184. doi:10.1016/j.smrv.2007.08.008 [CrossRef]
- Neylan TC, Marmar CR, Metzler TJ, et al. Sleep disturbances in the Vietnam generation: findings from a nationally representative sample of male Vietnam veterans. Am J Psychiatry. 1998;155(7):929–933. doi:10.1176/ajp.155.7.929 [CrossRef]
- Leskin GA, Woodward SH, Young HE, Sheikh JI. Effects of comorbid diagnoses on sleep disturbance in PTSD. J Psychiatr Res. 2002;36(6):449–452. doi:10.1016/S0022-3956(02)00025-0 [CrossRef]
- Krakow B, Schrader R, Tandberg D, et al. Nightmare frequency in sexual assault survivors with PTSD. J Anxiety Disord. 2002;16(2):175–190. doi:10.1016/S0887-6185(02)00093-2 [CrossRef]
- Krakow BJ, Ulibarri VA, Moore BA, McIver ND. Posttraumatic stress disorder and sleep-disordered breathing: a review of comorbidity research. Sleep Med Rev. 2015;24:37–45. doi:10.1016/j.smrv.2014.11.001 [CrossRef]
- Mellman TA, Kulick-Bell R, Ashlock LE, Nolan B. Sleep events among veterans with combat-related posttraumatic stress disorder. Am J Psychiatry. 1995;152(1):110–115. doi:10.1176/ajp.152.1.110 [CrossRef]
- Ohayon MM, Shapiro CM. Sleep disturbances and psychiatric disorders associated with posttraumatic stress disorder in the general population. Compr Psychiatry. 2000;41(6):469–478. doi:10.1053/comp.2000.16568 [CrossRef]
- Mysliwiec V, O'Reilly B, Polchinski J, Kwon HP, Germain A, Roth BJ. Trauma associated sleep disorder: a proposed parasomnia encompassing disruptive nocturnal behaviors, nightmares, and REM without atonia in trauma survivors. J Clin Sleep Med. 2014;10(10):1143–1148.
- Kobayashi I, Boarts JM, Delahanty DL. Polysomnographically measured sleep abnormalities in PTSD: a meta-analytic review. Psychophysiology. 2007;44(4):660–669. doi:10.1111/j.1469-8986.2007.537.x [CrossRef]
- Germain A. Sleep disturbances as the hallmark of PTSD: where are we now?Am J Psychiatry. 2013;170(4):372–382. doi:10.1176/appi.ajp.2012.12040432 [CrossRef]
- Straus LD, Drummond SP, Nappi CM, Jenkins MM, Norman SB. Sleep variability in military-related PTSD: a comparison to primary insomnia and healthy controls. J Trauma Stress. 2015;28(1):8–16. doi:10.1002/jts.21982 [CrossRef]
- Germain A, Buysee DJ, Nofzinger E. Sleep-specific mechanisms underlying posttraumatic stress disorder: integrative review and neuorbiological hypotheses. Sleep Med Rev. 2008;12:185–195. doi:10.1016/j.smrv.2007.09.003 [CrossRef]
- Walker MP, van der Helm E. Overnight therapy? The role of sleep in emotional brain processing. Psychol Bull. 2009;135(5):731–748. doi:10.1037/a0016570 [CrossRef]
- Pace-Schott EF, Germain A, Milad MR. Effects of sleep on memory for conditioned fear and fear extinction. Psychol Bull. 2015;141(4):835–857. doi:10.1037/bul0000014 [CrossRef]
- Gutner CA, Casement MD, Stavitsky Gilbert K, Resick PA. Change in sleep symptoms across cognitive processing therapy and prolonged exposure: a longitudinal perspective. Behav Res Ther. 2013;51(12):817–822. doi:10.1016/j.brat.2013.09.008 [CrossRef]
- Ulmer CS, Edinger JD, Calhoun PS. A multi-component cognitive-behavioral intervention for sleep disturbance in veterans with PTSD: a pilot study. J Clin Sleep Med. 2011;7(1):57–68.
- Talbot LS, Maguen S, Metzler TJ, et al. Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial. Sleep. 2014;37(2):327–341.
- Aurora RN, Zak RS, Auerbach SH, et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010;6(4):389–401.
- Baddeley JL, Gros DF. Cognitive behavioral therapy for insomnia as a preparatory treatment for exposure therapy for posttraumatic stress disorder. Am J Psychother. 2013;67(2):203–214.
- Bajor LA, Ticlea AN, Osser DN. The Psychopharmacology Algorithm Project at the Harvard South Shore Program: an update on posttraumatic stress disorder. Harv Rev Psychiatry. 2011;19(5):240–258. doi:10.3109/10673229.2011.614483 [CrossRef]
- Brownlow JA, Harb GC, Ross RJ. Treatment of sleep disturbances in post-traumatic stress disorder: a review of the literature. Curr Psychiatry Rep. 2015;17(6):41. doi:10.1007/s11920-015-0587-8 [CrossRef]
- Neylan TC, Metzler TJ, Schoenfeld FB, et al. Fluvoxamine and sleep disturbances in posttraumatic stress disorder. J Trauma Stress. 2001;14(3):461–467. doi:10.1023/A:1011100420978 [CrossRef]
- Dieperink ME, Drogemuller L. Zolpidem for insomnia related to PTSD. Psychiatr Serv. 1999;50(3):421. doi:10.1176/ps.50.3.421 [CrossRef]
- Pollack MH, Hoge EA, Worthington JJ, et al. Eszopiclone for the treatment of posttraumatic stress disorder and associated insomnia: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2011;72(7):892–897. doi:10.4088/JCP.09m05607gry [CrossRef]
- Hertzberg MA, Feldman ME, Beckham JC, Davidson JR. Trial of trazodone for posttraumatic stress disorder using a multiple baseline group design. J Clin Psychopharmacol. 1996;16(4):294–298. doi:10.1097/00004714-199608000-00004 [CrossRef]
- Raskind MA, Peskind ER, Kanter ED, et al. Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: a placebo-controlled study. Am J Psychiatry. 2003;160(2):371–373. doi:10.1176/appi.ajp.160.2.371 [CrossRef]
Sleep Disturbances Associated with PTSD
Periodic leg movements
Disruptive nocturnal behaviors (night sweats, dysphoric dreams, and dream enactment)
Targeted Treatments for Sleep Disturbance in PTSD
| IRT for nightmares
| Combination of CBT-I and IRT
| Hypnotic medications (eg, or zolpidem to treat insomnia)
| Prazosin to treat nightmares