Sleep Problems and PTSD

Almost everyone with PTSD reports sleep problems. In fact, trouble sleeping is the main reason that people first go to a doctor to get help for PTSD. Both insomnia—trouble falling or staying asleep—and nightmares are PTSD symptoms. The good news is there are evidence-based treatments that can help with PTSD and sleep problems. And, these treatments help whether your sleep problems began before a traumatic event or only came about after the trauma.

Why is sleep important?

Both how well (quality) and how much (quantity) a person sleeps are important.

Poor sleep may lead to:

• Slow reaction time

• Trouble with learning and memory

• Feeling irritable and mood problems

• Trouble with thinking and concentration

• Thinking about suicide or acting in ways that self-harm

Also, sleep problems that last a long time are related to medical problems such as heart disease, depression, kidney disease, high blood pressure, diabetes, obesity, and stroke.

How does PTSD affect sleep?

Both nightmares and insomnia are symptoms of PTSD. Nightmares are often a replay of the traumatic event; and, if the dreams cause kicking and screaming, bed partners can be affected too. Nightmares can also make it difficult to fall back asleep. Insomnia is when a person has trouble falling or staying asleep at least 3 nights a week. This lack of sleep continues for a few months or more and is severe enough to cause problems at work and at home.

Because people with PTSD may try to push away trauma memories during the day, it may cause worries to get worse at night and disrupt sleep. Here are some examples:

• Avoidance. People with PTSD may avoid going to sleep. Nightmares and flashbacks—feeling like the trauma is happening again—can create fear or feeling as if going to bed is unsafe.

• Loss of sleep time. Whether or not insomnia is diagnosed, people with PTSD often report less sleep due to problems falling asleep, being restless during the night and waking up earlier than wanted. Even brief periods of sleep loss can affect daily life.

• Increased arm and leg movement. After a trauma, people may have more arm and leg movements during sleep. This can make someone feel restless.

• Talking during sleep. After a trauma, people may talk more in their sleep. Talking during sleep can affect bed partners.

• Feeling "on alert." People with PTSD may feel the need to be on guard, to protect themselves from danger. It is difficult to have restful sleep when you feel the need to be always alert or are startled easily by noise.

• Not liking silence. Some may be uneasy with silence after a trauma. When this happens, a person may keep a TV on all night. Changes in light and sound can disrupt the deepest and most needed level of sleep.

What is the relationship between PTSD, sleep problems, and substance use?

Sleep problems may become their own disorders that cause distress. As a result, some will use substances such as alcohol, marijuana, or other drugs to fall asleep. Over time, drug and alcohol use can also have negative effects on sleep quality and on overall health and functioning.

What is the best treatment for sleep problems?

The best treatment for insomnia is Cognitive Behavioral Therapy for Insomnia (CBT-I). This talk therapy is recommended over medicine because it is more effective. CBT-I has been shown to work in multiple research studies—and has fewer side effects than medicine. CBT-I improves sleep in 7 out of 10 people who complete it. Research also shows that CBT-I reduces how many nightmares people have and the distress related to upsetting dreams.

How does CBT-I work?

CBT-I focuses on a person's beliefs, feelings, and behaviors that affect sleep. A trained CBT-I therapist may offer the treatment in one-on-one appointments or to a group of people with insomnia. It usually lasts 6 sessions. CBT-I can be delivered in person or through video medical appointments. There are also online programs and an app—CBT-I Coach—designed to help with the treatment.

Sleep hygiene and CBT-I

Sleep hygiene includes various practices and habits that are important for good sleep. It includes tips to change behaviors that may get in the way with sleep. For example, you may limit drinks with caffeine before bedtime to help you fall asleep more easily. Or you may need to make changes to your sleep environment to be more comfortable, such as limiting smartphone use or watching TV in bed. CBT-I, on the other hand, is a more focused treatment for chronic insomnia. Sleep hygiene is not the same as CBT-I treatment, but it is often included as a part of CBT-I.

What are the pros and cons of using sleep medicine?

Sleep medicine is easy to take and usually provides quick, temporary relief. There are many different types of medicines used for sleep, from herbal supplements and over-the-counter sleep aids to prescription medicines. If you choose to take medicine, you should be familiar with the side effects and risks before you take it.

Sleep medicine side effects usually include daytime drowsiness, dizziness, and confusion. It is often recommended for short-term use only (2 to 4 weeks). These medicines usually become less helpful over time and don't get to the core cause of sleep problems.

Certain prescription sleep medicines can cause serious side effects with long-term use.

Sleep medicines can include:

• Benzodiazepines such as alprazolam, clonazepam, diazepam, or lorazepam

• Nonbenzodiazepines (or "Z-drugs") such as zolpidem, eszopiclone, and zaleplon

Learn more about benzodiazepines and PTSD. Although benzodiazepines (benzos) can make people feel calm, relaxed, or sleepy, they can become a problem in the long-run, and are not recommended for PTSD treatment.

Compare your treatment options

What other sleep problems affect people with PTSD?

Sleep apnea is common among people with PTSD, particularly in Veterans. Sleep apnea is a breathing problem that disrupts normal sleep. People with sleep apnea may wake up not feeling rested and struggle with feeling tired or needing to sleep during the daytime.

Being aware of sleep apnea can be difficult. There are many causes of fatigue or feeling tired during the day. Also, with sleep apnea, breathing pauses (or disruptions) happen during sleep, so a person may be unaware of those symptoms. Often a bed partner notices those breathing changes or snoring first.

To diagnose sleep apnea, your health care team may recommend a sleep study. Treatment can include lifestyle changes and use of a breathing device (continuous positive airway pressure (CPAP) machine) at night. Research suggests that for those with PTSD and sleep apnea, using a CPAP device may benefit PTSD treatment.

PTSD and sleep

With PTSD, it can take some time and effort to get good sleep. Using marijuana, alcohol, and street drugs to manage PTSD or sleep problems is related to a higher risk of thinking about suicide and suicide attempts. There are effective treatments available for sleep problems and PTSD. Work with your health care team to learn about your treatment options and decide on the best fit for your needs.