Nightmares can happen to anyone. While disturbing, most individuals can fall back to sleep. It is quite a different story for those who suffer from post-traumatic stress disorder (PTSD). Not only do these individuals live with distressing symptoms during their waking hours, but up to 72% also experience persistent nightmares. PTSD related nightmares can cause insomnia and further worsen other PTSD symptoms.
Knowing why and how PTSD and nightmares occur can help broaden the understanding of this condition, as well as pave the way for effective treatment for those who suffer from PTSD nightmares.
How PTSD Affects Sleep
Sleep is essential to healthy human functioning and without it, the brain cannot function or complete necessary tasks. However, obtaining a full night of sleep with PTSD can be a challenge for many. Researchers are not sure what the exact relationship is between nightmares and PTSD, but they both appear to be related to altered activity in the same region of the brain. In comparison to those without PTSD, the overall sleep quality of individuals with PTSD and nightmares is lower, with noted decreases in sleep time and increased nighttime awakenings.
A typical full night of sleep consists of both rapid eye movement (REM) and non-REM sleep. In one night, people cycle several times through these stages, with increasingly longer and deeper REM periods of sleep toward the early morning hours. PTSD sleep issues and nightmares can occur during any of these sleep stages but tend to more frequently occur during the latter part of the night. Frequent disruptions due to PTSD can cause sleep deprivation and feelings of helplessness in those it affects.
While PTSD and sleep disorders are two distinct conditions, one cannot be treated without addressing the other when they occur together. The effects of PTSD alone are enough to significantly impact an individual’s quality of life, but sleep deprivation due to nightmares can introduce additional health risks such as obesity, heart disease, diabetes and shortened life expectancy.
The Impact of Nightmares on PTSD
Nightmares are considered a central feature of PTSD. While a generic nightmare may feel extreme and life-threatening, it is usually unrelated to actual events. PTSD nightmares, however, are usually directly related to a previously experienced, traumatic event. For veterans, an example of a PTSD nightmare usually involves the replaying of traumatic events they witnessed or took part in. Similar to civilians who suffer from PTSD, their nightmares could be a replay of the traumatic event, such as physical abuse or violence.
One sleep therapist described what PTSD nightmares are like based on the experience of their clients. They involved a replay of traumatic and vivid images, such as being knocked over by blown up body parts of a close friend, seeing the face of a person they killed in battle, or seeing the same image over and over again, such as what occurred with many people who witnessed the terrorist attacks of 9/11.
The trauma of reliving these nightmares causes many to dread or fear sleep. The avoidance of sleep in combination with an already inefficient sleep cycle causes many to become irritable and affects family, professional and social life. In one study, the risk of becoming suicidal or having suicidal thoughts was three times more likely in PTSD sufferers. With the addition of nightmares, individuals can be made to feel defeated and hopeless, contributing to the risk for suicidal ideation.
In contrast to waking hours, where triggers can be clearly seen and often avoided by those with PTSD, nightmares occur irrespective of triggers and can persist even decades after the trauma originally occurred. Researchers have also noted that once nightmares are present, they can increase the rate at which PTSD progresses.
Treating Sleep Disorders in People with PTSD
The most appropriate treatment for PTSD nightmares varies from person to person and is determined by the individual and the provider’s assessment of the severity of the nightmares, and access to treatment options. After a thorough assessment of the individual’s life experiences and symptoms, a treatment plan can be initiated to help them overcome PTSD nightmares. There are currently many types of treatment available to help people cope with PTSD, including image rehearsal therapy, cognitive behavioral therapy, EMDR therapy and medication.
Image Rehearsal Therapy
Image rehearsal therapy is a preferred treatment for post-traumatic nightmares. The recurring nightmare is rehearsed during the day and altered into a new scene with a different ending. The newly modified script is to be rehearsed on a daily basis with the goal of removing the fear factor within the nightmares and replacing it with something more positive. This form of therapy typically lasts for 12 weeks and can be done in an individual or group format. In one study, 60% experienced a reduction in nightmares and PTSD symptoms.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is often used to identify and adjust distorted thoughts and emotions and the behaviors they lead to. There are now specific techniques of CBT for nightmares related to PTSD. These include:
- Image rehearsal therapy
- Lucid dreaming therapy
- Sleep dynamic therapy
- Self-exposure therapy
- Systematic desensitization
These CBT techniques can be used in combination or alone, though future research is needed to determine the best practice for nightmares related to trauma.
Eye movement desensitization and reprocessing (EMDR) therapy is an intervention that incorporates several different therapies and techniques into one. The idea behind EMDR is that nightmares, or the remembrance of a disturbing event, have not been completely processed in the brain but are retained in a dysfunctional form. Through EMDR a person is made to recall distressing images while performing a type of bilateral sensory input such as side to side eye movement or hand tapping. By doing these in tandem, the working memory becomes overloaded and emotional arousal and imagery decreases.
Noted physiologic and emotional changes seen during this type of therapy include synchronized respirations and a lowered heart rate, indicative of relaxation. EMDR for PTSD has shown positive and promising results, with one study demonstrating a reduction in the severity of nightmares in comparison to other interventions.
Medication for PTSD nightmares has been studied, though the small number of controlled trials limit what guidelines are in place. One such medication that has been studied and is recommended for PTSD is prazosin. Initially introduced as an antihypertensive medication, prazosin reduces the central nervous system’s (CNS) sympathetic output. This is significant for those with PTSD who typically experience elevated CNS activity. There have been many controlled studies thus far with prazosin, and the effects have included an increase in total sleep time and increased REM sleep time. In all the studies, prazosin had moderate to strong benefits on the participants, with a significant reduction in PTSD nightmares.
Other proposed PTSD nightmare medications include:
Preventing PTSD Nightmares
While PTSD nightmares can occur regularly and persistently, there are some simple steps people can incorporate to help prevent PTSD nightmares.
- Creating a comfortable and safe sleeping space: Practicing good sleep hygiene involves setting adequate time for sleep and avoiding electronic devices or blue light that can add to insomnia.
- Sleeping when needed and avoiding forcing sleep: Taking naps during the day is okay. It’s also okay to get up at night when sleep is not coming easily. Engaging in a quiet activity until becoming sleepy is much better than forcing oneself to sleep and adding more stress to an already stressful situation.
- Avoiding alcohol and drugs: Turning to alcohol or drugs to forget the pain associated with trauma can only add to the problem. When faced with the stress of those negative feelings, try a form of exercise to release stress, such as walking, running or yoga.
If you want to help someone with PTSD nightmares, offering support in practical ways can be of the most benefit. Being available to listen or act as a companion for some activity can be of great encouragement to a person with PTSD.
Summing Up: PTSD Nightmares
PTSD nightmares can be scary, but they don’t have to be a regular, nightly feature. With many forms of therapy available, it is possible to welcome sleep instead of avoiding it. Much of the research done on nightmares is directly related to PTSD and the results show much promise.
Current therapies and medications to keep in mind when considering treatment for PTSD include:
- Prazosin: A medication that decreases CNS output
- Image Rehearsal Therapy: A form of therapy that rewrites the original story of trauma to include a positive ending
- EMDR Therapy: A form of therapy that helps to lessen arousal associated with traumatic memories
If you or someone you know struggles with PTSD nightmares and uses alcohol or other substances to cope, know you are not alone. Contact The Recovery Village today to speak to a representative and discuss a treatment plan appropriate for you.
El-Solh, Ali A. “Management of nightmares in patients with posttraumatic stress disorder; current perspectives.” Nature and Science of Sleep, November 26, 2018. Accessed June 28, 2019. NHS. “Why lack of sleep is bad for your health.” Last reviewed May 30, 2018. Accessed June 28, 2019. Aurora, R. Nisha; et al. “Best Practice Guide for the Treatment of Nightmare Disorder in Adults.” Journal of Clinical Sleep Medicine, August 15, 2010. Accessed June 29, 2019.
El-Solh, Ali A. “Management of nightmares in patients with posttraumatic stress disorder; current perspectives.” Nature and Science of Sleep, November 26, 2018. Accessed June 28, 2019.
NHS. “Why lack of sleep is bad for your health.” Last reviewed May 30, 2018. Accessed June 28, 2019.
Aurora, R. Nisha; et al. “Best Practice Guide for the Treatment of Nightmare Disorder in Adults.” Journal of Clinical Sleep Medicine, August 15, 2010. Accessed June 29, 2019.