By: Shana Hansen, Lt. Col., USAF, MC, and Shannon N. Foster, Major, USA, MC on July 6th, 2020
Sleep Disturbances Associated With Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) is a trauma and stress-related disorder characterized by re-experiencing, avoidance, hyperarousal and negative alterations in cognition or mood.1 Events that involve threat to integrity of self or others such as rape, physical assault, natural disasters and combat exposure are commonly associated with the development of PTSD.1 The lifetime prevalence of PTSD among adults in the United States ranges from 6-10%,2,3 with women being more than twice as likely to have PTSD at some point.
Significantly higher estimates have been reported in combat veterans (15-30%).4 Rates of PTSD in veterans are higher if they were stationed in combat zones, had tours of longer than one year, experienced combat or were injured. Specifically, among veterans with deployments to Iraq and Afghanistan, 31-86% report multiple traumatic combat exposures and 11-20% endorse significant PTSD symptoms.5,6
Sleep Disturbances Associated With PTSD
Following traumatic experiences, sleep complaints are common. Subjective and objective sleep disturbances are associated with an increased risk of meeting PTSD diagnostic criteria,7 and insomnia and nightmares are core diagnostic features of PTSD.1 Sleep terrors, sleep avoidance, nocturnal anxiety, acting out dreams, and increased motor behaviors and vocalizations are also frequently reported by PTSD patients.8,9 These sleep disturbances are known to exacerbate daytime symptoms and contribute to worsened clinical outcomes.10,11 This stresses the importance of monitoring for the development of sleep disturbances in patients with trauma history and the role they may have as mediators for clinical outcomes in PTSD. Sleep disturbances in this population are often resistant to first-line PTSD treatment.12 Sleep-specific interventions are commonly employed to alleviate insomnia and nightmares. Effective treatment has been associated with improved daytime PTSD symptoms, depression, quality of life and subjective physical health.13,14,15
Nightmares are characterized by disturbing, well-remembered dreams that cause distress or daytime impairment (ICSD-3). Nightmares in the general population are not uncommon, with up to 85% of adults reporting at least one nightmare per year.16 In patients with PTSD and psychiatric disorders, occurrence of nightmares is much more common.17
Additionally, nightmares are associated with an increased risk of suicidal ideation.18,19 Despite this, nightmares are frequently under-reported by patients and thus under-recognized by clinicians.17 The high prevalence of PTSD and psychiatric disorders in military personnel leads to an even higher rate of nightmares. In military personnel referred for a sleep evaluation, nightmares at least weekly were reported in 31%, which is significantly higher than the general population of 0.9-6.8%.17
Treatment options for nightmares include a combination of behavioral techniques and medical therapy. Imagery rehearsal therapy (IRT) is a technique where patients are taught to “rescript” their nightmares and thus unlearn the behavior.20 This therapy has been successful in combat veterans as well civilian trauma victims.13,21 A variation of IRT, called exposure, rescripting and relaxation therapy (ERRT) incorporates aspects of traditional cognitive behavioral therapy (CBT) with IRT.22 A combination of CBT for insomnia and IRT shows promising short-term effects in veterans with PTSD.23 Finally, pharmacologic therapy with prazosin or positive airway pressure (PAP) therapy in patients with obstructive sleep apnea (OSA) can also be successful in nightmare patients.24,25
Trauma-associated sleep disorder
In a subset of PTSD patients, trauma-related nightmares (TRN) are accompanied by parasomnias.26 Trauma-associated sleep disorder (TSD) is a recently proposed unique parasomnia that describes the clinical features of TRNs in association with disruptive nocturnal behaviors (DNBs).27,28
DNBs consist of abnormal vocalizations (screaming, groaning) and movements (thrashing, turning, sleepwalking) as well as combative behaviors (striking or kicking bed partner). It is not uncommon for the DNBs to mimic nightmare content. Autonomic hyperarousal signs (increased heart rate, quickened breathing, night sweats) are often linked with these behaviors.
Polysomnogram (PSG) evaluation commonly shows dream re-enactment behavior and increased muscle activity during REM (REM without atonia). Nightmares are almost universally reported in these patients.28 TSD may also present along with insomnia and OSA. Therefore, in patients who present with symptoms of TSD, a PSG is recommended to look for sleep disordered breathing (SDB) in addition to evaluating whether the patient has abnormal REM behavior and/or movements.
Currently, no evidenced-based guidelines for treatment of this newly proposed sleep disorder are available. Obtaining an adequate quantity of sleep, avoiding triggers and promoting a safe sleep environment are critical. In some cases, medical therapy to suppress these events may be necessary. Some patients respond well to a combined treatment with prazosin for nightmares and DNB, behavioral therapy for insomnia and PAP therapy for OSA.29
Insomnia is the most common sleep complaint in civilian as well as military populations (MSMR 2013). It is also the most reported symptom among service members returning from deployment and in combat veterans with PTSD.30 Up to 74% of combat veterans with PTSD meet clinical criteria for insomnia.31
In addition, veterans who have experienced sexual trauma have higher rates of insomnia symptoms (61%) than veterans who did not experience trauma (53%).32 Insomnia is associated with higher PTSD severity and does not tend to resolve spontaneously over time.31
Treatment options for insomnia in patients with PTSD are similar to those for the general population. However, insomnia in PTSD patients can be complicated by their symptoms of PTSD as well as comorbid sleep disorders and unhealthy sleep practices. CBT improves sleep quality as well as daytime PTSD symptoms in this population.33 In addition, combined therapy of CBT and IRT can be beneficial in those patients with comorbid nightmares.23 There are currently no evidence-based guidelines on pharmacologic treatment of insomnia in the PTSD population due to lack of quality studies.33
While PSG is not routinely recommended by the American Academy of Sleep Medicine (AASM) in chronic insomnia patients, patients with PTSD have high rates of comorbid sleep disorders, such as OSA and periodic limb movement disorders.13,34 PSG should be considered in PTSD patients with insomnia, especially if standard insomnia treatment fails.26
Sleep disordered breathing
While insomnia and nightmares have been the most frequently reported sleep symptoms in PTSD literature, recently more attention has been given to the prevalence and significance of SDB in PTSD patients. SDB, most commonly in the form of OSA, affects 9-38% of the adult population,35,36 with higher estimates among men, the elderly and obese populations. In addition, OSA rates of up to 60-85% have been reported in military samples.37,38
Further, recent literature indicates that individuals with PTSD have a disproportionately higher rate of SDB than the general population,39,40 with rates of co-morbid PTSD and OSA (15-90%) being reported, depending on diagnostic methodology used. Krakow et, al. proposed a novel hypothesis involving a bidirectional pathway to explain why high rates of sleep breathing disorders among PTSD patients have been observed.40 In this pathway, the sleep fragmentation (nightmares, insomnia) seen in PTSD affects the airway, causing upper airway collapsibility and SDB events. These events further fragment sleep, leading to exacerbation of insomnia and nightmares, which worsens overall PTSD symptoms.
This may have clinical implications for a subgroup of PTSD patients who also suffer from SDB, and more research is needed in order to clarify best diagnostic and treatment practices. Studies evaluating treatment in patients with comorbid PTSD and SDB suggest that positive airway pressure therapy may improve sleep by decreasing sleep fragmentation and nightmares.41, 24
Unfortunately, patients with PTSD typically have suboptimal PAP adherence.42,43 Due to the potential adverse outcomes of comorbid mental illness and sleep disorders, including suicide, interventions should begin early.44
Sleep disturbances are prevalent in patients with PTSD and are often resistant to standard first-line treatments. This can lead to worsening of PTSD symptoms and poorer clinical outcomes. Insomnia and nightmares are the most commonly reported sleep problems in patients with PTSD and treatment consists of a combination of behavioral methods and pharmacologic therapy. TSD is a newly described parasomnia that can occur in some patients with PTSD. OSA prevalence is higher in PTSD patients than the general population. Thus, PSG should be considered in PTSD patients with sleep disturbances, especially if resistant to initial treatment. PAP therapy can improve daytime functioning as well as PTSD symptoms, but compliance is generally low. Evaluation and treatment of sleep disorders should be an integral part of PTSD treatment in order to limit their adverse effect on daytime symptoms and overall functioning.
Shana Hansen, Lt. Col., USAF, MC, and Shannon N. Foster, Major, USA, MC, work at the Wilford Hall Ambulatory Surgical Center’s Sleep Disorders Center at Lackland Air Force Base in San Antonio, Texas.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-V), 5th ed. Arlington, VA: American Psychiatric Association: 2013.
- Harvard Medical School, 2007. National Comorbidity Survey (NCS). (2017, August 21). Retrieved from https://www.hcp.med.harvard.edu/ncs/index.php.
- Kilpatrick D, Resnick H, Milanak M, et al. National estimates of exposure to traumatic events and prevalence using DSM-IV and DSM-5 Criteria. J of Trauma Stress. 2013;26(5):537-54.
- Weiss D, Marmar C, Schlenger W, et al. The prevalence of lifetime and partial post-traumatic stress disorder in Vietnam theater vetarans. J Trauma Stress 1992;5:365-76.
- Ramchand R, Schell TL, Karney BR, Osilla KC, Burns RM, Caldarone LB. Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: possible explanations. J Trauma Stress. 2010;23(1):59–68.
- Hoge C, Castro C, Messer S, etc al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351(1):13-22.
- Koren D, Arnon I, Lavie P, et al. Sleep complaints as early predictors of posttraumatic stress disorder: a 1-year prospective study of injured survivors of motor vehicle accidents. Am J Psychiatry 2002;159(5):855-7.
- Germain A, Hall M, Krakow B, et al. A brief sleep scale for posttraumatic stress disorder: Pittsburgh Sleep Quality Index Addendum for PTSD. J Anxiety Disord 2005;19(2)233-44.
- Krakow B, Melendrez D, Pederson B, et al. Complex insomnia: insomnoia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD. Biol Psychiatry 2001;49(11):948-53.
- Krakow B, Artar A, Warner T, et al. Sleep disorder, depression, and suicidality in female sexual assault survivors. Crisis 2000;21(4):163-70.
- Krakow B, Melendrez D, Johnston L, et al. Sleep-disordered breathing, psychiatric distress, and quality of life impairment in sexual assault survivors. J Nerv Ment Dis 2002;190(7):442-52.
- Zayfert C, DeViva J. Residual insomnia following cognitive3 behavioral therapy for PTSD. J Trauma Stress 2004;17(1):69-73.
- Krakow B, Hollifield M, Johnston L, et al. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA 2001;286(5)537-45.
- Raskind M, Peskind E, Kanter E, et al. Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: a placebo-controlled trial. Am J Psychiatry 2003;160(2):371-3.
- Germain A, Shear MK, Hall M, et al. Effecgts of a brief behavioral treatment for PTSD-related sleep disturbances: a pilot study. Behav Res Ther 2007;45:627-32.
- Levin R, Nielsen TA. Disturbed dreaming, posttraumatic stress disorder, and affect distress: a review and neurocognitive model. Psychol Bull. 2007;133(3):482-528.
- Creamer JL, Brock MS, Matsangas P, et al. Nightmares in United States Military Personnel with sleep disturbances. J Clin Sleep Med. 2018;14(3):419-426.
- Lande RG. Sleep problems, posttraumatic stress, and mood disorders among active-duty service members. J AM Osteopath Assoc. 2014;114(2):83-89.
- Nadorff MR, Nazem S, Fiske A. Insomnia symptoms, nightmares, and suicidal ideation in a college student sample. Sleep. 2011;34(1):93-98.
- Kellner R, Singh G, Irigoyen-Rascon F. Rehearsal in the treatment of recurring nightmares in post-traumatic stress disorders and panic disorders: case histories. Ann Clin Psychiatry 1991;3:67-71.
- Nappi CM, Drummond SPA, Thorp SR, McQuaid JR. Effectiveness of imagery rehearsal therapy for the treatment of combat-related nightmares in veterans. Behav Ther 2010;41:237-44.
- Davis J, Wright DC. Randomized clinical trial for treatment of chronic nightmares in trauma-exposed adults. J Trauma Stress 2007;20:123-33.
- 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.
- Tamanna S, Parker JD, Lyons J, Ullah MI. The effect of continuous positive air pressure (CPAP) on nightmares in patients with posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA). J Clin Sleep Med 2014;10(6):631-636.
- Raskind MA, Thompson C, Petrie EC, et al. Prazosin reduces nightmares in combat veterans with posttraumatic stress disorder. J Clin Psychiatry. 2002;63(7):565-568.
- Wallace DM, Shafazand S, Ramos AR, et al. Insomnia characteristics and clinical correlates in Operation Enduring Freedom/Operation Iraqi Freedom veterans with post-traumatic stress disorder and mild traumatic brain injury: an exploratory study. Sleep Med. 2011;12(9):850-859.
- 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.
- Mysliwiec V, Brock M, Creamer J, et al. Trauma associated sleep disorder: A parasomnia induced by trauma. Sleep Med Reviews 2018;37:94-104.
- Kaminer H, Lavie P. Sleep and dreaming in Holocaust survivors dramatic decrease in dream recall in well-adjusted survivors. J Nerv Ment Dis 1991;179(11):664-9.
- McLay, R. N., Klam, W. P., & Volkert, S. L. (2010). Insomnia is the most commonly reported symptom and predicts other symptoms of post-traumatic stress disorder in US service members returning from military deployments. Military medicine, 175(10), 759-762.
- Pigeon WR, Campbell CE, Possemato K, Ouimette P. Longitudinal relationships of insomnia, nightmares, and PTSD severity in recent combat veterans. J Psych Res. 2013;75:546-550.
- Jenkins M, Colvonen P, Norman S, et al. Prevalence and mental health correlates of insomnia in first-encounter veterans with and without military sexual trauma. Sleep. 2015;38(10):1547-54.
- Nappi CM, Drummond S, Hall J. Treating nightmares and insomnia in posttraumatic stress disorder: a review of current evidence. Neuropharm. 2012;62(2):576-585.
- Capaldi V, Guerrero M, Killgore W. Sleep disruptions among returning combat veterans from Iraq and Afghanistan. Mil Med. 2011;176(8):879.
- Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328(17):1230-5.
- Senaratna C, Perret J, Lodge C, et al. The prevalence of obstructive sleep apnea in the general population: a systematic review. Sleep Med Reviews 2017;34:70-81.
- Mysliwiec V, Gill J, Lee H, et al. Sleep disorders in US Military Personnel: a high rate of comorbid insomnia and obstructive sleep apnea. Chest. 2013;144(2):549-557.
- Foster S, Capener, D, Hansen H, et al. Gender differences in sleep disorders in the US military. Sleep Health 2017;3(5):336-41.
- van Liempt S, Westenberg H, Arends J, et al. Obstructive sleep apnea in combat-related posttraumatic stress disorder: a controlled polysomnography study. Eur J Psychotraumatol 2001. Epub.
- Yesavage J, Kinoshita L, Kimball T et al. Sleep-disordered breathing in Vietnam veterans with posttraumatic stress disorder. Am J Geriatr Psychiatry 2012:20(3):199-204.
- Krakow B, Ulibarri V, Moore B, et al. Posttraumatic stress disorder and sleep-disordered breathing: a review of comorbidity of research. Sleep Med Reviews 2015;24:37-45.
- Amin M, Gold M, Gold A. The effect of nasal continuous positive airway pressure (nasal CPAP) on nightmares in patients with posttraumatic stress disorder (PTSD) symptoms among veterans population. Sleep 2013;36:A145 [Abstract].
- Lockwood A, Steinke DT, Botts SR. Medication adherence and its effect on relapse among patients discharged from a Veterans Affairs posttraumatic stress disorder treatment program. Ann Pharmacother. 2009;43(7):1227-1232.
- Means MK, Ulmer CS, Edinger JD. Ethnic differences in continuous positive airway pressure (CPAP) adherence in veterans with and without psychiatric disorders. Behav Sleep Med. 2010;8(4):260-273.
- Ribeiro JD, Pease JL, Gutierrez PM, et al. Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military. J Affect Disord. 2012;136(3):743-750.