Each year, millions of Americans are exposed to major traumatic events. Family violence, sexual violence, natural disasters, or surviving a deadly accident or incident are unfortunately common experiences in our modern lives. Coping in the aftermath can often be challenging, and many survivors live every day with symptoms of traumatic stress.
As a PTSD specialist, the most common complaints trauma survivors bring to me are sleep disturbances. Careful attention to correcting these disturbances is integral to healing in the aftermath of trauma.
The classic nightmares of trauma.
The classic PTSD nightmare involves a repetitive replay of the traumatic incident, complete with related emotions, bodily responses, and movements. Many spouses of trauma survivors tell of frequently being awakened from a deep slumber by a thump, slap, or bloodcurdling scream as their spouses reenact their trauma in their nightmares.
What’s important to understand about trauma is that the symptoms can sometimes linger for months or even years after the actual event: Among those with PTSD, nightmares can continue up to five decades after the original trauma.
Beyond nightmares.
As a culture, we seem to be forgetting how to sleep in general. It started with irregular work schedules and shift work that messed up our body clocks, and then came a wave of popular heavily caffeinated beverages and energy supplements that kept people too wired to stay awake. Cheap large-screen TVs found their way into bedrooms and primed our brains to equate bedtime with channel surfing as opposed to falling asleep. The arrival of smartphones and tablets brought to our bedrooms a never-ending stream of alerts, notifications, and messages.
In this already sleep-deprived society, trauma survivors have an added exacerbating factor making it even harder to get that critical shuteye.
In the first decade of the 21st century, sleep researchers discovered many sleep-related problems in people who’ve experienced trauma. In addition to the debilitating issue of nightmares, insomnia is a distinct problem for almost 50 percent of PTSD sufferers. A high incidence of sleep-disordered breathing and limb movements is also seen in sleeping PTSD patients.
Moreover, people who’ve experienced trauma do not sleep as deeply as healthy people. For example, a woman who has experienced assault in her home may, 20 years later, fall asleep with ease, but any noise—a car screeching to a halt on the street, her child getting up to use the bathroom, the heating system kicking on—might awaken her more easily than it would the average person. Once awake, she may feel compelled to double-check that the doors and windows are locked.
Sleep needs to be a top priority for people who’ve been through trauma.
The sleep disturbances common among people who’ve been through trauma often develop into independent sleep problems. This can create a cycle of negative consequences: As the PTSD creates sleep disorders, those sleep disorders exacerbate the PTSD symptoms, creating a feedback loop that’s hard to break.
This means that people who’ve suffered from trauma don’t only require treatment for their PTSD symptoms—their sleep itself requires its own focused treatment as well.
Sleep is, of course, critical to all people: Research tells us that high-quality sleep is a requirement for humans to live well in all dimensions of their lives from the psychological to the hormonal to their daily executive functioning in everyday activities. It boils down to a basic matter of biology; sleep offers the brain an abundance of restorative functions and allows the body to rest, recover, and process after being active all day.
Not only is sleep deprivation linked to a bevy of diseases and disorders (from diabetes and obesity to heart disease and stroke to depression and anxiety), but it also deeply affects our ability to process memories and subconscious thoughts, to handle stress, and to think clearly. It can also increase our sensitivity to pain, exacerbate negative emotions, and make you more averse to human connection.
These are deeply problematic consequences for someone who’s already dealing with all the intrusive thoughts, emotional turbulence, and feelings of social isolation that typically comes with PTSD. Chronically disturbed sleep can leave them even more vulnerable to developing depression and anxiety. The lack of sleep also means they might lack the energy and verve that supports finding joy, excitement, and connection in daily life, and they can become irritable and short-tempered with their loved ones—when, in fact, they need that strong support system as part of their healing.
How trauma survivors can get better sleep:
1. Lifestyle changes.
If you’re struggling with getting enough sleep, you probably already know a lot of the main habits you need to adopt or cut back—I implore you to make an effort to prioritize these lifestyle changes. I always recommend having a regular sleep routine, avoiding caffeine and long daytime naps, and making the bedroom a screen-free zone as essentials for anyone living with PTSD.
2. For nightmares, consider image rehearsal therapy.
Image rehearsal therapy (IRT) is a talk treatment that specifically targets nightmares. The therapy involves recalling the nightmare, writing it down, and changing the theme into a more positive story line. Under the guidance of a therapist, patients rehearse the rewritten dream scenarios so that they can displace the traumatic content when the dream recurs. They do this by practicing 10 to 20 minutes during the day. For example, for someone who survived a deadly car crash that killed a loved one, to replace the nightmare, they rehearse an alternative outcome where the loved one survived. IRT has been shown to inhibit the original nightmare by providing a critical shift in thinking that challenges its very origins.
3. Consider cognitive behavioral therapy for insomnia.
Known as CBTi, this therapeutic method consists of several sessions that are tailored to one’s specific sleep issue. The therapist makes several recommendations to changes in lifestyle or habits that, ultimately, strengthen the bed as a cue for sleep and weaken it as a cure for insomnia. CBTi aims to improve sleep quality and, once this is achieved, focuses on quantity. Initially, the time spent in bed is restricted to the hours spent asleep, i.e., no more “tossing and turning” in bed. In subsequent sessions, the time spent in bed is gradually increased. CBTi protocols also include strategies for reducing sleep-interfering worries, stress, and overly active minds that won’t shut off.
The key is taking the stress out of “trying hard to sleep” and restoring the natural inclinations of the human brain and body to allow sleep to happen. CBTi promotes empowering people’s biological clocks and aims to align bedtime and rise time with one’s internal rhythm.
4. If possible, avoid prescription sleep medications.
The current medical practice encourages doctors to avoid prescribing medications for insomnia. Such recommendations come from decades of hard-earned knowledge and the gradual realization that many commonly prescribed hypnotics have serious side effects such as being habit-forming, leading to memory problems and falls, and even contributing to premature death.
Of course, there are times when sleep disruption is severe and contributing to high levels of distress, and in such cases, a sleep aid may be warranted. But even under those circumstances, sleep medications should ideally be used as a short-term solution, used at the lowest dose possible in accordance with your doctor’s recommendations, and closely monitored.
But as much as possible, prioritizing sleep wellness is the much safer and more effective way of dealing with sleep issues rather than seeking out a prescription.
Living a healthy lifestyle is inextricably linked to mental well-being. I tell patients that any steps taken toward improving their wellness will augment and reinforce the positive effects of their other treatments. Eating a well-balanced, nutritious diet, and exercising regularly are integral to good mental health, especially for people who’ve been through trauma and may always have some lingering symptoms. Alongside these, make sleep a non-negotiable top priority.
- Shaili Jain, M.D.
Author’s Note:
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