PTSD & Sleep Disorders: How Trauma Affects Sleep
Trauma is defined as a physically or psychologically damaging event. Unfortunately, the majority of people will experience trauma at some point in their lives. For many, these traumas can create lasting health effects related to sleep, including insomnia.
Past trauma and trouble sleeping are closely linked, with the vast majority of Post Traumatic Stress Disorder (PTSD) sufferers also experiencing sleep disturbances. In fact, a 2006 study found that “Subjective reports of sleep disturbance indicate that 70-91 percent of patients with post-traumatic stress disorder (PTSD) have difficulty falling or staying asleep.”
Post traumatic stress disorder, or PTSD, affects millions of people around the world. It’s thought to affect more than 7 percent of American adults at some point in their lives. Based on the clinical findings, it’s likely that the vast majority of these PTSD sufferers also struggle to get good quality sleep.
This article will discuss the connection between trauma and sleep. It will explain clinical findings of how PTSD can affect our sleep, and lay out options for PTSD sufferers looking to improve sleep quality.
What is Trauma?
When someone has an experience that’s very disturbing, life-threatening, or otherwise significantly harmful to their physical and psychological well-being, they go through what we call a “trauma.” Trauma can be limited to a one-time event or can happen repeatedly, over a long period of time. That means war, accidents, sexual assault, physical assault, physical abuse, sexual abuse, emotional abuse, domestic violence, death, and injuries are all examples of the many experiences that fall under the umbrella of “traumatic events.”
- Negative emotions such as anxiety, anger, fear, sadness, and being “on edge”
- Issues with sleep
- Issues with concentration and cognition
- Obsessive thoughts about the experience
- Upsetting memories of the experience
For most people, these responses are short-term, and they can resume living like how they did before the traumatic event relatively soon. But according to the National Institute of Mental Health, some people develop psychological and physical symptoms that interfere with their well-being and indicate they need professional help:
- Experiencing any of the previously mentioned responses for longer than 30 days
- Overly emotional responses to everyday events
- Flash-backs, nightmares, and night terrors
- Chronic fatigue, pain or headaches
- Digestive issues, nausea
- Numbness, withdrawal or personality shifts
- Stress responses like a racing heart, sweating, and jumpiness
Most people, even if they do end up needing some type of medical care for their trauma, never end up getting PTSD. But for around 7-8% of the U.S. population, their symptoms last long enough and become severe enough to be diagnosed as PTSD.
What Are the Causes of Trauma?
There are two basic types of trauma: Physical trauma and psychological trauma. In many cases, the victim can experience both forms of trauma at the same time. Physical trauma involves bodily harm. In the medical community, the term usually refers to very severe injuries, but technically any injury could cause trauma. Psychological trauma involves damage to the human psyche caused by experiencing or witnessing an emotionally upsetting event. Examples of traumatic events include:
- Physical assault or violence
- Witnessing or participating in military violence
- Rape or sexual assault
- Physical, emotional or verbal abuse
- Natural disasters, accidents or loss of a loved one
- Traumatic brain injuries
These are just a few examples - practically any significant event could potentially cause trauma. Life experiences that are traumatic for one person may not be for another. Furthermore, trauma affects people in different ways and symptoms can manifest differently.
Trauma affects people in starkly different ways. Some people will go on to develop symptoms of clinical PTSD, while others will show no symptoms at all. A 2014 book called Trauma-Informed Care in Behavioral Health Services noted that “The impact of trauma can be subtle, insidious, or outright destructive”.
With so much variation in both causation and symptoms, correctly identifying conditions associated with trauma can be challenging. While conditions like PTSD affect millions of people, it’s likely that many more have the condition but have not been diagnosed.
What is Post-Traumatic Stress Disorder (PTSD)?
Post-traumatic stress disorder (PTSD) is believed to affect around 8 million Americans every year, according to the National Center of PTSD. It is not a mental illness, reports PTSD UK, but instead the result of physical changes to someone’s brain after they experience trauma. The parts of the brain injured by PTSD can include:
- The prefrontal lobe: the language center, making it hard for some PTSD patients to articulate their feelings and experiences
- The amygdala: critical for regulating emotion, making it hard for some PTSD patients to control or understand their feelings
- The hippocampus: the center of memory management and processing, meaning some PTSD patients suffer short-term memory loss
- The medial prefrontal cortex: the cortex that manages fear responses, making some PTSD patients hyperaroused and feeling inappropriately scared
The medical community does not fully understand the mechanisms behind why PTSD develops, although there are some theories. One prevalent theory is that by continually reliving past traumas, we are better able to avoid similar dangerous situations in the future. In other words, PTSD may be a survival mechanism of sorts.
There are also physiological reasons for PTSD symptoms. PTSD sufferers often have high levels of adrenaline, which can cause tension, irritability, and trouble sleeping (many of the primary symptoms of the disorder). Adrenaline is a hormone that is produced when we are under stress, and researchers now believe that reliving traumatic experiences can keep adrenaline levels permanently elevated. Additionally, high levels of adrenaline can affect the proper functioning of the hippocampus, the part of the brain that processes memory. Because the traumatic memories cannot be processed, they are continually relived in flashbacks and nightmares.
PTSD can also develop as a result of a traumatic brain injury, or TBI. In addition to affecting people from a range of backgrounds and situations, PTSD can develop any time after someone experiences a traumatic event, from immediately after to months, or even years, in the future.
Generally speaking, for someone to be diagnosed with PTSD, they have to experience the symptoms for more than four weeks, or to such a degree that it interferes with their daily life. There are many PTSD symptoms, all of which fall under four main categories, according to the National Center of PTSD:
- Re-experiencing symptoms. PTSD patients relive the event emotionally and psychologically. These include nightmares and flash-backs, and can be triggered by a variety of sights, smells, and other sensory input that reminds you of the event.
- Symptoms of avoidance. PTSD patients go out of their way to avoid these mental and physical triggers.
- Significant, negative changes to PTSD patients’ thoughts and beliefs. Some examples include how they approach relationships with other people, their feelings about things they used to enjoy, or problems remembering things.
- Symptoms of hyperarousal and hypervigilance. Some PTSD patients constantly respond to a danger that isn’t there. Some examples include feeling scared, suffering from anxiety, and behaving as though they’re under attack.
As you might imagine, a lot of these symptoms either directly include issues with sleep, or can lead to issues with sleep. Someone who has nightmares every night, someone who can’t sleep alone but has trouble with physical touch, and someone who is hypervigilant to the point that they can’t fall asleep are all a few examples of the different ways PTSD can lead to chronic sleep deprivation. Furthermore, a lot of these symptoms either directly include or can lead to anxiety, which can also be a major factor in sleep deprivation. And with PTSD and anxiety worsened by a lack of sleep, being sleep deprived while living with these conditions can become a vicious cycle.
Traumatic Brain Injury (TBI)
Traumatic brain injury (TBI) results from a violent blow to the head, or an extreme jolt to the body. Car accidents, combat incidents, falls and sports accidents can all cause TBI. The condition is common, with 1.6 to 3 million cases per year in the United States alone.
In many cases, TBI can lead to PTSD, because the events that can cause a significant brain injury are generally quite traumatic. However, TBI does not necessarily cause PTSD, although it may cause similar symptoms. As the two conditions can share symptoms, they are often confused - but it’s important to understand the differences.
Traumatic brain injury can cause symptoms including:
- Vertigo, confusion and disorientation
- Nausea or vomiting
- Chronic headaches or fatigue
- Sensory problems, like blurred vision
- Memory and concentration problems
- Anxiety, depression and insomnia
- Slurred speech
There are a large variety of TBI symptoms, and the specific signs will vary depending on the severity of the injury. There are typically two classes of TBI: mild, and moderate to severe. Moderate to severe traumatic brain injuries can cause significant side effects that could even be life-threatening. For instance, severe TBI can cause seizures, and can even cause a patient to enter a coma or vegetative state. On the other hand, the symptoms of mild TBI are generally more manageable with routine treatment.
Traumatic brain injury can often cause sleep problems. According to a 2013 study, up to 70 percent of individuals with traumatic brain injury may also experience sleep disturbances. The most frequent sleep issues associated with TBI include insomnia, fatigue and narcolepsy.
Symptoms of TBI can often be confused with symptoms of PTSD. Although TBI can lead to post traumatic stress disorder, the two conditions are completely separate and do not always co-occur. Proper diagnosis of the correct condition requires medical expertise.
Trauma's Impact on Children
As mentioned earlier, trauma, PTSD, and TBIs can all happen to anyone, regardless of age. But that doesn’t mean the symptoms present the same at every age. In fact, preschoolers, elementary school students, and middle and high schoolers all react differently to trauma.
TBIs in Children
TBIs both look and manifest differently in children and adults. Since children’s brains are still developing, states the Brain Injury Association of America, a TBI will do far greater damage to a child’s brain, impairing their thinking, learning, and social skills. That said, this may not be clear for a while, since it can take years for TBI symptoms to show up.
Even so, the CDC warns that if a child presents any of these symptoms of a possible TBI, then they should receive emergency medical treatment immediately:
- A “bump, blow, or jolt” to their head or body
- The danger signs of a TBI for adults
- Refusing to stop crying
- Refusing to nurse or eat
Trauma Expressions by Age
PTSD also presents slightly differently in children. According to Stanford Children’s Health, some child-specific symptoms of PTSD can include reenacting traumatic events, having trouble in school, and regressing to more childish behavior like thumb-sucking and bed-wetting. When it comes to diagnosis, too, criteria is more detailed for children. This is partly because PTSD and ADD/ADHD have several overlapping symptoms, and can be mistaken for each other, the CDC reports.
In children six years old and younger, according to the Anxiety and Depression Association of America, children can also be diagnosed with PTSD if they’ve witnessed the traumatic event happen to someone else or learn it happened to their caregiver, even if they haven’t experienced it directly themselves. They also need to show at least one of five re-experiencing symptoms (including re-enactments and very intense flashbacks), at least one of five symptoms of avoidance or negative changes to their feelings (including social withdrawal and avoiding a triggering place), and at least two hyperarousal symptoms (including sleep issues and aggressive behavior).
According to the Substance Abuse and Mental Health Services Administration, preschoolers may have fears about being separated from their parents or guardians, frequently cry and scream, lose weight from not eating well, and get nightmares. Meanwhile, kids in elementary school may develop anxiety, fear, feelings of guilt or shame, issues with concentration, and sleep issues. Finally, middle and high school-aged children may develop depression, feelings of loneliness, eating disorders, and self-harm behaviors, as well as start to abuse substances or become sexually active.
Trauma-Related Sleep Disorders
Trauma and PTSD can have significant effects on sleep quality. Patients experiencing PTSD symptoms may find that it’s difficult to get to sleep, and even harder to get a full night’s rest. The vast majority of PTSD patients also experience sleep issues, with one study reporting that more than 70 percent of PTSD patients reported sleep disturbances. There are a number of reasons why PTSD sufferers may struggle with sleep.
Even if PTSD is not formally diagnosed, individuals with past trauma can still experience significant difficulty with sleeping. To make matters worse, insomnia and related symptoms tend to build on themselves.
The frequent sleep disturbances that PTSD sufferers endure can lead to PTSD sleep deprivation and even full-blown insomnia. Unfortunately, this only worsens the symptoms, as sleep deprivation contributes to anxiety, while anxiety can further exacerbate PTSD symptoms. In other words, a lack of sleep makes it even more difficult to get quality sleep in the future.
Many people with trauma in their past feel trapped in a cycle of poor sleep with no end in sight. And indeed, without treatment of the underlying conditions, this cycle can continue indefinitely. It’s vital for PTSD sufferers to seek the help of medical professionals to help address the underlying conditions related to sleep disturbances.
While most of these sleep disturbances are simply symptoms of PTSD itself, in other situations the disorder can actually contribute to the risk of separate sleep disorders including sleep apnea.
PTSD and Sleep Apnea
Researchers have uncovered a link between PTSD and sleep apnea. A study published in the Journal of Clinical Sleep Medicine noted that 69 percent of participants who had PTSD were considered a high risk for developing obstructive sleep apnea. The study also noted that as the severity of PTSD increased, so too did the risk factors for sleep apnea.
This is another reason to address PTSD symptoms as early as possible, as the disorder may lead to an increased risk for other health concerns. The director of the PTSD Consultation Program at the National Center for PTSD, Sonya Norman, PhD, noted that “This is critical information because sleep apnea is a risk factor for a long list of health problems such as hypertension, cardiovascular disease and diabetes, and psychological problems including depression, worsening PTSD and anxiety.”
Unfortunately, researchers found that younger veterans with PTSD often aren’t screened for sleep apnea, so many don’t get diagnosed and can’t receive the right treatment (usually a device, like a CPAP machine, that keeps the patient’s throat open).
Researchers are still working to understand the mechanisms behind this link between sleep apnea and PTSD. However, some likely contributing factors include prolonged sleep deprivation due to PTSD, hyperarousal due to the psychological stressors of military combat, and disturbed sleep during military service.
Sleep Help for People with Trauma Disorders
If you have a trauma disorder such as PTSD, there are steps you can take to try to improve your sleep quality. This starts with addressing the root cause of the disruptions: PTSD itself.
Treatment for PTSD
Treatments for PTSD come in a number of forms, from different types of trauma-focused cognitive behavioral therapies, to trauma-focused exposure therapies, to medication. In some, people may expose themselves to triggers related to the traumatic event, try to change their thoughts and feelings about the traumatic event, put the traumatic event into words, or otherwise try to process the traumatic event.
The top four most supported treatments, according to the National Center of PTSD, are Cognitive Processing Therapy, Eye Movement Desensitization & Reprocessing, Prolonged Exposure, and SSRI/SNRIs, two types of antidepressant medications.
Cognitive processing therapy is a specialized type of cognitive behavioral therapy used specifically for PTSD. The practice aims to help patients learn how to challenge unhelpful beliefs related to past trauma. Ideally, this helps the patient to create a new understanding of the traumatic experience.
Cognitive processing therapy is generally practiced over twelve in-person sessions with a psychotherapist. Individual and group sessions are generally available, depending on patient preference. The process begins with learning about the relationship between PTSD and thoughts and motional processing. Next, the patient begins to process the complex emotions associated with the trauma. Finally, the patient will use their newfound skills to continue evaluating and modifying beliefs surrounding their past trauma.
Cognitive processing therapy is considered effective for PTSD treatment. Approximately 53 percent of patients who receive treatment of this type will overcome their PTSD. Risks include discomfort while discussing or thinking about past trauma.
Type of Treatment: Psychotherapy - Reframe negative thoughts
What's Required: CPT involves talking about and writing down your thoughts, doing structured worksheets, and develop different strategies with your therapist for dealing with negative trauma-related thoughts and feelings.
Effectiveness: In a study, Veterans Affairs found that 53% of people who received CPT no longer had PTSD after the three-month mark.
Length of Treatment: Treatment consists of 12 weekly 60-90 minute sessions, spread out over 3 months or so.
Risks: The only risk posed by CPT is “mild to moderate discomfort” during the talking and writing parts of the therapy.
Treatment for TBIs
In the case of traumatic brain injury, treatment options may differ. The most common options include light therapy, CPAP/BiPAP therapy, and acupuncture.
Light therapy is often used for mild TBIs. The treatment consists of staying near a bright light, usually a near-infrared or bright blue light. Light therapy is thought to have neuroregenerative effects, helping the brain to heal itself. Research suggests that daily blue wavelength light therapy may help to improve sleep and reduce fatigue in patients with mild TBI.
Most light therapy treatments can be self-applied at home. There are various setups, including bright lamps to place near your bed, and lights that you physically strap to your head. Most treatment regimens recommend daily application of light therapy.
Additional Treatments for Sleep
Another way to sleep better while living with trauma, PTSD, and TBIs is to work on treating your sleep issues first. Additional treatments that focus on sleep, rather than their underlying conditions, include Image Rehearsal Therapy, Sleep Restriction, and Meditation and Relaxation Therapy.
Imagery rehearsal therapy is an interesting technique that’s used to reduce the frequency and intensity of chronic nightmares. Working with a therapist, the patient will write down alternative, non-threatening endings to chronic nightmares they have been having. The patient will then rehearse the new version of the nightmare, which helps to imprint the new version into the brain’s memory.
IRT is considered effective for PTSD patients suffering from chronic nightmares. One study of sexual assault survivors found that IRT significantly reduced the nights per week with nightmares as well as the total number of nightmares per week. Keep in mind that this form of therapy only addresses nightmares, and is unlikely to improve other PTSD symptoms.
Learn More About Trauma and Sleep
For parents of children with PTSD, check out KidsHealth.org. This resource guide explores all aspects of PTSD from the perspective of parents of trauma-affected children.
For parents of children who have experienced trauma, check out the National Child Traumatic Stress Network. This organization compiles resources and provides services to children who have experienced significant trauma.
For veterans with PTSD, check out the VA’s PTSD resources. This article explores the relationship between sleep and PTSD, focusing specifically on aspects relevant for veterans.
For PTSD patients looking for treatment options, check out the PTSD decision guide from the VA. This resource compares and explains the most popular PTSD treatment options.
For those interested in reading PTSD and sleep related medical studies, check out this resource from the National Center for PTSD. The PDF resource gives an overview of the relationship between post traumatic stress disorder and sleep, and links out to many relevant clinical studies.
For those interested in using meditation to improve sleep, check out Mindful.org. This nonprofit aims to help individuals become more mindful through the ongoing practice of meditation.
For individuals and families looking for mental health resources, check out the National Alliance on Mental Illness. NAMI provides resources and learning materials for all types of mental health concerns, including PTSD.
For those interested in using technology to improve sleep, check out our list of the best sleep apps for 2019. The list focuses on apps for insomnia and trouble sleeping.
For PTSD sufferers looking for a qualified therapist, check out this WebMD guide on how to find a mental health professional. The article covers tips and tricks on how to go about finding the right therapist for you.
For PTSD patients looking for a peer support group, check out this resource from the VA. The article explains how peer group works, and where to find them.