PTSD and sleep disruption: Trauma-related nightmares

In this 4-part series, guest experts have discussed the connection between trauma and sleep problems and identified available treatment options. Some Service Members who have experienced traumatic events also might have nightmares and feel anxious, scared, sad, or angry due to trauma-related dreams. Nearly 80% of people diagnosed with post-traumatic stress disorder (PTSD) report having nightmares, so it’s important to understand the connection between trauma and nightmares and what you might be able to do about it.

Nightmares that result from trauma can be worse than other nightmares. You might vividly recall images and sensations like a scary movie. You also might experience smells, sounds, touch, or pain as if in real life. Or your nightmares might repeat exactly the same way each time or connect with a theme such as danger or helplessness. And they might reenact the traumatic event exactly or change over time, weaving in pieces of your current daily life. It also can be hard if not impossible to return to sleep afterward, making things worse.

Nightmares typically occur in the stage of sleep called Rapid Eye Movement (REM) sleep, and your brain paralyzes your body to prevent you from acting out those dreams. This keeps people from accidentally hurting themselves. For reasons still unknown, this safety mechanism might not work as well with trauma-related nightmares, and some Service Members report body movements, thrashing, and other actions that seem aggressive to their bed partners.

Trauma and nightmares

It’s still unclear exactly why nightmares occur after a trauma, but some possible reasons include:

  • Your brain might be repeatedly trying to make sense of, or process, the trauma.
  • REM sleep might be disrupted after a trauma, which doesn’t allow for the traumatic memory to be digested.
  • Early nightmares might become regular over time, as if your brain has a “bad habit.”

Lower the frequency of nightmares

Unfortunately, no treatment has been found to completely eliminate nightmares, but some behavioral treatments might bring relief. For example, Imagery Rehearsal Therapy (IRT) and Exposure, Relaxation, and Rescripting Therapy (ERRT) rely on the assumptions that nightmares are changeable and don’t have to follow the rules of reality. Both treatments involve “rescripting your nightmare,” which means you discuss the details with your therapist and then change them so the nightmare is less upsetting. You then rehearse—or practice—the new dream several times a day and before bedtime to “break the bad habit.” Along with other skills, these strategies can reduce the frequency of nightmares.

Since nightmares often relate directly to your trauma, the recommended course of action is usually to start with an effective treatment for PTSD, which might reduce nightmares for over half of those who complete treatment. On the other hand, an effective treatment for insomnia might improve nightmares as much as IRT or ERRT. Some medications might reduce the frequency of nightmares, so ask your primary care manager (PCM) about appropriate treatment options.

Debrief

This article by guest experts* from the Center for Deployment Psychology is the fourth and last in a series on the complex relationship between PTSD and sleep. There are several treatments that can help address sleep issues and PTSD, as well as the authors’ insights on which to tackle when. Nightmares can further complicate things, and it might be necessary to target one or all three of these difficulties directly. However, in the end, these complex issues can be managed.

* Diana Dolan, PhD and Carin Lefkowitz, Psy.D.

References

Aurora, R. N., Zak, R. S., Auerbach, S. H., Casey, K. R., Chowdhuri, S., Karippot, A., . . . Morgenthaler, T. I. (2010). Best practice guide for the treatment of nightmare disorder in adults. Journal of Clinical Sleep Medicine, 6(4), 389–401. 

Harb, G., PhD (Chair), & Ross, R., MD, PhD (Discussant). (2015, November 5–7, 2015). Treatment of sleep disturbance in PTSD: Nightmare-focused and insomnia-focused treatments, treatment moderators, and the effects of neurocognitive functioning. Paper presented at the ISTSS 31st Annual Meeting—Back to Basics: Integrating Clinical and Scientific Knowledge to Advance the Field of Trauma, New Orleans, Louisiana.

Foa, E. B., & Rothbaum, B. O. (1998). Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. New York, New York: The Guilford Press.

Mysliwiec, V., O'Reilly, B., Polchinski, J., Kwon, H. P., Germain, A., & Roth, B. J. (2014). Trauma associated sleep disorder: A proposed parasomnia encompassing disruptive nocturnal behaviors, nightmares, and REM without atonia in trauma survivors. Journal of Clinical Sleep Medicine, 10(10), 1143–1148. doi:10.5664/jcsm.4120

Zayfert, C., & DeViva, J. C. (2004). Residual insomnia following cognitive behavioral therapy for PTSD. Journal of Traumatic Stress, 17(1), 69–73. doi:10.1023/B:JOTS.0000014679.31799.e7