PTSD and sleep disruption: Which to tackle when?

PTSD and insomnia often are connected. And while there are effective treatments available for both, deciding the order in which to tackle them can feel like a challenge. Is it better to treat the PTSD first in the expectation that addressing the PTSD will improve your sleep? Or is it better to treat your sleep issues first to help with later treatment of PTSD? Or is it possible to do both at the same time? In this article, guest experts discuss these three options to inform your decision on how to seek treatment for PTSD and insomnia.

Option #1: Address PTSD first with a method such as Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT). (See “PTSD and sleep disruption: Available treatments” for explanations of the methods mentioned in this article.) Insomnia and trauma-related nightmares are both symptoms of PTSD, so it makes sense to assume that resolving PTSD could fix poor sleep. Several studies have looked into whether sleep improves after effective treatment for PTSD. The research results are mixed: Some studies show significant improvement in sleep, some show no improvement, and others show that sleep improves a little but doesn’t return to normal.

Option #2: Address insomnia first with a treatment such as Cognitive Behavioral Therapy for Insomnia (CBTi). Poor sleep makes it hard to recover from a trauma because you need good sleep in order to process memories, especially trauma-related ones. Good-quality sleep also helps your ability to learn the difference between truly dangerous and relatively safe situations. The research results here also are mixed: Some studies suggest that insomnia treatment can reduce PTSD symptoms, while other studies found no change in PTSD symptoms.

Option #3: Address PTSD and insomnia at the same time to deal with both symptoms simultaneously. This is difficult to accomplish with behavioral treatment for a few reasons: First, treatments for PTSD and insomnia both require regular appointments and at-home practice, so it might be hard to devote enough time to both treatments at once. Second, treatments for PTSD and insomnia sometimes have conflicting goals, which could lead you to feel like you’re being pulled in 2 directions at once. For example, in PTSD treatment you might be asked to talk about difficult memories or feelings, while your insomnia treatment might call for you to avoid thinking and talking about those things at certain points in the day.

How to decide?

Although the research results are mixed about which issue to tackle when, the bottom line is that you can benefit regardless of the order of treatment. You might want to start by tackling PTSD, which might drive you to want to target your insomnia later. Alternatively, resolving insomnia first can enable you to feel more ready to tackle the toughest symptoms of PTSD. Ultimately your personal preference is the most important factor in choosing the order of treatment. Some questions you might consider discussing with your provider are:

  • Which symptoms bother me the most right now?
  • Which problem makes it most difficult to get along with my family or succeed at school or work?
  • Which treatment seems most doable to me right now?

The bottom line

Service Members tend to get the best results when they put in the most effort. So take the time to learn about the different options available to you, think about what is most important to you to address first, and then make a plan with your provider. You will boost your success when you commit to a plan that makes sense to you.

This article by guest experts* from the Center for Deployment Psychology is the third in a series on the complex relationship between PTSD and poor sleep. If you haven’t done so already, read the first article in this series—“A double whammy”—to learn more about the interaction between these two problems. For more information about sleep and PTSD, visit the Center for Deployment Psychology website.

Note that the focus of this article is on behavioral treatments. If you’re interested in medication, please talk with your primary care provider.

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

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Belleville, G., Guay, S., & Marchand, A. (2011). Persistence of sleep disturbances following cognitive-behavior therapy for posttraumatic stress disorder. Journal of Psychosomatic Research, 70(4), 318–327. doi:10.1016/j.jpsychores.2010.09.022

Galovski, T. E., Harik, J. M., Blain, L. M., Elwood, L., Gloth, C., & Fletcher, T. D. (2016). Augmenting cognitive processing therapy to improve sleep impairment in PTSD: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 84(2), 167–177. doi:10.1037/ccp0000059

Pace-Schott, E. F., Germain, A., & Milad, M. R. (2015). Effects of sleep on memory for conditioned fear and fear extinction. Psychological Bulletin, 141(4), 835–857. doi:10.1037/bul0000014

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