Sleep Problems - PTSD: National Center for PTSD
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PTSD: National Center for PTSD

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Sleep Problems

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Sleep Problems and PTSD

Almost everyone with PTSD reports sleep problems. In fact, trouble sleeping is the main reason that people first go to a doctor to get help for PTSD. Both insomnia—trouble falling or staying asleep—and nightmares are PTSD symptoms. The good news is there are evidence-based treatments that can help with PTSD and sleep problems. And, these treatments help whether your sleep problems began before a traumatic event or only came about after the trauma.

Why Is Sleep Important?

Both how well (quality) and how much (quantity) a person sleeps are important.

Video

Sleep Helps Us To Be Our Best

Dr. Elissa McCarthy explains why sleep is important.

Poor sleep may lead to:

  • Slow reaction time
  • Trouble with learning and memory
  • Feeling irritable and mood problems
  • Trouble with thinking and concentration
  • Thinking about suicide or acting in ways that self-harm

Also, sleep problems that last a long time are related to medical problems such as heart disease, depression, kidney disease, high blood pressure, diabetes, obesity and stroke.

How Does PTSD Affect Sleep?

Both nightmares and insomnia are symptoms of PTSD. Nightmares are often a replay of the traumatic event; and, if the dreams cause kicking and screaming, bed partners can be affected too. Nightmares can also make it difficult to fall back asleep. Insomnia is when a person has trouble falling or staying asleep at least three nights a week. This lack of sleep continues for a few months or more and is severe enough to cause problems at work and at home.

Video

How Trauma Can Lead to Sleep Problems

Dr. Elissa McCarthy explains how trauma can lead to insomnia.

Because people with PTSD may try to push away trauma memories during the day, it may cause worries to get worse at night and disrupt sleep. Here are some examples:

  • Avoidance. People with PTSD may avoid going to sleep. Nightmares and flashbacks—feeling like the trauma is happening again—can create fear or feeling as if going to bed is unsafe.
  • Loss of sleep time. Whether or not insomnia is diagnosed, people with PTSD often report less sleep due to problems falling asleep, being restless during the night and waking up earlier than wanted. Even brief periods of sleep loss can affect daily life.
  • Increased arm and leg movement. After a trauma, people may have more arm and leg movements during sleep. This can make someone feel restless.
  • Talking during sleep. After a trauma, people may talk more in their sleep. Talking during sleep can affect bed partners.
  • Feeling "on alert." People with PTSD may feel the need to be on guard, to protect themselves from danger. It is difficult to have restful sleep when you feel the need to be always alert or are startled easily by noise.
  • Not liking silence. Some may be uneasy with silence after a trauma. When this happens, a person may keep a television on all night. Changes in light and sound can disrupt the deepest and most needed level of sleep.

What Is the Relationship Between PTSD, Sleep Problems and Substance Use?

Sleep problems may become their own disorders that cause distress. As a result, some will use substances such as alcohol, marijuana, or other drugs to fall asleep. Over time, drug and alcohol use can also have negative effects on sleep quality and on overall health and functioning.

What Is the Best Treatment for Sleep Problems?

The best treatment for insomnia is Cognitive Behavioral Therapy for Insomnia, or CBT-I. This talk therapy is recommended over medication because it is more effective—CBT-I has been shown to work in multiple research studies—and has fewer side effects than medication. CBT-I improves sleep in 7 out of 10 people who complete it. Research also shows that CBT-I reduces how many nightmares people have and the distress related to upsetting dreams.

Video

Cognitive Behavioral Therapy for Insomnia (CBT-I)

Dr. Elissa McCarthy and Dr. Keith Warren describe CBT-I and the benefits of this treatment.

How does CBT-I work?

CBT-I focuses on a person's beliefs, feelings, and behaviors that affect sleep. A trained CBT-I therapist may offer the treatment in one-on-one appointments or to a group of people with insomnia. It usually lasts six sessions. CBT-I can be delivered in person or through video medical appointments. There are also online programs and a smartphone app—CBT-I Coach—designed to help with the treatment.

Video

Example of How CBT-I Works

Dr. Elissa McCarthy describes how CBT-I helped a busy mother.

What is "sleep hygiene" Is it the same as CBT-I?

Sleep hygiene includes various practices and habits that are important for good sleep. It includes tips to change behaviors that may interfere with sleep. For example, you may limit beverages with caffeine before bedtime to fall asleep more easily. Or, you may find that you need to adjust your sleep environment—such as limiting smartphone use or television viewing in bed—to be more comfortable. CBT-I, on the other hand, is a more focused treatment for chronic insomnia. Sleep hygiene is not the same as CBT-I treatment, but it is often included as a part of CBT-I.

Video

CBT-I vs. Sleep Hygiene

Dr. Elissa McCarthy explains the difference between CBT-I and sleep hygiene.

What are the pros and cons of using sleep medication?

Sleep medication is easy to take and usually provides quick, temporary relief. There are many different types of medications used for sleep, from herbal supplements and over-the-counter sleep aids to prescription medications. If you choose to take medication, you should be familiar with the side effects and risks before you take it.

Sleep medication side effects usually include daytime drowsiness, dizziness and confusion. Sleep medication is often recommended for short-term use only (2 to 4 weeks). These medications usually become less helpful over time and don't get to the core cause of sleep problems.

Certain prescription sleep medication can cause serious side effects with long-term use. Examples include:

  • Benzodiazepines: such as Xanax, Klonopin, Valium or Ativan
  • Nonbenzodiazepines (or "Z-drugs"): such as Ambien, Lunesta and Sonata

Learn more about Benzodiazepines and PTSD. Although benzodiazepines—or "benzos"—can make people feel calm, relaxed or sleepy, they can become a problem in the long run and are not recommended for the treatment of PTSD.

Compare Your Treatment Options

CBT for Insomnia (CBT-I) Sleep Medication
How It Works
  • Talk therapy addresses thoughts and behaviors that affect sleep
  • Chemicals bind to receptors in the brain and make people feel calm or sleepy
Side Effects
  • Time and practice to learn skills (sleep efficiency training)
  • Some get less effective over time (tolerance)
  • Some are linked to dependence, withdrawal, accidental overdose, addiction, accidents, falls, confusion and memory problems
  • Next-day sleepiness
  • Pregnancy risks
Things to Consider
  • Making time for weekly visits for therapy
  • Requires being open to making changes in sleep behaviors
  • Taking time to track your sleep (sleep diary)
  • Don't address the underlying problem (PTSD, worry, pain, or poor sleep habits)
  • May not be recommended for people 65 and older or for people with substance use issues
  • Dangerous interactions with alcohol and opioids
Cost
  • Transportation and office co-pays
  • Medication co-pay
Benefit
  • Skills learned can be used for a lifetime
  • Helps for one night

What Other Sleep Problems Affect People with PTSD?

Sleep apnea is common among people with PTSD, particularly in Veterans. Sleep apnea is a breathing problem that disrupts normal sleep. People with sleep apnea may wake up not feeling rested and struggle with feeling tired or needing to sleep during the daytime.

Being aware of sleep apnea can be difficult. There are many causes of fatigue or feeling tired during the day. Also, with sleep apnea, breathing pauses (or disruptions) happen during sleep, so a person may be unaware of those symptoms. Often a bed partner notices those breathing changes or snoring first.

To diagnose sleep apnea, a provider may recommend a sleep study. Treatment can include lifestyle changes and use of a breathing device—continuous positive airway pressure, or CPAP machine—at night. Research suggests that for those with PTSD and sleep apnea, using a CPAP device may benefit PTSD treatment.

Video

Sleep Apnea

Dr. Keith Warren explains what sleep apnea is and lists common signs of sleep apnea.

Final Points About PTSD and Sleep

With PTSD, it can take some time and effort to get good sleep. Using marijuana, alcohol and street drugs to manage PTSD or sleep problems is related to a higher risk of thoughts about suicide and suicide attempts. There are effective treatments available for sleep problems and PTSD. Work with your provider to learn about your treatment options and decide on the best fit for your needs.

Video

Advice from a Provider

Dr. Elissa McCarthy explains you don't have to dread sleep and gives advice.

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Get help for PTSD

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PTSD Information Voice Mail:
(802) 296-6300
ncptsd@va.gov
Also see: VA Mental Health

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