Post-Traumatic Stress Disorder affects 3.6% of the American population each year (Kessler et al, 2005). PTSD symptoms must persist for more than 1 month, and must lead to functional impairment or significant distress (DSM-5, APA, 2013). PTSD mostly occurs immediately or soon after an individual experiences a traumatic event, but for 15% of the population it can take months or even years for the first symptoms to manifest (McNally, 2003). Whether immediate or delayed, PTSD and insomnia frequently occur together. Many events can cause PTSD to develop, including car accidents, assaults, witnessing a crime, combat, serious injury and other traumatic experiences. and is defined as a ‘trauma and stressor-related disorder’ which manifests in four symptom clusters:
– Intrusion, defined as the persistent re-experiencing of the traumatic event, and includes intrusive memories, flashbacks and nightmares.
– Avoidance, defined as the effortful behaviour which aims to distance oneself from trauma-related stimuli after a stressful event.
– Negative alterations in cognitions and mood, including persistent negative automatic thoughts about the world (e.g. the world is a dangerous place), distorted blame, a diminished interest in previously enjoyable activities and feeling alienated from others.
– Alterations in arousal and reactivity, including irritable and aggressive behaviour, hyper-vigilance to events and ones surroundings, problems in concentration and sleep disturbances.
Insomnia is an extremely common symptom of PTSD; for instance Ohayon and Shapiro (2000) found that it affects 66% of the PTSD population but only 10% of the general population are affected by insomnia (Ford and Kamero, 1989). Insomnia is defined by a difficulty initiating and/or maintaining sleep, and can also include early rising. Insomnia is only considered a disorder when it also leads to difficulties functioning during the day.
Pigeon, Campbell, Possemato and Ouimette (2013) have recently completed a longitudinal study of the relationship between PTSD and insomnia as well as nightmares in recent combat veterans. They assessed 80 combat veterans before and after a 6-month interval, and found that insomnia and nightmares were strongly associated with the severity of PTSD, and that insomnia did not go away on its own over time. They also found that PTSD and insomnia were ongoing and suggested that treatment for insomnia is an important component in the treatment of PTSD.
Not only can PTSD and insomnia co-occur, but insomnia can be caused by PTSD and it has also been found that insomnia can predict PTSD (Gehrman et al, 2013). A study of military veterans found that having a history of insomnia disorder before being deployed predicted the future development of PTSD, to nearly the same extent as being exposed to combat. This suggests there is an increased risk military personnel with pre-deployment insomnia to develop PTSD if they are exposed to combat or other traumatic events. The relationship between PTSD and insomnia is a complicated one.
Despite the high comorbidity of the PTSD and insomnia, and the risk of developing insomnia as a symptom of PTSD, there are fortunately many therapies available which have been shown to be effective in the treatment of insomnia.
Insomnia Treatment for People with PTSD
Sleep restriction involves reducing the time in bed to the amount of time an individual spends asleep, so if a person only slept 4 hours but was in bed for 8, the time in bed would be reduced to 4 hours. If sleep improves, the time in bed gradually increases.
Stimulus control describes teaching the participants about their negative sleep habits, such as staying in bed even if they are not falling asleep. Stimulus Control therapy involves reducing these negative sleep habits, in order to create an association between the bed and sleepiness, rather than the bed and wakefulness.
Sleep hygiene therapy involves promoting good sleep habits, such as keeping the bedroom dark and quiet, not watching tv in bed, not eating in bed, not drinking alcohol after 7pm, etc.
Imagery rehearsal therapy involves education about the role of learning in nightmares, and specific instructions for how to ‘rescript’ nightmares.
Relaxation therapies have also been shown to be effective for comorbid PTSD and Insomnia (e.g. Haimov et al, 2010), and success is also shown in the reduction of symptoms for one disorder when the other is being treated.
There are extremely large effects for the treatment of PTSD and insomnia.
When seeking treatment for PTSD, with or without insomnia, just remember that treating the problem early will likely lead to the best results, and that anxiety after a trauma is a normal, healthy reaction. If you have developed PTSD, you are not abnormal; you simply have a more severe reaction to trauma. By addressing the problem, you will be empowered to live as you wish, rather than be tied to your trauma for the rest of your life.
If you or a loved one is showing signs of PTSD or depression, they should be assessed by a trained mental health professional who can help design a treatment plan for depression that can result in recovery. Treatment for depression and anxiety, including PTSD, can be highly successful and people who have completed our program have resulted in our treatment program receiving very highly consumer satisfaction scores and reviews. Call us at 901-682-6136 to schedule an appointment.