Posttraumatic stress disorder (PTSD), previously known as “war neurosis,” is a psychiatric condition which develops in approximately 10% of persons who are exposed to severely threatening trauma (a single event or repeated episodes). One of the most distressing symptoms associated with this disorder are PTSD nightmares, insomnia, and other sleep problems.
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The trauma is usually an event that is
- Life-threatening to the physical integrity of self or others, such as a
- violent attack with physical injury.
- sexual assault.
- serious motor vehicle collision.
- Abruptly life-altering, such as a
- sudden death of a loved one.
PTSD is approximately twice as prevalent in women as men.
Common sources of PTSD in men are:
- Military combat.
- Physical assault.
In women common sources include:
- Intimate partner violence.
- Violent injury (often associated with sexual assault).
The traumatic event elicits responses of intense fear, helplessness, or horror.
Children often respond with disorganized or agitated behavior.
Intrusive / Reexperiencing
Intrusive symptoms such as reexperiencing the traumatic event and feeling it is recurring along with intrusive and distressing:
- Flashbacks, a sense of reliving the experience, thoughts, and recollections of the event.
- Nightmares, including recurrent distressing dreams related to the traumatic event in content or emotion. In fact, trauma replication in dreams is a distinguishing feature of PTSD. Recurrent nightmares are most commonly caused by PTSD.
Young children express the trauma in repetitive play and may have frightening dreams with unrecognizable content.
Avoidance / Numbing
The person with PTSD has a physiological reactivity along with intense psychological distress on exposure to anything which reminds of the traumatic event. As a consequence, one learns to avoid such reminders and has numbing of general responsiveness. This can manifest in different ways:
- Avoiding thoughts, feelings, conversations, activities, places, or people associated with the trauma.
- Inability to recall an important aspect of the trauma.
- Less interest/participation in significant activities.
- Detachment/estrangement from others.
- Restricted emotions (e.g., unable to have loving feelings).
- Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).
Heightened arousal and reactivity (Hyperarousal)
- Difficulty falling or staying asleep.
- Irritability or outbursts of anger.
- Difficulty concentrating.
- Hypervigilance (e.g., combat veteran spending hours each night “patrolling” his home to ensure that it is protected from intruders).
- Increased startle response.
Why & What is PTSD?
Anyone may experience periods of anxiety, recurrent thoughts, and insomnia after severe traumatic experiences, however when these symptoms persist more than a few days and cause functional impairment, accompanied by prominent feelings of unreality or memory problems (i.e., dissociative symptoms), a diagnosis of acute stress disorder may be appropriate.
When symptoms do not wane over the ensuing weeks (at least 1 month) and interfere with functioning or cause great distress, this may indicate PTSD.
During a traumatic event, we switch into a hypervigilant, reactive mode. In PTSD the brain seems not to shift back into its normal state. As a result, symptoms and behaviors arise, which can range from relatively mild to totally debilitating and interfering with everyday life.
Why do some people develop PTSD after experiencing a traumatic event? PTSD may develop when there is an impairment in REM sleep, which normally plays an adaptive memory-processing function.
The acute stage of PTSD lasts up to 3 months, while in chronic cases, symptoms are experienced for 3 months or longer.
When PTSD enters a chronic phase, trauma memories continue to be represented in recurring nightmares. Dream content of patients with established PTSD is not limited to trauma memories, however, and it might reflect the negative and restricted emotional state of the dreamer in other ways as well.
In delayed onset PTSD, the symptoms may begin 6 months or longer after the trauma.
Approximately 50% of PTSD cases resolve within 3 months with treatment, but posttraumatic nightmares may persist throughout life.
Although the severity of PTSD seems similar in younger and older adults, the elderly report less reexperiencing but more hyperarousal symptoms compared with younger people.
PTSD & Related Problems
Common sleep complaints and related problems among PTSD patients include:
- Hyperarousal & Insomnia – Heightened arousal during sleep. Approximately 41% to 47% of people with posttraumatic stress disorder (PTSD) report symptoms of insomnia.
- Recurrent awakenings, including awakenings with somatic anxiety symptoms.
- Disturbing dreams and nightmares, often accompanied by vivid recall on awakening as well as panic/fear.
- Excessive motor activity, movement abnormalities, violent, or injurious activities during sleep.
- Alcohol or other substance abuse or dependence. 40-60% of depressed patients smoke with even higher rates in those affected by PTSD.
- Obstructive sleep apnea and sleep-disordered breathing.
- Hypnagogic and hypnopompic hallucinations.
- Isolated sleep paralysis.
- Anxiety disorders, such as panic disorder.
PTSD and Sleep Stages
Development of PTSD symptoms is more likely in people who before (or right after) the trauma exhibit the following:
- A shorter average duration of REM sleep before a stage change along with more periods of REM sleep.
- Increased sympathetic activation during REM sleep (“the fight or flight response”).
- A more fragmented pattern of REM sleep.
- Nightmare replicative of the trauma.
Sleep in PTSD is characterized by REM sleep abnormalities. Overall, PTSD patients seem to have:
- Increased stage 1 sleep.
- Decreased slow wave sleep (deep sleep).
- Increased frequency of eye movements during REM sleep periods (REM sleep density).
- More transitions from REM sleep to waking.
- Greater apnea-hypopnea index (higher risk for sleep apnea).
- Greater REM sleep fragmentation. For example, increased frequency of REM sleep to wakefulness and REM sleep to stage 1 transitions (linked to adrenergic surges).
- Decreases in the total time spent in REM sleep.
- Older patients with PTSD have less slow wave sleep and more REM sleep than older adults without PTSD.
PTSD, REM Sleep, and Dreams
The hallmark of PTSD seems to be disturbance in REM sleep in addition to trauma nightmares.
Rapid eye movement (REM) sleep is when we normally experience dreams that are elaborate, visual, emotional, and bizarre. But dreams can also occur during NREM sleep stages.
PTSD nightmares unlike REM dreams do not exhibit as a lack of correspondence with actual events, bizarreness, and mixing of time frames and contexts.
So do PTSD dreams occur during REM sleep or are they like night terrors and related parasomnias, which arise in NREM sleep stages, particularly slow wave sleep?
In general, most of PTSD nightmares arise during REM sleep in a pattern of REM interruption insomnia, although they sometimes emerge during NREM sleep, specifically stage 1 and 2 (light sleep).
The representation of the memory of a trauma in dreams is a distinguishing feature of PTSD. In fact, one of the most persisting and distressing symptoms of this condition are recurrent distressing dreams of the event and trauma-related nightmares (e.g., recurrently themed nightmares that replay the trauma or dreams which incorporate actual memories of frightening experiences).
80% of PTSD patients have nightmares within 3 months of the traumatic event, which may persist throughout life.
Nightmares are much more frequent among those suffering from PTSD (50-75%) than they are among healthy individuals (2-5%).
7-20% of children experience nightmares while 20-81% of trauma-exposed children have them.
It is normal, and may even be emotionally adaptive, to dream of life stressors, especially when they involve a traumatic event. However, in PTSD there are persistent maladaptive trauma-replicating dreams. Also, if there are recurring nightmares, this may worsen the course of the PTSD because they reinforce the memory of the trauma.
PTSD nightmares are more common in
- people of a lower socioeconomic and education levels.
- people with a history of psychopathology.
- people with personality traits such as schizoid or borderline personality disorder.
PTSD Nightmares Vs. Non-PTSD Nightmares
Recurring dreams are associated with more negative dream content, increased distress, and a lower degree of psychological well-being compared with nonrecurrent dreams.
PTSD nightmares are often even more distressing than non-PTSD recurring dreams.
But the main difference between PTSD and non-PTSD dreams is that while normal dreams rarely correspond to actual events (not episodic memories), PTSD dreams contain more representations of events that include or are closer to unaltered memories (of traumatic events).
Normal dreams are hyperassociative. Characters, places, and sequences that typically are not linked in waking conscious thought tend to be juxtaposed in dreams.
Chronic PTSD is associated with recurring dreams that represent specific memories of a traumatic experience. For example:
- Dreams featuring a threat.
- Dreams with specific trauma-related or thematically related content.
- Anxious dreams.
- Dreams set in the past.
- Aggressive dreams.
- Dreams about interpersonal conflicts.
- Dreams with content related to general and physical misfortune, as well as more negative emotions
- Combat veterans often experience dreams containing direct references to combat experiences.
If there’s a comorbid medical, psychiatric, or sleep disorder, such as alcohol or substance abuse, obstructive sleep apnea (OSA), etc., then that should be treated. This is important to emphasize because, to take one example, veterans with PTSD and OSA are often less willing to use CPAP. The REM sleep becomes even more impaired, leading to an aggravated disease course and worse prognosis.
As for PTSD itself, effective pharmacologic treatments include the antidepressant SSRIs (e.g., paroxetine and sertraline), the SNRI venlafaxine (Effexor; may produce negative results), and, to a lesser extent, tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs). These drugs reduce the severity of reexperiencing symptoms.
Unfortunately, the drugs used for PTSD may in themselves cause sleep problems.
For example, paroxetine (Paxil) may cause sedation/somnolence/drowsiness and insomnia among its many side effects. It increases nocturnal awakenings, the time it takes to fall asleep, and the incidence of periodic limb movements during sleep (PLMS), while reducing total sleep time and REM sleep.
Sertraline (Zoloft) may cause insomnia and somnolence and increase the time it takes to fall asleep and enter REM sleep and the incidence of periodic limb movements during sleep (PLMS), while also reducing total sleep time and REM sleep.
It is therefore best to resort to trauma-focused cognitive-behavioral psychotherapeutic therapies (CBT), which are also effective for reexperiencing symptoms.
While nightmares tend to decrease in frequency and intensity as PTSD generally abates, sometimes residual sleep symptoms may remain, especially insomnia and/or nightmares.
Nightmare-focused treatments can also alleviate PTSD symptoms, and are what I most frequently recommend for most of my clients who suffer from PTSD-related nightmares.
Pharmacological Treatments for PTSD Nightmares
For PTSD nightmares, currently the most helpful drug is prazosin (Minipress), an alpha1-noradrenergic antagonist.
Recall that PTSD dreams are episodic unlike normal dreams, which may be due to impaired inhibition of noradrenergic tone during sleep. Prazosin blocks noradrenergic stimulation, thereby restoring normal dreaming.
Drugs which are less recommended include:
- Clonidine (Catapres)
- Atypical antipsychotics, such as olanzapine (Zyprexa), aripiprazole (Abilify), and risperidone (Risperdal)
- Topiramate (Topamax)
- Fluvoxamine (Luvox)
- Benzodiazepines, such as triazolam (Halcion), nitrazepam (Mogadon), and clonazepam (Klonopin)
- Gabapentin (Neurontin)
- Cyproheptadine (Periactin)
- Tricyclic antidepressants, such as imipramine (Tofranil), doxepin, and amitriptyline (Elavil)
- Phenelzine (Nardil)
- Nabilone (Cesamet)
Psychological Treatments for PTSD Nightmares
The use of evidence-based psychotherapy is critical for the successful treatment for PTSD, especially psychosocial treatments that focus on sleep aspects of PTSD such as nightmares.
The treatment of nightmares not only can ameliorate sleep disturbances but also can reduce overall symptoms of PTSD, although not to the point of remission.
The most recommended therapy for PTSD nightmares by the American Academy of Sleep Medicine is Imagery rehearsal therapy (IRT), which involves writing out the content of a distressing dream, rescripting the content any way one wishes, and then rehearsing the images of the altered dream scenario.
Other recommended sleep-focused psychological treatments which reduce nightmare severity and frequency include:
- Exposure, relaxation, and rescripting therapy (EERT) – combining relaxation training (which alone may not be effective) and direct, repeated exposure to disturbing dream content with rescripting of the dreams.
- Exposure therapy – exposure without rescripting, facilitating successful emotional processing by developing new associations with the traumatic memories much like REM sleep does in people without PTSD.
- Lucid dreaming therapy (LDT) – an approach that uses lucid dreaming techniques wherein patients learn to alter dream content as the dream actually occurs.
- Eye-Movement Desensitization and Reprocessing (EMDR) – a 5-week treatment can improve sleep consolidation and reduce nocturnal awakenings. Here one induces a REM sleep-like state by moving the eyes while processing the trauma.
Psychological Treatments for Insomnia in PTSD
The most recommended approach to treating insomnia in both PTSD and non-PTSD patients is cognitive behavioral therapy (CBT), specifically CBTI, or CBT for insomnia.
In addition, education and encouragement about behavioral factors that disturb sleep are essential.
If there are many heightened safety concerns, then these should be addressed to avoid interference with sleep onset and worrying throughout the night.
It’s also important to get high quality sleep, which has an impact on the severity and trajectory of PTSD symptoms and may even contribute to suicidality.
Behavioral insomnia treatments can be effective even if they are delivered remotely. For example, a group of veterans with PTSD went through a video CBT-I program.
Herbal Medicine and PTSD
Nervine (affecting the nervous system) and adaptogenic (increasing resistance to stressors) herbs are able to respond to the symptoms of PTSD without side effects and may therefore be able to replace selective serotonin reuptake inhibitors (SSRI) medications.
A primary adaptogen-nervine formula could be created using the following herbs:
- Adaptogens with an affinity for the adrenal glands, such as:
- Eleuthero (Eleutherococcus senticosus)
- Licorice (Glycyrrhiza glabra)
- Wild yam (Dioscorea villosa)
- Schisandra (Schisandra chinensis)
- Oat tops (Avena sativa)
- Holy Basil (Ocimum sanctum) – anti-anxiety, antidepressant, and neuroprotective, specifically effective for stagnant depression, including PTSD.
- Golden root (Rhodiola rosea) – stimulates the release of dopamine and serotonin in the brain. This herb strengthens the central nervous system adapting to both the increase and decrease of nervous system activity. It’s also an antidepressant, may reduce insomnia and emotional instability, and may improve self-esteem.
Additional herbs may be added, which are relaxing nervines and/or adaptogens shown to be effective in the treatment of anxiety, nervous tension, insomnia, and mental exhaustion:
- Kava (Piper methysticum)
- Gotu kola (Centella asiatica)
- Ashwagandha (Withania somnifera)
If there’s a comorbid depression, the following herbs can be added:
- St. John’s wort (Hypericum perforatum)
- Saffron (Crocus sativus)
Additional anti-anxiety herbs include:
- Lemon balm (Melissa officinalis)
- Chamomile (Matricaria chamomilla)
- Hops (Humulus lupulus)
Traditional Chinese medicine also offers herbal formulas to treat PTSD.
A 2011 randomized, double-blind, placebo-controlled trial compared a Chinese herbal formula, Xiao-Tan-Jie-Yu-Fang (XTJYF), to placebo in 2008 Sichuan earthquake survivors with PTSD.
Compared to placebo, the XTJYF group was significantly improved in somatization, obsessive-compulsive behavior, depression, anxiety, hostility, and in sleep quality score.
While you won’t find it on eBay.com, these are the ingredients:
- Bupleurum chinense root, 4.5%
- Angelica sinensis root, 4.5%
- Wolfiporia extensa sclerotium, 15.2%
- Atractylodis macrocephalae rhizome, 4.5%
- Paeonia alba root, 7.6%
- Mentha haplocalyx herbage, 3%
- Glycyrrhiza uralensis root, 3%
- Coptis chinensis rhizome, 1.5%
- Pinellia ternata rhizome, 7.6%
- Citrus reticulata aged peel, 4.5%
- Fossilized animal bones, 15%
- Oyster shell, 15%
- Rheum officinale root, 6.1%
- Acorus gramineus rhizome, 7.6%
Learn more about Chinese herbs for insomnia, Chinese herbs for nightmares, or Chinese non-herbs for various sleep problems.
What is PTSD And Why Does it Happen? The Function of Dreams
According to one theory of the function of dreams, dreams help us deal with stress. Stressful waking experiences are more likely to be incorporated into dreams and have an impact on dream emotional content. Recurring nightmares reflect continuing attempts to integrate a trauma.
However, just experiencing threat dreams also not correlate with actual adaption to threatening events, on the contrary, reexperiencing nightmares are often debilitating.
Further, the occurrence of nightmares before or after trauma exposure is often a risk factor for developing PTSD.
So do dreams help or interfere with healthy emotional processing of stress?
Dream narratives normally incorporate elements of current concerns including the incorporation of daily stressors as distressing dream content. Stressful life experiences tend to also cause recurring dreams, which have more negative content than nonrecurring dreams.
According to the emotional information processing theory, dreams help only when they process the information by incorporating it in typical dreams and not when they simply repeat the traumatic memories. While in normal dreams the stressful situation is incorporated, referenced to, or represented, and not necessarily replicated as is typical in PTSD. Simply replicating the experience of the trauma is not as helpful as reprocessing the memory.