Sleep Disturbances in Posttraumatic Stress Disorder: Updated Review and Implications for Treatment

Abstract

Sleep disturbances are common in adults with PTSD and range from insomnia and nightmares to periodic leg movements and disruptive nocturnal behaviors. Together these findings suggest profound disturbances in rapid eye movement (REM) and non-REM (NREM) sleep, although there is a lack of consensus regarding a distinct profile of objective sleep disturbances associated with PTSD. Prospective, longitudinal studies have established that sleep disturbances represent a risk factor for the development and course of PTSD, suggesting that sleep is an important neurobiological mechanism in the etiology and maintenance of this disorder. This research highlights the importance of early identification and treatment of sleep disturbances in at-risk and trauma exposed populations. A number of psychological and pharmacological treatments are effective at treating sleep disturbances in PTSD. Additional research is needed to further develop clinical guidelines informing when and how to integrate sleep-specific treatment with PTSD focused clinical care.

Posttraumatic Stress Disorder Severity and Insomnia‐Related Sleep Disturbances: Longitudinal Associations in a Large, Gender‐Balanced Cohort of Combat‐Exposed Veterans

“…Regarding the temporal association between sleep disturbance and PTSD severity, studies have supported similar effects of sleep disturbance on PTSD symptomatology, as reported in the current study in both civilian and military populations (Breslau et al, 2004;Miller et al, 2017). It has also been proposed that treating sleep problems directly is beneficial for both civilians and military populations with PTSD (Brownlow, Harb & Ross, 2016;Koffel et al, 2016).…”

“…We were also unable to assess nightmare frequency or intensity in our cohort as our independent measure of sleep disturbance (i.e., the JSS did not include any nightmarerelated items). The prevalence of nightmares and their relation to PTSD severity and outcomes is an important and relatively unexplored topic for future research (Cox et al, 2017;Koffel et al, 2016;Miller et al, 2017). Finally, although we report on a high rate of prescriptions given for sedative-hypnotic drugs, we did not assess the use of other psychotropic drugs, such as benzodiazepines, tricyclic antidepressants, opiates, or nonprescription sleep aids.…”

“…Previous studies have failed to adequately address the role of gender in PTSD-related sleep disturbances (Koffel et al, 2016;Miller et al, 2017), although some authors have proposed that female veterans with PTSD may have increased susceptibility to sleep difficulties in light of higher rates of insomnia generally in women (Cox et al, 2017;Miller et al, 2017), although evidence for this hypothesis has been scant. In our study, we observed similarly high rates of insomnia and nonrestorative sleep complaints in male and female, combat-exposed veterans with PTSD.…”

“…From a neurobiological perspective, it has been proposed that chronic sleep loss can lead to emotional dysregulation (Koffel et al, 2016) or heightened autonomic arousal (Miller et al, 2017), which in turn may be a risk factor for PTSD in trauma-exposed individuals (Cox et al, 2017). It has also been proposed that prior sleep disturbance may attenuate the effects of extinction learning, leading to more enduring or severe symptoms in trauma-exposed individuals with concomitant sleep disorders (Brownlow, Harb & Ross, 2015;Miller et al, 2017).…”

“…Moreover, given the prominent role of depression, traumatic brain injury (TBI), and other prevalent comorbidities in combat-exposed veterans (Green et al, 2016;Holowka et al, 2014;Rosen et al, 2012) and the significant risk for both PTSD and sleep disturbance associated with each of these comorbidities (Kessler et al, 2011;Sarsour et al, 2010), the role of comorbidities may be central to understanding the association. Third, the role of gender as a potential risk factor or moderator of sleep symptoms among veterans has not been adequately addressed in prior studies (Koffel et al, 2016). This is a key omission as women in the general population have a higher risk for insomnia-related sleep complaints (Sarsour et al, 2010) and higher rates of prescription drug use for insomnia than men (Bertisch et al, 2014;Kessler et al, 2011).…”