Sleep is a universal problem in PTSD, but early research in this area reported inconsistent findings. Luckily recent research focused on REM SLEEP has discovered an underlying problem.
People with PTSD have lots of REM sleep, but the cycles are very short, end abruptly, and may end in a nightmare or panic attack. It seems that the usual alternating cycle between non-REM and REM sleep has become seriously disturbed.
Most researchers view non-REM sleep (stages 1-4) as restorative sleep—a time when our bodies and minds rest and heal. By contrast, REM sleep is a time when our mind is very busy processing memories, emotions, and visual images—which produce dreams—while our bodies and muscles can relax totally.
The normal cycle of REM sleep begins after an hour or two of non-REM sleep. It’s followed by shorter periods of non-REM sleep and longer periods of REM until you’re awake. This cycle is mediated by a slew of chemicals from sleep control centers in our brain. Most relevant to PTSD is that REM sleep starts when the sympathetic nervous system and noradrenaline secretion are at their lowest level. And it stops when those levels get too high.
That may explain the irregular periods of REM sleep seen in PTSD. When the sympathetic nervous system is overactive and produces increased levels of noradrenaline, it may cause the sudden termination of REM sleep cycles into panic and nightmare attacks.
The disruption of REM sleep leads to a host of new problems including inflammation, reduced immunity, confusion, poor memory, difficulty making decisions, and more nightmares.
NIGHTMARES in PTSD are often traumatic memories being triggered into awareness and are closely related to flashbacks and panic attacks, which may also occur upon awakening. These events further activate the sympathetic nervous system, cause the secretion of more noradrenaline, and make it more difficult to sleep.
Other sleep problems in PTSD include MOTOR MOVEMENT DISORDERS and SLEEP BREATHING DISORDERS. The motor movements may also be due to high levels of noradrenaline causing our muscles to twitch during sleep. It’s less clear how sleep breathing problems are related to PTSD. Guess we’ll have to wait for better research.
To date the most effective treatment for PTSD sleep disturbances and nightmares has been Prazosin in doses from 1 mg to 15 mg at night. Prazosin is an alpha1-blocker blood pressure medicine that blocks the effect of noradrenaline on the brain. In studies it has worked to reduce nightmares and improve sleep in about 75% of military veterans and civilians with PTSD. Furthermore, the erratic REM sleep cycles seen in PTSD quickly return to normal on Prazosin, which supports the theory that excessive noradrenaline initiates and drives these symptoms.
Trazodone works both as an alpha-blocker and by stabilizing serotonin levels, making it a very useful drug for sleep. Doses range from 25 mg to 150 mg with some people needing 300 mg. Not as short acting as some other drugs, it can hang you over the next morning.
Gabapentin may be useful if the others fail. The mechanism of action for this seizure medication is poorly understood but it seems to either mimic GABA (the primary calming chemical in our brain) or inhibit Glutamate (the primary stimulating chemical in our brain). Either way, it is calming for most people and reduces nightmares and sleep disruptions. Gabapentin has some significant side effects, but lower doses are needed for sleep that for seizures, so usually it is well tolerated. But if you take too much, it can make you sleepy and depressed.
Thorazine, Risperdal, Seroquel, and other antipsychotics also act as alpha-blockers and are often used for sleep. They have other actions on the brain which you may find useful or harmful. Many people with PTSD complain of feeling overmedicated and “blah” on these meds. Some folks have muscle twitches or tightness. They can also cause metabolic side effects of weight gain and increased blood sugar. Use with caution.
B) SLEEP HYGIENE:
Here are some non-medical ways to improve your sleep.
1) To induce sleep, you need a comfortable mattress in a cool, dark, and quiet room.
2) You need to keep regular sleep hours. This is best done by getting up at the same time every day and going to bed when you get sleepy.
3) Sleep is initiated by melatonin, a chemical made in your brain. Your first exposure to sunlight turns off melatonin production for the next twelve hours. After that, it gradually increases. That means you need direct exposure to sunlight at least twelve hours before you want to sleep. Morning exposures work well, even on a cloudy winter day.
4) Exercising during the day relaxes and prepares your body for deep sleep. DON’T exercise right before bed—it wakes you up.
5) Bedtime routines help prepare your body for sleep. Do something relaxing (shower, read a book, listen to music, meditate) before bed. Computers and TV screens have been shown to interfere with sleep.
6) Avoid caffeine and other stimulants in the afternoon and evening hours.
7) Avoid overuse of alcohol or benzodiazepines (Valium, Xanax, Ativan, etc.). Excessive use can lower GABA levels and make your brain more hyper.
8) Avoid arguments and stress before bedtime. Anger and anxiety keep you awake.
9) If you’re in pain, treat the pain before you sleep.
10) Try relaxation exercises like deep breathing and progressive muscle tightening and relaxing to get your body ready for sleep.
C) REWRITING YOUR NIGHTMARE:
This technique works well for recurrent nightmares that may have a trauma basis. You have to start at the beginning of the dream, at the same place the nightmare always starts. But then you change the story so it has a happy ending. The story you create doesn’t have to be real. You’re working with a dream, after all. But it must satisfy your needs emotionally. Then you practice, practice, practice visualizing the new story. Remember that the old dream wore a rut into your brain, and you have to practice the revised dream until it makes an even deeper rut. If you practice long enough, you’ll never dream the nightmare again.
Sleep disturbance is central to PTSD and appears to be caused by an overactive sympathetic nervous system secreting increased levels of noradrenaline. Fixing that problem is essential to your mental and physical health. Try Prazosin or Trazodone plus good sleep hygiene. If you still have nightmares, try rewriting them.