For many who suffer from post traumatic stress disorder, symptoms not only present themselves in the form of anxiety and emotional afflictions experienced during waking hours, but also in the form of nighttime symptoms such as insomnia, nightmares and disturbed sleep patterns, all of which can detract from one’s quality of rest.

Research performed at the University of California, San Diego School of Medicine and Veterans Affairs San Diego Healthcare System suggests that PTSD may be more effectively treated by placing an initial emphasis on addressing the nighttime symptoms that an estimated 70 percent of the civilian population and 90 percent of combat veterans diagnosed with the disorder experience, according to an Aug. 27 study published in The Journal of Neuroscience.

“Sleep disturbances are pretty universal in PTSD,” said Sean Drummond, a psychologist and a professor of psychiatry at the Veterans Affairs San Diego Healthcare System and UCSD.

Drummond, who led the research team, explained that while nighttime symptoms are seen almost across the board in PTSD patients, the type and degree of sleep disturbances  can vary.

Some who suffer from PTSD will become hyper-vigilant at night and experience difficulties falling asleep, according to Drummond. Others fall asleep normally but wake up for long periods of time throughout the night or in the early morning hours and are unable to get back to sleep. 

“All of [those symptoms] can make sleep broken up and fragmented,” Drummond said. “They all have slightly different effects on the stages of sleep someone experiences … but what they do in common is reduce the quality, efficiency and consolidation of that sleep.” 

According to the National Institutes of Health, rapid eye movement sleep is a stage that people normally fluctuate in and out of over the course of a night’s rest. REM sleep is associated with stimulating regions of the brain involved in learning and memory consolidation. Drummond explained that, in general, REM sleep is related to the consolidation of emotional memories. When someone experiences an event with an emotional component to it, it is during the REM sleep stage when that information is turned into a long-term memory. Drummond’s research also included a focus on fear conditioning and safety signaling—standard treatments used to help people with PTSD process emotional trauma.

“Fear conditioning is when someone learns to associate a threat with a prior stimulus that could be positive or negative,” Drummond said. “Safety signaling is sort of the opposite: learning that a particular stimulus is safe and means that one is out of harm’s way.” 

The process of unlearning the fear that one might associate with a certain stimulus and learning safety cues both contribute to helping people discriminate between what in someone’s environment may or may not be harmful. When a patient’s disturbed sleep patterns negatively impact the REM sleep stage, his or her ability to consolidate those emotional memories processed in daytime treatments can suffer. 

“Disturbed sleep associated with what we now call PTSD has been known for a very long time,” said Dr. Matthew J. Friedman, a Ph. D. and  professor of psychiatry at the Geisel School of Medicine at Dartmouth College and a senior advisor at the National Center for PTSD. “Some of the earliest biological research into PTSD was looking at sleep and the occurrence of nightmares.”

Friedman explained that in some respects, the research into PTSD and sleep has been disappointing. Characterizing the link in a quantifiable way has been more elusive than in a condition like depression, where there is a more easily measured and consistent type of sleep disturbance, he said.

“There is a general consensus that dreaming is disturbed, sleep is more fragmented and REM periods are more frequent but shorter in duration,” Friedman said. 

This leads researchers to question whether the integrity of REM sleep—which helps process the day’s events, produce a therapeutic internal narrative and even has physiological implications for health—is maintained.

Friedman said there is some debate about whether PTSD is primarily a fault of the disturbed sleep patterns or if the disturbed sleep is a consequence of all the other deregulation that occurs from the disorder, but there is likely some basis for both perspectives.

Regardless of the apparent link between PTSD and sleep, the current first line of treatment for those suffering from the disorder does not involve any sleep-related component, said Joanne Davis, a Ph. D. and associate professor in the department of psychology at the University of Tulsa.

Cognitive-behavioral therapy for insomnia and exposure relaxation and rescripting therapy are two approaches researchers are beginning to incorporate into treating the nighttime symptoms of PTSD, according to Davis.

“As much as we know about sleep and nightmares, there’s an awful lot we don’t know,” Davis said. “We attempted to develop a model that outlines all of the possible perpetuating factors that contribute to the cycle of experiencing nightmares, feeling distressed during the day, becoming sleep deprived and having anticipatory anxiety.” 

Cognitive-behavioral therapy for insomnia involves education about the interaction of trauma and sleep problems while incorporating a number of relaxation techniques designed to target specific disturbed sleep patterns. 

Davis said some elements of exposure relaxation and rescripting therapy are borrowed from cognitive processing therapy, one of the standard treatments of the daytime symptoms of PTSD. In ERRT, patients write down and analyze their nightmares and  rewrite the dreams to address traumatic themes. Most PTSD patients will experience at least one recurring nightmare in the form of a flashback or a repetition of themes like loss of control or feelings of powerlessness.

“There seems to be a real coalescence of trauma literature right now in terms of realizing how crucial sleep is to recovery,” Davis said. “Get people to sleep well and give them more cognitive and behavioral resources during the day they can use to tackle their symptoms.”