Recurring Nightmares and Post-Traumatic Stress

Twice as many women suffer as men

Thomas Neylan, MD

April, 2004

Combat vets and earthquake survivors are likely to suffer from post-traumatic stress syndrome (PTSD) and its debilitating symptoms: flashbacks, recurring nightmares, and sleep disturbances. But PTSD is not just limited to acts of God and acts of war. It's now the fifth most prevalent psychiatric disorder in the United States. And it's twice as likely to strike women as men.¹

The average American female has a 10 percent chance of developing PTSD over the course of her lifetime.² At greatest risk are those who have been raped or physically attacked. Yet simply witnessing a crime or violent act also can produce PTSD-related anxiety and nightmares. Other triggers include sudden injuries and accidents.

While PTSD is usually associated with a single event, it also affects those who have been repetitively abused or sexually assaulted. In each case, the victim remains in a state of high alert, suffering from sleepless nights and repetitive dreams that replay the initial trauma.

How PTSD affects the sleep cycle

PTSD disturbs the sleep cycle in two significant ways. It shortens REM sleep or the "light sleep" that's associated with dreaming. It also interrupts Delta or "deep sleep" that's associated with tissue rejuvenation.

PTSD patients usually have trouble falling asleep, wake more often during the night, and have greater difficulty getting back to sleep. They may also have the following complaints:³

• Daytime fatigue
• Nightmares Nighttime thrashing -- not repetitive leg kicks but full-body movements
• Anxiety
• Depression
• Irritability
• Startle response
• Poor concentration

Preliminary evidence also links PTSD to increased blood pressure, heart disease, and metabolic disturbances and suggests that it may pave the way for other illnesses. These physical responses have been documented in normal people whose sleep has been systematically interrupted in a sleep lab.

It may be hard for the clinician to separate PTSD-related sleep problems from other symptoms. Sleep can be disrupted by something as common as cold medication or hot flashes. That's why it is important to ask appropriate follow-up questions and determine whether a sleep disorder is related to a triggering event.

New Approaches to PTSD-related Sleep Disorders

At the Veterans Affairs Medical Center in San Francisco, we take a team approach to PTSD, using a combination of medication, patient education, and psychotherapy. Although most patients show a significant improvement with treatment, very few achieve total remission of PTSD.

"Teresa," a combat nurse during the Vietnam War, had recurring nightmares for 23 years and finally came us for help at the urging of her family. It's not uncommon for PTSD patients to resist treatment because talking about the trauma increases their anxiety or arouses shame and guilt.

Teresa improved significantly in the course of eight weeks on an SSRI antidepressant and a low dose of clonidine. There is some evidence that clonidine, an antihypertensive, reduces nighttime arousal and may reduce nightmares, as well.⁴

She also responded well to a technique called "imagery rehearsal." Here the patient selects a portion of the nightmare, and then constructs a new ending - one that draws on pleasant memories and associations. Instead of being harmed in the dream, the individual prevails and reaches safety. Practicing this scenario 15 minutes daily has been shown to reduce frequency of disturbing dreams and help PTSD victims sleep through the night. It may also reduce the fear and anxiety they experience throughout the day.⁵

But there is still room for improvement in our treatment. The sleeping pills we routinely use for PTSD have been tested in a short-term paradigm. We are only now beginning to need develop drugs that target chronic sleep disorders.

The most intriguing advances involve our understanding of the endocrine system and the way it regulates our sleep patterns. Researchers have been testing metyrapone, an inhibitor of cortisol that affects our response to arousal and anxiety. The goal is to mimic the way the body deals with fear and stress. If studies are successful, we may see a complete revolution in way we treat PTSD-related sleep disorders in the next five years⁶. Further work is also needed on the way sleep affects our ability to process emotions, release or deprogram irrelevant information, and restack the memory bank.

For more information on PTSD, contact the International Society for Traumatic Stress Studies. The web site provides resources for both patients and clinicians.

Notes

1 Harvey, 2002

2 Kessler 1995

3 Harvey, 2002 and Mellman, 2002

4 Kinzie, 1989

5 Krakow, 2001 and Krakow, 2002

6 Neylan, 2003