Managing PTSD and Insomnia With CBT-I

Post-traumatic stress disorder (PTSD) is a mental health condition that people can experience after a traumatic event such as an assault, a natural disaster, or a car accident. It can also affect people who witness these events. For example, it can affect first responders, who frequently witness both trauma happening to others and traumatic responses in other witnesses.¹

PTSD symptoms can include anxiety, nightmares, and insomnia. Evidence-based insomnia treatments can help people suffering from PTSD not only sleep better but cope better with their other symptoms.²

PTSD-related insomnia

Both biological and psychological factors are in play for people with PTSD-related insomnia. The high levels of arousal and vigilance people with PTSD experience are related to changes in how the part of the brain called the amygdala processes fear.³

After a traumatic event, this part of the brain can become highly active. It stimulates large amounts of stress hormones, such as cortisol, to be released. Cortisol is involved in our waking cycle, and so this naturally creates sleep challenges for people living with PTSD.⁴

In my experience as a sleep therapist, when a person is feeling under threat (real or perceived), this arousal disrupts sleep. I view this as a protection mechanism – we can't sleep and fight off a bear at the same time!

In some, a vicious cycle happens: Sleep disruption becomes a key source of stress, and that stress actually keeps people awake and worsens any biological tendency toward insomnia.

Nightmares

Many people with PTSD have nightmares in which they relive the traumatic event or the fear and distress it caused. The nightmares themselves can disrupt sleep. But people can also become anxious before bed because they do not wish to relive the experience through a nightmare. This can make sleep more difficult.¹

There are effective treatments for nightmares. In my experience, the behavioral sleep medicine approaches for nightmares are very effective.

The impact of insomnia on PTSD symptoms

To add insult to injury, insomnia often worsens other symptoms of PTSD. Poor sleep quality can make daily living challenging, leading to concentration problems and irritability. Often, this can increase social isolation and reduce available support. It is another vicious cycle, where insomnia makes PTSD symptoms worse, and those symptoms then make the insomnia worse.⁵

Cognitive behavioral therapy for insomnia (CBT-I)

Many people assume that the PTSD must resolve before sleep can be improved, but research does not bear this out. Cognitive behavioral therapy for insomnia (CBT-I) is a behavioral sleep medicine approach that is very effective in treating insomnia, particularly in people with PTSD. Unlike sleep medicines, which may provide only temporary relief and often have side effects, CBT-I addresses the thoughts and behaviors that contribute to sleep problems.¹

CBT-I includes several key components. In real life and 1-to-1 sleep therapy, they may be used only sometimes. Or they may be adapted to fit the person's situation. The main components are described below.

Sleep hygiene education

Many of my own clients have better sleep hygiene than I do! But reviewing and correcting any environmental issues that may be playing a part in the sleeping difficulties is "low hanging fruit" for helping improve sleep.⁶

One very common issue in my clients is the overuse of caffeine, which contributes to wakefulness too late in the day. Another is using alcohol to help fall asleep, only to wake up later and have poor sleep quality.

Cognitive restructuring

This element of CBT-I helps people identify and challenge negative thoughts about sleep and sleeplessness. For example, someone who believes they will never sleep well again may learn to replace that belief with something more helpful and realistic.⁶

Stimulus control therapy

This technique encourages people to associate the bed with sleep by using the bed only for sleep. It also involves going to bed only when sleepy and getting out of bed if sleep doesn't come within 20 minutes.⁶

My personal experience with this technique is that it is best to adapt it from the standard recommendation. First, watching the clock is problematic because it gives people something to be anxious about. Second, in reality, we will all be awake in bed at some point, and I feel it is helpful not to turn this into a problem.

However, a person needs to learn to manage arousal when in bed so they do not associate the bed with "fight or flight" feelings. This also helps them avoid long periods of wakefulness in bed.

Time in bed restriction therapy

This sleep therapy method limits the time a person spends in bed. Many people who don't sleep well go to bed early and lie awake in bed in the morning. In general, they spend too much time in bed awake. This worsens sleep over time. But it can be helped by shortening the chunks of time they spend in bed.⁶

There are a lot of caveats to how this is done, and it is not appropriate or safe for everyone. It may sound scary, but it is not forever. Over time, as sleep improves, the time in bed gradually increases until the person is sleeping for a more solid block of time.

CBT-I, insomnia, PTSD, and you

Does CBT-I help improve insomnia in people with PTSD? Yes, it improves sleep in people with PTSD, and not only in the short term. Sleep improvement can be maintained over time. And a perk is that PTSD symptoms can also improve with sleep therapy.^1,2

Do you have PTSD and insomnia? Have you ever tried this approach? Let us know in the comments.