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PTSD Questions & Answers
Joyce Boaz & Dr. Frank Ochberg, M.D.

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PTSD Symptoms: Not Being Able To Sleep

Q: Dear Frank, Can you respond to this question, posted on our Facebook site?

One of my worst symptom is not being able to go to sleep. I do eventually but my dreams are like intrusive thoughts and they can be annoying. Sometimes I dream ok and sleep ok. Any ideas how to better sleep?

A: Dear Joyce, Sleep is so important. Shakespeare wrote it "knits the raveled sleeve of care." While many professionals have differing ideas about the purpose of sleep and the meaning of dreams, there can be no doubt that our brains are quite active after we nod off. The theory that makes most sense to me is that our memories from the past day are filed and cross-filed and linked to relevant memories from the near and distant past. If any of these memories include strong sensation, particularly the sensation of fear, then parts of the brain that are within the "fear circuit" are turned on. We are wired much like other mammals when it comes to fear-memory. We need that wiring for survival. It helps us anticipate and react in potentially lethal emergencies. During sleep our fear pathways run rehearsals for future dangers, particularly when we are still absorbing dangerous encounters from the recent past.

Good sleep lets these fear connections calm down. Troubled sleep keeps them in a state of alert and alarm. So what are we to do? Our conscious waking brain has already gotten the message. We know we survived a trauma or a tragedy. We have learned what we need to know. Can't that alarm bell in the head turn off?

This is classic PTSD. The trauma memory exists in an undigested form. It tries to burst into awareness when we don't want to have any more replays. it comes in the day as an unwelcome reminder. Worse, it comes as a flashback -meaning it feels very much in the present, not in the past. And it comes at night. A trauma dream is, in the beginning, a replay of the actual event. But then it changes, woven into other events and (some say) into wishes for a different ending. A father's face may replace the face of an assailant. Some interpret that as a connection to family issues yet to be understood. Some might say that is a good sign, showing unconscious connection to a familiar and safe relationship.

If you have PTSD disturbance of sleep, you may find that sleep improves as you overcome other PTSD issues. You find peers and friends and professionals who validate your experiences. They treat you with respect. You become comfortable with them and then more comfortable with yourself. You realize you are not crazy, weak or odd. You also experience some gradual improvement in your tolerance for strangers, your ability to resume social activity, your enjoyment of leisure time.

With a bit less stress in everyday life your autonomic arousal subsides. That refers to pathways from the brain to the guts (and many other organs) and back again to the brain. This pathway produces a state of readiness to grapple with threat, but also to unpleasant feelings that we know too well: churning in the belly, clenching of the jaw, racing of the pulse, or, in some of us, an eerie numbness and detachment. When these sensations diminish, our dreams become less troubling. Our sleep can return to normal.

So the best way to restore healthy sleep after trauma is to treat the trauma-memory. That is done with "working through." Working through means (1) finding a safe place and a respecting person who can listen and understand. It means (2) learning enough about PTSD to apply self-help, figuring out what relaxes you, what inspires you, what affirms your values and the meaning of your life. It means (3) becoming productive - having a purpose. That usually involves helping others. It is difficult to have self-respect if all you do is soothe yourself. But returning to a job or an avocation or a fulfilling role as a parent, spouse or friend may be very slow work after a very large trauma.

Getting onto a healing path without a good night's rest is particularly difficult. So short-cuts to better sleep are often indicated. Let's start with the pills. There are pills that work. The problem with pills that knock you out are that they stop working after a while and they are dangerous when the dose is too high, or when they are mixed with alcohol and other medications -- and they have side-effects. Extended release Ambien has been known to cause dangerous behavior when a person awakens, still impaired by the sedative, and they drive a car or have access to a weapon. I've often prescribed Ambien and other rapid acting sedatives early in the course of PTSD, just to help establish a pattern of reliable sleep. But I get nervous when a patient stays on the drug too long, or comes to me already habituated to this class of medication. Ambien, Klonopin, Xanax and many other medications are in the class of "benzodiazapines." Some are used primarily as sedatives, helping a person fall asleep. Some are used primarily as minor tranquilizers, helping a person feel less anxious, or helping a person overcome a panic attack. These drugs act quickly and are metabolized quickly (but extended release forms keep acting as long as 8 or 10 hours). They all are known to build tolerance. That means it takes higher and higher doses to work. And once that happens, you are "hooked." It is hard to break the habit.

On the other hand, there are meds that reduce nightmares and meds that help a person stay asleep instead of waking up at 2 or 3AM and staying awake the rest of the night. This pattern is called "late insomnia" or "early morning wakening." I've prescribed Trazodone for this condition and found it very helpful most of the time. Trazodone is not a benzodiazapine. It was first marketed as an anti-depressant, but it never worked that well as a mood enhancer. It did work as a remedy for early morning wakening. It is safe. It has a very wide dosage range, meaning you can start with as little as 25 mg at bedtime and push the dose up to 300 mg, finding the level that works without giving a hang-over in the morning. There are few side effects. It needs to be used regularly and there is no harm (in most instances) using it for decades. You will not need to increase the dose over time.

Prazosin, a drug for high blood pressure, has a good track record treating PTSD nightmares. I want to be sure there are no cardiac or low blood pressure issues when prescribing Prazosin. Some of my PTSD patients with nightmares and insomnia have used both Prazosin and Trazodone and done well.

If you can lessen the fear of sleep by treating nightmares and early morning wakening, you often find you fall asleep more easily and regularly. Then you can avoid becoming "hooked" on benzodiazapines.

There are many over-the-counter sleep aids. There are holistic health remedies. You can read about them and experiment with them and see what works for you. But there are also some life style issues that matter more.

Pay close attention to your diet, particularly your liquid intake in the late afternoon and evening. Stimulants exist in many forms. It is silly to suffer from insomnia and take caffeine after 4PM. Late dinners may make sleeping difficult. Having a full bladder doesn't help you make it through the night. Please, think these things through and act sensibly.

If you are stressed, you are likely to keep yourself awake thinking about tasks you must do or people you must see or insults that still sting. You have to learn how to substitute bland thoughts when your head hits the pillow. It often helps to have a pad of paper near the bed so you can write a reminder that you will read in the morning. (Then you need to read that reminder and take some action the next day). This little trick helps many people overcome obsession. To be anxious is often to be obsessed. Being obsessed is a problem when it robs us of sleep. That bedtime pad can become a helpful habit, freeing us of distraction during the time for carefree drowsiness.

Watch out for excessive light or noise at bedtime. It may be that you cannot fully control that. A partner snores. The walls are thin. An inconsiderate house mate makes a racket. These are large issues when you need a good night's rest. Do what you can to fight for your right to sleep.

If you are awake after bed time, you may benefit from going to another room, reading, changing your mental activity. That way your bed is a place associated with falling asleep, not with lying in the dark, wide awake.

There are sleep clinics and sleep specialists. Your insurance may cover an evaluation, particularly when your diagnosis is PTSD plus insomnia. Consider a sleep study to rule out medical problems that contribute to insomnia. There is a lot on the web that can be helpful. Here are two reliable links:

You will find many more.

Thank you for raising this important question, Joyce. I take this subject very seriously as a doctor and as an educator. PTSD is almost always associated with sleep problems. Making progress with one helps progress with the other.

I wish you well! Good luck and good night!

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