Why directly treating insomnia and nightmares in your clients with PTSD is likely to save their life
by Brian Curtis, Ph.D.
If you take anything from this blog post, I hope it’s these two points: 1) Chronic insomnia and recurring nightmares are extremely common in your clients with trauma-related difficulties; 2) Directly treating your client’s insomnia and nightmares is likely to save their life.
Here’s what the research is telling us: 7 out of 10 of your clients meeting diagnostic criteria for posttraumatic stress disorder (PTSD) will also report symptoms of ongoing insomnia (i.e., difficulty falling asleep, difficulty staying asleep, or waking too early with difficulty returning to sleep)1. Depending on the severity of your client’s PTSD symptoms, between 19-96% will tell you they regularly experience extended, extremely frightening, well-remembered dreams (i.e., nightmares) that routinely disrupt their sleep2.
Across all mental health difficulties, PTSD ranks among the highest for increased risk of suicide3. And here’s what we’re learning about the link between sleep and suicide: Epidemiological findings suggest that if your client frequently experiences nightmares, they have a 105% increased risk of suicide4. Cross-sectional data on people who attempted suicide reveals that 73% reported difficulty falling asleep, 69% reported difficulty staying asleep, and 66% reported experiencing nightmares, with recurring nightmares being associated with a 500% increased risk of suicidality5.
Let’s pause for a second and let these numbers soak in. 70% your clients are struggling, perhaps every night, to sleep. Even if they can sleep, at least 20% of your clients may dread this ability because of recurring, terrifying dreams.
Although sleep is known to improve following PTSD treatment, research indicates that chronic insomnia and recurring nightmares are likely to remain problematic if they’re not treated directly6–8.
Knowing that your clients are struggling with their sleep represents an immediate opportunity for you to save their life.
As a mental health professional, you can deliver the most effective, gold standard treatments for chronic insomnia and nightmare disorder.
Based on over 50 years of experimental evidence, the American College of Physicians and the American Academy of Sleep Medicine recommend Cognitive Behavioral Therapy for Insomnia (CBT-I) as the most effective treatment option for chronic insomnia9–12. Based on over 30 years of experimental evidence, the American Academy of Sleep Medicine recommends Imagery Rehearsal Therapy (IRT) and related interventions like Exposure, Relaxation, and Rescripting Therapy (ERRT) as the most effective treatment options for nightmare disorder13.
Emerging evidence indicates that if you treat your client’s insomnia with CBT-I, you may also find clinically meaningful reductions in their depression and suicidal ideation14. Research in a population of combat veterans with PTSD indicates that you can combine the treatment of your client’s chronic insomnia with CBT-I and nightmare disorder with IRT and find significant reductions in their insomnia, nightmares, depression, and PTSD severity15.
Based on the research we have in hand, recommendations have been made to fully integrate the treatment of insomnia and nightmares in PTSD.
As stated by Spoormaker and Montgomery:
“With findings such as these, it is neither ethical nor cost-effective for mental health professionals to neglect sleep disturbances in PTSD treatment. Sleep treatment should (and can) be incorporated into any kind of PTSD treatment, whether pharmacological or cognitive behavioral” (p. 1777).
As a clinical psychologist, trauma therapist, and specialist in behavioral sleep medicine, I completely agree!
A well-known barrier to your clients with trauma-related difficulties overcoming their chronic struggles with insomnia and nightmares is that few mental health clinicians have been exposed to the field of behavioral sleep medicine16, received training in the assessment of sleep disorders, CBT-I for insomnia13,17,18, or IRT or ERRT for nightmare disorder13,19.
One of my career goals is to help overcome this barrier by helping fellow mental health providers increase their competence in the assessment and treatment of sleep-related difficulties with their clients.
Please don't hesitate to reach out to me directly (for FREE) if you're interested in being the solution to this incredibly consequential problem: firstname.lastname@example.org
Remember, chronic insomnia and recurring nightmares are extremely common in your clients with trauma-related difficulties. Directly treating your client’s insomnia and nightmares is likely to save their life.
Let’s begin this life-saving work together.
1. Maher MJ, Rego SA, AsnisGM. Sleep disturbances in patients with post-traumatic stress disorder:Epidemiology, impact and approaches to management. CNS Drugs.2006;20(7):567-590. doi:10.2165/00023210-200620070-00003
2. Miller KE, Brownlow JA, Woodward S,Gehrman PR. Sleep and Dreaming in Posttraumatic Stress Disorder. CurrPsychiatry Rep. 2017;19(10):1-10. doi:10.1007/s11920-017-0827-1
3. Chesney E, Goodwin GM, Fazel S. Risks ofall-cause and suicide mortality in mental disorders: A meta-review. WorldPsychiatry. 2014;13(2):153-160. doi:10.1002/wps.20128
4. Tanskanen A, Tuomilehto J, Viinamäki H,Vartiainen E, Lehtonen J, Puska P. Nightmares as predictors of suicide. Sleep.2001;24(7):844-847.
5. Sjöström N, Wærn M, Hetta J. Nightmaresand sleep disturbances in relation to suicidality in suicide attempters. Sleep.2007;30(1):91-95. doi:10.1093/sleep/30.1.91
6. Gutner CA, Casement MD, Stavitsky GilbertK, Resick PA. Change in sleep symptoms across Cognitive Processing Therapy andProlonged Exposure: A longitudinal perspective. Behav Res Ther.2013;51(12):817-822. doi:10.1016/J.BRAT.2013.09.008
7. Spoormaker VI, Montgomery P. Disturbedsleep in post-traumatic stress disorder: Secondary symptom or core feature? SleepMed Rev. 2008;12(3):169-184. doi:10.1016/j.smrv.2007.08.008
8. Taylor DJ, Pruiksma KE. Cognitive andbehavioural therapy for insomnia (CBT-I) in psychiatric populations: Asystematic review. Int Rev Psychiatry. 2014;26(2):205-213.doi:10.3109/09540261.2014.902808
9. Qaseem A, Kansagara D, Forciea MA, CookeM, Denberg TD. Management of Chronic Insomnia Disorder in Adults: A ClinicalPractice Guideline From the American College of Physicians. Ann Intern Med.2016;165(2):125-133. doi:10.7326/M15-2175
10. Schutte-Rodin S, Broch L, Buysse D, DorseyC, Sateia M. Clinical guideline for the evaluation and management of chronicinsomnia in adults. J Clin Sleep Med. 2008;4(5):487-504.doi:10.5664/jcsm.6470
11. Sateia M, Buysse DJ, Krystal AD, NeubauerDN, Heald JL. Clinical practice guideline for the pharmacologic treatment ofchronic insomnia in adults: An American Academy of Sleep Medicine clinicalpractice guideline. J Clin Sleep Med. 2017;2:307-349.
12. Edinger JD, Arnedt JT, Bertisch SM, et al.Behavioral and psychological treatments for chronic insomnia disorder inadults: An American Academy of Sleep Medicine clinical practice guideline. JClin Sleep Med. 2021;17(2):255-262. doi:10.5664/JCSM.8986
13. Morgenthaler TI, Auerbach S, Casey KR, etal. Position paper for the treatment of nightmare disorder in adults: AnAmerican Academy of Sleep Medicine position paper. J Clin Sleep Med.2018;14(6):1041-1055. doi:10.5664/jcsm.7178
14. Trockel M, Karlin BE, Taylor CB, Brown GK,Manber R. Effects of Cognitive Behavioral Therapy for Insomnia on SuicidalIdeation in Veterans. Sleep. 2015;38(2):259-265. doi:10.5665/sleep.4410
15. Bishop TM, Britton PC, Knox KL, Pigeon WR.Cognitive behavioral therapy for insomnia and imagery rehearsal in combatveterans with comorbid posttraumatic stress: A case series. Mil Behav Heal.2015;4(1):58-64. doi:10.1080/21635781.2015.1100564
16. Stepanski EJ. Behavioral sleep medicine: ahistorical perspective. Behav Sleep Med. 2003;1(1):4-21.http://www.tandfonline.com/doi/abs/10.1207/S15402010BSM0101_3.
17. Taylor DJ, Perlis ML, McCrae CS, Smith MT.The future of behavioral sleep medicine: a report on consensus votes at thePonte Vedra Behavioral Sleep Medicine Consensus Conference, March 27-29, 2009.In: Behavioral Sleep Medicine. Vol 8. Department of Psychology,University of North Texas, 1155 Union Circle, Denton, TX 76203-5017, USA.email@example.com; 2010:63-73.http://www.tandfonline.com/doi/abs/10.1080/15402001003622776.
18. Thomas A, Grandner M, Nowakowski S, NesomG, Corbitt C, Perlis ML. Where are the Behavioral Sleep Medicine Providers andWhere are They Needed? A Geographic Assessment. Behav Sleep Med.2016;14(6):687-698. doi:10.1080/15402002.2016.1173551
19. Margolies S, Rybarczyk B, Vrana S,Leszczyszyn D, Lynch J. Efficacy of a cognitive-behavioral treatment forinsomnia and nightmares in Afghanistan and Iraq veterans with PTSD. J ClinPsychol. 2013;69(10):1026-1042.