Sleep continues to be a common issue found within survivors of trauma and can act as a catalyst for a host of additional symptoms which are associated with trauma. Traumatic experiences often lead a survivor to experience high levels of epinephrine and adrenaline which are released to continue the survival response and act as a protective factor. These neurochemicals remain present in the brain following past trauma and can serve to interrupt an individual’s normal sleep cycle causing difficulties with; insomnia, nightmares and daytime fatigue caused by poor sleep hygiene/quality.
Trauma responses such as flashbacks and troubling thoughts can make the act of falling asleep seem impossible at times. Not only interfering with sleep hygiene but the actual quality of sleep. In a sleep state, there is no control. An individual is victim to whatever images are produced by the brain and has no ability to alter this (there are cases of individuals practicing the act of dream modification however this post looks at the consensus population of which follow REM paths). To sleep ‘perchance to dream’ , survivors commonly fear the dreams that may come due to the uncontrollable aspect that flashes them back to the past.
Within waking life, a survivor of trauma may feel the need to maintain a high level of vigilance. Experiencing day to day life in a manner that protects and ensures safety. A survivor may engage in behaviors which are self protective, avoiding stimuli that are perceived potentially dangerous (or uncontrollable). As a survival response (each of the 4f responses), a survivor of trauma may live their life in ways that are predictable and calculated. This safe place is in stark contrast to the dream world; where dreams and at times; night terrors plague an individual with no ability to change or control that environment. Going to sleep therefore can transform into a negative association with the pattern of night terrors serving to exemplify that.
Darkness itself may present anxiety and agitation within many survivors of trauma. It can cause a survivor to be triggered, to experience reliving of the trauma (flashbacks) or result in the use of maladaptive coping and reliance in order to deal with the uncomfortable feelings that it brings. Fearing darkness leads to added stress and anxiety; especially as the hours pass and darkness nears. This fear can result in manifestations of SAD (seasonal affective disorder), depression, anxiety and produce phobias. At times when an individual is in such a heightened emotional state, it is possible to visually see things which may not be there. Individuals with anxiety over darkness commonly report associating shadows and objects negatively as well as see insects and objects which aren’t physically there. These visual manifestations are a way for the brain to remain vigilant during exhaustion and research has found exhaustion and poor sleep quality to be a huge factor in physiological health.
Survivors of trauma often report as using sleep to cope with symptoms of trauma. Commonly taking frequent naps throughout the day as a response to the tiredness that comes along with vigilance, obsession and control. The efforts that are placed in controlling one’s environment can not be overlooked. As a coping mechanism; a survivor may meticulously plan, analyze and control their environment as a self protective measure. Although helpful, taking naps during the day can be maladaptive if done to remove oneself from an anxiety inducing situation or if taken too much. Too many naps will obviously directly interfere with an individual’s ability to fall asleep and stay asleep.
Nightmares often cause individuals to have difficulty falling asleep afterwards. A night terror commonly wakes an individual from REM sleep and such crude awakening leads to instant agitation and anxiety. Such feelings may come even before full consciousness is achieved and an individual can turn to 4f reliance at breakneck speed due to the nature of waking becoming uncontrollable and triggering. Not only that, but an individual waking from a night terror commonly has memories of said terror. For survivors of trauma who often process their individual trauma during sleep; this can lead to memories that have been blocked becoming evident and residing for a prolonged period of time. It can take many hours (if at all) for a survivor to calm down enough to return to sleep; however , the fear of continuing the memory or terror can directly affect one’s ability to sleep (even if desperate to).
Night terrors (or trauma memories manifesting within dreams) cause the brain to switch directly on to survival mode. This 4f response carries with it extra adrenaline and is fueled by vigilance and a deep desire for safety. No animal or species – human or not; would be able to sleep in a state of uncertainty. Not only can it take a great deal of time to come back down from this state, but commonly, survivors resort to maladaptive coping in the time between. A survivor of trauma in this state is completely driven to achieve a state of safety and the uncomfortable feelings which go hand in hand with feeling unsafe may cause an individual to reach for things which are not safe in the long term however produce quick, instant feelings of euphoria or ease. Research has reported individuals upon waking often leave their bed and go forth to cope with their insomnia in a maladaptive way including; drinking coffee/tea, watching TV, cleaning, writing, eating snacks or making a meal, gambling, online gaming, scrolling through their phone and using substances as a way of forcing a desired state (either sleep/alertness).
Using substances to numb or dull feelings can help in the short term, however long term it builds a reliance that requires more of said substance in order to achieve feelings close to past usage. In terms of substances, that is not always to say drugs are used. Substances include; alcohol, caffeine, food, sexual needs, prescriptions, painkillers and dissociative tasks (such as scrolling through Facebook at 4am). Although substances work in the short term, it can lead to an exacerbation of symptoms and neural changes within the brain.
Trauma alters the brain by changing neural pathways and volume. Sleep disturbances are listed by the DSM-IV as insomnia, frequent wakening or night terrors as one of many symptoms associated with PTSD and CPTSD. Each symptom however acts as a potential issue with regards to sleep. For example, issues with arousal with regards to anxiety and hypervigilance cause direct issues with an individual’s ability to fall asleep. A survivor with a heightened startle response may jump awake easily during the night at the smallest sound; this change in sleep can also serve to exacerbate other trauma related symptoms. An exhausted individual will undoubtedly be more irritable and agitated or have greater difficulty concentrating. Trauma symptoms lead a survivor to face difficulty in leading their day to day life and adding sleep issues and consequences on top of that can be debilitating.
Sleep problems can intensify daytime (C)PTSD symptoms, this can make it even more difficult to sleep at night. Survivor’s who feel anxious or fatigued during the day may ruminate more on their traumatic memories or experiences this further increases the risk of nightmares and other issues when sleep is attempted.
Coping
For those who are experiencing temporary sleep problems, there are a number of recommendations for dealing with insomnia, bad dreams, and daytime fatigue. Sleep experts recommend trying to reduce feelings of stress, especially before bedtime. Don’t watch the news right before going to bed. Avoid coffee in the afternoon and evening. Take a warm bath or soak in a hot tub before bedtime. If sleep problems persist, see your doctor, who can prescribe medications that will help you sleep but won’t make you groggy in the morning.
Tips
- Go to bed when you feel ready to sleep. Try not to force sleep, which can add to the pressure of wanting to get to sleep. Developing the harmful habit of lying in bed awake for long periods when you want to sleep is counter-productive.
- Engage in a relaxing, non-alerting activity at bedtime such as reading or listening to music. For some people, soaking in a warm bath or hot tub can be helpful. Avoid activities that are mentally or physically stimulating, including discussion about your violent experience, right before bedtime.
- Create an environment in which you can sleep well. It should be safe, quiet, cool and comfortable. While it often helps to sleep in a dark room, if keeping a night light on helps bring about a more safe feeling, then consider keeping the room dimly lit. It may also help to have a friend or family member stay in the room, or perhaps in a nearby room, while you are sleeping.Rest when you need to rest. It is common to feel exhausted after a violent trauma, so you may need more rest or to rest differently during this time. Relaxing and resting for brief times throughout the day and taking short naps (15-45 minutes) may help.
Do not eat or drink too much before bedtime and recognize the negative role that alcohol can have on your sleep. - Sleep in a location where you will feel most rested and safe. While the bedroom is optimal, it may not be possible to rest there soon after the trauma if you experienced violence in that room.
- Stress and anxiety management strategies can be helpful for managing (C)PTSD-related sleep problems. Some people find relief from meditation or yoga,guided imagery or positive mantras
Medications, including anti-anxiety and sleeping medications, may help some people in the short term. However, when the underlying PTSD symptoms remain, sleep problems will likely return when you stop using medication. - Therapy can help with both sleep issues and (C)PTSD. A compassionate trauma informed therapist will help you work through your trauma in a safe space, free of judgment, help you set goals, help you understand how trauma changes the brain and work with your GP to decide which (if any) medications are appropriate.
Further research
Although a study completed in Sweden showed that sleep deprivation actually aids a trauma survivor by that intrusive thought and flashbacks are reduced; no other research has furthered this.
Research carried out by the University of Oxford, the MRC Cognition and Brain Sciences Unit in Cambridge and the Karolinska Institute and published in the peer reviewed medical journal of sleep included 42 participants; 20 within the ‘sleep deprived’ group and 22 within the ‘sleep’ group. Participants resided in a sleep facility for 6 days, both groups were shown the same clip and informed that they could stop the recording at any time. They were not permitted the use of devices (phones, laptops etc) and were provided a sandwich and fruit every two hours – being allowed to shower and use the bathroom.
The study looked at participants’ perception of stress and intrusive thought through their diary entries throughout the study. Findings showed that both groups experienced similar levels of negative mood and feelings of detachment following watching the film, day one results showed the sleep deprived group obtained lower impact of event scale results than the group that had slept. Over the next six days, this trend continued.
The group which were deprived of sleep reported less intrusive memories than the participants who were allowed sleep and this led researchers to state; that sleep deprivation on one night, rather than sleeping, reduces emotional effect and intrusive memories.
This study had its limitations, it was criticized for various reasons; that being the entire fact that the experiment was staged within a laboratory could have confounded and altered results. The study was further criticized due to its short time frame, difference in individual sleep issues, participant size and generalized results.
In contrast to this, a study conducted at the University of Zurich has provided evidence that sleep within the first 24 hours post-trauma has a positive impact on distress and memories related to said traumatic event(s). This led researchers to believe that sleep has a medicinal effect in regards to processing trauma(s). Birgit Kleim stated that on the one hand; sleep can weaken emotions connected to existing memories; it also helps to put recollection into context and process them in a different way. Such research has helped recommend early treatment for trauma survivors in offering a non invasive alternative to current treatment (Kleim, 2016).
Sleep plays a hugely important role with regards to integrating emotional memories (Walker, 2008). In order for the brain to adequately process memory it must do so through offline memory consolidation where memories are labeled and encoded during unconsciousness. Sleep enhances previous encoded emotional pictures and consolidates it with relevant retained emotional stimuli. That is why sleep is so important, especially for a survivor of trauma. Not only does sleep help to build a clear picture of memory, but it reduces the degree of emotional arousal experienced with said memory. In short, sleep helps our traumatic memories become more accessible and less fearful (Pace-Schott et al, 2011).
Non-rapid eye-movement (NonREM) sleep has been associated with the strengthening of hippocampus dependent declarative memories (Stickgold, 2009), whereas REM sleep has been implicated in the modulation of emotional memories and arousal (van der Helm et al., 2011b, Walker and van der Helm, 2009) and the extinction of conditioned fear (Spoormaker et al., 2011, Spoormaker et al., 2010)
Some research suggests that sleep problems are more than just a symptom of PTSD. Instead, they may be a core component of the diagnosis. Research published in 1989 suggests that disturbances in rapid eye movement (REM) sleep are a PTSD hallmark that play a key role in other PTSD symptoms. Subsequent research has yielded mixed results. While some studies, including of animals, find a pattern of REM disturbances associated with PTSD, others do not.
A 2013 review of the literature argues that disturbances in sleep, especially REM sleep, may increase the risk of PTSD. Sleep issues may also worsen outcomes in people with PTSD. The study further argues that sleep issues can decrease the effectiveness of many PTSD treatments and that targeted treatments for sleep issues may speed recovery.
A study that compared people with insomnia who did not have PTSD to those with combat-related PTSD and insomnia found important differences in the two groups. Those included:
- More repetitive nightmares in people with PTSD.
- People with PTSD were more likely to say their nightmares made it difficult to go back to sleep.
- More anxiety during the day in people with PTSD.
- Increased day time fatigue with those with PTSD
As we can see, sleep is paramount for recovery from trauma. There are many helpful ideas to help with poor sleep however, in the instance of such tips being unhelpful – I would strongly suggest seeking help from a GP for short term relief to reactivate individual sleep patterns. Further support on sleep and trauma can be found within our Facebook group and accessed through our social links at the top of the page.
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