Staff Perspective: Understanding the Relationship Between PTSD, Sleep Disturbances, and Suicidality
PTSD and Sleep Disturbance
Results from PTSD literature reveal a high prevalence of sleep disturbances. Estimates range between 80-90% of PTSD patients experience insomnia symptoms and 50-70% experience nightmares (Koffel et al., 2017). The high frequency of sleep related problems for patients with PTSD is understandable given that both nightmares and difficulties sleeping are included in the DSM-5 diagnostic criteria. Existing literature supports a bidirectional relationship of sleep disturbance and PTSD (Weber et al., 2020). For example, research has shown that pre-deployment insomnia and short sleep duration (i.e., total sleep time < 5 hours) are significant predictors of post-deployment PTSD symptoms (Osgood et al., 2018). One proposed mechanism to explain the connection between sleep disruption and PTSD is increased noradrengic activity during REM. This contributes to REM sleep fragmentation and reduced medial prefrontal cortex activity during REM. As result, increased noradrengic activity during REM may contribute both to sleep fragmentation (i.e., higher levels of arousal interfering with sleep functioning) and emotional dysregulation in PTSD (i.e., sleep disturbance disrupts memory and adaptive learning functions). This blog will examine and summarize findings in literature related to the relationship between different types of sleep disturbances and suicidality for patients with PTSD.
Insomnia, Suicidality, and PTSD
Research studies examining service members have found mixed results when looking at the relationship between insomnia and suicidality. Studies have found a significant relationship between insomnia symptoms and suicidal ideation (Weber et al., 2020). Riberio et al. (2012) found that insomnia was significantly associated with suicidal ideation after controlling for age, alcohol dependence, depression, and PTSD. These findings suggest an independent relationship between insomnia and suicidality apart from PTSD and depression. However, other studies have found that depression mediates the relationship between insomnia and suicidal ideation (Weber et al., 2020). For example, Morgan et al. (2018) found that after accounting for mental health symptoms (i.e., depression, perceived stress, and PTSD) that sleep no longer had a significant direct effect on suicidal ideation. Due to these mixed results, more research is needed to clarify the nature of the relationship between service members with PTSD, insomnia and suicidality. For example, could the relationship between these constructs vary based on the type of trauma, duration or severity of symptoms?
Nightmares, Suicidality, and PTSD
Nightmares are very common for those who have PTSD. However, research examining the link between nightmares and suicidality have not consistently found a direct relationship (Weber et al., 2020). Similar to studies examining the link between insomnia and suicidality, research on nightmares has found that after controlling for psychiatric disorders (e.g., PTSD) the relationship between nightmares and suicide attempts was no longer significant. A few studies looking at Prazosin, a medication used to treat nightmares, also did not find any significant improvements in suicidal ideation or day time PTSD symptoms. Finally, in a study using a civilian population, researchers found both a direct and indirect relationship (i.e., pathway partially mediated by perceptions of defeat, entrapment, and hopelessness) between nightmares and suicidal behavior independent of insomnia and depression (Littlewood et al., 2016). These findings highlight the importance of additional research to clarify differences between military and civilian populations regarding the relationship between PTSD, nightmares, and suicidality.
Other Forms of Sleep Disturbances and Suicidality
Studies examining patients with obstructive sleep apnea (OSA) have found higher levels of depression and suicidality compared to those patients without any potential sleep disorder (Weber et al., 2020). In one sample of civilian females with PTSD, the authors found a direct relationship between the severity of OSA symptoms and suicidal ideation. However, further analyses revealed that depression mediated the relationship between respiratory disturbance index scores and suicidal ideation (Gupta & Jarosz, 2018). One study found that eveningness chronotype, a type of circadian rhythm, in patients with PTSD was associated with increased likelihood of suicidal ideation. Given that military members experience a variety of sleep related complaints, it is important for future research to continue to examine the link between PTSD, various sleep problems and suicidality.
Summary and Clinical Considerations
Increasingly research is examining the link between PTSD, various types of sleep disturbances and their respective relationship to suicidality (i.e., suicidal ideation and attempts). For PTSD, research has shown that re-experiencing and avoidance symptom clusters are significantly correlated with suicide attempts (Weber et al., 2020). At times, both insomnia and nightmares have demonstrated direct and indirect relationships (i.e., mediated through either depression symptoms, constructs related to depression such as hopelessness and Interpersonal Theory of Suicide’s thwarted belongingness, perceived burdensomeness, or symptoms of PTSD) with suicidality for patients with PTSD. Studies vary in how they assess sleep related disturbances, and whether they assess for mediating and or moderating variables to better explain the relationship between these constructs. Despite these methodological differences, it is important to consider the following clinical considerations.
- It is important to screen and assess sleep related problems when working with service members (for more information check Dr. Mann’s blog on the importance of the Assessment of Sleep Problems during Treatment)
- It is important to screen and assess for sleep related problems when working with service members who have PTSD.
- It is important to assess for suicidality with patients who have PTSD and experiencing sleep disturbance (for more information check Dr. Shillinglaw’s blog on Screening for Suicide Risk in Adult Sleep Patients).
- It is important to realize that specific treatments for sleep disturbances (e.g., CBT-I for insomnia and Prazosin for nightmares) may not significantly reduce suicidality of patients (i.e., significant decrease in suicidal ideation). Additional measures to address suicidality with patients should be considered.
- Using evidence based treatments for PTSD may not resolve sleep disturbances. A high percentage of patients continue to report problems with insomnia and nightmares that require specific treatment interventions (e.g., CBT-I for insomnia, Image Rehearsal Therapy for nightmares)
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Timothy Rogers, Ph.D., is a Senior Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology and serves as the Associate Program Director for the Air Force Clinical Psychology Internship Program at Joint Base San Antonio-Lackland Texas.
References:
Koffel, E., Khawaja, I. S., & Germain, A. (2016). Sleep disturbances in posttraumatic stress disorder: Updated review and implications for treatment. Psychiatric Annals, 46(3), 173-176. doi: 10.3928/00485713-20160125-01
Osgood, J. M., Finan, P.H., Hinman, S. J., So, C. J., & Quartana, P. J. (2019). Combat exposure post-traumatic stress symptoms, and health-related behaviors: the role of sleep continuity and duration. Sleep, 42(3), 1-11. doi: 10.1093/sleep/zsy257
Riberio, J. D., Pease, J. L., Gutierrez, P. M., Silva, C., Bernert, R. A., & Rudd, M. D. (2012). Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military. Journal of Affective Disorders, 136, 743-750. doi: 10.1016/j.jad.2011.09.049
Weber, F. C., Norra, C., & Wetter, T. C. (2020). Sleep disturbances and suicidality in posttraumatic stress disorder: An overview of the literature. Frontiers in Psychiatry, 11 (167), 1-12. doi: 10.3389/fpsyt.2020.00167
Gupta, M. A., & Jarosz, P. (2018) Obstructive sleep apnea severity is directly related to suicidal ideation in posttraumatic stress disorder. Journal of Clinical Sleep Medicine, 14, 427-435. doi: 19.5664/jcsm.6992
Morgan, J. K., Hourani, L., Tueller, S., Strange, L., Lane, M. E., & Lewis, G. F. (2018). Effects of sleep issues on suicidal ideation in a military sample: the mediating role of mental health. Military Behavioral Health, 6, 234-242. doi: 10.1080/21635781.2017.1406415
PTSD and Sleep Disturbance
Results from PTSD literature reveal a high prevalence of sleep disturbances. Estimates range between 80-90% of PTSD patients experience insomnia symptoms and 50-70% experience nightmares (Koffel et al., 2017). The high frequency of sleep related problems for patients with PTSD is understandable given that both nightmares and difficulties sleeping are included in the DSM-5 diagnostic criteria. Existing literature supports a bidirectional relationship of sleep disturbance and PTSD (Weber et al., 2020). For example, research has shown that pre-deployment insomnia and short sleep duration (i.e., total sleep time < 5 hours) are significant predictors of post-deployment PTSD symptoms (Osgood et al., 2018). One proposed mechanism to explain the connection between sleep disruption and PTSD is increased noradrengic activity during REM. This contributes to REM sleep fragmentation and reduced medial prefrontal cortex activity during REM. As result, increased noradrengic activity during REM may contribute both to sleep fragmentation (i.e., higher levels of arousal interfering with sleep functioning) and emotional dysregulation in PTSD (i.e., sleep disturbance disrupts memory and adaptive learning functions). This blog will examine and summarize findings in literature related to the relationship between different types of sleep disturbances and suicidality for patients with PTSD.
Insomnia, Suicidality, and PTSD
Research studies examining service members have found mixed results when looking at the relationship between insomnia and suicidality. Studies have found a significant relationship between insomnia symptoms and suicidal ideation (Weber et al., 2020). Riberio et al. (2012) found that insomnia was significantly associated with suicidal ideation after controlling for age, alcohol dependence, depression, and PTSD. These findings suggest an independent relationship between insomnia and suicidality apart from PTSD and depression. However, other studies have found that depression mediates the relationship between insomnia and suicidal ideation (Weber et al., 2020). For example, Morgan et al. (2018) found that after accounting for mental health symptoms (i.e., depression, perceived stress, and PTSD) that sleep no longer had a significant direct effect on suicidal ideation. Due to these mixed results, more research is needed to clarify the nature of the relationship between service members with PTSD, insomnia and suicidality. For example, could the relationship between these constructs vary based on the type of trauma, duration or severity of symptoms?
Nightmares, Suicidality, and PTSD
Nightmares are very common for those who have PTSD. However, research examining the link between nightmares and suicidality have not consistently found a direct relationship (Weber et al., 2020). Similar to studies examining the link between insomnia and suicidality, research on nightmares has found that after controlling for psychiatric disorders (e.g., PTSD) the relationship between nightmares and suicide attempts was no longer significant. A few studies looking at Prazosin, a medication used to treat nightmares, also did not find any significant improvements in suicidal ideation or day time PTSD symptoms. Finally, in a study using a civilian population, researchers found both a direct and indirect relationship (i.e., pathway partially mediated by perceptions of defeat, entrapment, and hopelessness) between nightmares and suicidal behavior independent of insomnia and depression (Littlewood et al., 2016). These findings highlight the importance of additional research to clarify differences between military and civilian populations regarding the relationship between PTSD, nightmares, and suicidality.
Other Forms of Sleep Disturbances and Suicidality
Studies examining patients with obstructive sleep apnea (OSA) have found higher levels of depression and suicidality compared to those patients without any potential sleep disorder (Weber et al., 2020). In one sample of civilian females with PTSD, the authors found a direct relationship between the severity of OSA symptoms and suicidal ideation. However, further analyses revealed that depression mediated the relationship between respiratory disturbance index scores and suicidal ideation (Gupta & Jarosz, 2018). One study found that eveningness chronotype, a type of circadian rhythm, in patients with PTSD was associated with increased likelihood of suicidal ideation. Given that military members experience a variety of sleep related complaints, it is important for future research to continue to examine the link between PTSD, various sleep problems and suicidality.
Summary and Clinical Considerations
Increasingly research is examining the link between PTSD, various types of sleep disturbances and their respective relationship to suicidality (i.e., suicidal ideation and attempts). For PTSD, research has shown that re-experiencing and avoidance symptom clusters are significantly correlated with suicide attempts (Weber et al., 2020). At times, both insomnia and nightmares have demonstrated direct and indirect relationships (i.e., mediated through either depression symptoms, constructs related to depression such as hopelessness and Interpersonal Theory of Suicide’s thwarted belongingness, perceived burdensomeness, or symptoms of PTSD) with suicidality for patients with PTSD. Studies vary in how they assess sleep related disturbances, and whether they assess for mediating and or moderating variables to better explain the relationship between these constructs. Despite these methodological differences, it is important to consider the following clinical considerations.
- It is important to screen and assess sleep related problems when working with service members (for more information check Dr. Mann’s blog on the importance of the Assessment of Sleep Problems during Treatment)
- It is important to screen and assess for sleep related problems when working with service members who have PTSD.
- It is important to assess for suicidality with patients who have PTSD and experiencing sleep disturbance (for more information check Dr. Shillinglaw’s blog on Screening for Suicide Risk in Adult Sleep Patients).
- It is important to realize that specific treatments for sleep disturbances (e.g., CBT-I for insomnia and Prazosin for nightmares) may not significantly reduce suicidality of patients (i.e., significant decrease in suicidal ideation). Additional measures to address suicidality with patients should be considered.
- Using evidence based treatments for PTSD may not resolve sleep disturbances. A high percentage of patients continue to report problems with insomnia and nightmares that require specific treatment interventions (e.g., CBT-I for insomnia, Image Rehearsal Therapy for nightmares)
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Timothy Rogers, Ph.D., is a Senior Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology and serves as the Associate Program Director for the Air Force Clinical Psychology Internship Program at Joint Base San Antonio-Lackland Texas.
Osgood, J. M., Finan, P.H., Hinman, S. J., So, C. J., & Quartana, P. J. (2019). Combat exposure post-traumatic stress symptoms, and health-related behaviors: the role of sleep continuity and duration. Sleep, 42(3), 1-11. doi: 10.1093/sleep/zsy257
Riberio, J. D., Pease, J. L., Gutierrez, P. M., Silva, C., Bernert, R. A., & Rudd, M. D. (2012). Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military. Journal of Affective Disorders, 136, 743-750. doi: 10.1016/j.jad.2011.09.049
Weber, F. C., Norra, C., & Wetter, T. C. (2020). Sleep disturbances and suicidality in posttraumatic stress disorder: An overview of the literature. Frontiers in Psychiatry, 11 (167), 1-12. doi: 10.3389/fpsyt.2020.00167
Gupta, M. A., & Jarosz, P. (2018) Obstructive sleep apnea severity is directly related to suicidal ideation in posttraumatic stress disorder. Journal of Clinical Sleep Medicine, 14, 427-435. doi: 19.5664/jcsm.6992
Morgan, J. K., Hourani, L., Tueller, S., Strange, L., Lane, M. E., & Lewis, G. F. (2018). Effects of sleep issues on suicidal ideation in a military sample: the mediating role of mental health. Military Behavioral Health, 6, 234-242. doi: 10.1080/21635781.2017.1406415