The sleep-trauma feedback loop

Photo Cred: Castorly Stock/Pexels

By Catherine Darley, ND

In the midst of the novel coronavirus (COVID-19), in the Untied States and around the world, we are experiencing what could be seen as a collective traumatic experience, with the ongoing pandemic, economic uncertainty, and social unrest. At our clinics, more patients are coming in with worsening sleep, experiencing insomnia due to worry and circadian disruption.

Poor sleep often follows a traumatic experience, which intuitively makes sense. What has been less well-recognized, however, is when a person is not sleeping well, a new traumatic experience is more likely to cause long-term negative effects. Different types of trauma impact sleep, and sleep health both predicts and can mitigate the effects of trauma.

It’s well-established that when children experience Adverse Childhood Events (ACEs), they are at increased risk of sleep disorders, including sleep apnea, nightmares, narcolepsy, insomnia, and sleep paralysis. A broader range of experience is captured by the term Traumatic Childhood Experiences (TCEs), which also includes natural disasters, major accidents and dysfunctional households.

When 40,082 adult women were questioned in the Sister Study, 55 percent reported some type of TCE experienced before age 18. The women who had TCEs were more likely to sleep less than seven hours nightly, take longer to fall asleep, wake up more often in the night, and nap more frequently. This demonstrates how the impact of TCEs can last decades.

Dialing down further into the data, the sleep disruption is worse when the perpetrator is considered socially close. Integrative practitioners should include social-emotional evaluation in primary care visits by finding out about the home emotional environment, safety, and stability. Ask about sleep disruptions following any type of trauma in pediatric patients, and then treat holistically.

Natural disasters of many types afflict people worldwide each year, from storms to drought to the type of wild fires currently raging in California. In 2011 an earthquake and tsunami caused disaster in East Japan. In Iwanuma, older people reported on their sleep and social support the year prior to the disaster in 2010, and were asked about their sleep again in 2013, along with the types of hardship the disaster had caused them. Those who suffered financial hardship were at increased risk of many types of sleep disruption, including short sleep, insomnia, and poor sleep quality. Those whose home had been destroyed were more likely to use sleep medication, while healthcare disruption was associated with poor sleep quality.

Interestingly, loss of loved ones did not predict sleep problems. Two types of social support were differentiated, and each had different impact on sleep after the disaster. Instrumental support was defined as having someone to take care of you if sick and confined to bed for a few days, while emotional support was defined as having someone to listen to your concerns. Instrumental support seemed to alleviate sleep problems more than emotional support did.

Thinking about this, as integrative practitioners we already either provide ourselves or have a referral system for emotional support. We can provide additional help to our patients by having informational resources on hand and connections to a variety of programs that may be needed after a disaster or other trauma such as housing assistance, utility discounts, home repair, and food services.

Recently in the U.S., unemployment has mushroomed, more people are facing food insecurity, and increased homelessness is forecast. It’s a perfect time to check in with patients about how they are weathering the pandemic financially and provide information and services if needed.

When practitioners and researchers talk about trauma, soldiers are often one of the first groups to come to mind. The mainstream news regularly reports on the rise in post-traumatic stress disorder (PTSD) among our military. PTSD is characterized by intrusive memories, negative feelings and thoughts, avoidance of trauma reminders, and trauma-related hyperarousal. It is debilitating. Those soldiers with insomnia before deployment have greatly increased risk of developing post-traumatic stress disorder three or nine months after deployment, 1.5 times that of soldiers without insomnia. Suicidal ideation is also increased at 1.43 times that of those without insomnia.

Along similar lines, people with both short sleep of less than seven hours or long sleep of nine or more hours duration develop more severe PTSD than those with a moderate seven to 8.9 hours nightly sleep duration. This is particularly relevant as the military is one of the occupational groups with the shortest sleep durations. From this standpoint, military policy to support moderate hours of sleep for every soldier would be expected to reduce the prevalence of PTSD, which would be a huge benefit.

Policing is the other occupation with high prevalence of short sleep duration, and likely exposure to traumatic experiences, so therefore can also benefit from health-informed policy. The sleep and PTSD association continues to also impact adverse health-related behavior such as alcohol and opioid use, aggression, and other high-risk behaviors in combat veterans. Sleep problems predict PTSD and risky behaviors. As clinicians, although we may not be setting policies, this is information we can use with the patients in front of us:

• How much sleep is your patient getting each night?
• Is their sleep sufficient quantity and quality to protect from long-term consequences following a traumatic event?

Trauma-associated sleep disorder (TASD) is a new proposed disorder based upon case studies of soldiers. After the inciting traumatic event, the clinical picture includes some features of REM behavior disorder, namely REM sleep without atonia and dreams related to that traumatic event. REM behavior disorder is more prevalent in veterans with PTSD (15 percent), and increased again at 21 percent of veterans with both PTSD and traumatic brain injury. It is unknown at this time if synucleinopathy is associated with RBD in people with PTSD as it is for those with idiopathic RBD. This is an emerging body of work worth keeping an eye on, particularly if you work with soldiers or others with PTSD.

Working with patients every day through this turbulent year gives us the opportunity to use this information about sleep and trauma, the ways in which poor sleep increases the fallout of a traumatic event, and how trauma impacts sleep. Then we can offer integrative, holistic care at a time when people need it most.

References

Elliott, J.E., Opel, R.A., Pleshakov, D., Rachakonda, T., Chau, A.Q., Weymann, K.B., Lim, M.M. (2020) Posttraumatic stress disorder increases the odds of REM sleep behavior disorder and other parasomnias in Veterans with and without comorbid traumatic brain injury. Sleep. Retrieved from: https://academic.oup.com/sleep/article/43/3/zsz237/5582031

Li, X., Buxton, O.M., Hikichi, H., Haneuse, S., Aida, J., Kondo, K., Kawachi, I. (2018) Predictors of persistent sleep problems among older disaster survivors: a natural experiment from the 2011 Great East Japan earthquake and tsunami. Sleep. Retrieved from: https://academic.oup.com/sleep/article/41/7/zsy084/4991879

McCall, C.A., Turkheimer, E., Tsang, S., Avery, A., Duncan, G.E., Watson, N.F. (2019) Sleep duration and post-traumatic stress disorder symptoms: a twin study. Sleep. Retrieved from: https://academic.oup.com/sleep/article/42/12/zsz179/5549607

McWhorter, K.L., Parks, C.G., D’Aloisio, A.A., Rojo-Wissar, D.M., Sandler, D.P., Jackson, C.L. (2019) Traumatic childhood experiences and multiple dimensions of poor sleep among adult women. Sleep. Retrieved from: https://academic.oup.com/sleep/article/42/8/zsz108/5481583

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. Retrieved from: https://academic.oup.com/sleep/article/42/3/zsy257/5250906

Wang, H.E., Campbell-Sills, L., Kessler, R.C., Sun, X., Heeringa, S.G., Nock, M.K., Ursano, R.J., Jain, S., Stein, M.B., (2019) Pre-deployment insomnia is associated with post-deployment post-traumatic stress disorder and suicidal ideation in US Army soldiers. Sleep. Retrieved from: https://academic.oup.com/sleep/article/42/2/zsy229/5228726