Trauma, sleep, and nightmares
Sleep disturbance — including trauma nightmares, insomnia, hypervigilance at bedtime, and sleep paralysis — is one of the most common and distressing features of PTSD. Up to 70% of people with PTSD report trauma nightmares. Sleep disruption then worsens PTSD symptoms, creating a vicious cycle that requires direct treatment.
Image Rehearsal Therapy (IRT)
IRT is the most evidence-based treatment specifically for trauma nightmares. It involves writing down a nightmare, modifying it in any way you choose (changing the ending, making it less distressing), and rehearsing the new version during waking hours. The process gives the brain new material to work with and gradually shifts nightmare content. IRT produces significant reductions in nightmare frequency and distress in most people who complete it.
Prazosin for trauma nightmares
Prazosin, a blood pressure medication, has the strongest pharmacological evidence for trauma nightmares. It blocks the norepinephrine surge that activates trauma nightmares during REM sleep. It is typically well-tolerated and can provide significant relief while trauma processing work continues.
Sleep-focused treatment for PTSD is increasingly recognized as important in its own right — not just a symptom to manage while treating "real" PTSD. Evidence suggests that improving sleep may actually accelerate overall PTSD recovery.