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Sleep Disturbances as the Hallmark of PTSD: Where Are We Now?
Open accessAbstract
The hypothesis that rapid eye movement (REM) sleep disturbances are the hallmark of posttraumatic stress disorder (PTSD), proposed by Ross and colleagues in 1989, has stimulated a wealth of clinical, preclinical, and animal studies on the role of sleep in the pathophysiology of PTSD. The present review revisits this influential hypothesis in light of clinical and experimental findings that have since accumulated. Polysomnographic studies conducted in adults with PTSD have yielded mixed findings regarding REM sleep disturbances, and they generally suggest modest and nonspecific sleep disruptions. Prospective and treatment studies have provided more robust evidence for the relationship between sleep disturbances and psychiatric outcomes and symptoms. Experimental animal and human studies that have probed the relationship between REM sleep and fear responses, as well as studies focused more broadly on sleep-dependent affective and memory processes, also provide strong support for the hypothesis that sleep plays an important role in PTSD-relevant processes. Overall, the literature suggests that disturbed REM or non-REM sleep can contribute to maladaptive stress and trauma responses and may constitute a modifiable risk factor for poor psychiatric outcomes. Clinicians need to consider that the chronic sleep disruption associated with nightmares may affect the efficacy of first-line PTSD treatments, but targeted sleep treatments may accelerate recovery from PTSD. The field is ripe for prospective and longitudinal studies in high-risk groups to clarify how changes in sleep physiology and neurobiology contribute to increased risk of poor psychiatric outcomes.
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“PTSD is characterized by hyperreactivity to emotional stimuli and an inability to extinguish traumatic memories (American Psychiatric Association, 2013) and sleep disturbances and recurrent nightmares are recognized as the hallmark of PTSD (Levin et al., 2010; Germain, 2013).”
From The Functional Role of Dreaming in Emotional Processes (2019) · cites this paper as Germain, 2013
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“Stress, thus, influences sleep physiology and dream patterns and may cause both immediate and long-lasting sleep disruption (364–366), which may, in turn, enhance maladaptive stress regulation (367).”
From Developmental Trajectories of Early Life Stress and Trauma: A Narrative Review on Neurobiological Aspects Beyond Stress System Dysregulation (2019) · cites this paper as [367]
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“Specifically, PTSD patients report dreams with vivid images and negative emotions associated with the traumatic events (Germain, 2013).”
From The Functional Role of Dreaming in Emotional Processes (2019) · cites this paper as Germain, 2013
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“These abnormalities are consistent with an underlying hyperarousal in PTSD that lightens sleep, prevents deeper, more restorative sleep stages, and alters the distinct physiology of REM sleep [20, 29, 36, 134, 143].”
From Sleep and REM sleep disturbance in the pathophysiology of PTSD: the role of extinction memory (2015) · cites this paper as [36]
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“Therefore, both objective and subjective sleep disturbances represent core features of PTSD [36, 134, 136].”
From Sleep and REM sleep disturbance in the pathophysiology of PTSD: the role of extinction memory (2015) · cites this paper as [36]
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Metadata
- Authors
- Germain, A.
- Affiliations
- University of Pittsburgh (US)
- Corresponding author
- Germain, Anne
- ORCID
- Germain, Anne
- Venue
- American Journal of Psychiatry
- Published
- 2013-04
- Volume
- 170
- Issue
- 4
- Pages
- 372-382
- ISSN
- 0002-953X (ISSN-L)
- 1535-7228
- PMC
- PMC4197954
- OpenAlex
- W2102756647
- Semantic Scholar
- e9d1a019386f28018bcb41195e229c22cc06a117
- Cited by
- 634
- References
- 91
- Citations by year
- 2026: 71 · 2025: 42 · 2024: 34 · 2023: 56 · 2022: 50 · 2021: 60 · 2020: 48 · 2019: 51 · 2018: 40 · 2017: 50 · 2016: 40 · 2015: 39 · 2014: 34 · 2013: 16
- FWCI
- 38.55
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- American Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (R21MH083035)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Life Sciences › Neuroscience › Cognitive Neuroscience › Sleep and Wakefulness Research
- Keywords
- post-traumatic stress disorder, sleep disorders, PTSD pathophysiology, nightmares, fear response, sleep-dependent memory consolidation, sleep interventions, polysomnography findings
- MeSH terms
- Animals, Dreams, Emotions, Humans, Sleep Initiation and Maintenance Disorders, Memory, Stress Disorders, Post-Traumatic, Polysomnography, REM Sleep Behavior Disorder, Resilience, Psychological, Brain Waves
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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