After 14 sessions of an evidence-based psychotherapy (EBP) for PTSD, my patient’s improvement was undeniable. His score on the PTSD Checklist for DSM-5 (PCL-5) had decreased from 62 at baseline to 18 at our final session, which reflected a clinically meaningful change. He described that his trauma memories no longer had a hold over him, they were fading away in a healthy way. When trauma images surfaced, he could tolerate the distress and ride them out like a wave. He no longer fought to avoid thinking about his terrifying childhood or combat experiences.
In addition, he informed me that he had recently joined an online group for veterans and was finding it very positive. This was something he never would have done before our treatment. I also noticed him laughing and smiling in our later sessions. He even made a few jokes, which was new. I was happy with all of this progress. Likewise, when I looked closely at his final PCL-5, I was pleased to see that he had rated all of the items 0 or 1, except for item #20 (trouble falling or staying asleep), which he rated 4. I had hoped this symptom would have improved as treatment progressed, yet no matter how well our work was going, item #20 hardly budged. My patient always rated it 3 or 4.
Consistent with this finding, my patient’s scores on the Insomnia Severity Index (ISI) had not improved throughout treatment. I had been monitoring his ratings on the ISI along with the PCL-5. At baseline, he started at 22 on this measure and by the end of treatment he was at 21. In a few sessions during the treatment, his score on the ISI was even as high as 26. I was mindful that any score between 22-28 on the ISI is suggestive of clinical insomnia. This trend had been disappointing to see.
When I reviewed these sleep patterns with my patient, he admitted that his sleep had always been problematic since the childhood trauma he was targeting in our work. It had continued to worsen after his combat traumas. At the same time, he explained that he wasn’t really fazed by his poor sleep. He had gotten used to getting little sleep while serving in the military; it was not a big deal to him now, even after retiring 10 years ago. Then he surprised me by adding a positive spin: less sleep actually gave him more time to get things done during his days since he woke up so early.
Nonetheless, this case underscored to me the research findings I had read and heard about. Despite effective EBPs for PTSD, certain symptoms persist in some patients even after these treatments are successfully completed (e.g., Schnurr & Lunney, 2019). Lingering sleep problems are one of the top culprits. Sleep can put up a good fight and not improve following an effective round of trauma-focused treatment.
When I spoke with my patient about the option of treating his unresolved sleep problems with a targeted approach such as Cognitive Behavioral Therapy for Insomnia (CBT-I), he wasn’t interested. He was happy with the results of the trauma-focused treatment. Candidly, he admitted that he had been a “doubter” but had been pleasantly surprised that the EBP had benefited him. He reiterated that he wasn’t bothered by his sleep issues. Instead, he wanted to consider couples therapy next. He asked if I could recommend any couples therapists. This discussion was a good reminder to me. The next phase of treatment for this patient needed to be what he wanted. He considered his marriage to be his top priority at this time in his recovery, not his sleep.
For me, a priority will be learning additional ways to reduce sleep problems in PTSD patients, like weaving in CBT-I or other interventions while concurrently doing a trauma-focused treatment. As Schnurr & Lunney (2019) highlight, some patients may need additional strategies to address all of their PTSD symptoms.
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.
Paula Domenici, Ph.D., is a Director of Training and Education for the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. She oversees the development of courses and training programs for providers on evidence-based treatments for service members and veterans.
Schnurr P.P., & Lunney C.A. (2019). Residual symptoms following prolonged exposure and present-centered therapy for PTSD in female veterans and soldiers. Depression and Anxiety, 36, 162–169. https://doi.org/10.1002/da.22871