For Veterans With PTSD, Sleep Is Not Just a Symptom
Insomnia, nightmares, and sleep apnea are common in Veterans with PTSD, and the evidence increasingly says they need their own assessment and their own treatment.
A question that comes up in consultation: a Veteran is months into trauma-focused therapy, the intrusions have quieted, and treatment is working by every measure anyone charts. And he is still awake at three in the morning, or still bracing at bedtime for what sleep might bring. Shouldn’t the sleep have followed?
For a long time the field assumed it would. Sleep problems sit inside the PTSD diagnosis itself: PTSD is the only diagnosis in the DSM-5-TR that carries multiple sleep-related criteria, with difficulty falling or staying asleep in the arousal cluster and recurrent nightmares in the intrusion cluster. On the traditional reading, those were symptoms like any other. Treat the disorder, and the nights come back.
The current evidence points the other way. A 2026 review from the VA’s National Center for PTSD (So, Gehrman, & Miller, PTSD Research Quarterly, Vol. 37, No. 2) describes sleep disturbance as something closer to a co-occurring condition: it can precede PTSD, it tracks with PTSD severity, and it frequently outlasts otherwise successful treatment.
The Numbers
Across a meta-analysis of 75 studies, insomnia affected roughly 63% of people with PTSD or significant posttraumatic stress symptoms (Ahmadi et al., 2022). In a nationally representative sample of US Veterans, more than half of those with PTSD had clinically significant insomnia alongside it (Georgescu et al., 2025). Nightmares show the same pattern: about 15% of Veterans report trauma-related nightmares over a lifetime, but the figure reaches 80% among Veterans with a lifetime PTSD diagnosis (Worley et al., 2025). Overnight sleep studies add an objective layer: less total sleep, less deep slow-wave sleep, more time awake in the night (Zhang et al., 2019).
Obstructive sleep apnea also runs high alongside PTSD. A twin study found a PTSD diagnosis associated with roughly ten additional apneas or hypopneas per hour of sleep (Shah et al., 2024). Not every sleep problem in a Veteran with PTSD is a PTSD symptom. Some of it is a breathing disorder with its own workup and its own equipment, and it does not care how well the trauma treatment went.
The Persistence Problem
The finding that has done the most to change clinical thinking comes from treatment studies. Among active-duty service members who completed PTSD-focused psychotherapy and no longer met diagnostic criteria afterward (the good outcome), 57% still reported insomnia (Pruiksma et al., 2016). Nightmares proved far more responsive, persisting in about 13%. The residual problem, over and over, is the insomnia.
That is not an argument against trauma-focused care. It is an argument against waiting. A sleep problem that persists after PTSD remits was never going to resolve on the trauma timeline, and it warrants its own targeted intervention. The same logic applies at intake as at termination: sleep gets asked about directly rather than assumed to be along for the ride.
The Stakes
PTSD with sleep disturbance tends to be the heavier clinical picture. Veterans with both PTSD and insomnia showed higher odds of co-occurring major depression and generalized anxiety, and substantially worse cognitive, emotional, and social functioning, than Veterans with PTSD alone (Georgescu et al., 2025). The same study found the combined group carried higher odds of current suicidal ideation and of suicide attempts. Sleep is one of the places where risk becomes visible. That is a reason to bring a sleep problem to a provider rather than manage it alone, and it is the reason the resource section below starts with the crisis line.
What Direct Treatment Looks Like
Effective, sleep-specific treatments exist, and Veterans can ask about them directly.
For chronic insomnia, cognitive behavioral therapy for insomnia (CBT-I) is the first-line recommendation of the 2025 VA/DoD Clinical Practice Guideline. It is a structured, skills-based therapy, considerably more involved than a sleep-hygiene handout. The guideline notes one timing consideration: when a patient is engaged in exposure-based PTSD psychotherapy, CBT-I may need adaptation or delay, a sequencing question for the treating clinicians to work out together.
For nightmares, imagery rehearsal therapy (IRT), in which the client selects a recurring nightmare, rewrites its storyline, and rehearses the revised version, is the one treatment the American Academy of Sleep Medicine recommends for PTSD-associated nightmares (Morgenthaler et al., 2018). The AASM lists a longer set of options that “may be used,” among them CBT-I and EMDR; a “may be used” designation is a modest one. Prazosin, long the default medication for posttraumatic nightmares, has a mixed record: early trials were positive, but the largest VA cooperative trial found no advantage over placebo (Raskind et al., 2018).
For sleep apnea, positive airway pressure remains the primary treatment, and consistent use has been associated with reductions in PTSD symptom severity. Adherence is harder for patients with prominent re-experiencing and hyperarousal (Colvonen et al., 2023). A struggling PAP trial is a reason to go back to the sleep clinic rather than a reason to quit.
On combining treatments: a pilot trial in active-duty personnel found that adding sleep-focused therapy to PTSD therapy outperformed PTSD therapy alone on both sleep and PTSD outcomes, with some advantage to delivering the sleep treatment after the trauma work (Taylor et al., 2023). The evidence is early and the trial small, but it points the same direction as everything above.
For Clinicians: Sleep in the EMDR Treatment Plan
The planning implications are concrete enough to spell out.
Ask about sleep at Phase 1, in plain words. A history that asks directly about insomnia, nightmares, and snoring or observed pauses in breathing costs nothing, and it catches what a general self-care question misses. The prevalence figures above are high enough that sleep belongs in every intake.
The same numbers help with expectation-setting. Nightmares respond to trauma-focused therapy far more reliably than insomnia does. In the Pruiksma cohort, 13 percent of successfully treated service members still had nightmares afterward, while 57 percent still had insomnia. A client whose nightmares fade while the insomnia stays is following the documented pattern. Saying that early spares the client the conclusion that treatment failed.
The AIP model deserves a light touch here. It is natural to treat sleep disturbance as downstream of unprocessed material, something reprocessing will reach in time. The persistence data suggest otherwise often enough to matter. Insomnia that survives successful trauma work behaves like a condition of its own, and referring it out says nothing about the quality of the reprocessing.
Referrals go three directions: CBT-I for chronic insomnia, first-line in the 2025 VA/DoD guideline; a sleep medicine evaluation when apnea is plausible, which the rates above make common; and IRT when nightmares are the main complaint. On timing, the best current evidence comes from CBT-I paired with exposure-based PTSD therapies, not EMDR specifically, and it favors adding sleep treatment rather than choosing between tracks, with some advantage to doing the sleep work after the trauma work (Taylor et al., 2023).
None of this makes EMDR a treatment for insomnia. The AASM’s “may be used” listing for PTSD-associated nightmares is the strongest sleep-specific claim EMDR holds, and it is modest. What the evidence does support is sleep as a standing line in EMDR case conceptualization: asked about at intake, tracked through treatment, and referred out when it persists.
Where Veterans Can Start Today
Veterans Crisis Line: Dial 988, then press 1; text 838255; or chat at VeteransCrisisLine.net. For any Veteran, family member, or friend, for any reason, at any hour. No VA enrollment required.
Don’t Wait. Reach Out.: va.gov/REACH. VA’s support hub matched to specific pressures: money, housing, work, relationships. A June 2026 VA guide pairs it with plain-language tips for spotting building stress in yourself or in a Veteran you know.
Vet Centers: vetcenter.va.gov. Community-based counseling centers, many staffed by fellow Veterans. No VA enrollment required.
A sleep evaluation: Ask a VA or community provider directly about insomnia, nightmares, or snoring and breathing pauses. The VA/DoD guideline’s patient materials are at healthquality.va.gov.
None of this is medical advice, and none of it replaces VA or DoD care.
The review anchoring this piece closes with a sentence that would once have been contested and now reads like the field catching up to its own data: sleep-focused assessment and treatment “should be established as standard care for Veterans with PTSD.” For clinicians, that means sleep gets asked about and acted on at intake, during treatment, and after treatment succeeds. For a Veteran awake at three in the morning, it means something simpler. The sleep problem is not the residue of the diagnosis. It is a treatable problem with named treatments, and it is allowed to be the thing you get help for first.
Selected Sources
- So, C., Gehrman, P., & Miller, K. E. (2026). PTSD and Sleep. PTSD Research Quarterly, 37(2). National Center for PTSD.
- VA/DoD Clinical Practice Guideline. Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea. 2025.
- VA News. A guide to help Veterans manage stressors that increase suicide risk. June 30, 2026.
- Veterans Crisis Line.
- VA. Don’t Wait. Reach Out.
- VA. Vet Centers.
- VA Chesapeake Vet Center. Vet Center eligibility language noting VA health care enrollment is not required.
Additional studies named in this article are discussed in the National Center for PTSD review above, including Ahmadi et al. (2022), Georgescu et al. (2025), Worley et al. (2025), Zhang et al. (2019), Shah et al. (2024), Pruiksma et al. (2016), Morgenthaler et al. (2018), Raskind et al. (2018), Colvonen et al. (2023), and Taylor et al. (2023).
