Why I Ask About Your Sleep Before I Ask About Your Trauma
There’s a question I ask early in nearly every first session, and it isn’t the one people expect.
Not what happened to you. Not yet.
How are you sleeping?
People often treat it as small talk — a warm-up before the real conversation. It isn’t. By the time someone is sitting across from me describing a decade of hypervigilance, their answer to that question has usually told me a great deal about what we can safely do together and in what order.
And the answer is almost never good. It’s some version of: I fall asleep fine and I’m up at three. Or: I haven’t slept properly since 2019. Or, most often, said with a shrug: I don’t really sleep. I’ve just gotten used to it.
That shrug is the thing I want to write about.
Sleep is not a side effect of trauma
The conventional assumption — among patients, and honestly among plenty of clinicians — is that sleep problems are downstream. You went through something, it damaged your sleep, and once the trauma is properly treated the sleep will come back on its own.
Treat the cause and the symptom resolves.
The research doesn’t support that, and a widely cited review in Sleep Medicine Reviews says so directly. Spoormaker and Montgomery (2008) describe the view that sleep disturbance is a secondary symptom of PTSD which will “resolve once PTSD has been treated,” and argue that this view and the clinical practices that follow from it are “as much unhelpful as incorrect.”
Three findings from that review are worth sitting with.
Disturbed sleep predicts PTSD, rather than only following it. The authors report that several studies have found disturbed sleep to be a risk factor for the subsequent development of PTSD. If sleep problems were purely a consequence of trauma, they couldn’t precede it.
Sleep problems frequently remain after successful treatment. The review describes sleep disturbance as “a frequent residual complaint after successful PTSD treatment” — and notes this holds for both psychological and pharmacological treatment. Meaning: people can complete a course of trauma therapy, meet criteria for improvement, lose the intrusive memories, and still not sleep.
Treating sleep directly helps the PTSD. The authors state that treatment focused on sleep “does alleviate both sleep disturbances and PTSD symptom severity.” That’s a two-way street, and it’s the part that changes how you ought to sequence care.
Their conclusion is unambiguous: disturbed sleep “seems to be a core feature” of PTSD rather than a secondary symptom.
That reframing matters enormously in practice. A side effect is something you tolerate while you treat the real problem. A core feature is part of the problem.
What happens to the emotional brain without sleep
There’s a piece of research I think about often, though I want to be careful about what it does and doesn’t show.
Yoo and colleagues (2007) took 26 healthy young adults and kept 14 of them awake for roughly 35 hours while 12 slept normally. Then they put everyone in a scanner and showed them a series of images ranging from neutral to increasingly distressing.
The sleep-deprived group showed what the authors called a “remarkable +60% greater magnitude of amygdala activation” compared with the rested group, and roughly a three-fold increase in how much of the amygdala was activated at all.
The connectivity finding is the part I find most clinically useful. In the rested group, the amygdala was functionally well-connected to the medial prefrontal cortex — the region involved in regulating and contextualising emotional responses. In the sleep-deprived group, that coupling was weaker, and the amygdala was instead more strongly connected to brainstem regions associated with autonomic arousal.
I want to be precise about the limits here, because this study gets over-extended constantly. These were healthy young adults after a single night without sleep. This was not a study of people with PTSD, and the authors themselves described the broader implications as speculative. It doesn’t tell us what thirty years of four-hour nights does to someone with a trauma history.
What it does show is something about the ordinary architecture of emotion: the brain’s alarm system and the brain’s braking system are connected by sleep, and removing sleep weakens the connection in people with no psychiatric history at all.
Now consider what that implies for someone who already has an alarm system set too sensitive, and who hasn’t slept properly in years.
Why this changes how I sequence treatment
Here’s where this stops being interesting and starts being practical.
EMDR in its basic, original form is an eight-phase treatment. Most of what goes wrong with it goes wrong in the first two — history-taking and preparation — because reprocessing began before the person had the capacity to tolerate it. As an EMDRIA-Approved Consultant, a part of my professional work is helping other clinicians untangle cases that stalled, and this is the single most common reason.
Sleep belongs in that preparation phase, and it’s routinely left out.
Think about what reprocessing actually asks of someone. You bring a distressing memory to mind, deliberately, and stay with it while it moves. That requires a nervous system with enough reserve to become activated and then come back down. It requires the braking system to work.
Asking someone averaging four and a half hours a night to do that is asking them to do the most demanding work in therapy with the least capacity they’ve had all year. Sometimes it works. Often what happens instead is that they destabilise, the session ends badly, and both of us conclude that EMDR isn’t right for them — when the actual finding was that preparation wasn’t finished.
There’s also a consolidation question I can’t answer and won’t pretend to. A good deal of memory processing happens during sleep, and it’s reasonable to wonder what reprocessing work consolidates into when sleep is badly fragmented. I don’t know, and the evidence isn’t settled enough for me to claim otherwise. But it’s one more reason I’d rather address sleep early than hope it resolves later.
The trap of “I’ll sleep when this is sorted out”
Almost everyone says some version of this.
Once I get through this project. Once the trauma work is done. I’ve always been a bad sleeper, it’s just how I am.
I understand the logic. Sleep feels like the thing you’d fix after you fix the real problem. And there’s a particular stoicism in it — a sense that complaining about sleep when you’re also carrying something much heavier would be self-indulgent.
But if the research is right that sleep is a core feature rather than a side effect, then waiting means treating the condition with one of its central mechanisms left running.
There’s also something worth naming about the shrug. When someone tells me they’ve “gotten used to” not sleeping, what they usually mean is that they stopped expecting it to change. That’s not resilience. It’s accommodation — and it’s often the same accommodation they’ve made to everything else they’ve been carrying.
What I actually do about it
I ask, specifically. Not “how’s your sleep” but: What time do you get into bed? How long until you’re asleep? How many times do you wake? What wakes you? What’s happening in your body when you wake? What do you do then?
I find out whether it’s a sleep problem or a fear problem. A meaningful number of trauma survivors aren’t struggling to sleep. They’re avoiding it — because sleep is when the nightmares come, or because being unconscious is unsafe, or because the quiet of 1am is when the material arrives. That’s a different clinical problem with a different answer.
I treat it as part of the work rather than as homework. A review by Brownlow, Miller and Gehrman (2020) in Current Treatment Options in Psychiatry describes sleep disturbances as being among the most frequently endorsed symptoms of PTSD, and notes that targeted sleep-focused interventions can improve sleep symptoms and reduce daytime PTSD symptoms. Sleep isn’t a lifestyle appendix to trauma treatment. It’s a target.
I refer when it’s medical. Sleep apnoea is common, it’s frequently missed, and no amount of psychotherapy will fix it. If the history suggests it — snoring, witnessed pauses in breathing, waking unrefreshed regardless of hours, morning headaches — that’s a referral, not a reframe.
I don’t begin reprocessing until there’s enough stability to come back down. Sometimes that’s a short delay. Sometimes it’s the main work for a while. With complex trauma, the preparation phase substantially is the treatment, and sleep is part of it.
The version of this I see most in the DMV
I work with clients across Washington DC, Maryland and Virginia, and the regional pattern is distinct enough to name.
In this area, not sleeping is close to a professional norm. The hours are the job. Email at eleven is unremarkable. There’s a widely shared understanding that sleep is what you trade for the thing you’re trying to achieve — and in a region organised around proximity to importance, that trade feels obviously worth making.
So the sign that something is wrong gets absorbed into a culture where everyone looks the same way. You’re not sleeping, but nor is anyone else in your office, so it reads as commitment rather than as a symptom.
What I notice is how long people carry this before they mention it. Someone will describe hypervigilance, intrusive thoughts, an inability to be still, and a decade of five-hour nights — and present only the first three as the problem. The sleep gets mentioned last, almost apologetically, as context.
It isn’t context. It’s frequently the most treatable thing in the room, and improving it tends to make everything else more workable.
If any of this sounds familiar
You don’t need to be in crisis to take this seriously. Some reasonable prompts:
- You’ve stopped expecting to sleep well
- You’re awake at the same time most nights
- You dread going to bed, or you delay it without quite knowing why
- You wake with your heart racing and no memory of a dream
- You’ve been told you stop breathing in your sleep
- You sleep a full night and wake unrefreshed anyway
- You’ve concluded this is simply your personality
Any of those is worth raising — with me, with your doctor, with whoever you’re already working with.
I work with adults across Washington DC, Maryland and Virginia by secure video, and I’m independently licensed in all three. If you’re considering trauma therapy and you haven’t slept properly in years, that’s not a reason to wait. It’s one of the first things I’d want to work on. (I am also licensed in Florida and Vermont with an office in Fort Lauderdale, FL.)
References
Brownlow, J. A., Miller, K. E., & Gehrman, P. R. (2020). Treatment of sleep comorbidities in posttraumatic stress disorder. Current Treatment Options in Psychiatry, 7(3), 301–316. https://doi.org/10.1007/s40501-020-00222-y
Spoormaker, V. I., & Montgomery, P. (2008). Disturbed sleep in post-traumatic stress disorder: Secondary symptom or core feature? Sleep Medicine Reviews, 12(3), 169–184. https://doi.org/10.1016/j.smrv.2007.08.008
Yoo, S.-S., Gujar, N., Hu, P., Jolesz, F. A., & Walker, M. P. (2007). The human emotional brain without sleep — a prefrontal amygdala disconnect. Current Biology, 17(20), R877–R878. https://doi.org/10.1016/j.cub.2007.08.007
