By Steven J. Anglés, Attorney at Law
People suffering from sudden injury following a traumatic event find themselves dealing with a host of issues from the injury, beyond obvious pain: stress, work problems, anxiety, household concerns, and burdened family obligations. One common thread we hear over and again is that the person injured “just can’t sleep.” A common consequence of a traumatic personal injury is the interruption of normal and restful sleep cycles.
Disturbed sleep can of course be from the inability to get comfortable due to pain, or it can result from the inability to calm one’s mind after experiencing the event, resulting in conditions such as post traumatic stress disorder (PTSD). This can also disrupt the body’s regular and predictable rhythm sleep cycles, making it more difficult to recover from the initial injury. A recent study helps answer the question of whether sleep within 24 hours after a traumatic event actually helps in the mental processing of stress and trauma, or, instead solidifies emotional reactions and memories of the traumatic event, leading to what is known as “intrusive emotional memory formation”.
THE STAGES OF SLEEP
First, it is important to revisit the various stages of the sleep cycle. In healthy adults, sleep typically begins with what is known as “NREM” sleep, or non-rapid-eye-movement sleep. NREM sleep can be broken down into three distinct stages: N1, N2, and N3. The N1 stage often lasts just one to seven minutes, with the N2 stage lasting 10 to 25 minutes, while the N3 stage generally lasts 20 to 40 minutes, and is referred to as “slow-wave” or “deep” sleep. As these stages progress, brain waves slow down, become more synchronized, and eyes remain still. Finally, the typical sleep cycle results in REM, or rapid-eye-movement sleep, which comprises about 20 to 25% of total sleep in typical healthy adults.
Researchers at the Department of Psychology at the University of Zürich and the Psychiatric University Hospital Zürich performed an interesting study, published in December 2016. 65 healthy participants were asked to view several pieces of film in a laboratory setting: one which was considered “neutral”, and one considered to be “traumatic”. The study participants were then randomly assigned to either a group that slept after the film viewing or a second group that remained awake instead. A portion of the participants in the sleep group were fitted with electroencephalograms (an electrophysiological monitoring method to record electrical activity of the brain, commonly known as an “EEG”). The participants were then asked to record the images that troubled them for several days in a diary, causing them to see the trauma in their mind’s eye, reawakening unpleasant feelings and thoughts. The quality of these memories were thought to resemble those of patients suffering traumatic injury, such as patients who experience PTSD.
Although all of the study participants reported experiencing intrusive memories in the week after viewing the traumatic film, the group that slept within 24 hours of the distressing film experienced fewer and less severe levels of traumatic memories compared to the group that did not sleep. As the week following the viewing went on, the effects became more pronounced. The group that slept spent longer in the N2 stage of sleep, as opposed to just the N1 stage. This group also showed a lower number of fast parietal sleep spindles on EEG, and more rapid eye movement.
WHAT DOES THIS STUDY POSSIBLY MEAN?
The study’s results suggest that patients who sleep soon after trauma may experience fewer and less distressing recurring emotional memories than those who do not sleep. As a result, sleep may have a protective effect in the aftermath of traumatic experiences by weakening emotions connected to an existing memory, providing context for traumatic recollections, and help processing the information before it is stored in long-term memory. These important implications can help offer an early, less-invasive alternative to minimize traumatic memories following the injury. People suffering from impaired sleep or traumatic memories following such an event should always seek help from a medical professional.
WHAT CAN BE DONE TO IMPROVE SLEEP?
Changes in behavior and environment are the first line to treating sleep difficulties. Here are some tips for changes related to the daytime and nighttime.
- Set an alarm to try to wake up at the same time every day.
- Include meaningful activities in your daily schedule.
- Get off the couch and limit TV watching.
- Light aerobic exercise every day, as able. People with TBI who exercise regularly report fewer sleep problems.
- Try to get outdoors for some sunlight during the daytime. If you live in an area with less sun in the wintertime, consider trying light box therapy.
- Don’t nap more than 20 minutes during the day.
- Try to go to bed at the same time every night and set your alarm for the next day.
- Follow a bedtime routine. For example, put out your clothes for morning, brush your teeth and then read or listen to relaxing music for 10 minutes before turning out the light.
- Avoid caffeine, nicotine, alcohol and sugar for five hours before bedtime.
- Avoid eating prior to sleep to allow time to digest, but also do not go to bed hungry, as this can also wake you from sleep.
- Do not exercise within two hours of bedtime but stretching or meditation may help with sleep.
- Do not eat, read or watch TV while in bed.
- Keep stress out of the bedroom. For example, do not work or pay bills there.
- Create a restful atmosphere in the bedroom, protected from distractions, noise, extreme temperatures and light.
- If you don’t fall asleep in 30 minutes, get out of bed and do something relaxing or boring until you feel sleepy.
WHAT IF THE SLEEP DIFFICULTIES CONTINUE?
If your sleep problems persist, talk to your doctor to explore safe and effective solutions. Evaluation of sleep problems should include a thorough history of such problems, medication review, an assessment of your bedtime routines, and a comprehensive medical evaluation. Before recommending any action, your physician will explore with you a variety of possible causes for your sleep problems, including pain, post-traumatic stress, anxiety or depression. If necessary, he or she may recommend a polysomnographic evaluation (also known as a sleep lab). Based on your symptoms, medical history and specific needs, your doctor will be able to make a personalized treatment plan to help you achieve restful sleep, including non-medication, medication, and even natural remedies.
If sleep problems are related to a traumatic injury, then a consultation with an experienced personal injury attorney may reduce stress by answering questions and providing guidance in a sometimes difficult and confusing legal and insurance process.
 “Effects of Sleep after Experimental Trauma on Intrusive Emotional Memories” by Birgit Kleim, PhD; Julia Wysokowsky, MSc; Nuria Schmid, MSc; Erich Seifritz, MD; and Björn Rasch, PhD in Sleep. Published online December 2016 doi:10.5665/sleep.6310
 A sleep spindle is a burst of brain activity that occurs during stage to sleep. It is considered to be a period where the brain is inhibiting processing to keep the sleeper in a more tranquil state.