Sleep Disturbances in Patients with Post-Traumatic Stress Disorder

Abstract

Subjective reports of sleep disturbance indicate that 70-91% of patients with post-traumatic stress disorder (PTSD) have difficulty falling or staying asleep. Nightmares are reported by 19-71% of patients, depending on the severity of their PTSD and their exposure to physical aggression. Objective measures of sleep disturbance are inconsistent, with some studies that used these measures indicating poor sleep and others finding no differences compared with non-PTSD controls. Future research in this area may benefit from examining measures of instability in the microstructure of sleep. Additionally, recent findings suggest that sleep disordered breathing (SDB) and sleep movement disorders are more common in patients with PTSD than in the general population and that these disorders may contribute to the brief awakenings, insomnia and daytime fatigue in patients with PTSD. Overall, sleep problems have an impact on the development and symptom severity of PTSD and on the quality of life and functioning of patients. In terms of treatments, SSRIs are commonly used to treat PTSD, and evidence suggests that they have a small but significant positive effect on sleep disruption. Studies of serotonin-potentiating non-SSRIs suggest that nefazodone and trazodone lead to significant reductions in insomnia and nightmares, whereas cyproheptadine may exacerbate sleep problems in patients with PTSD. Prazosin, a centrally acting alpha1-adrenoceptor antagonist, has led to large reductions in nightmares and insomnia in small studies of patients with PTSD. Augmentation of SSRIs with olanzapine, an atypical antipsychotic, may be effective for treatment-resistant nightmares and insomnia, although adverse effects can be significant. Additional medications, including zolpidem, buspirone, gabapentin and mirtazapine, have been found to improve sleep in patients with PTSD. Large randomised, placebo-controlled trials are needed to confirm the above findings. In contrast, evidence suggests that benzodiazepines, TCAs and MAOIs are not useful for the treatment of PTSD-related sleep disorders, and their adverse effect profiles make further studies unlikely. Cognitive behavioural interventions for sleep disruption in patients with PTSD include strategies targeting insomnia and imagery rehearsal therapy (IRT) for nightmares. One large randomised controlled trial of group IRT demonstrated significant reductions in nightmares and insomnia. Similarly, uncontrolled studies combining IRT and insomnia strategies have demonstrated good outcomes. Uncontrolled studies of continuous positive airway pressure for SDB in patients with PTSD show that this treatment led to significant decreases in nightmares, insomnia and PTSD symptoms. Controlled studies are needed to confirm these promising findings.

The Comorbidity of Sleep Apnea and Mood, Anxiety, and Substance Use Disorders among Obese Military Veterans within the Veterans Health Administration

“…28 To date, there has been only one study investigating the relation between OSA and psychopathology within the VA Health Care System, which is surprising given the heightened prevalence of OSA among veterans. 2,22 This study was a cross-sectional retrospective review of a centralized VA database between the years 1998 and 2001.…”

Understanding Recent Insights in Sleep and Posttraumatic Stress Disorder from a Research Domain Criteria (RDoC) Framework

“…Sleep difficulties, in particular, have long been considered a hallmark of the disorder [2], with upward of 90 % of patients reporting some form of sleep disturbance [3][4][5]. Within the past few years, two new diagnostic categories regarding trauma-related sleep disturbances were proposed, including trauma-induced insomnia [6], which may also be a prodrome of chronic insomnia and PTSD, and trauma-associated sleep disorder [7], which encompasses a variety of symptoms across multiple parasomnias.…”

Treatment of sleep disturbances in posttraumatic stress disorder: A review

“…"Sleep disruption is reported by 70-87% of people suffering from PTSD with a 48-60% increase in disturbed sleep compared to those who have been traumatized but do not have PTSD" (Maher et al [4]). Nightmares were reported by 52 percent of veterans with PTSD compared with 5 percent of veterans without PTSD in a nationally representative sample of male Vietnam veterans (Neylan et al [5]).…”

“…* Untreated sleep symptoms can persist for years and intensify daytime PTSD symptoms and associated comorbid psychiatric problems (Germain et al [6]) and, thus, may contribute to the poor clinical outcomes often observed in PTSD. Because sleep has a restorative function (Horne [7]) and affects emotional regulation (Walker [8]), poor sleep may affect the emotional processing of traumatic experiences (Maher et al [4]). These factors emphasize the need for effective treatment interventions to minimize the impact sleep disturbance has upon people experiencing PTSD.…”

“…A meta-analysis of 20 polysomnographic studies showed PTSD patients had more stage 1 sleep, less slow-wave sleep, and greater REM density than with people without PTSD (Kobayashi et al [9]). However, polysomnography-based studies yielded inconsistent results with respect to other measures of sleep, such as sleep efficiency (percent of time asleep relative to time in bed), duration of awakenings, body movement during sleep, and time to the first REM episode among individuals with PTSD (Maher et al [4]). Nonetheless, the extant literature on objectively measured sleep suggests that individuals with PTSD have fragmented and nonrestorative sleep.…”