The Effect of Continuous Positive Air Pressure (CPAP) on Nightmares in Patients with Posttraumatic Stress Disorder (PTSD) and Obstructive Sleep Apnea (OSA)

Tamanna, Sadeka; Parker, Jefferson D.; Lyons, Judith A.; Ullah, Mohammad

doi:10.5664/jcsm.3786

Cited by 68 publications

(30 citation statements)

References 40 publications

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“…Regarding treatment, one ongoing study in a small sample of PTSD patients with SDB is prospectively comparing two groups: one using only standard cognitive-behavioral therapy with prolonged exposure versus combination treatment comprising both exposure and an auto-adjusting positive airway pressure device; the preliminary data suggest more benefit in the latter group [93]. A retrospective study recently published demonstrated a marked decrease in nightmares among PTSD patients using CPAP therapy for OSA [94]. Additional investigations could test the impact of PTSD treatment on sleep breathing problems as well as SDB treatment impact on PTSD.…”

Section: Discussionmentioning

confidence: 99%

Posttraumatic stress disorder and sleep-disordered breathing: a review of comorbidity research

Krakow

Ulibarri

Moore

et al. 2015

Sleep Medicine Reviews

103

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Section: Discussionmentioning

confidence: 99%

Posttraumatic stress disorder and sleep-disordered breathing: a review of comorbidity research

Krakow

Ulibarri

Moore

et al. 2015

Sleep Medicine Reviews

103

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“…14,15 In PTSD patients, recurrent arousals might potentiate nighttime symptoms, such as recall of nightmares, an assertion supported by the finding that treatment of OSA with CPAP appears to reduce the frequency of nightmares in PTSD patients. 16 Poor sleep quality related to sleep apnea may also contribute to daytime PTSD symptoms of irritability, impairment in concentration, fatigue, as well as comorbid psychiatric conditions. Sleep apnea has been associated with worsened scores across a wide range of daytime and nighttime symptoms.…”

Section: Introductionmentioning

confidence: 99%

Treatment of OSA with CPAP Is Associated with Improvement in PTSD Symptoms among Veterans

Orr

Smales

Alexander

et al. 2017

Journal of Clinical Sleep Medicine

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Study Objectives: Posttraumatic stress disorder (PTSD) is common among veterans of the military, with sleep disturbance as a hallmark manifestation. A growing body of research has suggested a link between obstructive sleep apnea and PTSD, potentially due to obstructive sleep apnea (OSA) related sleep disruption, or via other mechanisms. We examined the hypothesis that treatment of OSA with positive airway pressure would reduce PTSD symptoms over 6 months. Methods: A prospective study of Veterans with confirmed PTSD and new diagnosis of OSA not yet using PAP therapy were recruited from a Veteran's Affairs sleep medicine clinic. All subjects were instructed to use PAP each night. Assessments were performed at 3 and 6 months. The primary outcome was a reduction in PTSD symptoms at 6 months. Results: Fifty-nine subjects were enrolled; 32 remained in the study at 6 months. A significant reduction in PTSD symptoms, measured by PCL-S score was observed over the course of the study (60.6 ± 2.7 versus 52.3 ± 3.2 points; p < 0.001). Improvement was also seen in measures of sleepiness, sleep quality, and daytime functioning, as well as depression and quality of life. Percentage of nights in which PAP was used, but not mean hours used per night, was predictive of improvement. I NTRO DUCTI O NPosttraumatic stress disorder (PTSD) is highly prevalent among veterans of the United States armed forces, afflicting 11% to 22% of those returning from Iraq and Afghanistan.1,2 Among Vietnam veterans, the lifetime prevalence approaches 31%, and despite 40 years having elapsed since combat exposure, PTSD remains in 10% of veterans of this era, reflecting the challenges for recovery.3 Patients with PTSD have a substantially reduced quality of life and increased mortality.4,5 Sleep disturbance is often called the "hallmark" of PTSD, 6 and formal DSM-5 criteria includes several sleep-related complaints, including recurrent distressing dreams and sleep disturbances. Sleep disturbance has been recognized as both an early predictor of development of PTSD, and a marker of disease severity.7-9 However, whether sleep disturbance is a reflection of disease, or a predisposing factor in development and continuance of PTSD is an ongoing subject of debate. Moreover, treatment of PTSD has been elusive, leading to a search for potential therapeutic targets in this condition. Sleep and Pediatrics, Carmel Medical Center, Haifa, A growing body of research has suggested an association between OSA and PTSD. Prevalence estimations for OSA in PTSD patients range from 52% to 69%, with some as high as 95%. [10][11][12] The odds of PTSD have been estimated at 2.7-fold higher in patients with sleep apnea. SCIENTIFIC INVESTIGATIONS13 While the nature of this interaction is unclear, it has been hypothesized that OSA-related sleep disruption contributes to PTSD, either by contributing to symptoms or more direct influences on disease pathogenesis. In general, untreated OSA might contribute to symptoms of depression and anxiety. 14,15 In PTSD patients, recurrent BRI...

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“…8,40,41 In one of these studies involving 40 veterans with combat-related PTSD, a positive association was established between the reduction in PCL-M and the average of hours of CPAP use per night. 40 Similarly, Orr and colleagues 41 showed significant reduction in PTSD symptoms following 6 months of treatment with CPAP.…”

Section: Discussionmentioning

confidence: 99%

“…Recent clinical investigations suggest that treatment of OSA in veterans with PTSD may improve the underlying psychological disturbances and reduce nightmares. 4,8,9 However, despite the overall improvement in PTSD symptomatology with CPAP therapy, adherence to treatment is far worse in these patients compared with the general population with OSA. 10,11 The reasons behind this poor adherence have not been thoroughly investigated but anxiety disorder, nightmares, claustrophobia, and comorbid insomnia have been implicated in low CPAP usage.…”

Section: Introductionmentioning

confidence: 99%

A Randomized Crossover Trial Evaluating Continuous Positive Airway Pressure Versus Mandibular Advancement Device on Health Outcomes in Veterans With Posttraumatic Stress Disorder

El-Solh

Homish

Ditursi

et al. 2017

Journal of Clinical Sleep Medicine

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Study Objectives: Despite the overall improvement in posttraumatic stress disorder (PTSD) symptomatology with continuous positive airway pressure (CPAP) therapy, adherence to CPAP is far worse in veterans with PTSD compared to the general population with obstructive sleep apnea (OSA). The aim of this study was to compare the efficacy, adherence, and preference of CPAP versus mandibular advancement device (MAD) and the effect of these treatments on health outcomes in veterans with PTSD. Methods: Forty-two subjects with PTSD and newly diagnosed OSA by polysomnography were treated in a randomized, crossover trial of 12 weeks with CPAP alternating with MAD separated by a 2-week washout period. The primary outcome was the difference in titration residual apnea-hypopnea index (AHI) between CPAP and MAD. Secondary outcome measures included PTSD Checklist and health-related quality of life (Medical Outcomes Study 36-Item Short Form and Pittsburgh Sleep Quality Index). Results: Analyses were limited to the 35 subjects (mean age 52.7 ± 11.6 years) who completed the trial, regardless of compliance with their assigned treatment. CPAP was more efficacious in reducing AHI and improving nocturnal oxygenation than MAD (P < .001 and P = .04, respectively). Both treatments reduced PTSD severity and ameliorated scores of the Medical Outcomes Study Short Form 36 and Pittsburgh Sleep Quality Index, although no differences were detected between the CPAP and MAD arms. The reported adherence to MAD was significantly higher than CPAP (P < .001), with 58% preferring MAD to CPAP. Conclusions: Although CPAP is more efficacious than MAD at improving sleep apnea, both treatment modalities imparted comparable benefits for veterans with PTSD in relation to PTSD severity and health-related quality of life. 1 Veterans having PTSD suffer from nonrestorative sleep and nightmares leading to heightened state of arousal and anxiety, increased severity of depression, and poor quality of life.2 Accruing evidence suggests that patients with PTSD are at higher risk for sleep-disordered breathing than the general population.3,4 In a series of studies looking at postdeployment combat veterans with PTSD, rates of overall sleep disturbance symptoms approached 90%, with up to 70% considered to be at high risk for OSA. and substance abuse. BRIEF SUMMARYCurrent Knowledge/Study Rationale: In veterans with posttraumatic stress disorder (PTSD), the disturbed sleep can worsen the cognitive-behavioral manifestations of PTSD and contribute to poor mental and physical health outcomes. Because adherence to treatment with CPAP is less than optimal in this population, this study was undertaken to examine the clinical efficacy, compliance, and quality of sleep of mandibular advancement devices (MAD) compared to CPAP in veterans with OSA and PTSD. Study Impact: Although CPAP is more efficacious in eliminating respiratory events, both MAD and CPAP result in similar beneficial changes in daytime sleepiness, PTSD symptomatology, and healthrelated quality of life measures in v...

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The Effect of Continuous Positive Air Pressure (CPAP) on Nightmares in Patients with Posttraumatic Stress Disorder (PTSD) and Obstructive Sleep Apnea (OSA)

Abstract: In Veterans with PTSD and OSA, CPAP therapy reduces PTSD-associated nightmares and improves overall PTSD symptoms. We recommend that all PTSD patients should be screened clinically for symptoms of OSA and receive CPAP treatment whenever possible to improve PTSD symptoms.

Cited by 68 publications

References 40 publications

Posttraumatic stress disorder and sleep-disordered breathing: a review of comorbidity research

Posttraumatic stress disorder and sleep-disordered breathing: a review of comorbidity research

Treatment of OSA with CPAP Is Associated with Improvement in PTSD Symptoms among Veterans

A Randomized Crossover Trial Evaluating Continuous Positive Airway Pressure Versus Mandibular Advancement Device on Health Outcomes in Veterans With Posttraumatic Stress Disorder

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