The comorbidity of posttraumatic stress disorder (PTSD) and sleep disorders is staggeringly high, with 70 - 91% of individuals with PTSD reporting sleep disturbances. 1 The most common sleep disturbances include insomnia,2 obstructive sleep apnea (OSA) 3, 4 and nightmares,2 with prevalence rates in individuals with PTSD considerably higher than in unaffected individuals. Examined temporally, there is evidence that sleep disturbances may predict who will develop PTSD following a trauma.5 Additionally, poor sleep may make other PTSD symptoms more severe6 and may not remit following effective PTSD treatment.7 Finally, while the presence of nightmares and insomnia do not seem to interfere with effective evidence-based PTSD treatments, untreated OSA does.8,9 Taken together, targeted treatment of sleep disorders in the context of PTSD offers a unique and underutilized opportunity to advance clinical care and research.
Insomnia: Among individuals with PTSD, approximately 35-93.3% report insomnia.1,3,10 Although “trouble falling and staying asleep” are symptoms of PTSD, insomnia may be best considered a co-occurring and independent disorder. For instance, insomnia may precede the trauma and predict the development of PTSD.11 Further, when insomnia initially occurs as a symptom of PTSD, it can become an independent disorder when the behavioral and cognitive responses to acute insomnia lead to perpetuating factors (e.g., napping, sleeping pills). This suggests that insomnia needs to be assessed and treated separately from, or in conjunction with, PTSD.
Cognitive behavioral therapy for insomnia (CBT-I) is the front-line treatment for insomnia and is effective in PTSD patients.12 CBT-I is a protocol typically involving: 1) sleep restriction, or limiting patients’ time in bed to more closely correspond to the amount of sleep they are able to generate; and 2) stimulus control, or instructing patients to use bed for sleep only in order to strengthen the association between bed and sleep. CBT-I can be delivered individually or in group format over four to eight weeks. Integrated CBT-I and PTSD treatment has shown promise in addressing two clinically meaningful disorders in one treatment.13
Nightmares: 50-96% of individuals with PTSD report nightmares.2 Nightmares in PTSD have been shown to increase anxiety, depression and suicide. Similar to both insomnia and OSA, there is evidence that nightmares may precede PTSD.2 Nightmares may also influence insomnia through conditioned arousal (e.g., chronic nightmares pair the bed with arousal) and OSA (e.g., nighttime fragmentation leading to increased AHI). However, nightmares have been shown to significantly decrease with evidence-based PTSD treatment,14 insomnia treatment15 and OSA treatment.16 So, while there are effective nightmare treatments such as Imagery Rehearsal Therapy (IRT) and Exposure, Relaxation, and Rescripting Therapy (ERRT), they are often used for residual nightmares following sleep and trauma treatments or if nightmares are the primary complaint of a client.
Obstructive Sleep Apnea: Approximately 50–75.7% of individuals with PTSD have OSA.3,4,17 OSA is defined by repeated episodes of apneas (pauses in breathing) and hypopneas (shallow breathing) with decreases in blood oxygenation during sleep. Interestingly, there is increasing evidence that the classic predictors of OSA, such as body mass index (BMI), blood pressure and age, may not apply to younger veterans with PTSD. Two recent studies found 67.3%–69.2% of younger veterans (mean age = 33.40 - 35.1 years) with lower BMI (BMI = 19.08 - 28.9)4,18 were at high risk of OSA. Unfortunately, this means that the self-report questionnaires commonly used to screen that rely on age/BMI do not accurately predict OSA risk19 and require objective overnight testing (i.e., a “sleep study”). Using a positive airway pressure (PAP) device is the most effective treatment for OSA, but often requires a desensitization class to help individuals with PTSD get used to wearing the PAP device.
Research is still needed to create screening protocols, determine optimal order of treatment and understand treatment mechanisms. Addressing sleep disturbances alongside PTSD treatment has the potential to improve clinical outcomes and quality of life in patients with trauma histories. The Sleep Disorders and Traumatic Stress Special Interest Group (SIG) strives to foster advocacy and organize for improvements in research, prevention/intervention, diagnosis, treatment, services and life outcomes for individuals impacted by trauma.
The Sleep Disorders and Traumatic Stress SIG is chaired by myself (Peter Colvonen), Laura Straus (Co-Chair), and student chairs Guadalupe Rivera and Christopher McGrory. My fellow SIG chairs and I hope you reach out to us with questions and consider joining us as we advance these incredibly important research and clinical efforts The primary goal of the Sleep Disorders and Traumatic Stress SIG is to advance theory, research, assessment and evidence-based treatments in traumatic stress and sleep disorders. We hold dissemination, networking and collaboration as key to advancing science and clinical practice. Our diverse group provides opportunities for clinicians, researchers and scientists interested in different aspects of sleep and trauma research to learn from one another. We publish a newsletter, and host at least one networking event for those interested in learning more about and/or collaborating on projects related to sleep and trauma. Please consider joining the Sleep Disorders and Traumatic Stress SIG if you’re interested in learning more!
To join the Sleep Disorders and Traumatic Stress SIG:
1. Log in and go to your ISTSS member profile.
2. Go to the Listservs/Communities tab and select the SIG(s) you want to join from the dropdown.
3. Scroll down and click “next,” then “save changes.”
References
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19. Lyons R, Barbir L, Norman SB, Owens R, Colvonen PJ. Examining the association between subjective and objective measures of obstructive sleep apnea risk in veterans with posttraumatic stress disorder and insomnia. 2020.