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

Posttraumatic stress disorder as a diagnostic entity – clinical perspectives

Throughout history the consequences of psychological trauma and characteristic symptoms have involved clinical presentations that have had different names. Since the inclusion of the category of Posttraumatic Stress Disorder (PTSD) in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) with the symptomatic triad of re-experiencing the traumatic event, avoidance behaviors, and hypervigilance, this entity has been a source of controversy. Indeed, some authors have denied its existence, even considering it a diagnostic invention. In this article we review, from the clinician's perspective, historical aspects as well as the development of the nosological classifications and the contributions from the neurosciences that allow the consideration of the full validity of this diagnosis as a form of psychobiological reaction to psychological trauma.

Detailed Polysomnography in Australian Vietnam Veterans With and Without Posttraumatic Stress Disorder

STUDY OBJECTIVES

Recent results from the PTSD Initiative, a cross-sectional cohort study in Australian Vietnam veterans (VV) with and without posttraumatic stress disorder (PTSD), demonstrated an increased prevalence of self-reported sleep disturbances in those with PTSD. This study aimed to objectively assess the prevalence of sleep disorders in the same cohort using detailed polysomnography (PSG).

METHODS

Participants from the PTSD Initiative were recruited to undergo PSG. PTSD status was determined with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). Subjective sleep information was attained via structured questionnaires. Data from single night PSG were compared between trauma-exposed VV with and without PTSD.

RESULTS

A total of 74 trauma-exposed male VV (40 with PTSD) underwent PSG (prospective n = 59, retrospective n = 15). All PSG parameters were similar between groups. No difference was seen in PSG-diagnosed obstructive sleep apnea (OSA) or periodic limb movements of sleep (PLMS). VV with PTSD showed a trend toward increased duration of sleep with oxygen saturations < 90% (10% versus 1.8%; P = .07). VV with PTSD reported increased sleep onset latency (42.4 versus 13.3 minutes; P < .01); were less likely to report sleeping well (32.5% versus 67.5%; P < .01); had higher OSA risk using Berlin Questionnaire (BQ) (70% versus 38.2%; P < .01); and had higher rates of partner-reported limb movements (56.4% versus 17.6%; P < .01). No association between PSG-diagnosed OSA and PTSD severity was evident.

CONCLUSIONS

In Australian VV with and without PTSD, no difference was seen across all PSG parameters including the diagnosis and severity of OSA and PLMS. However, VV with PTSD demonstrated an increased perception of sleep disturbances.

Recent Advancements in Treating Sleep Disorders in Co-Occurring PTSD

PURPOSE OF REVIEW

Comorbidity of posttraumatic stress disorder (PTSD) and insomnia, nightmares, and obstructive sleep apnea (OSA) is high. We review recent research on psychotherapeutic and pharmacological interventions for sleep disorders in PTSD.

RECENT FINDINGS

PTSD treatments decrease PTSD severity and nightmare frequency, but do not resolve OSA or insomnia. Research on whether insomnia hinders PTSD treatment shows mixed results; untreated OSA does interfere with PTSD treatment. Cognitive behavioral therapy for insomnia is the recommended treatment for insomnia; however, optimal ordering with PTSD treatment is unclear. PTSD treatment may be most useful for PTSD-related nightmares. CPAP therapy is recommended for OSA but adherence can be low. Targeted treatment of sleep disorders in the context of PTSD offers a unique and underutilized opportunity to advance clinical care and research. Research is needed to create screening protocols, determine optimal order of treatment, and elucidate mechanisms between sleep and PTSD treatments.

Social support, mastery, sleep-related problems and their association with functional status in untreated obstructive sleep apnoea patients

BACKGROUND

Social support and mastery are important aspects in the treatment of chronic diseases, however their role in connection with Obstructive Sleep Apnoea (OSA) remains unclear.

OBJECTIVES

The study examined the associations between social support, mastery, sleep-related problems and functional status in untreated OSA patients.

METHODS

All patients in this cross-sectional study completed the Multidimensional Scale of Perceived Social Support, the Pearlin Mastery Scale, the Pittsburgh Sleep Quality Index, the Epworth Sleepiness Scale and the Functional Outcomes of Sleep Questionnaire. Multiple linear regression and mediation analyses were used to analyse the data.

RESULTS

Participants were 150 newly diagnosed OSA patients (Apnoea-Hypopnoea Index-AHI≥5; 68% male; mean age 48.9 ± 9.5years). Compared with social support, mastery was more strongly associated with functional status. The indirect effects of sleep-related problems on functional status via mastery varied between 17.7% and 23.3%.

CONCLUSIONS

Supporting OSA patients' sense of mastery may significantly contribute to better disease management.

Sleep Disturbances in Australian Vietnam Veterans With and Without Posttraumatic Stress Disorder

STUDY OBJECTIVES

Posttraumatic stress disorder (PTSD) is a condition that may develop after a traumatic event, particularly combat-related trauma. Although sleep disturbance is a hallmark of PTSD, the prevalence of sleep disturbances in Australian veterans with PTSD remains uncertain. This study aimed to subjectively compare the prevalence of sleep disturbances in Australian Vietnam veterans with and without PTSD.

METHODS

A cross-sectional cohort study compared trauma-exposed Australian Vietnam veterans with and without PTSD. PTSD diagnosis was confirmed using the Clinician Administered PTSD Scale for DSM-5. Sleep information was evaluated using supervised structured questionnaires, including Epworth Sleepiness Scale (ESS) and Berlin and Mayo Questionnaires.

RESULTS

Two hundred fourteen male Vietnam veterans (108 with PTSD) were included. Participants with PTSD had higher body mass index (30.3 versus 29 kg/m2; P < .05), higher ESS score (9.2 versus 7.6; P < .05), and increased alcohol or medication use to assist with sleep (19% versus 6%; P < .01; and 44% versus 14%; P < .01). Those with PTSD were less likely to sleep well (32% versus 72%; P < .01) and reported higher rates of restless legs (45% versus 25%; P < .01), nightmares (91% versus 29%; P < .01), nocturnal screaming (73% versus 18%; P < .01), sleep terrors (61% versus 13%; P < .01) and dream enactment (78% versus 11.8%; P < .01). The PTSD group had higher rates of diagnosed OSA (42% versus 21%; P < .01) and an increased risk of OSA on the Berlin Questionnaire (69% versus 43%; P < .01).

CONCLUSIONS

Compared to trauma-exposed controls, Australian Vietnam veterans with PTSD demonstrated an increased prevalence of a wide range of sleep disturbances, including OSA. In veterans with PTSD, detailed sleep assessment, including consideration of polysomnography, is paramount.

Relationships between obstructive sleep apnea and anxiety

PURPOSE OF REVIEW

To summarize recent research investigating the interaction between obstructive sleep apnea (OSA) and anxiety, and contextualize their bidirectional relationship.

RECENT FINDINGS

Recent investigations corroborate the bidirectional relationship between sleep-disordered breathing (SDB) and anxiety, evaluate the etiological and clinical manifestations through different mechanisms, and provide insight into clinical implications of this interaction. Much of the literature about anxiety as it relates to SDB is from small samples, using different tools of symptom measurement that are often subjectively quantified. The objective severity of OSA does not appear to be associated with subjectively reported sleepiness and fatigue, whereas physiological manifestations of anxiety are associated with the severity of subjective symptoms reported. Recent findings support that women are more likely to have comorbid SDB and anxiety than men. SDB may precipitate and perpetuate anxiety, whereas anxiety in OSA negatively impacts quality-of-life. Treating SDB may improve anxiety symptoms, whereas anxiety symptoms can be an obstacle and deterrent to appropriate treatment.

SUMMARY

The interaction between anxiety and SDB is still poorly elucidated. Being aware of the clinical associations, risk factors, and treatment implications for SDB as related to anxiety disorders in different populations can help clinicians with the diagnosis and management of both SDB and anxiety.

Suicidal ideation in patients with obstructive sleep apnoea and its relationship with disease severity, sleep-related problems and social support

We aimed to assess the prevalence of suicidal ideation and to examine the relationships between obstructive sleep apnoea severity, sleep-related problems, social support and suicidal ideation in obstructive sleep apnoea patients. We included 149 patients (68% male; mean age, 48.99 ± 9.57 years) with diagnosed obstructive sleep apnoea (Apnoea–Hypopnoea Index ⩾5) based on full-night polysomnography. The prevalence of suicidal ideation among obstructive sleep apnoea patients was 20.1 per cent. Structural equation modelling showed that suicidal ideation in obstructive sleep apnoea was strongly related to poor sleep quality and high fatigue levels. No relationship between social support and suicidal ideation in obstructive sleep apnoea patients was found.

Media use and insomnia after terror attacks in France

Direct exposure to traumatic events often precipitates sleep disorders. Sleep disturbance has also been observed amongst those indirectly exposed to trauma, via mass media. However, previous work has focused on traditional media use, rather than contemporary social media. We tested associations between both traditional and social media consumption and insomnia symptoms following 2015 terror attacks in Paris France, controlling for location and post-traumatic symptomology. 1878 respondents, selected to represent the national French population, completed an internet survey a month after the Bataclan attacks (response rate 72%). Respondents indicated different media use, post-traumatic stress and insomnia. Controlling for demographics, location and PTSD, insomnia was associated with both traditional (β 0.10, P = .001) and social media use (β 0.12, P = .001). Associations between social media and insomnia were independent of traditional media use. Interventions targeted at social media may be particularly important following mass trauma.

Response to Cognitive Processing Therapy in Veterans With and Without Obstructive Sleep Apnea

Recent studies have called attention to the need for enhancing treatment outcome in trauma-focused psychotherapies, such as cognitive processing therapy (CPT), with veterans. Given the prevalence of posttraumatic-related sleep disturbances, and the role of sleep in emotional learning and processing, sleep quality may be a target for improving CPT outcome. Elevated rates of obstructive sleep apnea (OSA) have been reported in samples of veterans with posttraumatic stress disorder (PTSD); however, the impact of OSA on response to CPT is unclear. In this study, CPT outcome was examined in veterans with and without a diagnosis of OSA. Following chart review, 68 OSA-positive and 276 OSA-negative veterans were identified. Generalized estimating equations were used to compare between-group differences in weekly self-reported PTSD symptomatology. The OSA-positive veterans reported greater PTSD severity over the course of treatment and at posttreatment compared with veterans without OSA (B = -0.657). Additionally, OSA-positive veterans with access to continuous positive airway pressure (CPAP) therapy reported less PTSD severity relative to OSA-positive veterans without access to CPAP (B = -0.421). Apnea appears to be a contributing factor to the reduced effectiveness of evidence-based psychotherapy for veterans with PTSD; however, preliminary evidence indicates that CPAP therapy may help mitigate the impact of OSA on treatment outcome.

Sleep and Dreaming in Posttraumatic Stress Disorder

PURPOSE OF REVIEW

Sleep disturbances are core features of posttraumatic stress disorder (PTSD). This review aims to characterize sleep disturbances, summarize the knowledge regarding the relationships between trauma exposure and sleep difficulties, and highlight empirically supported and/or utilized treatments for trauma-related nightmares and insomnia.

RECENT FINDINGS

Trauma-related nightmares and insomnia, and other sleep disorders, are frequently reported among trauma survivors. The roles of fear of sleep, REM density, and decreased parasympathetic activity are beginning to inform the relationship between trauma exposure and sleep difficulties. Additionally, the potential adaptive role of sleep loss immediately following a traumatic experience is being recognized. Interventions targeting these sleep disturbances show promise in reducing symptoms. Research in understanding the role of sleep on the development, course, and treatment of PTSD is expanding. Longitudinal investigations are needed to further elucidate these relationships and identify treatments most effective in ameliorating symptoms.

Repercusiones psiquiátricas del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS)

La apnea del sueño es un síndrome que afecta múltiples sistemas y produce variados síntomas. En el presente artículo se revisan las enfermedades psiquiátricas más frecuentes asociadas a este y la necesidad de realizar un diagnóstico adecuado y un tratamiento interdisciplinario. La entidad que más se ha podido encontrar en los pacientes con apnea del sueño es la depresión y se piensa que se debe a la fragmentación del sueño, la cual altera la producción de neurotransmisores a nivel cerebral. La ansiedad es la segunda entidad con mayor frecuencia, quizás debido a la liberación de catecolaminas durante la noche. Existen otras sintomatologías asociadas a la apnea del sueño que deben ser revisadas y que mejorarían con un tratamiento adecuado, así como también mejoraría la calidad de vida de los pacientes, pues la atención, la concentración y la memoria incrementarían o disminuirían la irritabilidad y otros síntomas.

Why did adolescents have sleep problems after earthquakes? Understanding the role of traumatic exposure, fear, and PTSD

To examine the relationships between trauma exposure, fear, post-traumatic stress disorder, and sleep problems in adolescents, 746 adolescent survivors of the 2008 Wenchuan earthquake in China were assessed at 1 year (T1) and 1.5 years (T2) after the earthquake using a trauma exposure questionnaire, a fear questionnaire, a child posttraumatic stress disorder symptom scale, and a subscale on child sleep problems. The results showed that T1 trauma exposure were not directly associated with sleep problems at T1 and T2, but played a positive role in sleep problems at both T1 and T2 indirectly through T1 posttraumatic stress disorder and T1 fear. T1 trauma exposure was also positively and indirectly associated with T2 sleep problems through T1 posttraumatic stress disorder via T1 sleep problems, or through T1 fear via the path from T1 posttraumatic stress disorder to T1 sleep problems. These findings indicated that fear and posttraumatic stress disorder 1 year after the earthquake played a mediating role in the relationship between trauma exposure at 1 year after the earthquake, and sleep problems at both 1 year and 1.5 years after the earthquake, respectively. In particular, posttraumatic stress disorder also had a multiple mediating effect in the path from trauma exposure to sleep problems via fear. Furthermore, the findings indicated that sleep problems were relatively stable between 1 and 1.5 years after an earthquake.

Sleep-Disordered Breathing Impact on Efficacy of Prolonged Exposure Therapy for Posttraumatic Stress Disorder

There is growing evidence that sleep disturbances may impede the utility of existing therapeutic interventions for people with posttraumatic stress disorder (PTSD). This retrospective medical record review examined the hypothesis that sleep disturbance affects the outcome of prolonged exposure (PE) therapy for PTSD. We identified 18 combat veterans with PTSD who had completed PE therapy. There were 6 subjects who had sleep-disordered breathing, 5 of whom were documented by sleep polysomnography. All subjects in the sleep-disordered group took part in a minimum of 10 sessions; the mean number of sessions was comparable between the sleep-disordered group and the group without a sleep disorder. Posttreatment PTSD Checklist scores were significantly reduced in those without a sleep disorder (-28.25; 58.0% reduction, F(1, 11) = 59.04, p < .001), but were not reduced in those with sleep-disordered breathing (-7.17; 13.5% reduction, d_IGPP = 2.25 [independent groups pretest-posttest design]). These observations supported the hypothesis that the efficacy of PE therapy is affected by sleep quality. If these findings are replicated, treatment algorithms may need to incorporate the presence or absence of sleep disorders as a factor in treatment choice.

Trauma associated sleep disorder: A parasomnia induced by trauma

Nightmares and disruptive nocturnal behaviors that develop after traumatic experiences have long been recognized as having different clinical characteristics that overlap with other established parasomnia diagnoses. The inciting experience is typically in the setting of extreme traumatic stress coupled with periods of sleep disruption and/or deprivation. The limited number of laboratory documented cases and symptomatic overlap with rapid eye movement sleep behavior disorder (RBD) and posttraumatic stress disorder (PTSD) have contributed to difficulties in identifying what is a unique parasomnia. Trauma associated sleep disorder (TSD) incorporates the inciting traumatic experience and clinical features of trauma related nightmares and disruptive nocturnal behaviors as a novel parasomnia. The aims of this theoretical review are to 1) summarize the known cases and clinical findings supporting TSD, 2) differentiate TSD from clinical disorders with which it has overlapping features, 3) propose criteria for the diagnosis of TSD, and 4) present a hypothetical neurobiological model for the pathophysiology of TSD. Hyperarousal, as opposed to neurodegenerative changes in RBD, is a component of TSD that likely contributes to overriding atonia during REM sleep and the comorbid diagnosis of insomnia. Lastly, a way forward to further establish TSD as an accepted sleep disorder is proposed.

Sleep Disturbance, Diabetes, and Cardiovascular Disease in Postmenopausal Veteran Women

PURPOSE OF THE STUDY

To compare the prevalence and cardiometabolic health impact of sleep disturbance among postmenopausal Veteran and non-Veteran participants in the Women's Health Initiative (WHI).

DESIGN AND METHODS

The prevalence of five categories of sleep disturbance--medication/alcohol use for sleep; risk for insomnia; risk for sleep disordered breathing [SDB]; risk for comorbid insomnia and SDB (insomnia + SDB); and aberrant sleep duration [SLD]--was compared in 3,707 Veterans and 141,354 non-Veterans using logistic or multinomial regression. Cox proportional hazards models were used to evaluate the association of sleep disturbance and incident cardiovascular disease (CVD) and Type 2 diabetes in Veterans and non-Veterans.

RESULTS

Women Veterans were more likely to have high risk for insomnia + SDB relative to non-Veteran participants. However, prevalence of other forms of sleep disturbance was similar across groups. Baseline sleep disturbance was not differentially associated with cardiometabolic health outcomes in Veteran versus non-Veteran women. Risks for SDB and insomnia + SDB were both linked to heightened risk of CVD and diabetes; SLD was consistently linked with greater risk of CVD and diabetes in non-Veterans but less strongly and consistently in Veterans.

IMPLICATIONS

Efforts to identify and treat sleep disturbances in postmenopausal women are needed and may positively contribute to the attenuation of cardiometabolic morbidity risk. Increased awareness of women Veterans' vulnerability to postmenopausal insomnia + SDB may be particularly important for health care providers who treat this population.

Retrospective, nonrandomized controlled study on autoadjusting, dual-pressure positive airway pressure therapy for a consecutive series of complex insomnia disorder patients

PURPOSE

Emerging evidence shows that positive airway pressure (PAP) treatment of obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS) in chronic insomnia patients (proposed "complex insomnia" disorder) leads to substantial decreases in insomnia severity. Although continuous PAP (CPAP) is the pressure mode most widely researched, intolerance to fixed pressurized air is rarely investigated or described in comorbidity patients. This retrospective study examined dual pressure, autoadjusting PAP modes in chronic, complex insomnia disorder patients.

PATIENTS AND METHODS

Chronic insomnia disorder patients (mean [SD] insomnia severity index [ISI] =19.11 [3.34]) objectively diagnosed with OSA or UARS and using either autobilevel PAP device or adaptive servoventilation (ASV) device after failing CPAP therapy (frequently due to intolerance to pressurized air, poor outcomes, or emergence of CSA) were divided into PAP users (≥20 h/wk) and partial users (<20 h/wk) for comparison. Subjective and objective baseline and follow-up measures were analyzed.

RESULTS

Of the 302 complex insomnia patients, PAP users (n=246) averaged 6.10 (1.78) nightly hours and 42.71 (12.48) weekly hours and partial users (n=56) averaged 1.67 (0.76) nightly hours and 11.70 (5.31) weekly hours. For mean (SD) decreases in total ISI scores, a significant (group × time) interaction was observed (F[1,300]=13.566; P<0.0001) with PAP users (-7.59 [5.92]; d=1.63) showing superior results to partial users (-4.34 [6.13]; d=0.81). Anecdotally, patients reported better tolerability with advanced PAP compared to previous experience with CPAP. Both adaptive servoventilation and autobilevel PAP showed similar ISI score improvement without statistical differences between devices. Total weekly hours of PAP use correlated inversely with change in insomnia symptoms (r=-0.256, P<0.01).

CONCLUSION

Insomnia severity significantly decreased in patients using autoadjusting PAP devices, but the study design restricts interpretation to an association. Future research must elucidate the interaction between insomnia and OSA/UARS as well as the adverse influence of pressure intolerance on PAP adaptation in complex insomnia patients. Randomized controlled studies must determine whether advanced PAP modes provide benefits over standard CPAP modes in these comorbidity patients.

Positive airway pressure adherence and subthreshold adherence in posttraumatic stress disorder patients with comorbid sleep apnea

STUDY OBJECTIVES

Patients with comorbid posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) manifest low adherence to continuous positive airway pressure (CPAP) due to fixed, pressure-induced expiratory pressure intolerance (EPI), a subjective symptom and objective sign aggravated by anxiety sensitivity and somatosensory amplification. As advanced PAP therapy modes (ie, auto-bilevel PAP [ABPAP] or adaptive servo-ventilation [ASV]) may address these side effects, we hypothesized such treatment would be associated with decreased expiratory intolerance and increased adherence in posttraumatic stress patients with co-occurring OSA.

METHODS

We reviewed charts of 147 consecutive adult patients with moderately severe posttraumatic stress symptoms and objectively diagnosed OSA. All patients failed or rejected CPAP and were manually titrated on auto-adjusting, dual-pressure ABPAP or ASV modes in the sleep laboratory, a technique to eliminate flow limitation breathing events while resolving EPI. Patients were then prescribed either mode of therapy. Follow-up encounters assessed patient use, and objective data downloads (ODDs) measured adherence.

RESULTS

Of 147 charts reviewed, 130 patients were deemed current PAP users, and 102 provided ODDs: 64 used ASV and 38 used ABPAP. ODDs yielded three groups: 59 adherent per insurance conventions, 19 subthreshold compliant partial users, and 24 noncompliant. Compliance based on available downloads was 58%, notably higher than recently reported rates in PTSD patients with OSA. Among the 19 partial users, 17 patients were minutes of PAP use or small percentages of nights removed from meeting insurance compliance criteria for PAP devices.

CONCLUSION

Research is warranted on advanced PAP modes in managing CPAP failure in PTSD patients with comorbid OSA. Subthreshold adherence constructs may inform clinical care in a patient-centric model distinct from insurance conventions. Speculatively, clinical application of this transitional zone ("subthreshold" number of hours) may increase PAP use and eventual adherence.

Sleep disturbances in veterans with chronic war-induced PTSD

Post-traumatic stress disorder is related to a wide range of medical problems, with a majority of neurological, psychological, cardiovascular, respiratory, gastrointestinal disorders, diabetes, as well as sleep disorders. Although the majority of studies reveal the association between PTSD and sleep disturbances, there are few studies on the assessment of sleep disruption among veterans with PTSD. In this review, we attempt to study the sleep disorders including insomnia, nightmare, sleep-related breathing disorders, sleep-related movement disorders and parasomnias among veterans with chronic war-induced PTSD. It is an important area for further research among veterans with PTSD.

Insomnia Symptoms Following Treatment for Comorbid Panic Disorder With Agoraphobia and Generalized Anxiety Disorder

Patients with panic disorder with agoraphobia (PDA) or generalized anxiety disorder (GAD) frequently also suffer from insomnia. However, the impact of cognitive-behavioral therapy (CBT) for anxiety disorders on insomnia has been understudied. Furthermore, comorbidity between anxiety disorders is common. Our main objective was to assess the impact of CBT for PDA or GAD on insomnia. In a quasi-experimental design, 86 participants with PDA and GAD received conventional CBT for their primary disorder or combined CBT for both disorders. Overall, CBTs had a significant impact on reducing insomnia symptoms (η = 0.58). However, among people with insomnia at pretest (67%), 33% still had an insomnia diagnosis, and the majority (63%) had clinically significant residual insomnia following treatment. In conclusion, the CBTs had a positive effect on the reduction of insomnia, but a significant proportion of participants still had insomnia problems following treatment. Clinicians should address insomnia during CBT for PDA and GAD.

Sleep Disturbances in Posttraumatic Stress Disorder: Updated Review and Implications for Treatment

Sleep disturbances are common in adults with PTSD and range from insomnia and nightmares to periodic leg movements and disruptive nocturnal behaviors. Together these findings suggest profound disturbances in rapid eye movement (REM) and non-REM (NREM) sleep, although there is a lack of consensus regarding a distinct profile of objective sleep disturbances associated with PTSD. Prospective, longitudinal studies have established that sleep disturbances represent a risk factor for the development and course of PTSD, suggesting that sleep is an important neurobiological mechanism in the etiology and maintenance of this disorder. This research highlights the importance of early identification and treatment of sleep disturbances in at-risk and trauma exposed populations. A number of psychological and pharmacological treatments are effective at treating sleep disturbances in PTSD. Additional research is needed to further develop clinical guidelines informing when and how to integrate sleep-specific treatment with PTSD focused clinical care.

A Comparative Analysis of Sleep Disordered Breathing in Active Duty Service Members with and without Combat-Related Posttraumatic Stress Disorder

STUDY OBJECTIVES

Posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) are frequently co-occurring illnesses. The purpose of this study was to determine whether comorbid PTSD/OSA is associated with increased PTSD symptoms or decreased OSA severity compared to PTSD or OSA alone in recently deployed Active Duty Service Members (ADSM).

METHODS

Cross-sectional observational study of ADSM who returned from combat within 24 months. Participants underwent an attended diagnostic polysomnogram and were assessed for PTSD, depression, combat exposure severity, sleepiness, and sleep quality with validated clinical instruments.

RESULTS

Our study included 109 military personnel who returned from a combat deployment within 24 months with a mean age of 34.3 ± 8.23 and BMI of 30.8 ± 3.99. Twenty-four participants had PTSD/OSA, 68 had OSA, and 17 had PTSD. Mean PTSD Checklist- Military Version (PCL-M) scores were 62.0 ± 8.95, 60.5 ± 4.73, and 32.5 ± 8.95 in PTSD/OSA, PTSD, and OSA, respectively. The mean AHI was 16.9 ± 15.0, 18.9 ± 17.0, and 1.73 ± 1.3 for those with PTSD/OSA, OSA, and PTSD. PTSD symptoms and OSA severity in military personnel with comorbid PTSD/OSA were not significantly different from those with PTSD or OSA alone. On multivariate analysis, BMI was a significant predictor of OSA (OR, 1.21; 95% CI, 1.04-1.44) and age trended towards significance. Depression, but not OSA severity, was associated with PTSD symptoms.

CONCLUSIONS

Following recent combat exposure, comorbid PTSD/OSA is not associated with increased PTSD symptoms or decreased severity of OSA. Early evaluation after traumatic exposure for comorbid OSA is indicated in PTSD patients with sleep complaints given the high co-occurrence and adverse clinical implications.

Cognitive-behavioral therapy for sleep disturbances in treating posttraumatic stress disorder symptoms: A meta-analysis of randomized controlled trials

Sleep disturbances are frequently reported in patients with posttraumatic stress disorder (PTSD). There is evidence that sleep disturbance is not only a secondary symptom but also a risk factor for PTSD. Sleep-specific psychological treatments provide an alternative to conventional trauma-focused psychological treatments. The current meta-analysis evaluated the efficacy of sleep-specific cognitive-behavioral therapy (CBT) in mitigating PTSD, sleep, and depressive symptoms. A total of 11 randomized controlled trials were included in the meta-analytic comparisons between sleep-specific CBT and waiting-list control groups at posttreatment. Random effects models showed significant reduction in self-report PTSD and depressive symptoms and insomnia severity in the sleep-specific CBT group. The corresponding effect sizes, measured in Hedges' g, were 0.58, 0.44, and 1.15, respectively. The effect sizes for sleep diary-derived sleep onset latency, wake after sleep onset, and sleep efficiency were 0.83, 1.02 and 1.15, respectively. The average study attrition rate of sleep-specific CBT was relatively low (12.8%), with no significant difference from the control group (9.4%). In conclusion, sleep-specific CBT appears to be efficacious and feasible in treating PTSD symptoms. Due to the relatively small number of randomized controlled trials available, further research is warranted to confirm its efficacy and acceptability, especially in comparison to trauma-specific psychological treatments.