November 1, 2008
Psychiatric Times.
No. 13
TRAUMA AND VIOLENCE
Sleep Disturbances Associated With Posttraumatic Stress Disorder
A Brief Review of Consequences and Treatment Options
Thomas C. Neylan, MD
Dr Neylan is associate professor in residence and researcher in psychobiological human laboratory research in the department of psychiatry at the University of California, San Francisco, and staff psychiatrist at the Department of Veterans Affairs Medical Center in San Francisco.
The author reports that he is a consultant for and/or research collaborator with Actelion, Forest Laboratories, Jazz Pharmaceuticals, sanofi-aventis, Sepracor, and Takeda corporations; neither he nor any of his family members hold equity positions in biomedical or pharmaceutical corporations.
Psychological treatment There are a small number of published trials of psychological treatment for both nightmares and insomnia in patients with PTSD. Most focus on sleep hygiene and core elements of cognitive-behavioral therapy for insomnia (CBT-I). Sleep hygiene focuses on stabilizing the time of sleep-wake activity; sleeping in a comfortable, quiet, and cool setting; avoiding stimulants and alcohol; and getting regular exercise. Sleep hygiene is undoubtedly good advice but may be difficult to implement in some patients. PTSD is associated with a sense of foreshortened future, and some patients do not always adhere easily to preventive health practices. One element of CBT-I, stimulus control behavior modification, focuses on eliminating the conditioned linkage of the bedroom with arousal.25 Patients are instructed to use their bed only for sleep and intimacy, to go to bed only when sleepy, to get out of bed and leave the bedroom when unable to sleep, and to return to bed only when ready to fall asleep. The overall goal is to extinguish the conditioned arousal associated with being in bed, simply by drastically limiting the amount of time lying in bed awake. Patients who awaken during the night are instructed to leave the bedroom. With practice, patients sleep more continuously and efficiently and no longer mount a conditioned arousal response when they get into bed. A complementary technique used in CBT-I is called sleep restriction therapy.26 Patients monitor the time they spend in bed with a sleep diary and estimate the amount of time awake or asleep each night. They are then instructed to adjust their time in bed with the goal of reaching a sleep efficiency of around 90%. Because patients with insomnia often compensate by extending time in bed to increase sleep opportunity, they develop a pattern of sleeping with low efficiency. Sleep restriction reduces time in bed, and initially results in some sleep loss. Over time, patients sleep more efficiently, and time in bed can be gradually liberalized. There is one pilot study of CBT-I that was given to 5 PTSD patients with residual insomnia after completing exposure therapy for PTSD. CBT-I was found to be effective in this small sample.27 Krakow and colleagues28 have reported on the effects of imagery rehearsal therapy in several studies in PTSD patient with repetitive stereotypic nightmares. The results have been promising, but the treatment is not always well tolerated.29 Imagery rehearsal therapy by necessity requires an exploration of dream narrative and hence involves some elements of trauma exposure therapy. Germain and colleagues30 found that a single session employing aspects of imagery rehearsal therapy with CBT-I was effective in a pilot sample of PTSD patients. Overall, there is promising data that psychological treatments for PTSD-related sleep disturbances can be effective. The main limitation is that these techniques have not been widely disseminated and involve interventions that require some specialized training. Fortunately, training programs for CBT-I are becoming more available and there are a growing number of Web-based resources for patients such as the National Center on Sleep Disorders Research (http://www.nhlbi.nih.gov/about/ncsdr/patpub/patpub-a.htm). Pharmacological treatment At present, there are only 2 medications approved by the FDA for the treatment of PTSD. Both of these are SSRI antidepressants, which are associated with frequent complaints of sedation and insomnia. Although SSRIs are effective in civilian patients with PTSD, the results of a multicenter sertraline PTSD trial and 2 placebo-controlled fluoxetine trials in US military veterans were negative.31-34 In patients who have a significant treatment response to SSRIs, there generally is a reduction in nightmares and improvement in insomnia.35 Prazosin, an alpha1-adrenergic antagonist, has been found to have positive benefits for nightmares and insomnia in 2 placebo-controlled trials that enrolled veterans who had chronic PTSD.36,37 Findings from these trials suggest titrating prazosin from an initial dose of 1 mg up to 15 mg at bedtime. Clinicians and patients should be aware of a significant hypotensive response to the first dose. Significant hypotension is generally not seen after repeated dosing, even with upward titration. Patients should be warned of possible hypotensive responses to coadministration of prazosin with phosphodiesterase-5 inhibitors used for treatment of erectile dysfunction. Recently, the Department of Veterans Affairs initiated a large-scale, multicenter, placebo-controlled study of prazosin that focuses on trauma nightmares, sleep disturbance, and global clinical status. The results of this trial will definitively address whether prazosin should be considered as a first-line treatment for PTSD-related sleep disturbances. The success of prazosin is support for the hypothesis that PTSD is associated with increased CNS adrenergic activity.38 However, 2 controlled trials with guanfacine, an alpha2-presynpatic agonist, have been negative.39,40 A large propranolol PTSD prevention trial in recently traumatized civilians was also clearly negative; it failed to confirm findings from 2 smaller studies that indicated a trend level effect of propranolol for PTSD prophylaxis.41-43 Compounding these failures is the recognized tendency of beta-adrenergic blockade to intensify dreams, an effect that may have amplified trauma-related nightmares in several combat veterans treated with propranolol.44,45 Hence, the role of antiadrenergic pharmacotherapy appears to be limited at present to postsynaptic alpha1-blockers. Prazosin is currently the only alpha1-blocker that has any significant effects in the brain. Conclusions Sleep disturbances are associated with an increased risk for physical health complaints, diminished ability to cope with stress, and a reduced capacity to carry out daily activities. CBT for insomnia has shown some promise for addressing insomnia complaints. It remains to be seen whether CBT-I without a focus on trauma experiences can reduce nightmares. Sedative-hypnotic drugs are virtually untested for PTSD despite the prominence of sleep complaints. More randomized controlled trials are needed to produce the evidence that will guide rational treatment. | Drugs Mentioned in this Article | | Fluoxetine (Prozac, Sarafem) | | Guanfacine (Tenex) | | Prazosin (Minipress) | | Propranolol (Inderal) | | Sertraline (Zoloft) |
Evidence-Based References
Calhoun PS, Wiley M, Dennis MF, et al. Objective evidence of sleep disturbance in women with posttraumatic stress disorder. J Trauma Stress. 2007;20: 1009-1018.
Hoge CW, Terhakopian A, Castro CA, et al. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatry. 2007;164:150-153.
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