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Effective sleep therapies are necessary for trauma survivors, as evidenced by the high prevalence of sleep disturbances linked to PTSD and trauma exposure—people who have experienced trauma report sleep disturbances more frequently than the public. Atypical sleep-disturbing behaviours, frequent awakenings, recurring nightmares, and trouble falling and staying asleep are some of these sleep disturbances.
Trauma-related sleep issues were often thought to be secondary symptoms of posttraumatic stress disorder (PTSD), but they are now understood to be fundamental symptoms that require focused therapies. They can exist without a PTSD diagnosis, they play a role in the onset and maintenance of PTSD, and they frequently recur when evidence-based PTSD-focused therapies are completed.
Effective sleep-focused therapies are desperately needed for this group, especially in light of this course and the new research that explicitly connects these symptoms to suicidal thoughts and behaviours. In addition to discussing the significance of enhancing integrated treatment methods, this blog will highlight the most recent data supporting empirically validated psychotherapy, pharmaceutical, and sleep medicine therapies for sleep disorders linked to PTSD.
Psychotherapeutic intervention: The first line of treatment for insomnia is widely recognised as cognitive behavioural therapy (CBT-I), a short session meant to improve overall sleep quality. CBT-I teaches sleep hygiene education, cognitive restructuring, control of stimuli, limitation of sleep, and relaxation techniques. In veterans with PTSD diagnoses, it is now the only psychotherapy treatment that is advised for sleep disorders, and recent research has demonstrated its effectiveness in PTSD samples. Apart from enhancing treatment objectives, CBT-I has shown a noteworthy amelioration of additional PTSD symptoms, which in turn diminishes the anxiety of sleep, a commonly documented aspect of PTSD. A chart review for Veterans in a residential PTSD treatment programme revealed that group-delivered CBT-I significantly improved sleep efficiency, time awake following sleep onset, and self-reported severity of insomnia, suggesting that it may also be susceptible to other treatment methods.
Unlike insomnia, there is little data to support any specific recommendations for psychotherapy methods for trauma-related dreams. To cure nightmares, the American Academy of Sleep Medicine's most current position paper suggested imagery rehearsal therapy (IRT), a cognitive behavioural method. IRT employs mental rehearsal or imaging exercises, wherein participants select a nightmare, usually one with a lower severity level, and create an altered, non-stressful version of this dream. Another therapeutic strategy that IRT created, especially for trauma-related nightmares, is exposure, relaxation, and rescripting therapy (ERRT). Despite having some IRT as a foundation, ERRT is distinct in that it emphasises both oral and written exposure to the most upsetting nightmare and trauma-related thematic rescripting. There are conflicting results on the effectiveness of ERRT and IRT. Significant decreases in the frequency of nightmares, increases in the quality of sleep, and improvements in waking PTSD symptoms have all been shown in studies including these therapies. The complete protocols have been compared against active comparison groups in two randomised control studies (RCTs); the latter included treatment protocols that had been disassembled, excluding any mention of nightmare content, exposure, and rescripting. According to the results of both investigations, there were no appreciable changes in the frequency of fewer nightmares and PTSD symptoms between the comparative circumstances and the entire treatment procedures. The conflicting results emphasise the need for more research into the essential elements of the treatment plan and the possibility that some patients might benefit from following the entire protocol, which includes exposure and rescripting.
The persistence of sleep complaints after PTSD-focused interventions and the potential benefit of sequential or integrated sleep-targeted and PTSD-targeted interventions after successful treatments for nightmares and insomnia may also be taken into consideration. In a study comparing the effectiveness of CBT alone against IRT before CBT for PTSD, there was no discernible improvement in PTSD symptoms with the sequential treatment approach. On the other hand, more improvements in sleep symptoms, such as nightmare frequency, nightmare-associated discomfort, and sleep quality, were seen in the group that got further IRT. Recently, a small pilot research was published in which the results of an integrated protocol of CBT-I and extended exposure (PE), an evidence-based treatment for PTSD, were examined in a sample of veterans with PTSD and insomnia.
Pharmacological interventions: Although CBT-I has shown better long-term results than medicine, the use of off-label pharmaceuticals for sleep and prescriptions for sedative-hypnotics (benzodiazepines and non-benzodiazepine receptor agonists, or "Z-drugs") remain the main therapy recommendations in groups with PTSD diagnoses. These drugs enhance the central nervous system's inhibitory action by increasing the effects of gamma-aminobutyric acid (GABA). Although these drugs provide short-term advantages, their frequent usage raises concerns because they are prescribed for situational or short-term insomnia, not the chronic sleep profile observed in individuals with PTSD diagnosis.
Consequently, despite the lack of research on the advantages and security of continuous medication for insomnia, patients can continue to obtain prescriptions. Furthermore, the effects of a combination of CBT-I and medication have not been well studied in clinical trials. The results lead the authors to hypothesise that these drugs might lessen CBT-I's effectiveness. The VA/DoD treatment guidelines suggest medication as a second-line option in the absence of good evidence. The use of pharmacological drugs with sedative qualities should be done with caution because of the increased risk of creating excessive daytime drowsiness. As of right now, there is no prescribed medication for the particular purpose of treating PTSD nightmares. The most emphasis has been paid to the pharmaceutical treatment of nightmares using the centrally acting alpha-1 adrenergic antagonist prazosin. Since increased noradrenergic activity in the central nervous system has been suggested to be a factor in PTSD symptoms, especially during the night, prazosin blocks norepinephrine's effects at the postsynaptic alpha-1 adrenoreceptor, which may help with nightmares and sleep by lowering nocturnal hyperarousal. According to researchers, the frequency of nightmares, the quality of sleep, and the intensity of PTSD were all significantly reduced in multiple controlled trials and a meta-analysis of prazosin. Nonetheless, there was no advantage of prazosin over placebo in a multicentred VA Cooperative trial that evaluated the medication's effectiveness on combat-related unpleasant dreams and overall sleep quality.
It is essential to consider the effects of obstructive sleep apnoea (OSA) in individuals with PTSD diagnoses. Because of upper airway obstruction, OSA is characterised by partial or total decreases in airflow during sleep, which causes arousal and fragmentation of sleep. Data indicate a correlation between sleep breathing disturbances and insomnia and nightmares in trauma-exposed groups, while the prevalence of OSA ranges widely (0.7%–83%). Currently, it is uncertain precisely what pathophysiological link exists between PTSD and OSA. According to some views, REM sleep deficiencies associated with PTSD may be exacerbated by sleep fragmentation from OSA, which would impede the emotional processing of the experience.
Further investigation is required to clarify the molecular connections between OSA and PTSD. Positive airway pressure, or PAP, is the most well-known treatment for OSA. Research indicates that using a PAP can ease nightmare disturbance and lessen the discomfort associated with PTSD symptoms throughout the day, in addition to helping with breathing and snoring issues. Reducing sleep fragmentation caused by OSA may result in consolidated sleep, which may improve daytime PTSD symptoms (such as irritability, exhaustion, and difficulty concentrating throughout the day) that overlap with OSA. This population faces a barrier in maintaining PAP adherence and continuous usage, which is necessary for these changes. There are few evidence-based therapies available to support PAP adherence in patients with co-occurring PTSD and OSA, and these patients adhere to PAP much less often. Advanced PAP modes can considerably reduce insomnia symptoms for individuals who are refractory to classic continuous PAP therapy, according to a new retrospective investigation of patients with OSA and PTSD symptoms. However, even among the most obedient PAP users, residual insomnia symptoms persisted. Consequently, if OSA is suspected, a thorough sleep examination is a suitable first step towards receiving therapy, and a multidisciplinary approach is probably required to maximise treatment results.
Improving care for trauma-related sleep disturbance: Although there are effective therapies for trauma-related sleep problems, there are obstacles that keep people from accessing and using these treatments more widely. Apart from the previously mentioned inadequate adherence to PAP, between 14 and 40 per cent of research subjects discontinued CBT-I. Adapting sleep-focused methods may also be necessary when working with specific groups, such as active-duty military people, to maximise therapy delivery.
Another approach is to consider the treatment delivery format in addition to modifications or new treatment techniques. Even while conventional in-person therapy is frequently chosen, PTSD veterans are receptive to online and app-delivered therapies. Based on research, Online and mobile apps show promising benefits in treating sleeplessness and nightmares. Digital platforms might be crucial in breaking down systemic obstacles to care and in stepped-care delivery models. Integrating behavioural and sleep medicine also requires a more clearly defined interdisciplinary approach, as the division of these services might impede the development of a holistic treatment plan. Multidisciplinary sleep therapy models have been presented, and they might be valuable resources for the development of interdisciplinary sleep care for patients with PTSD diagnoses. Evidence-based smartphone apps and web-based programmes for treating insomnia and nightmares are starting to show promising benefits. Digital platforms may be essential for improving care delivery and breaking systemic obstacles.
Lastly, there is a need for population-based preventive initiatives targeted at the populations most susceptible to both trauma exposure and sleep disruption, given the role that sleep disturbance plays as a premorbid risk factor for the development of PTSD after trauma exposure. Including sleep components in active-duty military personnel's pre-deployment health and operational preparation programmes makes this work especially noteworthy in the military context. Enhancing sleep quality before stress exposure may help increase resilience against the psychological effects of trauma.
In conclusion, even if there are beneficial sleep therapies for people with PTSD diagnoses, it would be oversimplifying the complicated presentations of many trauma-exposed patients to isolate the prescribed treatments without considering their integration in the larger context of PTSD and other comorbidities. There is much room for further research to determine how best to combine behavioural and sleep medicine techniques, when to combine these treatments with other interventions, and whether specific patient populations will find these treatments acceptable.
To your health,
Nwabekee.
Reference
Katherine E Miller, Janeese A Brownlow and Philip R Gehrman (2020).
So educative.