PTSD and Sleep

At the November, 2013 Updates in Sleep Medicine Conference Dr. David Neubauer1 (@DavidNeubauer88 on Twitter) presented a comprehensive and timely overview of Posttraumatic Stress Disorder as defined in the new DSM-5, the manual of the American Psychiatric Association; and he covered common sleep abnormalities and disorders associated with PTSD as well.  It was a compelling presentation that I have thought about repeatedly, especially because of the health issues facing our military personnel returning from active combat.

By now many of us have read or heard about PTSD symptoms associated with trauma:

Re-experiencing (recurrent memories, distressing dreams, flashbacks, psychological distress and physiological reactions, like a racing heart, to cues of the event)

Avoidance (feeling emotionally numb, avoiding physical reminders such as people or places associated with the trauma)

Reaction (irritability, outbursts, sleep disturbance — falling asleep or staying asleep)

Thinking and Mood (poor memory, negativity, detachment, inability to experience positive emotions)

Children may have symptoms such as bedwetting even though they have mastered toileting, and unusual clinginess with a parent or other adult

Teens may show symptoms like those of adults, but may also develop disruptive, disrespectful or destructive behavior or feel guilty or have thoughts of revenge

PTSD takes a terrific personal and social toll.  It can profoundly affect the closest relationships with family and friends, which generally means higher medical and treatment costs or may provoke “self-medication” and often results in employment and career blockages associated with high absenteeism and lower income.  And it invariably impedes healthy development in children and teens.

While we are sensitive to the high-incidence of PTSD in military personnel, it is important to remember that first responders and survivors of physical and sexual assault, abuse, accidents and disasters may also suffer from PTSD.  Some get PTSD after a friend or family member experiences danger or harm, or from a sudden unexpected death.   According to the National Institute of Mental Health 7.7 million Americans suffer from PTSD annually.

It is imperative that anyone with PTSD or suspected PTSD get professional medical attention and have a plan of care.  That plan of care may include counseling as well as some medications such as anti-depressants.

So what about sleep and PTSD?

According to the U.S. Department of Veterans Affairs National Center for PTSD, National Center for Post Traumatic Stress Disorderresearchers found that key sleep disturbances present in the majority of Veteran patients with PTSD included nightmares in 71% – 90% of patients and insomnia in 90%.  Importantly, standard PTSD treatments are less likely to help with nightmares and insomnia, so sleep-focused treatments, not specifically PTSD treatments, may benefit nighttime and daytime PTSD symptoms.

Dr. Neubauer’s presentation noted the clinical implication that “Sleep disturbances before and after trauma exposure result in worse psychiatric outcomes and with increased risk for PTSD.”  Further, he pointed out the importance of identifying and treating sleep disturbances following trauma in order to reduce the risk for PTSD.  In particular, Dr. Neubauer noted that research2 reveals that patients with PTSD and Obstructive Sleep Apnea (OSA) may specifically be helped with nightmares by CPAP therapy—nightmares resolved in 91% of consistent CPAP users compared with 36% of those refusing CPAP treatment.  Clearly sleep medicine professionals have an important opportunity to help PTSD patients with OSA by supporting their treatment compliance!

I firmly believe that sleep medicine professionals are uniquely positioned to ensure timely diagnosis and treatment of sleep disorders in patients suffering from PTSD.  We must always keep in mind that it is still socially more acceptable to have a “sleep problem” than an issue with emotional or mental health!

Medical professionals, especially sleep medicine professionals, as well as patients and their families, must be vigilant in identifying sleep disorders in trauma victims and tenacious in supporting and enhancing health sleep for victims of trauma.

1 David Neubauer, M.D., is Associate Director of the Johns Hopkins Sleep Disorders Center and Associate Professor in the Department of Psychiatry at the Johns Hopkins University School of Medicine and Director of the Psychiatry Mobile Treatment Program at the Johns Hopkins Bayview Medical Center.

2 BaHammam AS et. al. 2013 Sleep Medicine 2013; 14(2):149-154