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

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Abstract

<p class="first" id="P1">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. </p>

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Sleep disturbances as the hallmark of PTSD: where are we now?

Anne Germain (2013)

The hypothesis that rapid eye movement (REM) sleep disturbances are the hallmark of posttraumatic stress disorder (PTSD), proposed by Ross and colleagues in 1989, has stimulated a wealth of clinical, preclinical, and animal studies on the role of sleep in the pathophysiology of PTSD. The present review revisits this influential hypothesis in light of clinical and experimental findings that have since accumulated. Polysomnographic studies conducted in adults with PTSD have yielded mixed findings regarding REM sleep disturbances, and they generally suggest modest and nonspecific sleep disruptions. Prospective and treatment studies have provided more robust evidence for the relationship between sleep disturbances and psychiatric outcomes and symptoms. Experimental animal and human studies that have probed the relationship between REM sleep and fear responses, as well as studies focused more broadly on sleep-dependent affective and memory processes, also provide strong support for the hypothesis that sleep plays an important role in PTSD-relevant processes. Overall, the literature suggests that disturbed REM or non-REM sleep can contribute to maladaptive stress and trauma responses and may constitute a modifiable risk factor for poor psychiatric outcomes. Clinicians need to consider that the chronic sleep disruption associated with nightmares may affect the efficacy of first-line PTSD treatments, but targeted sleep treatments may accelerate recovery from PTSD. The field is ripe for prospective and longitudinal studies in high-risk groups to clarify how changes in sleep physiology and neurobiology contribute to increased risk of poor psychiatric outcomes.

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Disturbed sleep in post-traumatic stress disorder: secondary symptom or core feature?

Victor I Spoormaker, Paul Montgomery (2008)

Sleep disturbances are often viewed as a secondary symptom of post-traumatic stress disorder (PTSD), thought to resolve once PTSD has been treated. Specific screening, diagnosis and treatment of sleep disturbances is therefore not commonly conducted in trauma centres. However, recent evidence shows that this view and consequent practices are as much unhelpful as incorrect. Several sleep disorders-nightmares, insomnia, sleep apnoea and periodic limb movements-are highly prevalent in PTSD, and several studies found disturbed sleep to be a risk factor for the subsequent development of PTSD. Moreover, sleep disturbances are a frequent residual complaint after successful PTSD treatment: a finding that applies both to psychological and pharmacological treatment. In contrast, treatment focusing on sleep does alleviate both sleep disturbances and PTSD symptom severity. A growing body of evidence shows that disturbed sleep is more than a secondary symptom of PTSD-it seems to be a core feature. Sleep-focused treatment can be incorporated into any standard PTSD treatment, and PTSD research needs to start including validated sleep measurements in longitudinal epidemiologic and treatment outcome studies. Further clinical and research implications are discussed, and possible mechanisms for the role of disturbed (REM) sleep in PTSD are described.

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Polysomnographically measured sleep abnormalities in PTSD: a meta-analytic review.

Ihori Kobayashi, Jessica M Boarts, Douglas L Delahanty (2007)

Although sleep complaints are common among patients with Posttraumatic stress disorder (PTSD), polysomnographic studies examining sleep abnormalities in PTSD have produced inconsistent results. To clarify discrepant findings, we conducted a meta-analytic review of 20 polysomnographic studies comparing sleep in people with and without PTSD. Results showed that PTSD patients had more stage 1 sleep, less slow wave sleep, and greater rapid-eye-movement density compared to people without PTSD. We also conducted exploratory analyses aimed at examining potential moderating variables (age, sex, and comorbid depression and substance use disorders). Overall, studies with a greater proportion of male participants or a low rate of comorbid depression tended to find more PTSD-related sleep disturbances. These findings suggest that sleep abnormalities exist in PTSD, and that some of the inconsistencies in prior findings may be explained by moderating variables.