By Brenda L. Mooney
JACKSON, MS – For veterans suffering from post-traumatic stress disorder (PTSD), disrupted sleep and nightmares can be a vicious cycle — one feeding the other.
Now, new research in the relationship between PTSD and disordered sleep — one of its primary symptoms — is spotlighting new tools VA clinicians can employ to help troubled veterans. One of those is the use of continuous positive airway pressure (CPAP) to reduce the incidence of the disturbing dreams.
Results of the study, presented recently at SLEEP 2013, the 27th annual meeting of the Associated Professional Sleep Societies, indicate that the mean number of nightmares per week fell significantly with CPAP use. The greater the compliance with CPAP use, the more nightmare frequency was reduced, the authors noted. 1
“Patients with PTSD get more motivated to use CPAP once they get restful sleep without frequent nightmares, and their compliance improves” said principal investigator Sadeka Tamanna, MD, MPH, medical director of the Sleep Disorders Laboratory at G.V. (Sonny) VA Medical Center in Jackson, MS.
For the study, researchers retrospectively reviewed sleep clinic records between May 2011 and May 2012 to identify obstructive sleep apnea (OSA) patients with a concurrent PTSD diagnosis. They also documented the mean number of nightmares per week before treatment and up to six months after CPAP prescription.
CPAP memory cards provided evidence of compliance.
“One out of six veterans suffers from PTSD, which affects their personal, social and productive life,” Tamanna said. “Nightmares are one of the major symptoms that affect their daily life, and prevalence of OSA is also high among PTSD patients and can trigger their nightmares.”
The researchers also sought to determine whether CPAP effectiveness differed if the sleep apnea was related to rapid eye movement (REM).
To determine effectiveness, nightmare frequency and degree of daytime sleepiness repeatedly were measured before and after treatment, with analysis focusing on factors — including compliance, apnea-hypopnea index, age and body mass index — that might predict fewer nightmare attacks.
Citing complete data from 43 patients, 25 REM-related and 18 Non-REM-related, the authors reported that the mean number of nightmares per week feel significantly with CPAP use in both groups.
They added that reduced nightmare frequency with CPAP use was best predicted by compliance with the therapy (R2=0.55, p<0.01), which was higher in non-REM (75.3%) than REM-related (55.8%) OSA patients (p=0.04).
“In veterans, CPAP therapy reduces PTSD-associated nightmares in patients with either REM- or non-REM-related OSA, and compliance predicts the magnitude of treatment benefit,” the study noted. “Lower compliance in REM-related OSA patients may reduce net CPAP benefit for this subpopulation.”
Another Promising Treatment
Another promising treatment being tested to control PTSD-related nightmares is the use of prazosin, a high blood pressure medication.
Murray Raskind, MD, director of the VA Northwest Network Mental Illness Research, Education and Clinical Center and professor and vice chair of the Department of Psychiatry and Behavioral Sciences of the University of Washington School of Medicine, discussed the research at a DoD-sponsored webinar on sleep last summer.
“It does not help one get to sleep. It doesn’t make one feel tired. But when one achieves sleep and has sleep disruption, with or without trauma-related nightmares, prazosin reduces those. It normalizes sleep and extends sleep throughout the night,” Raskind said.
According to the VA’s National Center for PTSD symptoms such as nightmares or flashbacks usually start soon after a traumatic event, but they might not appear until months or years later. Symptoms that last longer than four weeks, cause great distress or interfere with daily life are used to help make a PTSD diagnosis.