By Sandra Basu
WASHINGTON — Disturbed sleep is a common complaint for patients with PTSD and TBI, but military clinicians have some new tools to help treat the issue, according to experts.
“Sleep problems are common symptoms of both physical- and mental-health problems,” said Col. Christopher Robinson, deputy director for Psychological Health at the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE), Arlington, VA. “Although the nature and specificity of sleep problems in PTSD and TBI continues to be studied, promising behavioral and pharmacological treatments are recommended for healthcare providers.”
Robinson and other providers spoke about treating sleep problems during a recent webinar hosted by DCoE.
U.S. Army Spc. Steven McGovern of Quartz Hill, Calif., from the 16th Military Police Brigade, 503rd Military Police Battalion (Airborne), 21st Military Police Company (Airborne) Fort Bragg, N.C., beds down for the night at Forward Operating Base Whitehouse, in the Kajaki district, Afghanistan in April. Photo by Tech Sgt. Denoris Mickle.
Research has documented that sleep disturbances in TBI and PTSD patients are common. One 2007 study suggested a high prevalence of sleep disorders (46%) and excessive sleepiness (25%) in TBI patients. Another study, conducted by the National Intrepid Center of Excellence (NICoE), Bethesda, MD, looked at 94 patients, most of whom had either TBI, PTSD or both, and found that most of them suffered from insomnia, according to Anthony Panettiere, MD, a neurologist and sleep medicine physician at the center.
Panettiere explained that a good “sleeper” will stay quietly asleep for most of the night and awaken feeling refreshed, mentally and physically. They will not have a desire to nap during the day, they will dream regularly, they will beat the alarm clock or awake easily to the alarm and also will look forward to going to bed.
TBI and PTSD patients, however, may face challenges in getting a good night’s sleep.
“These patients, no matter how long they sleep, will typically feel unrefreshed. Some even feel worse when they wake up. Much of their night can be restless, or at least their spouse will perceive they are restless, if the patient doesn’t recall that.”
Their sleep may be further disrupted by pain, nightmares and hypervigilance.
During the day, these patients may feel fatigued and need caffeine and other stimulants to stay awake. “Unlike the good sleeper, who will look forward to going to sleep, they ruminate about falling asleep because of all of the bad things they have already foreseen happening in their sleep,” Panettiere said.
At the NICoE, patients with sleep issues undergo a sleep-disorder workup that includes a polysomnogram. In addition, clinicians interview the bed partner of the patient when possible and employ actigraphy, which is a specialized watch that monitors patient’s movement.
“This is an additional measurement of the amount of sleep they are getting and how restless their sleep is,” he explained.
For sleep-disordered breathing (SDB), Positive Airway Pressure Therapy (PAP), is the “gold-standard way” for treatment. For insomnia, sleep restriction, light therapy, stimulus control and regular exercise are among the sleep prescriptions used, Panettiere said.Promising Therapies Available for Sleep Disorders Frequently Related to PTSD and TBI
Providers also can use pharmacological treatments that providers can use to help patients, such as prazosin, speakers noted.
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 use of prazosin as a treatment for PTSD.
|Registered sleep scorer Ana Diaz analyzes and monitors a sleep study of a patient who has sleep apnea at the Walter Reed National Military Medical Center in Bethesda, Md.
Photo from National Capital Region Medical website.
“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,” he said during the webinar.
Raskind, who noted that prazosin was originally introduced in 1973 for the treatment of hypertension, recounted that he was caring for Vietnam veterans as part of the VA Puget Sound African-American Veterans Group, when he discovered the drug could be use for patients with sleep disruptions.
“Working with these veterans, it became clear that their major complaint was, ‘I can’t sleep.’ The drug they were using most … to achieve a few hours of sleep was alcohol.”
He said that he originally gave propranolol to the first veteran he treated for severe, treatment-resistant, Vietnam-combat PTSD nightmares in 1996, after he read a case report suggesting its benefit. After two weeks, he recalled, the veteran said, “Doc, we are going the wrong direction. My nightmares are even worse.”
Raskind said he had not realized it at the time but learned that intensifying dreams is an established adverse effect of beta-adrenergic blockade. That caused him to question whether blocking brain alpha-1 adrenergic receptors with prazosin would suppress nightmares.
After two weeks of a gradual prazosin dose increase in his veteran patient, the nightmares disappeared. He said this veteran continues to be nightmare-free — and alcohol-free—for the past 12 years and that similar long-term benefits have occurred in many other veterans using the medication.
Raskind said he and his colleagues evaluated the effects of bedtime prazosin, versus a placebo, on sleep physiology and PTSD symptoms in 13 civilian trauma PTSD subjects with persistent trauma nightmares and sleep disturbance. In that study, researchers found that REM sleep time and total sleep time increased for the patients. Additional prazosin studies are ongoing, he said.1
Raskind cautioned that prazosin is “not a cure. No drug is 100% for any condition,” he added.
Prazosin must be taken every night, because nightmares usually return for patients soon after it is discontinued, usually one to two days. Still, he said that, although modest dose increases are sometimes necessary over years of treatment, loss of efficacy is rarely observed.
1. Taylor FB, Martin P, Thompson C, Williams J, Mellman TA, Gross C, Peskind ER, Raskind MA. Prazosin effects on objective sleep measures and clinical symptoms in civilian trauma posttraumatic stress disorder: a placebo-controlled study. BiolPsychiatry. 2008 Mar 15;63(6):629-32. Epub 2007 Sep 14. PubMed PMID: 17868655;PubMed Central PMCID: PMC2350188.
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