PTSD: National Center for PTSD
Sleep Problems in Veterans with PTSD
Sleep Problems in Veterans with PTSD
Continuing Education Course: Assessment and Treatment of Sleep Problems in PTSD
VA Staff CBT-I SharePoint: vaww.mentalhealth.va.gov/
Sleep problems, in particular chronic insomnia and nightmares, are frequently some of the most troubling aspects of PTSD. While these sleep problems are considered symptoms of PTSD, the evidence suggests that they tend to become independent problems over time that warrant sleep-focused assessment and treatment. There are both pharmacologic and cognitive behavioral treatment options available.
Prevalence of sleep problems in Veterans with PTSD
PTSD is unique among mental health disorders in that sleep problems are mentioned twice among its diagnostic criteria in DSM-5: the presence of insomnia qualifying as a symptom of an alteration in arousal and reactivity and the presence of frequent nightmares as an intrusion symptom. Insomnia is reported to occur in 90-100% of Vietnam era Veterans with PTSD (1,2). Insomnia was also the most commonly reported PTSD symptom in a survey of Veterans from Afghanistan and Iraq (OEF/OIF) (3). In the Millennium Cohort Study, 92% of active duty personnel with PTSD, compared to 28% of those without PTSD, reported clinically significant levels of insomnia (4).
It has been argued that sleep problems, rather than being just symptoms of PTSD, are a hallmark of the disorder (5). In support of this viewpoint, insomnia occurring in the acute aftermath of a traumatic event is a significant risk factor for the later development of PTSD in civilian (6,7) and active duty (8) populations. Studies also indicate that insomnia often persists following PTSD-focused treatments such as Prolonged Exposure or Cognitive Processing Therapy (9,10). Even when PTSD-focused treatment has been associated with statistically significant improvements in sleep, effect sizes are small and not clinically significant.
There are fewer data on the prevalence of chronic nightmares with PTSD. In the National Vietnam Veterans Readjustment Study, 52% of combat Veterans with PTSD reported significant nightmares (1). In a second study in the general community, 71% of individuals with PTSD endorsed nightmares; and, compared to civilians with PTSD, the nightmares of Veterans were more likely to be a replay of their trauma(s) (11). Posttraumatic nightmares are independently associated with daytime distress, and impaired functioning (12,13). Nightmares frequently do not improve with trauma-focused treatment although the degree of improvement is larger for nightmares than for insomnia in general (9,10).
Treatment of sleep problems in PTSD
There are two primary approaches to treating sleep problems in PTSD, pharmacology (i.e. sleep medications) and psychotherapy. To date, little is known about the efficacy of using both approaches concurrently. The preferred treatment approach, when available, is cognitive behavioral therapy.
There are a number of medications available that are either approved as sedative hypnotics (e.g. zolpidem) or that are used because of sedating side effects (e.g. trazodone, clonazepam). There are very few clinical trials examining the efficacy of these medications in Veterans with PTSD. Of note, some medications used to treat PTSD can cause or exacerbate insomnia (e.g. SSRIs). For a more detailed review of psychopharmacology for PTSD, see Clinician's Guide to Medications for PTSD.
Cognitive Behavioral Therapy for Insomnia
When available, cognitive behavioral therapy for insomnia (CBT-I) is a preferred treatment approach for sleep problems. CBT-I is a series of strategies focused on sleep hygiene, stimulus control, sleep restriction, and cognitive restructuring that can be delivered in either individual therapy or in a group format with 6-10 patients. Treatment length is typically 6 sessions but ranges from 4-8 sessions for most patients.
CBT-I has demonstrated efficacy in patients with primary insomnia as summarized in three meta-analyses (14-16). CBT-I demonstrated sustained improvement in insomnia symptoms on follow-up assessments ranging from 1 to 3 years. The durability of treatment effects is a clear advantage over long-term pharmacotherapy, as are the lower risks of side effects and potential drug interactions. A recent randomized trial in Veterans with PTSD found that CBT-I led to greater improvements in sleep and disruptive sleep-related behaviors than wait list, demonstrating the efficacy of CBT-I in this population (17). Improvements were maintained at 6 months.
VA CBT-I Rollout
In an effort to increase the availability for Veterans of empirically supported treatments for sleep problems, VA created a national dissemination program for CBT-I several years ago. Through this program, VA mental health providers can attend a 3-day intensive workshop to learn the fundamentals of CBT-I. Participants then meet weekly by phone with a consultant who reviewed recordings of CBT-I sessions in order to provide feedback to facilitate the learning process. This has been the largest CBT-I dissemination program ever conducted, with several hundred providers having attended the training, greatly increasing access to this standard care. Clinical outcomes data from the trainees have been collected demonstrating large improvements in insomnia over the course of treatment (18,19).
CBT-I can be delivered both individually and in a group format. Within VA, a typical CBT-I group consists of 6-8 Veterans and meets weekly for about 6 weeks for 90 minutes per visit. The material is the same as in individual CBT-I with the added element of hearing the experiences of other Veterans with insomnia. A recent meta-analysis found that clinical improvements from group CBT-I were generally strong but slightly smaller than for individual treatment (20).
Even with the national dissemination of CBT-I and the option to deliver in a group, many VA facilities still do not have access to a trained CBT-I provider or the demand for treatment is greater than available provider time. The latter is not really surprising given the high prevalence of insomnia in Veterans, especially among those with PTSD. Another option for increasing access to treatment is the use of clinical video telehealth (CVT) technology. CVT allows a provider with a video camera and monitor to provide treatment to a patient at another location with similar equipment. The content of treatment is the same, but it is delivered over a distance. This technology allows a provider to have a greater reach with treatment. It is even possible to deliver treatment to Veterans in their own home if they have the necessary computer equipment.
Treatments for Nightmares
There are fewer treatment options available for nightmares. In terms of pharmacotherapy, the main option available is prazosin, an alpha-adrenergic antagonist usually used for the treatment of high blood pressure. Prazosin has been found to be effective for reducing nightmares and improving sleep in Veterans with PTSD in multiple trials (21,22). A psychotherapeutic approach to treating nightmares is an approach called imagery rehearsal (IR), which is also called nightmare rescripting because it entails choosing a recurrent nightmare and picking a way to change (i.e. re-script) the content in a way to make it less intense or distressing. There are several trials with positive outcomes of IR in civilian populations (e.g. 23) but a large, randomized trial in Vietnam Veterans with PTSD failed to demonstrate clear efficacy (24). A recent systematic review found that most of the clinical trials to date were of mixed scientific rigor (25). Additional studies are needed before conclusions can be made regarding the efficacy of this treatment approach.
In summary, sleep problems are highly prevalent in Veterans with PTSD. Rather than just being a symptom of PTSD the sleep problems can become an independent disorder over time that is uniquely associated with significant distress and impairment. Fortunately, there are efficacious treatments available for both insomnia and nightmares. In many cases, sleep-focused treatment will be needed to maximize patient outcomes.
- Neylan, T. C., Marmar, C. R., Metzler, T. J., Weiss, D. S., Zatzick, D. F., & Delucchi, K. L. (1998). Sleep disturbances in the Vietnam generation: Findings from a nationally representative sample of male Vietnam Veterans. American Journal of Psychiatry, 155, 929-933. doi: 10.1176/ajp.155.7.929
- Lewis, V. L., Creamer, M., & Failla, S. (2009). Is poor sleep in Veterans a function of post-traumatic stress disorder? Military Medicine,174, 948-951. doi: 10.7205/MILMED-D-04-0208
- McLay, R. N., Klam, W. P., & Volkert, S.L. (2010). Insomnia is the most commonly reported symptom and predicts other symptoms of post-traumatic stress disorder in U.S. service members returning from military deployments. Military Medicine, 175, 759-762. doi: 10.7205/MILMED-D-10-00193
- Seelig, A. D., Jacobson, I. G., Smith, B., Hooper, T. I., Boyko, E. J., Gackstetter, G. D., Gehrman, P. R., & Smith, T. C. (2010). Sleep patterns before, during, and after deployment to Iraq and Afghanistan. Sleep, 33, 1615-1622.
- Ross, R. J., Ball, W. A., Sullivan, K. A., & Caroff, S. N. (1989). Sleep disturbance as the hallmark of posttraumatic stress disorder. American Journal of Psychiatry, 146, 697-707. doi: 10.1176/ajp.146.6.697
- Harvey, A. G., & Bryant, R. A. (1998). The relationship between acute stress disorder and posttraumatic stress disorder: a prospective evaluation of motor vehicle accident survivors. Journal of Consulting and Clinical Psychology, 66, 507-512. doi: 10.1037/0022-006X.67.6.985
- Mellman, T. A., Bustamante, V., Fins, A. I., Pigeon, W. R., & Nolan, B. (2002). REM sleep and the early development of posttraumatic stress disorder. American Journal of Psychiatry, 159, 1696-1701. doi: 10.1176/appi.ajp.159.10.1696
- Wright, K. M., Britt, T. W., Bliese, P. D., Adler, A. B., Picchioni, D., & Moore, D. (2011). Insomnia as predictor versus outcome of PTSD and depression among Iraq combat Veterans. Journal of Clinical Psychology, 67, 1240-1258. doi: 10.1002/jclp.20845
- Zayfert, C., & DeViva, J. C. (2004). Residual insomnia following cognitive behavioral therapy for PTSD. Journal of Traumatic Stress, 17, 69-73. doi: 10.1023/B:JOTS.0000014679.31799.e7
- Belleville, G., Guay, S., & Marchand, A. (2011). Persistence of sleep disturbances following cognitive-behavior therapy for posttraumatic stress disorder. Journal of Psychosomatic Research, 70, 318-327. doi: 10.1016/j.jpsychores.2010.09.022
- Leskin, G. A., Woodward, S. H., Young, H. E., & Sheikh, J. I. (2002). Effects of comorbid diagnoses on sleep disturbance in PTSD. Journal of Psychiatric Research, 36, 449-452. doi: 10.1016/S0022-3956(02)00025-0
- Levin, R., & Nielsen, T. A. (2007). Disturbed dreaming, posttraumatic stress disorder, and affect distress: A review and neurocognitive model. Psychological Bulletin, 133, 482-528. doi: 10.1037/0033-2909.133.3.482
- Zadra, A., & Donderi, D. C. (2000). Nightmares and bad dreams: Their prevalence and relationship to well-being. Journal of Abnormal Psychology, 109, 273-281. doi:10.1037/0021-843X.109.2.273
- Morin, C. M., Culbert, J. P., & Schwartz, M. S. (1994). Non-pharmacological interventions for insomnia: a meta-analysis of treatment efficacy. American Journal of Psychiatry, 151, 1172-1180. doi: 10.1176/ajp.151.8.1172
- Murtagh, D. R., & Greenwood, K. M. (1995). Identifying effective psychological treatments for insomnia: a meta-analysis. Journal of Consulting and Clinical Psychology, 63, 79-89. doi: 10.1037/0022-006X.63.1.79
- Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington,J., & Giles, D. E. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159, 5-11. doi: 10.1176/appi.ajp.159.1.5
- Talbot, L. S., Maguen, S., Metzler, T. J., Schmitz, M., McCaslin, S. E., Richards, A., Perlis, M. L., Posner, D. A., Weiss, B., Ruoff, L., Varbel, J., & Neylan, T. C. (2014). Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: A randomized controlled trial. Sleep, 37, 327-41. doi: 10.5665/sleep.3408
- Karlin, B. E., Trockel, M., Taylor, C. B., Gimeno, J., & Manber, R. (2013). National dissemination of cognitive behavioral therapy for insomnia in Veterans: Therapist- and patient-level outcomes. Journal of Consulting and Clinical Psychology, 81, 912-917. doi: 10.1037/a0032554
- Trockel, M., Karlin, B. E., Taylor, C. B., & Manber, R. (2014). Cognitive Behavioral Therapy for insomnia with Veterans: Evaluation of effectiveness and correlates of treatment outcomes. Behaviour Research and Therapy, 53, 41-46. doi: 10.1016/j.brat.2013.11.006
- Koffel, E. A., Koffel, J. B., & Gehrman, P. R. (2015). A meta-analysis of group cognitive behavioral therapy for insomnia. Sleep Medicine Reviews, 24, 6-16. doi: 10.1016/j.smrv.2014.05.001
- Raskind, M. A., Peskind, E. R., Hoff, D. J., Hart, K. L., Holmes, H. A., Warren, D., ... Mcfall, M. (2007). A parallel group placebo controlled study of prazosin for trauma nightmares and sleep disturbance in combat Veterans with post-traumatic stress disorder. Biological Psychiatry, 61, 928-934. doi: 10.1016/j.biopsych.2006.06.032
- Raskind, M. A., Peterson, K., Williams, T., Hoff, D. J., Hart, K., Holmes, H., ... & Peskind E. R. (2013). A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan. American Journal of Psychiatry, 170, 1003-10. doi: 10.1176/appi.ajp.2013.12081133
- Krakow, B., Hollifield, M., Johnston, L., Koss, M., Schrader, R., & Warner, T. (2001). Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial. JAMA, 286, 537-545. doi: 10.1001/jama.286.5.537
- Cook, J. M., Harb, G. C., Gehrman, P. R., Cary, M. S., Gamble, G. M., & Forbes, D. (2010). Imagery rehearsal for posttraumatic nightmares: A randomized controlled trial. Journal of Traumatic Stress, 23, 553-563. doi: 10.1002/jts.20569
- Harb, G. C., Phelps, A. J., Forbes, D., Ross, R. J., Gehrman, P. R., & Cook, J. M. (2013). A critical review of the evidence base of imagery rehearsal for posttraumatic nightmares: Pointing the way for future research. Journal of Traumatic Stress, 26, 570-579. doi: 10.1002/jts.21854