![]() Treatment length is typically 6 sessions but ranges from 4-8 sessions for most patients.ĬBT-I has demonstrated efficacy in patients with primary insomnia as summarized in three meta-analyses (24-27). The recommended first-line treatment approach in the VA/DoD Clinical Practice Guideline (CPG) for PTSD is Cognitive Behavioral Therapy for Insomnia (CBT-I), when available (21), which is agreeable to the American College of Physicians first-line recommended treatment approach for sleep problems (22) and the VA/DoD Clinical Practice Guideline (CPG) for Chronic Insomnia Disorder and Obstructive Sleep Apnea recommendation for treating chronic insomnia (23).Ĭlose Cognitive Behavioral Therapy for Insomnia (CBT-I)ĬBT-I is a series of strategies focused on stimulus control, sleep restriction, cognitive restructuring and sleep hygiene that can be delivered in either individual therapy or in a group format with 6-10 patients. To date, little is known about the efficacy of using both approaches concurrently. There are two primary approaches to treating sleep problems in PTSD, psychotherapy and pharmacotherapy (i.e. Of note, the classic predictors of OSA-older age and body mass index (BMI), in particular-may not be as relevant among Veteran samples, as indicated by a study of OEF/OIF/OND Veterans (20). Estimates vary based upon measurement (e.g., self-report, Apnea Hypopnea Index (AHI) thresholds) and, a meta-analysis found OSA rates were significantly higher in individuals with PTSD (ranging from 43.6% to 75.7% based upon AHI threshold) than without the diagnosis (19). Nightmares often do not fully remit with trauma-focused treatment although the degree of improvement is larger for nightmares than for insomnia in general (10,11,17).Īn additional consideration is obstructive sleep apnea (OSA), which has been found to be more common among individuals with PTSD than the general population (18). Posttraumatic nightmares are independently associated with daytime distress, and impaired functioning (15,16). 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) (14). In the National Vietnam Veterans Readjustment Study, 52% of combat Veterans with PTSD reported significant nightmares (2). There are fewer data on the prevalence of chronic nightmares with PTSD. Despite the efficacy of evidence-based treatments for PTSD such as Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT), the arousal and reactivity (hyperarousal) cluster symptoms that include sleep difficulties appear to be particularly difficult to resolve even after substantial PTSD improvement (10-13). 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 (7,8) and active duty (9) populations. ![]() It has been argued that sleep problems, rather than being just symptoms of PTSD, are a hallmark of the disorder (6). 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 (5). Insomnia was also the most commonly reported PTSD symptom in a survey of Veterans from Afghanistan and Iraq (OEF/OIF) (4). Insomnia is reported to occur in 90-100% of Vietnam era Veterans with PTSD (2,3). ![]() 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 (hyperarousal) and the presence of frequent nightmares as an intrusion symptom. Prevalence of sleep problems in Veterans with PTSD VA Software Documentation Library (VDL). ![]()
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