Response to Cognitive Processing Therapy in Veterans With and Without Obstructive Sleep Apnea

Mesa, Franklin; Dickstein, Benjamin D.; Wooten, Virgil; Chard, Kathleen M.

doi:10.1002/jts.22245

Cited by 17 publications

(14 citation statements)

References 47 publications

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“…Uncontrolled SDB may attenuate the effect of some therapeutic intervention in this domain, 39 but the study by Sweetman et al 40 shows that treatment for insomnia can be effective in the presence of comorbid sleep apnea. This situation is further complicated by the fact that low CPAP adherence rates are repeatedly observed among patients with PTSD, 41,42 and few evidence-based interventions exist for promoting CPAP adherence.…”

Section: Discussionmentioning

confidence: 99%

Two Independent Predictors of Nightmares in Posttraumatic Stress Disorder

Miller

Jamison

Gala

et al. 2018

Journal of Clinical Sleep Medicine

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Study Objectives: Understanding nightmares (NM) and disturbing dreams (DD) in posttraumatic stress disorder (PTSD) has been limited by the unpredictability of these events and their nonappearance in the sleep laboratory. This study used intensive, longitudinal, ambulatory methods to predict morning reports of NM/DD in veterans in whom chronic, severe PTSD was diagnosed. Methods: Participants were 31 male United States military veterans engaged in residential treatment for PTSD and participating in a service animal training intervention. Participants slept on mattress actigraphs and provided reports of momentary mood, as well as morning NM/DD reports, for up to 6 weeks. Mattress actigraphy provided sleep-period heart rate and respiratory sinus arrhythmia (RSA), and an actigraphic estimate of sleep efficiency. On one night, a respiratory event index (REI) was obtained using an ambulatory system. Results: A total of 468 morning reports were obtained, of which 282 endorsed NM/DD during the prior night, and 186 did not. After accounting for multiple predictors, only elevated REI and lower prior-night sleep RSA predicted morning endorsement of NM/DD. These two predictors did not interact. Conclusions: Elevated REI and lower sleep period RSA were independently predictive of NM/DD. The former result is consistent with studies showing that sleep-disordered breathing (SDB) is a factor in NM/DD, and that continuous positive airway pressure (CPAP) can reduce these symptoms in patients with comorbid PTSD and SDB. The latter result implicates dysregulated arousal modulation during sleep in trauma-related NM/DD. It is consistent with findings that NM/DD are reported in patients without SDB and can persist in patients with comorbid PTSD and SDB even when CPAP successfully remediates SDB.

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Section: Discussionmentioning

confidence: 99%

Two Independent Predictors of Nightmares in Posttraumatic Stress Disorder

Miller

Jamison

Gala

et al. 2018

Journal of Clinical Sleep Medicine

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“…Studies that examined whether baseline OSA affected change in PTSD symptoms over the course of psychotherapy were more consistent. A retrospective study of Veterans who had completed CPT at a VA found that those with OSA ( n = 69) showed less symptom improvement than those without OSA ( n = 276) [99••]. However, those with OSA who were being treated with CPAP showed more improvement than those who were not engaging in OSA treatment.…”

Section: Non-pharmacological Treatment Of Sleep Disordersmentioning

confidence: 99%

Recent Advancements in Treating Sleep Disorders in Co-Occurring PTSD

Colvonen

Straus

Stepnowsky

et al. 2018

Curr Psychiatry Rep

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PTSD treatments decrease PTSD severity and nightmare frequency, but do not resolve OSA or insomnia. Research on whether insomnia hinders PTSD treatment shows mixed results; untreated OSA does interfere with PTSD treatment. Cognitive behavioral therapy for insomnia is the recommended treatment for insomnia; however, optimal ordering with PTSD treatment is unclear. PTSD treatment may be most useful for PTSD-related nightmares. CPAP therapy is recommended for OSA but adherence can be low. Targeted treatment of sleep disorders in the context of PTSD offers a unique and underutilized opportunity to advance clinical care and research. Research is needed to create screening protocols, determine optimal order of treatment, and elucidate mechanisms between sleep and PTSD treatments.

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“…It appears that evaluating and treating independent (i.e., comorbid) sleep disorders in PTSD patients is an emerging paradigm with clear-cut opportunities to improve health outcomes in these vulnerable patients [33, 76–78]. However, many questions and some controversies are developing in both the research and clinical realms.…”

Section: Discussionmentioning

confidence: 99%

Changes in insomnia severity with advanced PAP therapy in patients with posttraumatic stress symptoms and comorbid sleep apnea: a retrospective, nonrandomized controlled study

Krakow

McIver

Obando³

et al. 2019

Military Med Res

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Background Sleep disorders frequently occur in posttraumatic stress disorder (PTSD) patients. Chronic insomnia is a common feature of and criteria for the diagnosis of PTSD. Another sleep disorder, obstructive sleep apnea (OSA), also occurs frequently in PTSD, and emerging research indicates OSA fuels chronic insomnia. Scant research has investigated the impact of OSA treatment on insomnia outcomes (Insomnia Severity Index, ISI) in trauma survivors. Methods OSA patients with moderately severe posttraumatic stress symptoms were studied in a retrospective chart review. Ninety-six patients who failed CPAP therapy due to expiratory pressure intolerance or complex sleep apnea or both underwent manual titration with advanced PAP modes [autobilevel (ABPAP); adaptive servo-ventilation (ASV)], which were subsequently prescribed. PAP use measured by objective data downloads divided the sample into three groups: compliant regular users (C-RU): n = 68; subthreshold users (SC-RU): n = 12; and noncompliant users (NC-MU): n = 16. The average follow-up was 11.89 ± 12.22 months. Baseline and posttreatment ISI scores were analyzed to assess residual insomnia symptoms as well as cure rates. Results The C-RU group showed significant improvements in insomnia with very large effects compared to those in the NC-MU reference group ( P = 0. 019). Insomnia severity significantly decreased in all three groups with large effects (C-RU, P = 0. 001; SC-RU, P = 0. 027; NC-MU, P = 0. 007). Hours of weekly PAP use and insomnia severity were inversely correlated ( P = 0. 001, r = − 0.321). However, residual insomnia symptoms based on established ISI cut-offs were quite common, even among the C-RU group. Post hoc analysis showed that several categories of sedating medications reported at baseline (hypnotics, anti-epileptic, opiates) as well as actual use of any sedating medication (prescription or nonprescription) were associated with smaller insomnia improvements than those in patients not using any sedating agents. Conclusions In a retrospective, nonrandomized analysis of a select sample of sleep clinic patients with OSA and PTSD symptoms, advanced PAP therapy was associated with significant improvement in insomnia severity for both compliant and partial users. However, residual insomnia symptoms persisted, indicating that PAP therapy provides only limited treatment. RCTs are warranted to assess the effect of ABPAP and ASV modes of therapy on adherence and sleep outcomes, and their potential impact on posttraumatic stress symptoms. Treatment arms that combine PAP with CBT-I would be expected to yield the greatest potency.

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Response to Cognitive Processing Therapy in Veterans With and Without Obstructive Sleep Apnea

Cited by 17 publications

References 47 publications

Two Independent Predictors of Nightmares in Posttraumatic Stress Disorder

Two Independent Predictors of Nightmares in Posttraumatic Stress Disorder

Recent Advancements in Treating Sleep Disorders in Co-Occurring PTSD

Changes in insomnia severity with advanced PAP therapy in patients with posttraumatic stress symptoms and comorbid sleep apnea: a retrospective, nonrandomized controlled study

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