The impact of prolonged exposure on sleep and enhancing treatment outcomes with evidence-based sleep interventions: A pilot study.

Abstract

Insomnia and nightmares are central features of posttraumatic stress disorder (PTSD). However, often they are inadequately assessed and ineffectively resolved following gold-standard PTSD treatment. Here we: (a) evaluate effects of prolonged exposure (PE) on subjectively measured sleep and (b) present pilot results of an examination of whether adding sleep interventions (imagery rehearsal therapy [IRT] and cognitive-behavioral therapy for insomnia [CBT-I]) to PE improves treatment response, relative to PE alone, for night-and/or daytime PTSD symptoms among returning U.S. veterans and postdeployment personnel. Method: In a parallel-groups, randomized controlled trial, participants received 12 sessions of PE followed by IRT (5 weeks) and CBT-I (7 weeks) or PE followed by 12 weeks supportive care therapy (SCT). Results: PE did not improve sleep to a clinically meaningful degree, despite significant improvements in both Clinical Administered PTSD Scale and PTSD Checklist. Enhancing treatment with IRT/CBT-I led to greater improvements in insomnia (diary-recorded sleep efficiency) symptoms with large effect size, relative to SCT (p ϭ .068, d ϭ 1.07). There were large improvements in nightmare frequency relative SCT that did not reach statistical significance (p ϭ .11, d ϭ 0.90). Moreover, there was small improvement in daytime symptoms (Clinical Administered PTSD Scale) that did not reach statistical significance (p ϭ .54, d ϭ .31). Conclusion: The addition of targeted, validated sleep treatment improves effects of PE and improves nighttime symptoms. Thus, evidencebased sleep treatment should be considered in comprehensive PTSD treatment.

Longitudinal investigation of the relationships between trauma exposure, post-migration stress, sleep disturbance, and mental health in Syrian refugees

“…Second, our findings call for further investigation for the effectiveness of sleep-focused interventions in improving psychological outcomes among refugees. Mindfulness-based training has shown potential in reducing pre-sleep arousal and improving sleep quality (Hassirim, Lim, Lo, & Lim, 2019) and Cognitive Behavioural Therapy for Insomnia is effective in targeting sleep disturbance commonly seen in PTSD (Walters et al, 2019).…”

“…In support of this, two studies have found sleep disturbance mediated the relationship between trauma exposure and PTSD symptoms among veterans (Picchioni et al, 2010) and military personnel (Steele, Germain, & Campbell, 2017). Sleep disturbance is also a predictor of PTSD treatment outcome and clinically addressing sleep disturbance can improve PTSD symptoms (Nappi, Drummond, & Hall, 2012;Walters et al, 2019). Wright et al (2011) longitudinally examined, among combat veterans, the relationship between sleep and PTSD symptoms.…”

Diurnal Rhythm Robustness in Individuals With PTSD and Insomnia and The Association With Sleep

“…To account for obvious sleep outside the reported lights-out/lights-on times, rest intervals could be extended up to 60 min either side. This process is similar to methods used in other actigraphy studies (Goldman et al, 2007; Straus et al, 2015; Walters et al, 2020).…”

“…Notably, brief behavioral treatment for insomnia (BBTI) has been found to consolidate sleep overnight and improve rest-activity stability in veterans with insomnia (Kanady et al, 2020). Presumably, full CBT for insomnia would accomplish the same goal, given the emphasis on maintaining regular sleep-wake schedules and the documented benefit of consolidating overnight sleep (Talbot et al, 2014; Taylor and Pruiksma, 2014; Walters et al, 2020). Bright light therapy would also be expected to perhaps even more directly address the impaired diurnal rhythms in these populations (Winkler et al, 2005).…”

“…While having insomnia increases the risk of developing PTSD after trauma exposure, once PTSD develops, insomnia and PTSD appear to have a bidirectional relationship (Germain, 2013; Spoormaker and Montgomery, 2008). For example, PTSD treatment can lead to small improvements in sleep outcomes, and cognitive-behavioral therapy for insomnia (CBT-I) can improve daytime PTSD symptoms (Talbot et al, 2014; Walters et al, 2020). Despite the overlap in nighttime symptoms between insomnia and PTSD, the sleep disturbance seen in PTSD is worse in certain ways, relative to non-comorbid insomnia.…”