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Treatment of sleep disturbances in posttraumatic stress disorder: A review

Explore primary sleep issues in PTSD such as nightmares and insomnia, addressing nonpharmacologic and pharmacologic treatments for effective management.

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Treatment of sleep disturbances in posttraumatic stress disorder: A review

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  1. Treatment of sleep disturbances in posttraumatic stress disorder: A review Frank B. Schoenfeld, MD; Jason C. DeViva, PhD; Rachel Manber, PhD

  2. Aim • Describe primary sleep disturbances associated with posttraumatic stress disorder (PTSD), with focus on nightmares and insomnia. • Relevance • Individuals experiencing PTSD report insomnia (trouble initiating and maintaining sleep) and recurrent distressing dreams among their most common and distressing symptoms.

  3. Topics Reviewed • VA/DOD Clinical Practice Guideline (CPG) recommends nonpharmacologic therapies as first-line treatments for PTSD-related sleep disturbances: • Imagery rehearsal. • Cognitive-behavioral therapy (CBT) for insomnia. Also potentially helpful: • Trauma-focused CBT (cognitive processing therapy, prolonged exposure).* • Eye movement desensitization and reprocessing. • Exposure, relaxation, and rescripting therapy. *Trauma-focused therapies may not fully resolve sleep disturbances in PTSD.

  4. Topics Reviewed • Pharmacological treatments also have important place in insomnia and nightmare management: • Selective serotonin reuptake inhibitors. • Serotonin antagonists/reuptake inhibitors. • Selective norepinephrine reuptake inhibitors. • Tricyclic antidepressants. • Monoamine oxidase inhibitors. • Anxiolytic and sedative hypnotic agents (benzodiazepines, benzodiazepine receptor agonists). • Antipsychotic agents (olanzapine, quetiapine, risperidone). • Adrenergic inhibiting agents (guanfacine, prazosin).

  5. Topics Reviewed • Pharmacological treatments for insomnia and nightmare management (cont): • Selective serotonin reuptake inhibitors and venlafaxine are considered by the VA/DOD CPG as the first-line treatment for global PTSD symptoms. • Prazosin is recommended as an adjunctive treatment for nightmares if cognitive behavior therapy and/or the first-line antidepressants are not fully effective. • Benzodiazepines are not recommended because of lack of efficacy and risk for developing dependence.

  6. Conclusions • Nightmares and insomnia are common, persistent, and significant problems in PTSD. • Comorbid conditions (e.g., depression, substance abuse, anxiety, TBI, other sleep disorders, chronic pain) can further contribute to sleep disturbance. • CBT and some pharmacologic treatments offer relief. • However, we need to develop treatments that are even more specific to the unique features of PTSD sleep disturbances.

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