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PTSD

Post – traumatic stress disorder

Abdul Alraiyes MD.

©2009 Alraiyes
PTSD
PTSD
 Posttraumatic stress disorder (PTSD), an
anxiety disorder that results from exposure to a
traumatic event.

 Three symptomatic clusters:


 (1) intrusive/re-experiencing symptoms
 (2) avoidance symptoms
 (3) hyperarousal symptoms

©2009 Alraiyes
SLEEP and PTSD
 Standard cognitive - behavioral treatment for
mood and anxiety disorders exclusively focuses
on daytime symptoms, and psychiatrists and
psychologists tend to know little about sleep
disorders due to a lack of training.

©2009 Alraiyes
PTSD

©2009 Alraiyes
PTSD
PTSD
 many PTSD experts know so little about sleep
 Sleep disorders are neglected not because of
unwillingness, but largely because of ignorance.

©2009 Alraiyes
PTSD
PTSD

 Disturbed sleep is prevalent, has a high impact and is


a risk factor for PTSD:

 Nightmares 50-70% “less during PSG”


 Insomnia 40-50%
 PLMs 33%

©2009 Alraiyes
•Geracioti Jr TD, Baker DG, Ekhator NN, West SA, Hill KK, Bruce AB, et al. CSF norepinephrine concentrations inposttraumatic
stress disorder.Psychiatry 2001;158:1227–30.
•Mellman TA, Kumar A, Kulick-Bell R, Kumar M, Nolan B. Nocturnal/daytime noradrenergicmeasures and sleep incombat-related
PTSD. Biol Psychiatry 1995;38:174–9
Objective Prevalence
 In PSG:
 More Stage 1
 Less SWS
 More REM to wake and REM to stage 1 short dense REM
and more PLMs during REM

REM fragmentation
©2009 Alraiyes
PTSD

Discrepancy between the


objective and subjective
sleep complaints

©2009 Alraiyes
PTSD
 Disturbed sleep is a residual symptom after PTSD
treatment

 Psychological treatment

 Cognitive - behavioral therapy (CBT)


 eye movement desensitization and reprocessing (EMDR)
 imagery rehearsal treatment (IRT).

Of the 38 included RCTs, only six included reported the


effects of PTSD treatment on sleep disturbance.

©2009 Alraiyes
PTSD

©2009 Alraiyes
PTSD
 Disturbed sleep is a residual symptom after PTSD
treatment

 Pharmacotherapy
 Cyproheptadine
 SSRI
 Benzodiazepines
 Atypical antipsychotic “Olanzapine” best results with SSRI

Only 14 placebo-controlled trials have measured the effects


of pharmacological agents on sleep in PTSD patients

©2009 Alraiyes
PTSD
 Treatment for disturbed sleep in PTSD alleviates
PTSD levels

 imagery rehearsal treatment (IRT). “nightmares reduction”


 IRT with CBT and Sleep hygiene stimulus control. “insomnia
reduction” also anxiety, depression and PTSD symptoms
reduced
 Praszosin “nightmares reduction”
 CPAP treatment for SBD “nightmares reduction”

©2009 Alraiyes
PTSD
 Conclusion:

 Sleep disturbances
 exacerbates the PTSD
 Unlikely to be secondary to PTSD
 Unlikely to be the primary problem in PTSD

©2009 Alraiyes
PTSD
 Disturbed sleep:

 May well be a risk factor for the


development of PTSD;
 Seems to develop into separate
disorder(s) during the course of PTSD
 Frequently exacerbates PTSD
symptom severity.

©2009 Alraiyes
PTSD

 Clinical implications:

 (1) screening for sleep disorders at intake


 (2) adequate referral or sleep treatment by
an appropriate clinician.

©2009 Alraiyes
PTSD

 Nightmares:

 (IRT) imagery rehearsal treatment after


the CBT and imagery transformation
 Praszosin

©2009 Alraiyes
PTSD

 Insomnia:

 Sleep hygiene
 Stimulus control
 Sleep restriction

©2009 Alraiyes
PTSD

 Research Implications:

 Screening for sleep disturbs


 Follow up sleep measurement
 Sleep focused treatment
 Implication of PSG more ambulatory forms.
 IRT
 Praszosin

©2009 Alraiyes
PTSD

Questions??

©2009 Alraiyes
PTSD

Thank You..

©2009 Alraiyes

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