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Sleep Assessment in PTSD: Is Sleep Disturbed ? (Node 2) David N. Osser, MD, Associate Professor of Psychiatry Harvard Medical School Brockton Division of the VA Boston Healthcare System

Sleep impairment: core PTSD symptom Spoormaker VI, Montgomery P. Disturbed sleep in posttraumatic stress disorder: secondary symptom or core feature? Sleep Med Rev 2008;12:169–84. Belleville G, Guay S, Marchand A. Impact of sleep disturbances on PTSD symptoms and perceived health. J Nerv Ment Dis 2009;197:126–32

Sleep impairment: core PTSD symptom Reassess after each step If they persist and overall unsatisfactory response Assess Initially Sleep assessment Sleep impairment: core PTSD symptom Spoormaker VI, Montgomery P. Disturbed sleep in posttraumatic stress disorder: secondary symptom or core feature? Sleep Med Rev 2008;12:169–84. Belleville G, Guay S, Marchand A. Impact of sleep disturbances on PTSD symptoms and perceived health. J Nerv Ment Dis 2009;197:126–32

Sleep disturbances in PTSD Hyperarousal Difficulties initiating or maintaining sleep Trauma-related nightmares Disturbed awakenings without nightmare recollection Prolonged sleep latency Fear of nightmares Neylan TC, Marmar CR, Metzler TJ, et al. Sleep disturbances in the Vietnam generation: findings from a nationally representative sample of male Vietnam veterans. Am J Psychiatry 1998;155:929–33. Mellman TA, Knorr BR, Pigeon WR, Leiter JC, Akay M. Heart rate variability during sleep and the early development of posttraumatic stress disorder. Biol Psychiatry 2004;55: 953–6.

Sleep disturbances in PTSD Hyperarousal Difficulties initiating or maintaining sleep Trauma-related nightmares Disturbed awakenings without nightmare recollection Prolonged sleep latency Fear of nightmares Neylan TC, Marmar CR, Metzler TJ, et al. Sleep disturbances in the Vietnam generation: findings from a nationally representative sample of male Vietnam veterans. Am J Psychiatry 1998;155:929–33. Mellman TA, Knorr BR, Pigeon WR, Leiter JC, Akay M. Heart rate variability during sleep and the early development of posttraumatic stress disorder. Biol Psychiatry 2004;55: 953–6.

Sleep disturbances in PTSD Hyperarousal Difficulties initiating or maintaining sleep Trauma-related nightmares Disturbed awakenings without nightmare recollection Prolonged sleep latency Fear of nightmares Neylan TC, Marmar CR, Metzler TJ, et al. Sleep disturbances in the Vietnam generation: findings from a nationally representative sample of male Vietnam veterans. Am J Psychiatry 1998;155:929–33. Mellman TA, Knorr BR, Pigeon WR, Leiter JC, Akay M. Heart rate variability during sleep and the early development of posttraumatic stress disorder. Biol Psychiatry 2004;55: 953–6.

Sleep disturbances in PTSD Hyperarousal Difficulties initiating or maintaining sleep Trauma-related nightmares Disturbed awakenings without nightmare recollection Prolonged sleep latency Fear of nightmares Neylan TC, Marmar CR, Metzler TJ, et al. Sleep disturbances in the Vietnam generation: findings from a nationally representative sample of male Vietnam veterans. Am J Psychiatry 1998;155:929–33. Mellman TA, Knorr BR, Pigeon WR, Leiter JC, Akay M. Heart rate variability during sleep and the early development of posttraumatic stress disorder. Biol Psychiatry 2004;55: 953–6.

Sleep Impairment Hypervigilance Avoidance Re-experiencing Thompson CE, Taylor FB, McFall ME, Barnes RF, Raskind MA. Nonnightmare distressed awakenings in veterans with posttraumatic stress disorder: response to prazosin. J Trauma Stress 2008;21:417–20

Important: assess other causes of insomnia

Other causes of insomnia Sleep apnea

Other causes of insomnia Restless legs syndrome Periodic limb movements of sleep Sleep apnea

Other causes of insomnia Restless legs syndrome Periodic limb movements of sleep Sleep apnea Sleep hygiene issues

Other causes of insomnia Restless legs syndrome Periodic limb movements of sleep Sleep apnea Sleep hygiene issues Medical problems

Other causes of insomnia Restless legs syndrome Periodic limb movements of sleep Sleep apnea Sleep hygiene issues Excessive caffeine consumption Medical problems

Pathophysiology of sleep disturbances in PTSD

Pathophysiology of sleep disturbances in PTSD Increased noradrenergic activity during sleep Mellman TA, Knorr BR, Pigeon WR, Leiter JC, Akay M. Heart rate variability during sleep and the early development of posttraumatic stress disorder. Biol Psychiatry 2004;55: 953–6. Raskind, MA et al (2003, 2007)

Pathophysiology of sleep disturbances in PTSD SSRIs Increased noradrenergic activity during sleep Can exacerbate sleep symptoms Lamarche LJ, De Koninck J. Sleep disturbance in adults with posttraumatic stress disorder: a review. J Clin Psychiatry 2007;68:1257– 70. Kobayashi I, Boarts JM, Delahanty DL. Polysomnographically measured sleep abnormalities in PTSD: a meta-analytic review. Psychophysiology 2007;44:660–9

Pathophysiology of sleep disturbances in PTSD Prazosin a1 adrenergic blocker Lamarche LJ, De Koninck J. Sleep disturbance in adults with posttraumatic stress disorder: a review. J Clin Psychiatry 2007;68:1257–70. Taylor FB, Martin P, Thompson C, et al. Prazosin effects on objective sleep measures and clinical symptoms in civilian trauma posttraumatic stress disorder: a placebo- controlledstudy. Biol Psychiatry 2008;63:629–32

Pathophysiology of sleep disturbances in PTSD Larger effect sizes in PTSD symptoms Prazosin a1 adrenergic blocker Lamarche LJ, De Koninck J. Sleep disturbance in adults with posttraumatic stress disorder: a review. J Clin Psychiatry 2007;68:1257–70. Taylor FB, Martin P, Thompson C, et al. Prazosin effects on objective sleep measures and clinical symptoms in civilian trauma posttraumatic stress disorder: a placebo- controlledstudy. Biol Psychiatry 2008;63:629–32

Pathophysiology of sleep disturbances in PTSD Larger effect sizes in PTSD symptoms Prazosin a1 adrenergic blocker Crosses the blood-brain barrier Lamarche LJ, De Koninck J. Sleep disturbance in adults with posttraumatic stress disorder: a review. J Clin Psychiatry 2007;68:1257–70. Taylor FB, Martin P, Thompson C, et al. Prazosin effects on objective sleep measures and clinical symptoms in civilian trauma posttraumatic stress disorder: a placebo- controlledstudy. Biol Psychiatry 2008;63:629–32

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