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2. 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

3. 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

4. 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

5. 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.

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.

7. 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.

8. 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.

9. 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

10. Important: assess other causes of insomnia

11. Other causes of insomnia
Sleep apnea

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

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

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

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

16. Pathophysiology of sleep disturbances in PTSD

17. 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)

18. 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

19. 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

20. 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

21. 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

22. Next Video: Prazosin for Nightmares or Disturbed Awakenings