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Abstract
Obstructive sleep apnea (OSA) and post-traumatic stress disorder (PTSD) are often co-morbid with implications for disease severity and treatment outcomes. OSA prevalence is higher in PTSD sufferers than in the general population, with a likely bidirectional effect of the two illnesses. There is substantial evidence to support the role that disturbed sleep may play in the pathophysiology of PTSD. Sleep disturbance associated with OSA may interfere with normal rapid eye movement (REM) functioning and thus worsen nightmares and sleep-related movements. Conversely, hyperarousal and hypervigilance symptoms of PTSD may lower the arousal threshold and thus increase the frequency of sleep fragmentation related to obstructive events. Treating OSA not only improves OSA symptoms, but also nightmares and daytime symptoms of PTSD. Evidence suggests that positive airway pressure (PAP) therapy reduces PTSD symptoms in a dose-dependent fashion, but also presents challenges to tolerance in the PTSD population. Alternative OSA treatments may be better tolerated and effective for improving both OSA and PTSD. Further research avenues will be introduced as we seek a better understanding of this complex relationship.
Highlights
Post-traumatic stress disorder (PTSD) is a psychiatric illness occurring after exposure to a traumatic event, in which the individual experiences intrusive memories such as flashbacks, avoidance of trauma reminders, negative changes in mood and cognition, hyperarousal symptoms, and impairment of social, occupational, and interpersonal functioning [1]
Studies on the effects of continuous positive airway pressure (CPAP) in patients with Obstructive sleep apnea (OSA)+post-traumatic stress disorder (PTSD) have shown improvement in PTSD-related symptoms in those who were adherent to CPAP. (Table 1) In 1998, a case report was published in which a Veteran with OSA+PTSD experienced dramatic improvement in sleep quality, nightmare frequency, and daytime sleepiness after starting CPAP therapy [81]
Nightmare frequency and intensity was improved after 4 months of positive airway pressure (PAP) therapy, as well as daytime PTSD symptoms
Summary
Post-traumatic stress disorder (PTSD) is a psychiatric illness occurring after exposure to a traumatic event, in which the individual experiences intrusive memories such as flashbacks, avoidance of trauma reminders, negative changes in mood and cognition, hyperarousal symptoms, and impairment of social, occupational, and interpersonal functioning [1]. Sleep disturbances are predictors of PTSD treatment nonresponse, and may continue even after successful treatment of daytime PTSD symptoms [18–23] This underscores the importance of identifying and managing sleep problems in this population. Treating sleep problems such as nightmares and insomnia is understood to improve daytime symptoms of PTSD [24,25] While this may not be surprising given that nightmares and sleep difficulties are core symptoms of PTSD diagnostic criteria, what has been surprising is the more recent evidence showing similar bidirectionality in PTSD and obstructive sleep apnea (OSA) diagnoses and treatment [26–28].
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