Sleep disturbances in patients with post-traumatic stress disorder: epidemiology, impact and approaches to management.
Michael J Maher, Simon A Rego, Gregory M Asnis
CNS Drugs 2006 DOI: 10.2165/00023210-200620070-00003 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Review Randomized Placebo-controlled Peer reviewed |
|---|---|
| Population | Patients with post-traumatic stress disorder (PTSD) |
| Interventions | SSRIs Nefazodone Trazodone Cyproheptadine Prazosin Olanzapine Zolpidem Buspirone Gabapentin Mirtazapine Benzodiazepines TCAs MAOIs Cognitive behavioural interventions Imagery rehearsal therapy (IRT) Continuous positive airway pressure |
| Topics | PTSD |
| Keywords | Humans Antipsychotic agents Antidepressive agents Stress disorders, post-traumatic Sleep wake disorders Cognitive behavioral therapy |
| Key findings | The authors report that most patients with PTSD experience insomnia and many report nightmares, though objective sleep measures are inconsistent. They argue sleep problems influence PTSD development, severity and functioning, and that sleep disordered breathing and movement disorders may contribute to symptoms. They report SSRIs have a small but significant positive effect on sleep disruption, that prazosin, nefazodone, trazodone and olanzapine augmentation may reduce nightmares and insomnia, and that group imagery rehearsal therapy reduced nightmares and insomnia in one large trial, while benzodiazepines, TCAs and MAOIs are not useful. |
Abstract
Subjective reports of sleep disturbance indicate that 70-91% of patients with post-traumatic stress disorder (PTSD) have difficulty falling or staying asleep. Nightmares are reported by 19-71% of patients, depending on the severity of their PTSD and their exposure to physical aggression. Objective measures of sleep disturbance are inconsistent, with some studies that used these measures indicating poor sleep and others finding no differences compared with non-PTSD controls. Future research in this area may benefit from examining measures of instability in the microstructure of sleep. Additionally, recent findings suggest that sleep disordered breathing (SDB) and sleep movement disorders are more common in patients with PTSD than in the general population and that these disorders may contribute to the brief awakenings, insomnia and daytime fatigue in patients with PTSD. Overall, sleep problems have an impact on the development and symptom severity of PTSD and on the quality of life and functioning of patients. In terms of treatments, SSRIs are commonly used to treat PTSD, and evidence suggests that they have a small but significant positive effect on sleep disruption. Studies of serotonin-potentiating non-SSRIs suggest that nefazodone and trazodone lead to significant reductions in insomnia and nightmares, whereas cyproheptadine may exacerbate sleep problems in patients with PTSD. Prazosin, a centrally acting alpha1-adrenoceptor antagonist, has led to large reductions in nightmares and insomnia in small studies of patients with PTSD. Augmentation of SSRIs with olanzapine, an atypical antipsychotic, may be effective for treatment-resistant nightmares and insomnia, although adverse effects can be significant. Additional medications, including zolpidem, buspirone, gabapentin and mirtazapine, have been found to improve sleep in patients with PTSD. Large randomised, placebo-controlled trials are needed to confirm the above findings. In contrast, evidence suggests that benzodiazepines, TCAs and MAOIs are not useful for the treatment of PTSD-related sleep disorders, and their adverse effect profiles make further studies unlikely. Cognitive behavioural interventions for sleep disruption in patients with PTSD include strategies targeting insomnia and imagery rehearsal therapy (IRT) for nightmares. One large randomised controlled trial of group IRT demonstrated significant reductions in nightmares and insomnia. Similarly, uncontrolled studies combining IRT and insomnia strategies have demonstrated good outcomes. Uncontrolled studies of continuous positive airway pressure for SDB in patients with PTSD show that this treatment led to significant decreases in nightmares, insomnia and PTSD symptoms. Controlled studies are needed to confirm these promising findings.
Comparable studies
Other narrative reviews on PTSD, most cited first.
| Study | Year | Design | Participants |
|---|---|---|---|
| Psychedelic Psychiatry's Brave New World. | 2020 | Review | |
| Reviewing the Potential of Psychedelics for the Treatment of PTSD | 2020 | Review | |
| Novel psychopharmacological therapies for psychiatric disorders: psilocybin and MDMA. | 2016 | Review | |
| MDMA-assisted psychotherapy for PTSD: Are memory reconsolidation and fear extinction underlying mechanisms? | 2018 | Review | |
| Clinical applications of hallucinogens: A review. | 2016 | Review |
Citations in the library
Cited by 19
- Neurochemical, Neurocircuitry, and Psychopathological Mechanisms of PTSD: Emerging Pharmacotherapies and Clinical Perspectives. ACS Chemical Neuroscience June 10, 2025
- Ketamine-assisted psychotherapy for trauma-exposed patients in an outpatient setting: A clinical chart review study Journal of Psychedelic Studies October 1, 2021
- Fragmented sleep - fragmented mind : the role of sleep in dissociative symptoms 2013
- The Impact of Cognitive-Behavioral Therapies for Nightmares and Prazosin on the Reduction of Post-Traumatic Nightmares, Sleep, and PTSD Symptoms: A Systematic Review and Meta- Analysis of Randomized and Non‐Randomized Studies InTech eBooks November 2, 2016
- The Effectiveness of Imagery Rescripting Interventions for Military Veterans With Nightmares and Sleep Disturbances: A Systematic Review and Meta‐Analysis Clinical Psychology & Psychotherapy July 1, 2024
and 14 more in the library
Cites 6
- Sleep in posttraumatic stress disorder. Annals of Clinical Psychiatry September 1, 2002
- Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA August 1, 2001
- A controlled study of imagery rehearsal for chronic nightmares in sexual assault survivors with PTSD: a preliminary report. Journal of Traumatic Stress October 1, 2000
- Post-traumatic stress disorder and sleep-what a nightmare! Sleep Medicine Reviews April 2000
- Elevated awaking thresholds during sleep: characteristics of chronic war-related posttraumatic stress disorder patients. Biological Psychiatry November 15, 1998
and 1 more in the library