Magazine article Clinical Psychiatry News

Sleep May Be Target in Treatment of PTSD

Magazine article Clinical Psychiatry News

Sleep May Be Target in Treatment of PTSD

Article excerpt

BOSTON -- Sleep disturbances may be an important target for treating posttraumatic stress disorder, according to Dr. R. Bruce Lydiard of the Medical University of South Carolina in Charleston.

Persistent, severe posttraumatic nightmares, REM sleep fragmentation, insomnia, excessive nocturnal periodic limb movements, and sleep-disordered breathing are frequently experienced by individuals with PTSD, Dr. Lydiard said. Although these sleep problems are often viewed as secondary symptoms of PTSD, "the evidence suggests that after a traumatic event, sleep disruption appears before the onset of PTSD and may be a risk factor for it," he proposed.

Polysomnographic data from 21 individuals with traumatic injuries showed that the number of REM periods and the (shorter) duration of REM periods within 1 month after the traumatic event were predictive of PTSD symptom severity 6 weeks later (Am. J. Psychiatry 2002;159:1696-701).

Neurobiologically, the association makes sense, Dr. Lydiard said. "Sleep is regulated in part by brain areas in which PTSD-related changes occur," which suggests that the stress response in PTSD and sleep dysfunction may be biologically linked.

Imaging studies suggest that exposure to trauma-related stimuli leads to hyper activation in the amygdala and decreased activation in the medial prefrontal cortex/anterior cingulate cortex and hippocampus, with the magnitude of the activation correlating with the clinical severity of PTSD symptoms.

Polysomnographic investigations in patients with PTSD and sleep disturbances have revealed increased REM density, reduced REM duration, and increased motor activity, Dr. Lydiard said.

Together with clinical reports, "these data provide the basis for REM sleep dysregulation as a core feature in PTSD," whereby increased activity in the amygdala and decreased inhibitory input from the medial prefrontal cortex lead to a persistently overactive noradrenergic system. "As a result, the usual rhythm of REM-NREM sleep is disrupted, and REM sleep is fragmented," he said.

Based on this model, investigators have hypothesized that targeting noradrenergic signaling during or near REM episodes may normalize REM sleep, which in turn might improve PTSD sleep disturbances and, potentially, other PTSD symptoms, Dr. Lydiard said.

The alpha adrenergic antagonist prazosin has shown promise in multiple case and chart reviews, open-label trials, and placebo-controlled studies. …

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