How problematic are sleep problems in the treatment of post-traumatic stress disorder?
It’s more often the rule than the exception: having sleep problems when suffering from another psychological disorder. Of patients who developed post-traumatic stress disorder (PTSD) after the experience of a traumatic event, the majority reports they have difficulty falling asleep, wake up during the night, or wake up very early in the morning. In fact, as sleep problems constitute one of the diagnostic criteria of PTSD, it is rather unsurprising that patients with PTSD often experience sleep difficulties.
“You can imagine that not sleeping well may affect your daily cognitive functioning”
Recently there has been an exciting change in the view on the role of sleep in PTSD. Research has shown that emotional information or events are processed during sleep, and sleep deprivation in the laboratory has been related to possible negative effects on memory processing. You can imagine that not sleeping well may affect your daily cognitive functioning: having trouble sleeping can make it difficult for you to concentrate during a lecture the next day, or remember afterwards what was said during the lecture! Similarly, patients with PTSD who don’t sleep properly might not take in all information during a therapy session, or may not retain that well what has been learned in therapy. So one rising concern in the past few years has been whether, in order to optimally benefit from cognitive therapy, sleep needs to improve first.
During my position as a postdoctoral researcher at the University of Oxford, I got the exciting opportunity to look into this question, using a dataset of patients with PTSD who received a trauma-focused treatment called cognitive therapy to process their trauma. Patients received weekly therapy sessions and rated their PTSD symptoms and sleep problems each week. I subsequently tested whether the severity of sleep problems at the start of the therapy predicted treatment outcome.
“patients with PTSD who don’t sleep properly might not take in all information during a therapy session”
The overall results suggested that the severity of initial sleep problems was not predictive of the decrease in PTSD symptoms in therapy. Self-reported sleep problems decreased along with the other PTSD symptoms. This implied that sleep problems do not necessarily need to improve in order to optimally benefit from trauma-focused treatment.
However, when the results were analyzed further, it turned out that for half of the patients, sleep problems did predict a slower recovery. These patients were also suffering from depression at the time. Interestingly, this group actually showed a comparable improvement on PTSD symptoms at the end of therapy but needed more sessions to get there. In conclusion, sleep problems in patients with PTSD do not seem to interfere with cognitive therapy for PTSD.
“those patients who reporting severe sleep problems and who are also suffering from depression may need some extra sessions”
So what do these results tell us? I would say that the main message is that clinicians do not necessarily need to treat sleep problems in patients with PTSD before they start trauma-focused treatment. Yet, they can expect that those patients who reporting severe sleep problems and who are also suffering from depression may need some extra sessions in order to obtain comparable improvements in PTSD symptoms to those patients without depression. It might be interesting to test whether the recovery in the group of patients with PTSD and depression could be speeded up by offering specific sleep interventions. In conclusion, the results of this study seem to somewhat temper the rising concerns about the necessity of treating co-occurring sleep problems in patients with PTSD.
Based on the results of this study, I argue that sleep problems do not necessarily need to be targeted in this group of patients in order to benefit from trauma-focused treatment. I personally feel this is a very positive outcome. If you are interested in the specifics of this study, I would recommend reading the full article that was recently published (online) in the journal of Depression and Anxiety. As what happened to me, I hope this concern regarding detrimental effects of sleep in PTSD treatment efficacy will no longer give you sleepless nights!
Lommen, M.J.J., Grey, N., Clark, D.M., Wild, J., Stott, R., & Ehlers, A. (2015). Sleep and treatment outcome in posttraumatic stress disorder: Results from an effectiveness study. Depression and Anxiety, doi: 10.1002/da.22420.
Note: Image by Adriano Agullo, licenced by CC BY 2.0.