PTSD May Be Affected by Sleep Disorders in Some Patients

SCOTTSDALE, ARIZ. – Untreated sleep-disordered breathing may perpetuate posttraumatic stress disorder over a period of weeks, months, and even years, Dr. Lois E. Krahn proposed at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

“Patients have a lot of sleep complaints. They have trouble falling asleep. They have nightmares, and one very interesting finding of late is they also have a fairly high rate of obstructive sleep apnea,” said Dr. Krahn, chair of the department of psychiatry and psychology at the Mayo Clinic in Scottsdale, Ariz.

In one posttraumatic stress disorder (PTSD) study cited by Dr. Krahn, subjective sleep disturbance was described as “a hallmark of PTSD” in elderly war veterans (Biol. Psychiatry 2000;47:520–5). Even though patients with untreated obstructive sleep apnea and sleep movement disorders were not included in the sample, the investigators reported finding many cases in patients screened for the study.

Dr. Krahn posited that obstructive sleep apnea may predispose some patients to wake in the middle of the night. “So that may be a feature that causes this condition [PTSD] to be perpetuated,” she said.

In an interview at the meeting, she suggested ordering polysomnography when PTSD patients do not improve with therapy. They may continue to relive their trauma at night, she said.

“Their sleep wasn't terrific before this traumatic event. Now they've got nightmares. With the combination, they have a more chronic disorder.”

Many psychiatric disorders overlap with sleep disorders, and can be difficult to distinguish, Dr. Krahn said. She suggested asking new sleep patients whether they are sleepy or fatigued during the day.

Patients who present only with daytime sleepiness are more likely to have a sleep disorder, according to Dr. Krahn. If the main complaint is fatigue or exhaustion, the differential diagnosis expands to a wide range of psychiatric and medical disorders.

Two key tools, she suggested, are the Epworth Sleepiness Scale and the clinical interview. Patients with obstructive sleep apnea or narcolepsy tend to score high on the Epworth; patients whose main complaint is fatigue score low.

The interview helps the physician tease out factors in daily life that might influence sleep. “If you have someone come to you with sleepiness, ask about their mood,” she said, suggesting simple questions such as, “Are you sad? Are you blue? Are you able to pursue your interests?”

She also recommended asking about mood if patients present with sleepiness in winter. “There is no seasonal hypersomnia,” she said, suggesting they might be suffering from seasonal affective disorder.

Similarly, Dr. Krahn noted that patients with panic disorder can have attacks during the day and at night. If attacks occur only at night, suspect sleep apnea.

People with bipolar and psychotic disorders sometimes seek help from a sleep clinic rather than a psychiatrist, according to Dr. Krahn.

To tease out bipolar disorder, Dr. Krahn suggested asking, “Have you had periods of your life where you have not needed to sleep–where you have not had more than 3 hours of sleep and you still had enough energy to function or even quite a bit of energy?”

“That is a pretty specific scenario for mania,” she said, warning that bipolar patients often resist their diagnosis. “It is more socially acceptable to have insomnia than to have bipolar disorder,” Dr. Krahn explained..

Psychotic disorders are often associated with insomnia, she said. Dr. Krahn also noted that many patients gain weight on the newer atypical antipsychotic drugs, which puts them at increased risk of obstructive sleep apnea. Educating these patients about continuous positive airway pressure therapy can be a challenge, she warned, describing a patient who was afraid of inhaling a poison gas.

SCOTTSDALE, ARIZ. – Untreated sleep-disordered breathing may perpetuate posttraumatic stress disorder over a period of weeks, months, and even years, Dr. Lois E. Krahn proposed at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

“Patients have a lot of sleep complaints. They have trouble falling asleep. They have nightmares, and one very interesting finding of late is they also have a fairly high rate of obstructive sleep apnea,” said Dr. Krahn, chair of the department of psychiatry and psychology at the Mayo Clinic in Scottsdale, Ariz.

In one posttraumatic stress disorder (PTSD) study cited by Dr. Krahn, subjective sleep disturbance was described as “a hallmark of PTSD” in elderly war veterans (Biol. Psychiatry 2000;47:520–5). Even though patients with untreated obstructive sleep apnea and sleep movement disorders were not included in the sample, the investigators reported finding many cases in patients screened for the study.

Dr. Krahn posited that obstructive sleep apnea may predispose some patients to wake in the middle of the night. “So that may be a feature that causes this condition [PTSD] to be perpetuated,” she said.

In an interview at the meeting, she suggested ordering polysomnography when PTSD patients do not improve with therapy. They may continue to relive their trauma at night, she said.

“Their sleep wasn't terrific before this traumatic event. Now they've got nightmares. With the combination, they have a more chronic disorder.”

Many psychiatric disorders overlap with sleep disorders, and can be difficult to distinguish, Dr. Krahn said. She suggested asking new sleep patients whether they are sleepy or fatigued during the day.

Patients who present only with daytime sleepiness are more likely to have a sleep disorder, according to Dr. Krahn. If the main complaint is fatigue or exhaustion, the differential diagnosis expands to a wide range of psychiatric and medical disorders.

Two key tools, she suggested, are the Epworth Sleepiness Scale and the clinical interview. Patients with obstructive sleep apnea or narcolepsy tend to score high on the Epworth; patients whose main complaint is fatigue score low.

The interview helps the physician tease out factors in daily life that might influence sleep. “If you have someone come to you with sleepiness, ask about their mood,” she said, suggesting simple questions such as, “Are you sad? Are you blue? Are you able to pursue your interests?”

She also recommended asking about mood if patients present with sleepiness in winter. “There is no seasonal hypersomnia,” she said, suggesting they might be suffering from seasonal affective disorder.

Similarly, Dr. Krahn noted that patients with panic disorder can have attacks during the day and at night. If attacks occur only at night, suspect sleep apnea.

People with bipolar and psychotic disorders sometimes seek help from a sleep clinic rather than a psychiatrist, according to Dr. Krahn.

To tease out bipolar disorder, Dr. Krahn suggested asking, “Have you had periods of your life where you have not needed to sleep–where you have not had more than 3 hours of sleep and you still had enough energy to function or even quite a bit of energy?”

“That is a pretty specific scenario for mania,” she said, warning that bipolar patients often resist their diagnosis. “It is more socially acceptable to have insomnia than to have bipolar disorder,” Dr. Krahn explained..

Psychotic disorders are often associated with insomnia, she said. Dr. Krahn also noted that many patients gain weight on the newer atypical antipsychotic drugs, which puts them at increased risk of obstructive sleep apnea. Educating these patients about continuous positive airway pressure therapy can be a challenge, she warned, describing a patient who was afraid of inhaling a poison gas.

SCOTTSDALE, ARIZ. – Untreated sleep-disordered breathing may perpetuate posttraumatic stress disorder over a period of weeks, months, and even years, Dr. Lois E. Krahn proposed at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

“Patients have a lot of sleep complaints. They have trouble falling asleep. They have nightmares, and one very interesting finding of late is they also have a fairly high rate of obstructive sleep apnea,” said Dr. Krahn, chair of the department of psychiatry and psychology at the Mayo Clinic in Scottsdale, Ariz.

In one posttraumatic stress disorder (PTSD) study cited by Dr. Krahn, subjective sleep disturbance was described as “a hallmark of PTSD” in elderly war veterans (Biol. Psychiatry 2000;47:520–5). Even though patients with untreated obstructive sleep apnea and sleep movement disorders were not included in the sample, the investigators reported finding many cases in patients screened for the study.

Dr. Krahn posited that obstructive sleep apnea may predispose some patients to wake in the middle of the night. “So that may be a feature that causes this condition [PTSD] to be perpetuated,” she said.

In an interview at the meeting, she suggested ordering polysomnography when PTSD patients do not improve with therapy. They may continue to relive their trauma at night, she said.

“Their sleep wasn't terrific before this traumatic event. Now they've got nightmares. With the combination, they have a more chronic disorder.”

Many psychiatric disorders overlap with sleep disorders, and can be difficult to distinguish, Dr. Krahn said. She suggested asking new sleep patients whether they are sleepy or fatigued during the day.

Patients who present only with daytime sleepiness are more likely to have a sleep disorder, according to Dr. Krahn. If the main complaint is fatigue or exhaustion, the differential diagnosis expands to a wide range of psychiatric and medical disorders.

Two key tools, she suggested, are the Epworth Sleepiness Scale and the clinical interview. Patients with obstructive sleep apnea or narcolepsy tend to score high on the Epworth; patients whose main complaint is fatigue score low.

The interview helps the physician tease out factors in daily life that might influence sleep. “If you have someone come to you with sleepiness, ask about their mood,” she said, suggesting simple questions such as, “Are you sad? Are you blue? Are you able to pursue your interests?”

She also recommended asking about mood if patients present with sleepiness in winter. “There is no seasonal hypersomnia,” she said, suggesting they might be suffering from seasonal affective disorder.

Similarly, Dr. Krahn noted that patients with panic disorder can have attacks during the day and at night. If attacks occur only at night, suspect sleep apnea.

People with bipolar and psychotic disorders sometimes seek help from a sleep clinic rather than a psychiatrist, according to Dr. Krahn.

To tease out bipolar disorder, Dr. Krahn suggested asking, “Have you had periods of your life where you have not needed to sleep–where you have not had more than 3 hours of sleep and you still had enough energy to function or even quite a bit of energy?”

“That is a pretty specific scenario for mania,” she said, warning that bipolar patients often resist their diagnosis. “It is more socially acceptable to have insomnia than to have bipolar disorder,” Dr. Krahn explained..

Psychotic disorders are often associated with insomnia, she said. Dr. Krahn also noted that many patients gain weight on the newer atypical antipsychotic drugs, which puts them at increased risk of obstructive sleep apnea. Educating these patients about continuous positive airway pressure therapy can be a challenge, she warned, describing a patient who was afraid of inhaling a poison gas.