Staff Perspective: PTSD and Sleep Apnea Are Intertwined
I have noticed that more than half of my military-connected patients with PTSD have been diagnosed with sleep apnea as well, and some are younger (e.g., in their 30s). Consistent with my observations, a study with 195 Iraq and Afghanistan Veterans between 21 to 59 seeking care at outpatient VA clinics identified nearly 70% of the participants with a high risk for sleep apnea and noted that the risk increased with the severity of PTSD symptoms (Colvonen et al., 2015). In fact, there was a 40% increase in the probability of screening as high risk for sleep apnea for every clinically significant increase in PTSD symptom severity, which is a lot. Similarly, the National Veteran Sleep Disorder Study found that Veterans with PTSD had significantly higher rates of sleep apnea compared to the general population (Alexander et al., 2016).
These types of observations have left me wondering why PTSD and sleep apnea often go hand-in-hand and how non-sleep experts like myself can help patients suffering from both conditions. While not fully understood, it has been hypothesized that PTSD may lead to sleep fragmentation and neuromuscular changes in the upper airway that in turn contribute to upper airway collapsibility and sleep breathing events, including apneas. These negative breathing events may then produce more sleep fragmentation, resulting in a vicious cycle where PTSD and sleep apnea co-occur. The two conditions may also be intertwined pathophysiologically since both involve negative changes or disruptions in the HPA axis and hippocampus. In addition, a pre-existing tendency to sleep-disordered breathing has been hypothesized to disrupt the ability to respond to trauma, increasing likelihood of developing PTSD if a trauma occurs in the future, or exacerbating previously subclinical PTSD if onset of sleep disordered breathing occurs later.
For behavioral health providers, one implication from these results is that we should routinely screen PTSD patients for sleep apnea even when they are younger so they can be properly diagnosed and treated if they have this chronic condition. Unfortunately, many Veterans with sleep apnea remain undiagnosed despite growing knowledge about the detrimental effects of untreated sleep apnea. In particular, younger Veterans with PTSD may be overlooked for such screening and thus go underdiagnosed. (CDP's Dr. Jeff Mann wrote a blog last week on the importance of assessing for sleep problems during treatment.)
Ultimately, sleep apnea needs to be diagnosed by a sleep specialist or primary care doctor/physician based on the results of a sleep study. However, we can do our part by noticing signs and referring patients to the medical professionals who can diagnose sleep apnea and provide evidence-based treatments. What signs of sleep apnea can we be on the lookout for when working with PTSD patients? One quick and easy sleep apnea screen is called STOP that is part of the larger questionnaire called STOP-Bang (http://www.stopbang.ca/osa/screening.php). The 4-item STOP screen asks patients the following: 1. Do you snore loudly? 2. Do you often feel tired, fatigued or sleepy during the daytime 3. Has anyone observed you stop breathing during sleep? 4. Do you have (or are you being treated) for high blood pressure?
If a patient responds "Yes" to two or more of the items, they may be exhibiting signs of sleep apnea and should be referred to a sleep specialist or primary care doctor/physician for a sleep study. I have just started including the STOP screen in my PTSD workups, in addition to routinely supplementing them with the PHQ-9 and AUDIT-C to check for signs of depression and alcohol abuse/unhealthy drinking.
Another step we can take as behavioral health professionals is to more actively educate patients, family members, other healthcare professionals and our community about how sleep apnea puts people at risk for developing a variety of health and mental problems including hypertension, cardiovascular disease, diabetes, depression, anxiety and PTSD or the worsening of these. A few websites that I have found helpful and share with others are:
- http://healthysleep.med.harvard.edu/sleep-apnea
- https://www.sleepdr.com/education-resources/sleep-apnea/
- https://www.healthysleep.net.au/sleep-apnea/
Finally, if a PTSD patient has been diagnosed with sleep apnea, check in regularly about how treatment for this sleep condition is going. Untreated sleep apnea can affect PTSD treatment progress, not just because of the disabling daytime effects and frustrating mask disruption, but it may also directly derail treatment by impairing memory consolidation and habituation, and may even relate to ongoing nightmares. Most recently a patient told me he is not able to use his CPAP effectively because it is uncomfortable and comes off. His PTSD remains severe. I have been reminding him to schedule an appointment with his doctor to see if his CPAP can be readjusted or to find another evidence-based treatment. He hasn’t done this yet, so I will keep trying!
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Paula Domenici, Ph.D., is Director of Training Education at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
Colvonen, P., Masino, T., Drummond, S., Myers, U., & Angkaw, A.,
Norman, S. (2015). Obstructive sleep apnea and posttraumatic stress disorder among OEF/OIF/OND veterans. Journal of Clinical Sleep Medicine, 11(5), 513-518. http://dx.doi.org/10.5664/jcsm.4692
Alexander, M., Ray, M., Hebert, J., Youngstedt, S., Zhang, H., Steck, S.,
Bogan, R. & Burch, J. (2016). The national veteran sleep disorder study: Descriptive epidemiology and secular trends, 2000-2010. Sleep, 39(7), 1399-1410.
doi:10.5665/sleep.5972
I have noticed that more than half of my military-connected patients with PTSD have been diagnosed with sleep apnea as well, and some are younger (e.g., in their 30s). Consistent with my observations, a study with 195 Iraq and Afghanistan Veterans between 21 to 59 seeking care at outpatient VA clinics identified nearly 70% of the participants with a high risk for sleep apnea and noted that the risk increased with the severity of PTSD symptoms (Colvonen et al., 2015). In fact, there was a 40% increase in the probability of screening as high risk for sleep apnea for every clinically significant increase in PTSD symptom severity, which is a lot. Similarly, the National Veteran Sleep Disorder Study found that Veterans with PTSD had significantly higher rates of sleep apnea compared to the general population (Alexander et al., 2016).
These types of observations have left me wondering why PTSD and sleep apnea often go hand-in-hand and how non-sleep experts like myself can help patients suffering from both conditions. While not fully understood, it has been hypothesized that PTSD may lead to sleep fragmentation and neuromuscular changes in the upper airway that in turn contribute to upper airway collapsibility and sleep breathing events, including apneas. These negative breathing events may then produce more sleep fragmentation, resulting in a vicious cycle where PTSD and sleep apnea co-occur. The two conditions may also be intertwined pathophysiologically since both involve negative changes or disruptions in the HPA axis and hippocampus. In addition, a pre-existing tendency to sleep-disordered breathing has been hypothesized to disrupt the ability to respond to trauma, increasing likelihood of developing PTSD if a trauma occurs in the future, or exacerbating previously subclinical PTSD if onset of sleep disordered breathing occurs later.
For behavioral health providers, one implication from these results is that we should routinely screen PTSD patients for sleep apnea even when they are younger so they can be properly diagnosed and treated if they have this chronic condition. Unfortunately, many Veterans with sleep apnea remain undiagnosed despite growing knowledge about the detrimental effects of untreated sleep apnea. In particular, younger Veterans with PTSD may be overlooked for such screening and thus go underdiagnosed. (CDP's Dr. Jeff Mann wrote a blog last week on the importance of assessing for sleep problems during treatment.)
Ultimately, sleep apnea needs to be diagnosed by a sleep specialist or primary care doctor/physician based on the results of a sleep study. However, we can do our part by noticing signs and referring patients to the medical professionals who can diagnose sleep apnea and provide evidence-based treatments. What signs of sleep apnea can we be on the lookout for when working with PTSD patients? One quick and easy sleep apnea screen is called STOP that is part of the larger questionnaire called STOP-Bang (http://www.stopbang.ca/osa/screening.php). The 4-item STOP screen asks patients the following: 1. Do you snore loudly? 2. Do you often feel tired, fatigued or sleepy during the daytime 3. Has anyone observed you stop breathing during sleep? 4. Do you have (or are you being treated) for high blood pressure?
If a patient responds "Yes" to two or more of the items, they may be exhibiting signs of sleep apnea and should be referred to a sleep specialist or primary care doctor/physician for a sleep study. I have just started including the STOP screen in my PTSD workups, in addition to routinely supplementing them with the PHQ-9 and AUDIT-C to check for signs of depression and alcohol abuse/unhealthy drinking.
Another step we can take as behavioral health professionals is to more actively educate patients, family members, other healthcare professionals and our community about how sleep apnea puts people at risk for developing a variety of health and mental problems including hypertension, cardiovascular disease, diabetes, depression, anxiety and PTSD or the worsening of these. A few websites that I have found helpful and share with others are:
- http://healthysleep.med.harvard.edu/sleep-apnea
- https://www.sleepdr.com/education-resources/sleep-apnea/
- https://www.healthysleep.net.au/sleep-apnea/
Finally, if a PTSD patient has been diagnosed with sleep apnea, check in regularly about how treatment for this sleep condition is going. Untreated sleep apnea can affect PTSD treatment progress, not just because of the disabling daytime effects and frustrating mask disruption, but it may also directly derail treatment by impairing memory consolidation and habituation, and may even relate to ongoing nightmares. Most recently a patient told me he is not able to use his CPAP effectively because it is uncomfortable and comes off. His PTSD remains severe. I have been reminding him to schedule an appointment with his doctor to see if his CPAP can be readjusted or to find another evidence-based treatment. He hasn’t done this yet, so I will keep trying!
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Paula Domenici, Ph.D., is Director of Training Education at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
Colvonen, P., Masino, T., Drummond, S., Myers, U., & Angkaw, A.,
Norman, S. (2015). Obstructive sleep apnea and posttraumatic stress disorder among OEF/OIF/OND veterans. Journal of Clinical Sleep Medicine, 11(5), 513-518. http://dx.doi.org/10.5664/jcsm.4692
Alexander, M., Ray, M., Hebert, J., Youngstedt, S., Zhang, H., Steck, S.,
Bogan, R. & Burch, J. (2016). The national veteran sleep disorder study: Descriptive epidemiology and secular trends, 2000-2010. Sleep, 39(7), 1399-1410.
doi:10.5665/sleep.5972