We recently received an interesting question about the possibility of integrating insomnia treatment into the Cognitive Processing Therapy for PTSD protocol. I thought it would be relevant and enlightening to share the response with a larger audience. The BLUF (bottom line up front): Based on the literature, I would NOT suggest simultaneous treatment of insomnia and PTSD using CBTI and either PE, CPT or EMDR at this time. Each treatment is, in its own right, somewhat time consuming and difficult for the patient and the combination would likely interfere with the effectiveness of both treatments assuming it did not increase dropout rates.
The rest of the story: this question is a great one and one that comes up fairly often in our workshops as well as in the literature. It brings up a larger issue of the ordering of evidence-based therapies when there are co-occurring or co-morbid conditions, which is being discussed in the literature lately (e.g., McCauley, Küleen, Gros, Brady, & Back, 2012).
There are currently no RCT studies, that we are aware of, that have integrated evidence-based treatment for sleep (CBT-I) and an EBP for PTSD either PE or CPT. The main reason, in my opinion, for this paucity of research on combined therapy is that combining the treatments would likely result in an increase in drop out and a reduction in the efficacy of both treatments. This is primarily because the combination would likely be overwhelming to the patient and confusing and hard to track for the therapist. Now, clinically, I am more of a PE guy, but I have been trained in CPT and am familiar with CPT-Group and discussed this with my CPT colleagues Laura Copland and Holly O'Reilly and I would say that that CPT and CPT-G have a good amount of homework and requirements for the patients to work on outside of session as does CBT-I. This, I think, would make the combination of the two more complicated and you would clearly be working outside of the protocol that we know has been evaluated as efficacious.
The treatment manual for CBT-I warns that an unresolved co-morbid psychiatric illness may complicate or even be contraindication for the use of CBT-I (Perlis, Jungquist, Smith & Posner, 2005). However, there is evidence that CBT-I can produce sleep improvements in individuals with co-morbid conditions (e.g., Gellis & Gehrman, 2011). But often in these studies while the effect size was moderate, the amount of change was minimal, in other words there is a good chance that CBT-I had a small impact. Likewise, many researchers have used CBT-I subsequent to PTSD treatment (e.g., DeViva et.al, 2005) and found moderate to large effect sizes as well. Effective CBT-I can be difficult for patients as well, motivation needs to be high and is often the most difficult part of CBT-I.
However, as you know, sleep disturbance is a common component of PTSD and is a primary residual complaint of patients successfully treated for PTSD (Zayfert & DeViva, 2004) and we know that PE and CPT both reduce symptoms of sleep disturbance, but often not to the point of complete remission (Gutner, Casement, Gilbert & Resick, 2013). We also know that sleep problems can interfere with treatment and can limit the long term effect of treatment for PTSD. So what to do?
In practice, I have typically taken the approach of "educate and let the patient decide." I will review the common symptoms associated with trauma exposure and if they have complained about sleep in particular I will highlight the availability of efficacious treatment of insomnia and what the typical course of treatment involves. I will then explain the availability to EBPs for PTSD and what is typically involved in each and let them decide. Some will choose to address sleep issues then address PTSD with the understanding that there may be a "ceiling effect" to how well the sleep treatment will work in the continued presence of PTSD symptoms. Anecdotally, a fair number of my male Service member, combat trauma guys will choose this option rather than talk about the trauma itself right away. Some will dive in and do a course of PTSD treatment and then address the sleep issues with CBT-I if they, in fact, remain for that particular person. In my experience a little more than half of my patients have continued or returned for CBT-I in this case.
If the sleep impairment is significant and a potential risk factor for injury or mishap, temporary medication for insomnia may be helpful, with the understanding that a course of CBT-I is what will ultimately be helpful in the long run. Either way, I would highly suggest simultaneous to your PTSD treatment, you monitor sleep with a quick assessment tool such as the Insomnia Severity Index.
I would also suggest a careful assessment of the sleep disruption in case the issue is more one of a Nightmare Disorder or an Obstructive Apnea, both of which can be common with this population and should be treated differently than an Insomnia Disorder (though CBT-I may also be needed).
Dr. Bill Brim is the Deputy Director of the Center for Deployment Psychology. The focus of his clinical work, supervision, and training is on deployment- and redeployment-related mental health issues, specifically assessment and treatment of Post-Traumatic Stress Disorder and Insomnia.
DeViva, J. C, Zayfert, C, Pigeon, W. R., & Mellman, T. A. (2005). Treatment of residual insomnia after CBT for PTSD: Case studies. Journal of Traumatic Stress, 18, 155-159.
Gellis, L. A., Gehrman, P. R. (2011). Cognitive behavioral treatment for insomnia in veterans with longstanding posttraumatic stress disorder: A pilot study. Journal of Aggression Maltreatment & Trauma, 20, 904-916.
Gutner, C.A., Casement, M.D., Gilbert, K.S. & Resick, P.A. (2013). Changes in sleep symptoms across Cogntive Processing Therapy and Prolonged Exposure Therapy: A longitudinal perspective. Behavior Research and Therapy. 51(12), 817-822.
McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., & Back, S. E. (2012). Posttraumatic stress disorder and co-occurring substance use disorders: Advances in assessment and treatment. Clinical Psychology: Science & Practice, 19, 283-304
Perlis, M. L., Jungquist, C, Smith, M. T., & Posner, D. (2005). Cognitive behavioral treatment of insomnia: A session-by-session guide. New York: Springer
Zayfert, C. & DeViva, J. C. (2004). Residual insomnia following cognitive-behavioral therapy for VIST). Journal of Traumatic Stress, 17, 69-73.