**Transcript of Cyberseminar**

**Mild TBI Diagnosis and Management Strategies**

**Sleep Disorders among Veterans with PTSD**

**Presenter: Sadeka Tamanna, MD, MPH**

**February 25, 2014**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact Sadeka.Tamanna@va.gov*

**Dr. Tamanna:**So we are going to -- I’m going to try to talk about two specific sleep disorders along the reference of PTSD, one is insomnia and the other one is obstructive sleep apnea. Both the diseases we’ll be talking about their clinical presentation, diagnosis, criteria and how to treat them and to discuss about the options that are available will take questions and talk from there. 

First question is a phone question about what is the role in treating the Veterans with PTSD for a clinician or a physician or nurse practitioner or Tbi physicians, psychologist, social workers or case managers, you can take any of these depending on your role in the treatment. 

**Moderator:**Great thank you; it looks like we’re getting a great response rate from our audience. 

**Dr. Tamanna:**Yes we are. 

**Moderator:**We’ve got about a 50% response rate and the answers are still coming in; we’ll give people just a little bit more time. We do appreciate your providing us this information as it helps gear the talk towards our specific audience. 

**Dr. Tamanna:**So far it looks like most of the ones that have voted about 31% are clinician, about 4% Tbi physicians, 25% psychologists, 9% social workers, 6-7% case manager and other we have 25%. Thank you very much. 

So we all treat folks/Veterans with post traumatic stress disorder from different point of view. The next question for the poll is in your experience is sleep a challenge for people who suffers, you can say yes or no. I see almost 100% is saying yes that it’s a challenge; now we got about 59%.

The next question in your regular practice do you routinely ask the question of the patient how well you sleep at night? And I see also the poll for yes is growing about 86 says yes they ask the question about the sleep, right. So sleep is a regular issue in our treatment for patients with post traumatic stress disorder or even without the post traumatic stress disorder. 

Now I’m going to ask a question for everybody and then we’ll discuss about the management options for this patient. This is a 55 year old Veteran with chronic post traumatic stress disorder that came in complaining that his sleep is getting worse with repeated awakening with nightmares and panic attacks. Waking up with headaches, feeling very tired and sleepy during the day. His wife also complains that he is awake most of the night and when he falls asleep he snores loud. He stops breathing during sleep, he is compliant with all his medications. What will be our next step in his management?

The answers for the poll are: 

1. Adjust his anti-depressant medicines.

2. Send for psychotherapy.

3. Ask to follow up with primary care provider.

4. Request sleep consult for sleep study.

**Moderator:**Give me just one second and I will pull that next one up. Having little technical difficulties there for just a minute. Thank you everybody for your patience, we appreciate it. It’s always fun when you’re doing online meetings. All right, there you go. 

**Dr. Tamanna:**Okay I guess we got answers. 88% said -- about 85% said request for sleep consult, 5% said adjust to anti-depressant medications, 6% send for psychotherapy and 5% said ask to follow up with primary care provider.

We’ll go through different moralities of treatment and I guess our answers change accordingly from what we learn today. Thank you for your response. 

Okay since most of you are here are more experienced than me I guess in psychology so we all know what is post traumatic stress disorder is an anxiety disorder that develops in response to severe traumatic life stress. Most of the studies have shown that certain type of trauma, special trauma like combat, rape or other form of assaultive violence those are more likely than others to result in PTSD. 

And the lifetime prevalence of PTSD also between the community and in the Veterans because I guess this assaultive violence is difference among these two groups of people. So in the communities are 5 to 6% and Veterans it’s about 15-31%. 

The syndrome of PTSD overall it puts a heavy toll on our Veterans, their quality of life on individuals, society and family, all over the place.

And among this patients do it or the Veterans do it post traumatic stress disorder 70-90% of them suffer from some form of sleep disorder and PTSD sufferers they have a much higher prevalence of insomnia, nightmares, restlessness in the sleep, and sleep related breathing disorders like obstructive sleep apnea, upper air resistance syndrome and some other breathing disorders as well. 

If we focus our treatment on sleep for those patients like specific sleep treatment or sleep disturbances and this population it can lead to significant improvement in their sleep as well as their global PTSD management apart from only what we’re doing for PTSD itself. 

This was a study done recently published in Journal of Psychiatry by the Zahava Solomon and their study contain data for 20 years and found that combat stress reaction compared to non-combat stress reaction sleep difficulties are there for every year after the combat. First year is in blue, second year is in pink, third year is in -- year three is in green and year four is in orange and all of them if you look here you can see the area is much higher for the sleep difficulties compared to non-combat stress reaction.

The next slide I’m going to highlight on our sleep cycle like for normal people and we have two types of sleep, non-rapid eye movement sleep and rapid eye movement sleep. Every night we go through about 90 to 120 minutes cycling of this sleep. First we start with a non-REM cycle go to a REM cycle and then we go with the cycle all over. So for example in stage one non-REM sleep we experience light transitional sleep because we have slow rolling eye movement, we start getting drowsy and our sleep begins. We kind of start to get associated [Indiscernible] our sensory and other areas. In stage two we get more stable sleep and we have different kind of transmitters working on that, so it brings many sense of -- difficult to wake during that period of time. Stage three is our deeper sleep where we get more hormone release in our organs get restored or get more rest that time. Then you go to the REM sleep, rapid eye movement sleep. This kind of sleep is a little different for PTSD sufferers and some of the studies have shown that we get revitalization of our memory and our neuro-cognitive functions if we have a good restoration of our REM sleep.

Now insomnia means when we don’t have good sleep in layman’s term. But difficulty initiating and maintaining sleep and resulting in some kind of daytime functioning impairment that how we call insomnia. You have to have the components of where it impairs your data and functioning like we get very sleepy and tired because we’re not able to sleep at night. And it is more common in the military personnel in the communities and especially for the ones who have come back from combat because it is a recent study by Vincent Mysliwiec, 88.2% have sleep disorders and 110 of military personnel who just came back from combat in 12 months of them coming back. And sleep disorders 63% had met the criteria for insomnia, 62% met the criteria for obstructive sleep apnea. 

Now for the diagnosis of obstructive -- now for the diagnosis of insomnia it’s basically the subject assessment and some questionnaires like self report questionnaires to diagnose that. So for the clinical evolution to through a sleep history and details, medical, substance abuse and history need to go through with the patient before we can diagnose with insomnia.

For the diagnosis and treatment of insomnia for the objective and assessment can do a sleep log or a diary for two weeks to see the sleep pattern, what time does he go to bed, what time does he wake up, how much time does he spend in bed and actigraphy is an option but polysomnography are multiple sleep patterns of testing; those are not required to diagnose insomnia unless the treatment phase are -- we have a suspicion for obstructive sleep apnea with this diagnosis of insomnia.

But the treatment of insomnia we need to address the sleep hygiene so maybe behavior therapy, pharmacological treatment and we have to treat the other causes that can treat the insomnia like the patient has anxiety or other sleep disorder breathing like obstructive sleep apnea.

Now for the sleep hygiene this is the part of questioning that they should when they see the patient for the sleep history and then if they figure out is he following a good sleep hygiene or not and then we can advise him on that. Like keeping a regular bedtime, waking time and avoid spending excessive time in bed. Avoid use of sleep disrupting products like avid caffeine, alcohol, or nicotine before bedtime. Avoid exercising two hours prior to bedtime. Avoid any stimulating activities close to bedtime; avoid watching television, reading, snacking in bed. And use the bed only for sleep and avoid using bed for other activities than sleep, maintaining comfortable sleeping environment, keep the bedroom quiet and cool. 

When we need to use hypnosis, this is a topic that I’m going to touch today that we can start with Benzodiazepine receptor against or melatonin receptor agonist like Ramleton. And among the Benzodiazepine receptor agonist we can start with the short acting one like Zolpidem, Eszopiclon, Temazepam, or Zaleplon and if the patient improves with that we can continue with that. The treatment option depend on the patient choice preference is cycle sleep and how it is reacting to this medication or his availability of the medications. If this does not improve his symptoms then we can increase the dosage like if this patient had only slept for two or three hours and wake up in the middle of the night that means he may need a longer acting Benzodiazepine agonist. Or we can do -- go for alternate agonist. If not improved we can think about adding anti-depressant with it like Amitriptyline or Triazodone or some other anti-depressant to go with the Benzodiazepine receptor agonist. 

Hypnotics that are used in insomnia like Ramelton is a melatonin receptor agonist, it works on MT1 and MT2; it can be given 8 mg 30 minutes before sleep. For the Benzodiazepine receptor agonist like Eszopiclon, Zaleplon, Zolpidem, Temazepam, triazolam those can be used. Trazodone is mostly use in VA and also in the community because they are receptor antagonist and reactor inhibitors most commonly used antidepressant and hypnotic agents. There is the data from national prescription medications showed that Zolpidem and Trazodone these two were the most commonly used meds for insomnia. 

Hypnotics that are also used for insomnia in PTSD are antidepressants like selective serotonin reuptake inhibitors (SSRI) like Sertraline, Fluoxetine, Paroxetine. Some antidepressants improve sleep disruption in PTSD and others may not be as beneficial. Some antidepressants can cause REM suppression and more sleep fragmentation. Some SSRI’s have been found to exacerbate periodic leg movement and you can see more periodic movement in the night and sometimes restless leg also increasing with SSRI in patients with PTSD.

Now for the non-pharmacological treatment we can go with the cognitive behavioral therapy specifically designed for PTSD related insomnia, primary insomnia strategy, sleep hygiene, sleep restrictions, stimulus control, imagery rehearsal, these treatments may benefit patients with trauma related nightmares and insomnia. Sometimes combined treatments with pharmacotherapy and non-pharmacologic therapy have proven to beneficial for the folks with insomnia with PTSD.

Now I’m going to talk about obstructive sleep apnea, which is also another common sleep disorder among the patients among obstructive -- patients with post traumatic stress disorder. Prevalence of obstructive sleep apnea is about 2-4% with -- among the population but the prevalence is much higher among patients with PTSD. For some reason we don’t know exactly why the reason is that patients with PTSD suffer more with obstructive sleep apnea. 47.6% of the combat Veterans with PTSD was found to have obstructive sleep apnea compared to 12.5% of healthy Veterans in the study by Dr. Mellman, published 1995 and still showing that this disturbance is still higher among the patients of PTSD.

There is a complex relationship between hyper-arousal mechanism. PTSD patients are always hyper aroused -- hyper arousable, and there is a biological connection in the brain that makes the respiratory system also get stimulated at the same time and there are some basic science research and clinical research going on but there is no conclusion to draw yet.

So for the symptoms of obstructive sleep apnea we will hear the patients having loud snoring, sometimes that can be heard from a closed door. There could be other apneas like stopping breathing during sleep and those observations are done by someone close to them, their spouse or some children or friend whoever has seen them sleeping. There could be gasping and choking during sleep and the patient can give the history that “I wake up choking”, “I wake up with a dry mouth and I feel like I couldn’t breathe”. They’ll be excessively sleeping in the day; they can wake up with sleepiness like an hour or so they will start feeling sleepy or it’s retrospectively show that they’re requiring more naps. They’re excessive fatigue, tiredness which is not explained by any other diseases. Usually patients of excessive sleep apnea have other diseases involved like hypertension or coronary artery disease or hypothyroidism. But excessive fatigue and tiredness will not be explained by those diseases only when those are optimally treated. They can have morning headaches or headaches throughout the day. Uncontrolled hypertension and poorly controlled or resistant hypertension can be seen on folks with obstructive sleep apnea. 

So this is a slide of -- showing that the spouse gets bothered with the loud snoring, the amount of snoring and they usually give us a good history about their sleep.

So for the diagnosis of obstructive sleep apnea we need evaluation of the patient. First of all asking about their sleep history, their sleep hygiene, hypersomnolence by EPWORTH sleepiness score. In our practice we mostly use the EPWORTH sleepiness score to see how high it is; if it’s more than 10 usually that is considered abnormal. If the questionnaire each of them have like mild, moderate and high one point for each; so the highest number of points you can get three times 8 is 24. If it’s more than 10 we consider it abnormal for data and sleepiness.

For the physical examination number one is obesity, put it here the bmi that will show how big is the patient. The higher the bmi the  higher the likelihood of getting obstructive sleep apnea. Again most of our patients with post traumatic stress disorder they are already on multiple psychiatric medications and they can be overweight from those meds as well. So there could be a factor of obesity already there. And the neck size for the male and female large neck size is related to higher risk of obstructive sleep apnea. Mandibular positioning, retromastia, or mandibular position posteriorly have more risk to have obstructive sleep apnea. We can do it oropharyngeal examination to look behind the tongue to look at the oropharyngeal space how big is it, or how narrow is it to cause obstructive sleep apnea. And the final diagnostic test for this is overnight sleep polysomnography is the gold standard for treatment for diagnosis.

So this is how we do the Mallampati score there’s four classes. Class one is when you can see the tonsils, uvula, soft pallet all of them. Class two is when the hard pallet and soft pallet and only a portion of the tonsils and uvula are seen. Class three is when soft and hard pallet and only the base of the uvula are seen. It’s getting narrower and narrower the higher the class we are going. For class four only the hard pallet is visible. So absolutely nothing of the tongue and the hard pallet and there is no space to look for the look when open his mouth.

Oropharynx examination this is patient previous sleep apnea, you can see that the uvula is touching the tongue almost and the uvula, all of them have [Indiscernible]. This is also common among patients with obstructive sleep apnea when they snore and get vibrations, there could be inflammation and also swelling of the soft tissue down there.

This is a sagittal section of a normal obstructive sleep apnea patient. When the normal subject can see behind the tongue and behind the pharynx there is a space that he can breathe through. Here in the -- behind the soft pallet and tongue the pharyngeal space is very narrow, there is a likelihood of closing this space up at night when he’s sleeping and having some apneic events causing obstructive sleep apnea. This other thing to look into the same picture is position of the mandible here. The first patient in a normal subject his mandible is positioned normally, this one, the next one has the -- some kind of mandibular pushing backward so the tongue and the retrilingual space is also compressed with that. 

Now what is polysomnography? Polysomnography comprises of multiple channels that give us an estimate of his breathing pattern, the patients EEG signals, sensors from the scalp and from the eyes to look at the rapid eye movement or non rapid eye movement, what kind of sleep is the patient having right now or he’s awake or asleep. From there there will be sensors from the nose getting their measure of air flow, sensors to check the snoring and also the respiratory [Indiscernible] to check the movement of the thorax and abdomen as those are going along with the breathing pattern; or there’s a central apnea or obstructive sleep apnea to differentiate between those. We also have sensors in the legs to see if patient is having periodic leg movements or something else.

Okay, since it’s called obstructive sleep apnea there is an episode of apnea during the sleep. What is apnea? Apnea is a complete cessation of air flow for at least 10 seconds or more during sleep and it has to be documented by the nasal flow. As we see here the state, the patient is asleep and the air flow was going on before and there is a cessation of breathing, the complex position more than 10 seconds. At the same time the air flow of the person’s abdomin is ongoing. So abdominal thorax is moving it’s the upper airway that completely close and we’re not getting any air flow; it has to be more than 10 seconds to call it an apnea. 

Next one is hypopnea, airflow is reduced in the apnea; so there’s a reduction of the airflow. There are two different criteria for hypopnea. Basically it’s a reduction in the airflow, it could be 30 to 50% reduction and 3 to 4% desaturation of the oxygen channel with that or there is [Indiscernible] after that. And with this picture also we can see there is expiration, inspiration and then there is reduction in the flow compared to the previous averages of the air flow. With that there is a desaturation but the airflow is still ongoing in the state of sleep so that we can call it a hypopnea.

Now with polysomnography we tried -- we calculate the total number of apnea and total number of hypopnea and add it together and then we see how much is left so we make an index of apnea, hypopnea index per hour of sleep, which is a quantification of how to categorize obstructive sleep apnea; so if it’s a mild, moderate, high or sufficient doesn’t meet the criteria for obstructive sleep apnea all of them will depend on his AHI or apnea hypopnea index.

So when -- this is airflow from REM sleep, you can see the rapid eye movement going on and there’s a blue in the area in the position of breathing so he has apnea during his REM sleep. REM sleep during apnea hypopnea is common in non REM sleep. So there are three categories of obstructive sleep apnea, when the patient have symptoms like and sleepiness This is 5 to 15 with data symptoms we can call it mild obstructive sleep apnea. We can call it moderate if the AHI or apnea hypopnea index is 15 to 30. When there’s more than 30 we can call it severe obstructive sleep apnea. 

What is the treatment for obstructive sleep apnea? So far we can say that continuous positive airway pressure therapy or sleep app, or bi-level positive airway pressure therapy (BiPAP) is the treatment mostly used in mostly at this point for obstructive sleep apnea. There is a possibility of surgical correction for oropharyngeal airway like inferolateral pharyngoplasty, dental appliances, maxillofacial advancement and many other therapy is possible that the review for obstructive sleep apnea, but most of the time the patient still needs to continue on CPAP or BiPAP.

Now how does the BiPAP or CPAP work? CPAP actually works as positive pressure; it’s like a stent to keep the airway open. So the higher the pressure, the larger the opening gets and the patient keeps getting the air as he’s supposed to.

Does it help and how does it help? So CPAP or BiPAP like I said it keeps like -- it works like a stent to keep the airway open and reduces apneic episodes or result apneic episodes depending on optimization of the therapy. Certain situations can be improved -- improved daytime sleepiness/tiredness, improved the comorbidities that come from obstructive sleep apnea. It reduces the risk of cardiovascular disease and it reduces the risk of stroke, hypertension and heart diseases, improves neurocognitive functioning, improves alertness, reduce motor vehicle accidents which a lot of you recall the motor vehicle accidents nowadays. And also reduces headaches. 

This further study in randomized trial 118 men they used optimal CPAP and sham CPAP to see if there’s difference in the blood pressure control with ambulatory monitoring. After a month of ambulatory hypertension monitoring they found that patients with obstructive sleep apnea who have been optimally treated have a blood pressure reduction of 2.5 mm both in systolic and diastolic and the folks that were not treated they had increase in their blood pressure.

This is a study from Heart Failure published in the Journal of Cardiology and 88 patients are enrolled in this study and they did CPAP treated group and untreated group and the cumulative event free survival over 25 months and the survival of significantly lower in untreated patients. So the treated patients have the highest survival compared to the untreated patients.

The effect of CPAP on PTSD will be the same for the cardiovascular group. But for the PTS symptoms specifically it does improve their nightmares, improves their neurocognitive functioning and memory, which it does to all patients with obstructive sleep apnea. It improves insomnia, maintains goo sleep through the night, restorative sleep through the night. And treatment of comorbidities, obstructive sleep apnea alleviates PTSD symptoms. So reducing the night terrors, periodic leg movement or panic attacks during sleep improves the overall symptoms of post traumatic stress disorder.

Nightmares have been studied in few research studies. One was done by Dr. Krakow and his colleagues in 2000 and they found that patients with obstructive -- patients with post traumatic stress disorder who either had obstructive sleep apnea or upper air resistance syndrome both responded well to CPAP. We, from here, me and my colleagues we looked at retrospective data on 69 patients Veterans with post traumatic stress disorder that had both obstructive sleep apnea and PTSD, chronic PTSD for more than a year. We found that those who have used their CPAP compliantly, they’re nightmares had reduced significantly without changing their medications. So we did not change any of their  medications except whatever it was going on by the mental health provider, but still their baseline nightmares which are about six or seven a week has reduced to 0 or 2 a week with the help of CPAP and those who are more compliant had more reductions.

Now problem with the CPAP among the post traumatic stress disorder Veterans is that they can’t tolerate CPAP very well. Their compliance is very poor; so CPAP adherence is one of the major barriers for PTSD sufferers. Dr. El-Solh did a study in New York and found that Veterans with post traumatic stress disorder were only 41% compliance compared to the Veterans without PTSD. So it’s almost like half and claustrophobia is one of the major barriers for compliance among this group. Most of our patients here when they use a CPAP they said “We can’t take anything on our face” or they will say it feels like they’re wearing a little gas mask when they were using the CPAP machine with the mask. 

CPAP compliance meaning that use of PAP therapy, positive airway pressure therapy for more than four hours per night for 70% of the night that’s compliance for 30 consecutive days. CPAP compliance has shown to improve to 86% if a designated team of personnel for trouble shooting and fixing the issues has been involved. This percentage is for overall patients with obstructive sleep apnea and not only PTSD. But patients can improve their compliance if the first two weeks of CPAP use, somebody is watching them or somebody is telling them about their problems, while they’re not using it and if the mask needs to be replaced or any other assistance that can be provided by the technician overseeing them by calling and asking about problems usually helps.

Now to improve the compliance of post traumatic stress disorder Veterans we can ask for a mask fitting follow up with the provider and basically talk to them why they are needing the CPAP machine, how bad is the sleep study, what are the treatment options that are available? And offering different masks for trial, nasal masks or the nasal pillows seem to work better or behavior therapy for CPAP use also have been found to be effective among non-compliance patients. In our view we have a group that works for folks who are non-compliant with CPAP and that has been working well so far.

That was all that I have to say for this conference; so for the first question in the poll the answer you probably already know by now that we need to get his sleep history in more detail and this patient might have some obstructive sleep apnea ongoing with the symptoms of loud snoring, stopping breathing and all that. 

I’ll take any questions if you have any.

**Moderator:**Thank you so much. We do have some questions that have come in. For those of you that have joined us after the top of the hour to submit a question or a comment please use that Q&A box that’s located in the upper right hand corner of your screen. You can also request a copy of the slides through that Q&A box if you’d like. The first question that came in is how many people -- how many patients do you see with blast injury?

**Dr. Tamanna:**We don’t see that often but maybe few -- few are two weeks, like that. Not too many.

**Moderator:**Thank you and when you were talking about pharmacological and non-pharmacological treatment what about Prazazine?

**Dr. Tamanna:**Prazazine works and that is pretty good one for us; it’s suppresses the REM and patients with -- patients with PTSD who have large amount of nightmares and sometimes they even continue having nightmares, some of them after studying them on CPAP because they get rebound REM sleep. And if you put them on Prazazine that helps to eliminate the REM or reduce the REM and they don’t get as many nightmares. So it’s a very good medication and I use it.

**Moderator:**Thank you for that reply. Would having a tonsillectomy help have a more open airway; should this be considered with sleep apnea?

**Dr. Tamanna:**It can be considered depending on how big are the tonsils and is it a barrier in his Mallampati Score and an ENT solution can see if it’s going to be helpful or not. And usually we perform a sleep study after the tonsillectomy has been done to see if his sleep has improved or still needs a CPAP.

**Moderator:**Thank you. Next question has there been studies done for PTSD patients with CPAP and therapy for PTSD versus CPAP alone as far as nightmares go?

**Dr. Tamanna:**PTSD versus CPAP?

**Moderator:**Yeah studies for PTS patients, PTSD patients with CPAP and therapy for PTSD versus CPAP?

**Dr. Tamanna:**There is studies showing the patients with CPAP but with not discontinuing the medication for PTSD. So it is adjunct treatment; not like a head to head trial showing if only CPAP will take care of it or only the medications will take care of it.

**Moderator:**Thank you for that reply.

**Dr. Tamanna:**I don’t know if it answers the question because it is unethical for us at this moment or it raises a lot of issues if we want to stop the medications and put the patients only on CPAP to see how they do.

**Moderator:**If that person has further questions they’re always more than welcome to write in. The next question how much of the sleep disorders associated with obstructive sleep apnea can be alleviated by promoting smoking cessation and options for weight reduction along with the CPAP use?

**Dr. Tamanna:**Smoking cessation is prescribed all the time but the risk of obstructive sleep apnea from smoking hasn’t been studied that well so I can answer only smoking cessation will alleviate obstructive sleep apnea. And the other part of the question that obesity or weight reduction, Definitely. Weight reduction helps and we have seen that 10 pounds of weight reduction may take off two [Indiscernible] of their CPAP now. So the further weight reduction you go the further reduction in obstructive sleep apnea happens.

**Moderator:**Thank you for that reply. The next question would you treat insomnia with non CPAP adherent patients?

**Dr. Tamanna:**Yes if the patient -- it’s basically patient in treatment for us. So if the patient has obstructive sleep apnea, he doesn’t want to wear the CPAP at any cost we can treat him; we still have to treat his insomnia. So in those cases we have to offer him other treatment options for obstructive sleep apnea other than CPAP, maybe surgery, maybe reduction of his oropharyngeal airway or maybe weight reduction or dental appliances. In some other form we have to get him there so he doesn’t get that many of some obstructive sleep apnea itself. And at the same time we should continue treating him for insomnia.

**Moderator:**Thank you. The next question -- just a moment, there’s a lot to get through. Okay can sleep apnea worsen PTSD symptoms?

**Dr. Tamanna:**Definitely it can. Sleep apnea causes the problems of non restorative sleep and waking up too many times through the night and those hypoxic triggers or the triggers from like when they stop breathing, like I said apnea that treats the flow of [indesc.] driving them and that can stay in their system for a while and they get hyper aroused, anxious, neurocognitive function -- over all their PTSD symptoms deterioriate when they don’t use the CPAP for obstructive sleep apnea with PTSD.

**Moderator:**Thank you. The next question we have can you speak about RBD in PTSD patients?

**Dr. Tamanna:**Yes REM behavior disorder is also common; I did not talk this subject here because it will be another long one to go with this. So sometimes it’s really difficult for us to differentiate the RBD or he is just getting nightmares or is it a periodic leg movement with that. Some of the RBD’s can be triggered from obstructive sleep apnea when they are having hyper arousal but when they’re having hypoxic triggers, triggering their RBD’s. RBD’s are more common in PTSD patients over all that I can see in my practice so the treatment also varies what we are treating depending on that. So if we have a comorbid sleep apnea I treat that with CPAP. At the same time for RBD we’ll do a sleep study on him seeing if he does any movement and if he has obstructive sleep apnea that is treatable. And then for RBD we usually use Clorazipam or one of the benzodiazepines resistant agoinists. 

**Moderator:**Thank you for that reply. The next question we have a lot to go through. Okay just to verify almost half of all Veterans with PTSD diagnosis also have concurrent OSA, correct?

**Dr. Tamanna:**Correct.

**Moderator:**Okay. Next question what percentage of patients referred for polysomnography are not able to tolerate the test?

**Dr. Tamanna:**Not able to tolerate the test maybe 5% that didn’t like to be hooked up with polysomnography. Once we get a baseline test some of them cannot tolerate or doesn’t want to be on CPAP for the night. So we offer either one night stay after the baseline therapy or two night stay depending on if he has been diagnosed with obstructive sleep apnea. The -- the second night test they usually don’t tolerate sometimes and that will be 5% to 8% like that.

**Moderator:**Thank you. Next question we have I might mispronounce this, I apologize. What about oral pharyngeal strengthening exercises to improve sleep apnea?

**Dr. Tamanna:**I couldn’t understand oro what?

**Moderator:**It’s spelled P-H-A-R-Y-N-G-E-A-L. 

**Dr. Tamanna:**Oropharyngeal.

**Moderator:**yeah.

**Dr. Tamanna:**Oropharyngeal.... like  uvulopalatopharyngoplasty, or some other trimming of the uvula or trimming of the tongue that can be done from ENT. And in some cases it resolves, but usually it improves obstructive sleep apnea, if it’s AHI 30 it will probably improve to 15, or 10. But most of the time people usually continue to have some residual symptoms that impairs their daytime activity they still need to be on CPAP.

**Moderator:**And they are asking about specifically about strengthening exercises?

**Dr. Tamanna:**I’m not very sure about that or I don’t know if that studies shows significant improvement compared to CPAP.

**Moderator:**Thank you. Is there a study that -- is there a study that PTSD can cause sleep apnea?

**Dr. Tamanna:**No there is no study showing that PTSD -- there is no causal relationship here that has shown anybody that PTSD can cause sleep apnea, or sleep apnea can cause PTSD. We don’t have any literature on that.

**Moderator:**Thank you. The next question what are the current areas of etiology of the high prevalence of OSA among patients with PTSD versus those without PTSD?

**Dr. Tamanna:**Very good question. We don’t know the answer but there are a lot of hypothesis and basic science literature one thing that patients with PTSD already have a hyperarousal issue. That they get aroused with small amount of stimuli and this hyperarousal system in the brain probably comprise some of the respiratory areas and the hyperarousal during the respiratory function and some of those functions can be compromised. We just mediated neurologoically so it could be complex with apnea or sleep apnea or could be mediated by sympatic drive; we have no clear answer for that why obstructive sleep apnea is more prevalent with the PTSD sufferers.

**Moderator:**Thank you for that reply. Can you say more about the efficacy of treatment using dental appliances?

**Dr. Tamanna:**Dental appliances does improve patients with obstructive sleep apnea and a variety of dental appliances and they usually do studies, case studies during after and after the modification of the treatment. So patients who are not tolerating CPAP are candidates for dental appliances. And efficacies are 70 to 75% for obstructive sleep apnea if they comply and adhere to the therapy.

**Moderator:**Thank you. Is there a difference in sleep issues in rape victims versus combat PTSD?

**Dr. Tamanna:**I don’t think I have seen any literature comparing the rape victims and combat victims in the difference in their clinical outcomes. I don’t know.

**Moderator:**Okay is there a study -- wait. So this person is asking is there a study that is for CPAP and then therapy versus CPAP -- oh okay is there a study for CPAP and therapy versus CPAP alone?

**Dr. Tamanna:**CPAP and therapy versus CPAP alone?

**Moderator:**Not referencing medications.

**Dr. Tamanna:**Not taking medications at all? I haven’t seen any studies yet doing only CPAP, like I said because it’s an ethical question to stop all medications and with the patients with PTSD just to give CPAP to see how they do because there is a high suicidal rate and other risks involved with that. Try to get it to think about it but we could not get it through.

**Moderator:**Wouldn’t the use of melatonin supplements impact the bodies natural production of this hormone, and if so would it cause a problem for patients who stop taking such supplements?

**Dr. Tamanna:**Melatonin and other over the counter supplements do not show any significant improvement or safety data to recommend or not recommend melatonin for insomnia. In the last consensus from American Academy of Sleep Medicine, they could not give any data or safety data to recommend of this.

**Moderator:**Thank you. I see a lot of use of Prazosin for PTSD nightmares. Do you know anything about related studies of this?

**Dr. Tamanna:**Yes I think the Raskind study did a lot of study on Prazosin relative to PTSD and it does help, like I said I use in my practice too for Prazosin and it does reduce the nightmares in PTSD patients.

**Unidentified male:**  Well in fact we have a webinar on that that’s available for viewing 24/7 that Dr. Raskind recently presented. 

**Dr. Tamanna:**Great I’d love to look at that too. I know he has many studies on that.

**Moderator:**Thank you. Yeah we do have several TBI and PTSD sessions that have taken place. You can visit our online archived catalog and view any of those. Okay, the next question do you use any biofeedback for breeding retraining?

**Dr. Tamanna:**We have psychotherapists here, they do biofeedback for that. 

**Moderator:**Great. Let’s see how do other factors race, ethnicity, weight, gender, etc. play into why there is a high rate of correlation between PTSD and OSA?

**Dr. Tamanna:**Very good question. Propensity for black population there’s a high risk of having obstructive sleep apnea and PTSD, BMI, like I said, overweight has a tendency to increase the risk or should effect sleep apnea overall and again some studies show patients with PTSD tend to be more overweight than people without PTSD. So there’s the relationship, a complex relationship between these two areas by weight, by body weight and ethnicity.

**Moderator:**Thank you. Any thoughts about exposure therapy to increase tolerance for the mask?

**Dr. Tamanna:**Yes actually we have CBTI here, Coginitive behavior therapy group here. Amy Hudson and she has a group, session that she offers for patients with non compliant sleep ap therapy and desensitize them along with her CBTI

**Moderator:**Thank you, do you say that Trazodone decreases REM sleep, wouldn’t this lead to less restorative sleep and an aggravation of the daytime symptoms?

**Dr. Tamanna:**It can. But Trazodone overall increases the sleep quality for non REM sleep for the folks so people may be more drowsy during the day from Trazodone itself or not having enough REM from Trazodone. So it depending on their quality of sleep and the goal of treatment. If the patient is improving in their sleep quality then we can continue, if they’re not improving and they have more data and sleepiness then I think our next option would be to rule out a sleep apnea or other respiratory disorders that the patient might have that we’re not able to detect yet. 

**Moderator:**Thank you, we’re getting down to the last few questions. Where do VA patients have to go if they want dental appliances fitted for OSA?

**Dr. Tamanna:**That’s a good question and this is a problematic one. For now the dental here our VA doesn’t cover for dental appliances; so for my folks that need dental appliances they don’t want CPAP, I do fund approval -- I ask for fund approval to send them out to the university where they do the dental appliances. 

**Moderator:**Thank you. The next question what are the components of the CBT group for PAP adherence that is offered at your facility?

**Dr. Tamanna:**For CBT group they have similar control relaxation techniques, Amy has all that but I’m not in that group so I cannot give specific instruction on that. If you like, I’ll send you the  emailthat the person who does it here so she can give you more update. 

**Moderator:**Thank you. Attendees go ahead and hang tight for just a second and I’m going to put up the feedback survey momentarily but for that I’d like to give you a chance to make any concluding comments. 

**Dr. Tamanna:**I’d like to thank you all for handling this and giving me an opportunity to talk to you all from other VA’s. I guess if it was helpful, give me your feedback about how it was and how could I improve myself.

**Moderator:**Okay well we really want to thank you for coming and sharing your expertise with the field and of course to Dr. DePalma for organizing this. Please check our calendar for upcoming tbi sessions; we will have three next month for you to join. So with that I’m going to close out the meeting and please take just a  moment to fill out our feedback survey; thank you very much again Sadeka.

**Dr. Tamanna:**Thank you.

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