Sleep Disorders among Veterans 

with PTSD

Sadeka Tamanna, MD, MPH.

Medical Director,

Sleep Disorders Laboratory,

G.V.(Sonny) Montgomery VA Medical Center, Jackson, MS. 
Learning objectives

• Sleep problems among veterans with post 

traumatic stress disorder (PTSD). 

– Insomnia: clinical presentation, diagnosis and 

treatment among veterans with PTSD.

– Obstructive sleep apnea: presentation, diagnosis 

and treatment options among veterans with PTSD.
Poll questions

What is your role in treating veterans with 

PTSD?

• A. Clinician

• B. TBI Physician

• C. Psychologist

• D. Social worker

• E. Case manager
Poll Question

In your experience, is “sleep” a challenge for PTSD 

sufferers?

• 1. Yes

• 2. No

In your regular practice, do you routinely ask the 

patients how well they sleep at night?

• 1. Yes

• 2. No
Poll Question

• A 55 year old veteran with chronic PTSD came 

in complaining his sleep is getting worse with 

repeated awakening with nightmares and 

panic attacks, waking up with headache, 

feeling very tired and sleepy during the day. 

His wife complains that he is awake most of 

the night and when he falls asleep, he snores 

loud, stops breathing during sleep. He is 

compliant with all his medications. What is 

your next step in management?
Poll question- answers

• 1. Adjust his anti-depressant medications

• 2. Send for psychotherapy

• 3. Ask to follow with primary care provider

• 4. Request sleep consult for sleep study
Post traumatic stress disorder

• PTSD is an anxiety disorder that develops in 

response to severe traumatic life stress. Studies 

have shown that certain type of trauma like 

combat, rape and other form of assaultive 

violence are more likely than others to result in 

PTSD. 

• Lifetime prevalence of PTSD in the community is 

around 5-6% compared to 15-31% among 

veterans.

• The syndrome of PTSD puts a heavy toll on the 

quality of life of the individual and society.
Sleep among PTSD sufferers

• 70% to 90% patients with PTSD suffer from sleep 

disturbances.

• PTSD sufferers have much higher prevalence of 

insomnia, nightmares, restless sleep and also 

sleep related breathing disorders like obstructive 

sleep apnea when compared to healthy cohorts.

• Specific sleep treatments for sleep disturbances 

in this population lead to significant improvement 

in sleep and global PTSD symptoms. 
Sleep difficulties after combat 
Sleep Cycle
Insomnia

• Difficulty in initiating and maintaining sleep 

resulting in daytime functioning impairment is 

termed as insomnia.

• In a recent study of 110 military personnel who 

returned from combat, 88.2% were diagnosed 

with sleep disorders. Among the sleep disorders, 

63.6% met the criteria for insomnia and 62.7% 

met diagnostic criteria for obstructive sleep 

apnea. 2 

• 2. Vincent Mysliwiec et al. Sleep Disorders in US Military personnel: a high rate of comorbid insomnia and 

obstructive sleep apnea. CHEST 2013
How to diagnose insomnia

• 1. Subjective 

assessment:

• By clinical interview 

with self report 

questionnaires like 

Insomnia severity index 

(ISI)

• Pittsburgh sleep quality 

index, or Epworth 

sleepiness scale. 
Diagnosis and treatment of insomnia

• Objective assessment:

• Sleep diary

• Actigraphy

• Polysomnography

• No objective tools are 

recommended for 

diagnosis of insomnia. 
Treatment of Insomnia

• Sleep Hygiene 

• Cognitive behavioral therapy

• Pharmacological treatment

• Treat other causes triggering insomnia like 

anxiety, depression or sleep disordered 

breathing like obstructive sleep apnea.
Sleep Hygiene

• Keep regular bedtime and waking time, avoid spending 

excessive time in bed.

• Avoid use of sleep disrupting products

• Avoid caffeine, alcohol, nicotine before bedtime

• Avoid exercise 2 hours prior to bedtime

• Avoid stimulating activities close to bedtime

• Avoid watching television, reading, snacking in bed

• Avoid use of bed for activities other than sleep 

• Maintain a comfortable sleeping environment

• Keep the bedroom quiet and cool.
Hypnotic indicated insomnia

BzRA/Melatonin 

receptor agonist 

Ramelton

Not improved

Increase dosages 

of BzRA or change 

alternative BzRA

BzRA+Sedative

anti-depressant

Improved

Continue

Zaleplon/Zolpidem/Eszopiclon/ 

Temazepam
Hypnotics used in insomnia

• Ramelteon: Melatonin 

receptor agonist (MT1 and 

MT2), 8 mg 30 min before 

sleep.

• Benzodiazepine receptor 

agonist: Eszopiclone, 

zaleplon, zolpidem, 

flurazepam, temazepam, 

triazolam

• Bertisch SM, Herzig SJ, Winkleman JW et al. 

National use of prescription medications for 

insomnia, SLEEP 2014

• Trazodone: serotonin 

receptor antagonist and 

reuptake inhibitor( SARIs), 

most commonly used 

antidepressant and 

hypnotic agent.

• National use of prescription 

medication showed that 

Zolpidem and Trazodone

were the two most 

commonly used med for 

insomnia from NHANES 

data. 
Hypnotics used for insomnia in PTSD

• Anti-depressants: 

Selective serotonin 

reuptake inhibitors 

(SSRI) like Sertraline, 

Fluoxetine, Paroxetine.

• Some antidepressants 

improve sleep 

disruption in PTSD 

where as others are less 

beneficial and can cause 

adverse sleep events.

• Some anti-depressants 

can cause REM 

suppression and sleep 

fragmentation. 

• SSRI and Venlafaxine 

have been found to 

exacerbate periodic leg 

movements during 

sleep.
Non-pharmacologic treatment

• Cognitive behavioral 

therapy specifically 

designed for PTSD 

related insomnia:

• Primary insomnia 

strategy: 

• Sleep hygiene

• Sleep restriction

• Stimulus control

• Imagery rehearsal 

therapy (IRT)

• These sleep treatments 

may benefit patients 

with trauma related 

nightmares and 

insomnia.
Obstructive sleep apnea

• Prevalence of OSA is higher among veterans with PTSD 

than those without PTSD. 

• 47.6% of combat veterans with PTSD was found to 

have OSA compared to 12.5% of healthy controls. 3 

• There is a complex relationship between hyper-arousal 

from PTSD, insomnia and respiratory disturbance 

generated by special neuro-endocrine connections 

which are being explored in different basic and clinical 

studies.

• 3. Mellman TA, Kulick-Bell R, Ashlock LE et al. Sleep events among veterans with 

combat-realetd post traumatic stress disorder. Am J Psychiatry 1995
Symptoms of OSA

• Loud snoring

• Observed apneas-stopping breathing during sleep 

observed by someone

• Gasping/choking during sleep

• Day time sleepiness

• Excessive fatigue/tiredness not explained by 

other diseases

• Morning headaches

• Uncontrolled hypertension 
Give me a break!
Diagnosis for sleep apnea

• History: Sleep hygiene, hypersomnolence by 

EPWORTH sleepiness score, observed 

breathing pauses, snoring

 Physical Examination: neck size, mandibular 

position, oropharyngeal examination with 

Mallampati Score

• Overnight Polysomnography (Gold standard)
Mallampati Score

• Scoring is as follows:

Class 1: Full visibility of 

tonsils, uvula and soft 

palate 

Class 2: Visibility of hard 

and soft palate, upper 

portion of tonsils and 

uvula 

Class 3: Soft and hard 

palate and base of the 

uvula are visible

Class 4: Only Hard Palate 

visible
Oropharyngeal examination
Sagittal section of a normal vs. OSA 

patient
What is polysomnography?
What is apnea?

• Complete cessation of 

airflow for 10 seconds 

or more during sleep is 

called apnea.
What is Hypopnea?

• Reduction of airflow by 

50% with 4% reduction 

of oxygen saturation is 

termed as hypopnea.

• Total number of apnea 

and hypopnea per hour 

of sleep is calculated to 

generate apnea 

hypopnea index (AHI).
Diagnosis of OSA

• Three categories of 

OSA:

• 1. Mild : AHI 5-15 with 

symptoms 

• 2. Moderate: AHI 15-30 

• 3. Severe: AHI >30
Treatment of OSA

• Continuous positive airway pressure therapy 

(CPAP) or Bi-level positive airway pressure 

therapy (BiPAP) is the gold standard of 

treatment for OSA.

• Surgical correction for increasing the 

oropharyngeal space is also used for therapy.

• Dental appliances and maxillofacial 

advancement are available therapy to use for 

OSA.
CPAP/BiPAP

Sleeping with CPAP/BiPAP How does it work?
How does CPAP/BiPAP help?

How does it help?

• Keeps airway open during 

sleep.

• Snoring and apneas should 

not happen or improve.

• Oxygen saturation during 

sleep will be normalized.

• Improves daytime 

sleepiness/tiredness

• Improves HTN

Reduces risk of diseases

• Improves neurocognitive 

functioning. 

• Improves alertness.

• Reduces risk of 

cardiovascular diseases.

• Reduces motor vehicle 

accident

• Reduces headaches
Improves HTN control

• A randomized trial on 

118 men with severe 

OSA treated with 

optimal CPAP and subtherapeutic CPAP 

showed significant 

reduction in both SBP 

and DBP after 1 month 

in optimally treated 

group.
Improves Heart failure

• 88 patients with heart 

failure was grouped into 

CPAP treated and untreated 

group and their cumulative 

event-free survival was 

calculated over 25 months. 

The cumulative event-free 

survival was significantly 

lower in untreated patients 

than in CPAP-treated 

patients (p = 0.001 [logrank test]).
Effect of CPAP on PTSD

• Improves nightmares

• Improves neurocognitive functioning and 

memory

• Improves insomnia and maintenance of sleep 

through the night.

• Treatment of co-morbid OSA alleviates PTSD 

symptoms

• Reduces night terrors, periodic leg movements 

and panic attacks during sleep.
Nightmares improve with CPAP

• Treatment of sleep apnea with CPAP has shown 

improvement on nightmares and PTSD symptoms 

in a retrospective study by Krakow and his 

colleagues in 2000.

• We retrospectively reviewed 69 veterans with 

PTSD at Jackson VAMC at MS and found a 

significant improvement in number of nightmares 

among PTSD sufferers who have used CPAP for 

their co-morbid OSA.

• Krakow et al. A retrospective study in improvement in nightmares and PTSD following treatment of 

co-morbid sleep disordered breathing. Journal of Psychosomatic research, 2000

• Tamanna et al. CPAP therapy reduces nightmares in veterans with PTSD and sleep apnea, AASM 

meeting, 2013.
CPAP compliance among PTSD

• CPAP compliance is very poor among veterans 

with PTSD

• CPAP adherence was compared between PTSD 

and non-PTSD group among veterans by El-Solh

et al. in VAMC at New York. Veterans with PTSD 

were only 41% compared to veterans without 

PTSD who were 70% compliant for CPAP use.

• Claustrophobia is a major barrier for compliance 

among this group.

• (El-Solh AA, Ayyar L, Akinnusi M et al. Positive airway pressure adherence in veterans 

with PTSD. SlEEP,2010)
CPAP compliance

Documentation of PAP therapy ( >4 hours per 

night for 70% of the night in 30 consecutive 

days ) is considered compliant by CMS.

CPAP compliance has shown to improve to 

86% by using a designated team of personnel 

for trouble shooting and fixing the issues.

First 2 weeks compliance can predict the 

overall compliance of the patient.
Improving Compliance among PTSD 

veterans

• CPAP mask fitting and follow up with sleep 

provider are important.

• Offering different masks for trial will give them 

more options to try.

• Nasal masks and nasal pillows seem to work 

better for this group.

• Cognitive behavior therapy (CBT) for CPAP use 

has been found to be effective among non- compliant patients.

• Richards S, Bartlett D, et al. Increased adherence to CPAP with a group cognitive 

behavioral treatment intervention: A randomized trial. SLEEP, 2007
References:

• 1. Zahava Solomon, Mario Mikulincer, Trajectories of PTSD: a 20 year longitudinal study, Journal of American Psychiatry, 

2006

• 2. Vincent Mysliwiec et al. Sleep Disorders in US Military personnel: a high rate of comorbid insomnia and 

obstructive sleep apnea. CHEST 2013

• 3. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and 

management of chronic insomnia in adults. J Clin Sleep Med. 2008;4(5):487–504

• 4. Bertisch SM, Herzig SJ, Winkleman JW et al. National use of prescription medications for insomnia, 

SLEEP 2014

• 5. Mellman TA, Kulick-Bell R, Ashlock LE et al. Sleep events among veterans with combat-realetd post 

traumatic stress disorder. Am J Psychiatry 1995

• 6. El-Solh AA, Ayyar L, Akinnusi M et al. Positive airway pressure adherence in veterans with PTSD. 

SlEEP,2010

• 7. Richards S, Bartlett D, et al. Increased adherence to CPAP with a group cognitive behavioral treatment 

intervention: A randomized trial. SLEEP, 2007

• 8. Inman D, Silver S, et al. Sleep disturbances in PTSD: a comparison with non-PTSD insomnia. J Trauma 

Stress 1990

• 9. Maher M, Rego S, et al. Sleep disturbances in patients with PTSD: epidemiology, impact and approaches 

to management. CNS drugs 2006
References and sources

• Krakow et al. A retrospective study in improvement in nightmares and PTSD following treatment of comorbid sleep disordered breathing. Journal of Psychosomatic research, 2000

• Tamanna et al. CPAP therapy reduces nightmares in veterans with PTSD and sleep apnea, AASM meeting, 

2013.

• Pepperell J.C., Ramdassingh-Dow S., Crosthwaite N., Mullins R., Jenkinson C., Stradling J.R., Davies R.J.; 

Ambulatory blood pressure after therapeutic and subtherapeutic nasal continuous positive airway pressure 

for obstructive sleep apnoea: a randomised parallel trial. Lancet. 359 2002:204-210.