The Benefits of PAP Therapy for Patients With PTSD

By Admin

While scientists and clinical researchers are still learning about the complex relationship between sleep apnea and post traumatic stress disorder, studies have shown that PAP therapy can potentially reduce the symptoms of both disorders simultaneously. Since PTSD has been known to cause CPAP adherence problems for patients with sleep apnea, the knowledge that PAP therapy is treating both conditions at once has had a significant impact on sleep disorder treatment, leading researchers to seek out new strategies to help encourage compliance and promote the use of PAP therapy for these comorbid conditions.

What is PTSD?

Post Traumatic Stress Disorder, or PTSD, is a condition that many people associate with war veterans, but a wide range of trauma or high-stress experiences can lead to PTSD symptoms. Assaults, natural disasters, vehicular accidents, and childhood abuse or neglect can lead to the development of PTSD. Symptoms can include negative or intrusive memories, nightmares, mood swings, and a heightened sense of emotional reactivity. Treatment for PTSD consists of a number of psychological approaches, including forms of psychotherapy, cognitive behavioral therapy, and stress reduction routines for daily life. In the U.S., mental health professionals are often trained in two key therapies called Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). Recommended by the American Psychiatric Association and the Department of Veterans Affairs, these trauma-focused therapies focus on the memories of the traumatic event and how it affects the patient’s state of mind. With the help of the doctor or therapist, the patient is allowed to process the traumatic experience through discussion, visualization, writing, or other forms of controlled recall. While these methods can be very successful, they take time and effort, and the process can be very difficult and emotional for the patient. Thus, the use of PAP therapy as a supplemental treatment can be an effective option for those also dealing with related sleep conditions.

A Link Between PTSD and Sleep Apnea

There is still a lot to learn about the link between sleep apnea and PTSD, but according to the research, the complex nature of sleep disorders, especially in the presence of stress or trauma, predisposes patients to a number of potential comorbidities, making those with PTSD susceptible to a number of sleep disorders, including sleep apnea. For U.S. veterans in particular, the risk of sleep apnea has shown increases that coincide with the severity of their PTSD. In one study, researchers looked at 195 Iraq and Afghanistan veterans who visited a Veterans Affairs PTSD clinic, and found that the risk for OSA (about 69 percent) rose with the severity of the PTSD. In fact, the study found that every clinically significant increase in PTSD symptom severity was matched with an increase in sleep apnea risk. This tells us that the two conditions are strongly linked, and that conditions arising from PTSD can lead to sleep disordered breathing. Doctors are now looking into the possibility that fragmented sleep may explain the high percentage of sleep apnea among PTSD patients. Dr. Barry Krakow, M.D., Medical Director of the Maimonides Sleep Arts and Sciences Center in Albuquerque, New Mexico, has published research on the possibility that sleep fragmentation, caused by PTSD or other anxiety or mood disorders, can actually cause destabilization in the airway, leading to obstructive sleep apnea. Dr. Krakow is a proponent of the idea of a more holistic treatment of sleep disorders, rather than treating each condition in isolation. Sleep problems, he suggests, can be viewed as a comorbid condition, rather than just symptoms of an underlying disorder.

PTSD and Adherence Problems

Studies in the past have shown that PAP usage and adherence are often lower in patients with PTSD. In particular, frequent nightmares and sleep fragmentation is correlated with poor adherence to PAP therapy, resulting in fewer hours of PAP use on fewer nights over time. While further studies have corroborated this, the focus has mostly been on combat veterans and combat-related PTSD. While these studies can help us understand how the veterans become susceptible to psychiatric problems such as PTSD, depression, anxiety, or substance use, further studies are needed to better assess adherence rates across the board, including civilians with PTSD who may or may not have the same issues with continued therapy. One reason for adherence difficulties among patients with PTSD is the high sensitivity that the disorder causes. Patients develop what’s known as expiratory pressure intolerance (EPI), which is a result of high levels of anxiety or somatosensory amplification. This can be treated with advanced PAP therapy modes, for example, auto-bilevel PAP (or standard spontaneous mode for BiPAP) or adaptive servo-ventilation (ASV), as the tolerance for these modes are often much higher as a result of the lower expiratory pressure. In other words, the patient does not have to struggle to exhale. The automated shifts in airflow allow for a more comfortable therapy and a more relaxing experience overall.

PAP Therapy Improves PTSD Symptoms

Once it was established that using CPAP or other PAP therapy devices lead to measurable reductions in PTSD symptoms, further studies were conducted to determine the extent of the effects, and the results were quite promising. Researchers not only found improvements of both PTSD and sleep apnea symptoms at the same time, but also found that these benefits to correlated with duration, symptom severity, and adherence. Improvements were greater with longer use of CPAP, and for each patient studied, adherence levels were directly linked to reduction of nightmares, less sleep fragmentation, and lower levels of distress in the night. Throughout the study, the only significant predictor of subjective improvement in PTSD symptoms was the use of CPAP. As a result, the researchers recommend that PAP therapy be considered a front-line treatment option for patients with both PTSD and sleep apnea. With adherence issues being the number-one challenge for PAP therapy treatment options, all benefits should be emphasized and promoted in the interest of public health and quality of life. For patients with PTSD, the challenges may be difficult and complicated. But as these studies have shown, the benefits may far outweigh any costs of compliance. It is up to each patient and provider to establish a tailored treatment plan that is both reasonable and adaptable. And with these benefits at stake, it is worth giving CPAP another try.