The Treatment of Sleep Disturbances in the PTSD Patient
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Abstract
ABSTRACT:
Introduction: Post-traumatic stress disorder (PTSD) is a debilitating anxiety disorder that develops in 25-30% of individuals exposed to a traumatic event. Sleep disturbances (i.e. nightmares and restless sleep) are common symptoms of PTSD, affecting approximately 70-87% of patients. Studies have shown that improving sleep disturbances improves disease severity and therapeutic outcomes. Although selective serotonin reuptake inhibitors (SSRIs) are considered first-line therapies for PTSD, sleep disturbances often remain refractory and require additional therapies for their resolution. Discussion: Pharmacological and non-pharmacological modalities are available for the treatment of PTSD sleep disturbances. Although cognitive behavioural therapy (CBT) is well supported to alleviate sleep disturbances, studies have shown patient drop-out by the time of long-term follow-up, suggesting CBT may be viewed as challenging to complete. Under these circumstances, the use of pharmacological therapies can be considered independently or in adjunct. Conflicting evidence surrounds the benefit of SSRIs in the treatment of sleep disturbances. Moreover, there is limited research surrounding the use of trazodone in this patient population. Benzodiazepines are poorly supported and the side effect profile of atypical antipsychotics limits their routine use. Prazosin holds the most promise and is the most well supported pharmacological agent in the literature. Nabilone, although a controversial agent, also holds promise of benefit. Conclusions: Several pharmacological and behavioural therapies are available to treat PTSD sleep disturbances. However, the evidence supporting any of these modalities as being superior is limited. Larger, randomized controlled trials are needed to gain a greater understanding of efficacious therapies available to address this clinical problem.
RÉSUMÉ:
Introduction: Le trouble de stress post-traumatique (TSPT) s’avère un trouble d’anxiété qui se développe chez 25 à 30% des individus qui sont exposés à des évènements traumatiques. Les troubles du sommeil tels que les cauchemars et l’insomnie sont des symptômes typiques du TSPT qui affectent entre 70 et 87% des patients. Plusieurs études démontrent qu’une amélioration des troubles du sommeil peut diminuer la sévérité du TSPT et augmenter l’effet thérapeutique. Malgré le fait que les inhibiteurs sélectifs de la recapture de sérotonine (ISRS) demeurent la première ligne de traitement pour le TSPT, les troubles du sommeil demeurent un symptôme important et des thérapies additionnelles sont nécessaires pour leur résolution. Discussion: Les modalités pharmacologiques et non pharmacologiques sont disponibles pour le traitement des problèmes du sommeil associés au TSPT. Malgré le fait que la thérapie cognitivo comportementale (TCC) a démontré des effets positifs pour minimiser les symptômes de troubles du sommeil, les études démontrent que les patients ont de la difficulté à respecter les critères de l’étude lorsqu’ils sont évalués au suivi, suggérant que la thérapie TCC est difficile à compléter. L’utilisation de la pharmacothérapie peut se faire de façon indépendante ou combinée à la TCC. Il y a des preuves contradictoires au sujet des bénéfices associés aux ISRS dans le traitement des troubles du sommeil. De plus, il y a des preuves limitées au sujet de l’utilisation de trazodone dans cette population cible de patients. Les benzodiazépines ne sont pas très bien tolérées par les patients à cause de leurs effets secondaires, ce qui limite leur utilisation. La prazosine donne de bons résultats et demeure l’agent pharmacologique le plus recommandé dans la littérature scientifique. Le nabilone, toutefois, est un agent controversé qui semble démontrer beaucoup de bienfaits potentiels. Conclusion: Plusieurs thérapies pharmacologiques et comportementales sont accessibles pour aider aux problèmes du sommeil reliés au TSPT. Toutefois, les preuves des bienfaits de ces modalités de traitement sont limitées. Des résultats d’essais aléatoires contrôlés à plus grande échelle sont nécessaires afin de mieux comprendre l’efficacité des thérapies qui sont disponibles dans le but d’optimiser le soin des patients atteints de troubles du sommeil.
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