The impact of prolonged exposure on sleep and enhancing treatment outcomes with evidence-based sleep interventions: A pilot study

Abstract

Objective: Insomnia and nightmares are central features of posttraumatic stress disorder (PTSD). However, often they are inadequately assessed and ineffectively resolved following gold-standard PTSD treatment. Here we: (a) evaluate effects of prolonged exposure (PE) on subjectively measured sleep and (b) present pilot results of an examination of whether adding sleep interventions (imagery rehearsal therapy [IRT] and cognitive-behavioral therapy for insomnia [CBT-I]) to PE improves treatment response, relative to PE alone, for night- and/or daytime PTSD symptoms among returning U.S. veterans and postdeployment personnel.

Method: In a parallel-groups, randomized controlled trial, participants received 12 sessions of PE followed by IRT (5 weeks) and CBT-I (7 weeks) or PE followed by 12 weeks supportive care therapy (SCT).

Results: PE did not improve sleep to a clinically meaningful degree, despite significant improvements in both Clinical Administered PTSD Scale and PTSD Checklist. Enhancing treatment with IRT/CBT-I led to greater improvements in insomnia (diary-recorded sleep efficiency) symptoms with large effect size, relative to SCT (p = .068, d = 1.07). There were large improvements in nightmare frequency relative SCT that did not reach statistical significance (p = .11, d = 0.90). Moreover, there was small improvement in daytime symptoms (Clinical Administered PTSD Scale) that did not reach statistical significance (p = .54, d = .31).

Conclusion: The addition of targeted, validated sleep treatment improves effects of PE and improves nighttime symptoms. Thus, evidence-based sleep treatment should be considered in comprehensive PTSD treatment. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Trial registration: ClinicalTrials.gov NCT01009112.

Conflict of interest statement

Conflicts of Interest

The authors declare no conflicts of interest associated with this publication.

Figures

Figure 1.

Consort chart.

Figure 2.

M ± SD scores at week 0 (baseline) and 6 (post-PE). Arrows indicate direction of improvement. Dotted lines indicate clinical thresholds used: for CAPS, Moderately severe (60) and Probably PTSD (40); Sleep Efficiency 85%; Number of Nightmares 2/week. *p < .05, ***p<.001.

Figure 3.

M ± SD scores at each assessment – week 0 (pre-treatment), 6 (post-PE), 11 (post-IRT or 5 weeks SCT) and 18 (post-IRT/CBTI or 12 weeks SCT) for the Evidence-Based Sleep Treatment (blue/light grey) and SCT (red/dark grey) groups. For SCT, n = 11 (weeks 0 and 6) and n = 8 (weeks 11 and 18). For Evidence-Based Sleep Treatments, n = 12 (weeks 0 and 6), n = 6 (week 11) and n = 7 (week 18). Arrows indicate direction of improvement. Dotted lines indicate clinical thresholds used: for CAPS, Moderately severe (60) and Probably PTSD (40); Sleep Efficiency, 85%; Number of Nightmares, 2/week. * p < .05.