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Sourced from Classic Sleep Care- The Southern Sleep Society 2018 – Dr. Krakow’s lectures on PTSD and CPAP compliance gain attention among top sleep professionals.

This year I was invited to deliver two talks at the one of the oldest annual sleep society conferences, The Southern Sleep Society, at their 40th annual meeting. My talks delved into the “PTSD Sleep Clinic and Nightmare Triad Syndrome” and “Advanced PAP Therapy to Increase Compliance and Decrease Insomnia.” Both talks were received very well and sparked a number of discussions afterwards with several of my colleagues and other attendees. I would like to describe some of the hot topics that were broached from the comments and questions that emerged.

Several key points were offered in my talks and this bullet point summary will cover the most important ones. The first talk covered PTSD topics:

  • In mental health circles, psychiatrists, psychologist and therapists still use the terminology of “sleep disturbances” when it should now be evident that mental health patients suffer from independent or co-morbid sleep disorders.
  • This sleep disorders distinction is highly relevant in the clinical environment, because PTSD patients in particular and mental health patients in general, are frequently receiving sub-standard care due to the lack of evidenced-based assessment and treatment of their sleep disorders.
  • Sleep professionals have a great deal to offer the mental health community. Including patients and professionals in providing the highest possible quality of sleep care because of our greater understanding about sleep disorders and our capacity to treat them.
  • Therefore, sleep professionals need not be defensive in attempting to help the mental health community – it makes the transition to more actively treating sleep disorders in their patients.
  • ‘The Nightmare Triad Syndrome’ is a prime example of this phenomenon, where in the past diagnostic criteria for PTSD included nightmares and insomnia as symptoms. Now, not only are the nightmares and insomnia recognized as independent treatable disorders in most trauma survivors, but sleep-disordered breathing in the form of OSA or UARS completes the triad and appears to occur with great frequency.
  • Treatment of any and all of these three common sleep disorders not only improves the sleep of PTSD patients, but all evidence to date strongly demonstrates (nightmares, insomnia) or suggests (OSA, UARS) that PTSD symptom severity decreases as well.
  • A key factor in these relationships appears to be how REM sleep manifests in sleep disorders patients. When REM is highly fragmented it not only worsens sleep disorders, but it appears to create a risk for developing PTSD. When REM sleep attains greater consolidation following evidence-based treatments, it appears to be associated with better outcomes.

The second talk delved into our work on advanced PAP therapy and compliance, including a discussion of many of our recent papers and current research projects:

  • Initially, segueing from the first talk, we looked at a couple of research groups who in the 1980s and 1990s predicted there would be a very strong relationship between REM sleep in the context of sleep-disordered breathing as a highly relevant clinical factor in PTSD patients.(1,2) This introduction concluded with Ali El-Solh’s recent work showing the correlation between increasing CPAP hours of use and decreasing PTSD symptoms.(3)
  • As part of this introduction, we briefly summarized our two most recent publications in which we demonstrated a strong association between the use of ABPAP or ASV in overcoming CPAP failure in general and PAP failure in PTSD patients in particular.(4, 5)
  • The cardinal principles underlying our work were described as a fastidious effort to normalize the airflow curve in OSA/UARS patients, which means aggressively targeting RERAs (flow limitation events) without triggering the problem of expiratory pressure intolerance.
  • Many examples were then provided showing how this fine tuning of the airflow curve (“rounding” on inspiration and expiration) leads to greater REM consolidation and better outcomes, including greater levels of PAP compliance.
  • Additional data were presented on our older and more recent work showing the benefits of advanced PAP on insomnia outcomes and in particular the potential advantages of ASV over CPAP in chronic insomnia disorder cases, including sleep onset insomnia as well as overall insomnia severity.(6-8)
  • In the current manuscript we are preparing for publication, we will show how the patients we recruited for the sample were unequivocally of a type consistent with chronic insomnia patients who present to primary care and mental health clinics. That is, they were not sleepy, overweight or complaining of sleep breathing symptoms. More importantly, they did report all manner of psychological symptoms and behavioral patterns typically described by chronic insomniacs. Creating a sample of this type means we were not looking at OSA patients who also had insomnia. Rather, we were looking at insomnia patients who never suspected they suffered from sleep breathing disorders. This approach means the research findings are highly relevant to other clinical populations where insomnia almost invariably presents with the focus on these psychological and behavioral issues. This elaboration also explains why it is has been so difficult for non-sleep specialists to recognize the OSA/UARS co-morbidity as only the insomnia problem is immediately visible to them during clinical encounters.
  • Finally, we delved into a new measuring tool we have begun using, “Normal Sleep Breathing Time” (NSBT), which is derived from starting with a patient’s total sleep time and subtracting out all the minutes of breathing-disrupted sleep fragmentation. What remains is NSBT, and our research shows that ASV patients had a larger percentage of normal sleep breathing than CPAP patients. We will speculate on whether this finding might explain why ASV patients report greater improvements in sleep quality compared to CPAP patients.

With this backdrop, several issues and questions were raised regarding familiar themes to anyone who reads this blog. And, unsurprisingly, there was a mixture of clinical and administrative (i.e. insurer barriers) concerns that were at the heart of most questions.

A large over-riding question and concern was how to deal with the insurers’ growing restrictions on the field of sleep medicine generally and on diagnostic/therapeutic decision-making for OSA specifically. Many individuals reported that they are seeing Medicare-creep, wherein the restrictive diagnostic criteria for other insurers increasingly embrace OSA. The two most obvious examples are the complete rejection of any recognition to the RERA scoring algorithms, that is, the flow limitation events of UARS and the further narrowing of hypopnea definitions by focusing on the 4% oxygen desaturation criteria. Though no one really knows with certainty how many people are being denied care for their OSA/UARS diagnoses due to these narrowly defined parameters, I have always assumed the proportion of cases who would meet eligibility with broader definitions numbers in the millions and potentially the tens of millions.

One of the critical facets to these issues is the conventional wisdom that continues to describe something called, “mild OSA” as a condition for which treatment is allegedly controversial. The problem with the construct of “mild OSA,” in my opinion, is that such cases rarely exist when a sleep professional takes into account either the full burden of the sleep breathing condition measured on a sleep study or the full burden the patient is reporting regarding daytime and nighttime symptoms.

Let’s examine the latter first. Suppose you are treating a young adult, female patient with so-called mild OSA, and who also reports extremely vexing nighttime insomnia. She also has a current psychiatric history of severe anxiety and PTSD, and both her sleeplessness and mental health are drastically curtailing her work productivity let alone her capacity to actually work full-time. Adding insult to injury she awakens twice per night due to nocturia episodes, and on each occasion she reports losing at least another hour of sleep trying to return to the Land of Nod. Not infrequently, she must use a sedative after the 2nd trip to the bathroom, which necessitates losing the first half of a day’s work. When she does arrive at work, the irritation in her employer’s face and voice increases her anxiety levels and further compromises her productivity. She knows the only reason she’s kept her job is she’s a very talented web designer who provides valuable services to the marketing department, but she worries about losing her job on a weekly basis and borders on panic whenever she notices her employer conducting job interviews.

Though the above is a relative composite for the sake of clarity, I have treated thousands of patients with very similar circumstances where the individual’s friends, family members and co-workers just don’t appreciate the distressing nature and impairing effects of insomnia. Such patients spend years trying out various medications, and when they finally make it to a sleep center, the sleep study is read out as “normal, borderline sleep apnea, or mild sleep apnea.” The patient is then told to avoid sleeping on her back and use good nasal hygiene. Instead, the main focus of the treatment could be:

1) Find a good therapist

2) Find the right prescription medication from your primary care physician

3) If lucky enough, return to our center for cognitive-behavioral therapy for insomnia (CBT-I).

The last of these, of course, is widely unavailable at most sleep centers. What is our (Maimonides Sleep Arts & Science) treatment approach to these patients? Quite simple. We first diagnose them properly with the UARS component of their mild OSA and explain that they essentially experience no normal sleep breathing the entire night. We then explain the connection between OSA/UARS and nocturia, a topic mentioned on this blog on various relevant posts, and at my recent TEDx talk. The patient then returns for a titration study where she quickly fails CPAP because of the problem of expiratory pressure intolerance. Switched over to a bilevel (BPAP), auto-bilevel (ABPAP) or as appropriate to adaptive servo-ventilation (ASV) PAP mode, the patient experiences the highest quality of slumber she’s felt in a decade. In fact, the effects of PAP are so dramatic, she reports vivid dreaming for the first time in years; and, she is astonished by the fact that she never awakened to use the bathroom.

As I noted at the conference, this relationship between insomnia and sleep breathing does NOT mean a patient will cure insomnia only with PAP. To be sure, many of these patients still need psychotherapy or CBT-I or both, and some still need medications. But, for starters, this patient’s life can be completely turned around by eliminating her nocturia, and these results have short and long-term benefits. Last, the patient understands experientially and intellectually why the construct of “mild OSA” was largely inaccurate in assessing her condition just on the basis of the nocturia angle for starters. Several of these points are frequently omitted throughout clinical care models for chronic insomnia provided within the field of sleep medicine, and as our discussion continues we will describe other similar perplexing trends.



  1. Reynolds CF 3rd, Coble PA, Spiker DG, Neil JF, Holzer BC, Kupfer DJ. Prevalence of sleep apnea and nocturnal myoclonus in major affective disorders: clinical and polysomnographic findings. J Nerv Ment Dis. 1982 Sep;170(9):565-7.
  2. Youakim JM1, Doghramji K, Schutte SL. Psychosomatics. Posttraumatic stress disorder and obstructive sleep apnea syndrome. 1998 Mar-Apr;39(2):168-71.
  3. El-Solh AA, Vermont L, Homish GG, Kufel T. The effect of continuous positive airway pressure on post-traumatic stress disorder symptoms in veterans with post-traumatic stress disorder and obstructive sleep apnea: a prospective study. Sleep Med. 2017 May;33:145-150.
  4. Krakow B, Ulibarri VA, McIver ND, Yonemoto C, Tidler A, Obando J, Foley-Shea MR, Ornelas J, Dawson S. Reversal of PAP Failure With the REPAP Protocol. Respir Care. 2017 Apr;62(4):396-408.
  5. Krakow BJ, Obando JJ, Ulibarri VA, McIver ND. Positive airway pressure adherence and subthreshold adherence in posttraumatic stress disorder patients with comorbid sleep apnea. Patient Prefer Adherence. 2017 Nov 20;11:1923-1932.
  6. Krakow B, Ulibarri VA, Romero EA, Thomas RJ, McIver ND. Adaptive servo-ventilation therapy in a case series of patients with co-morbid insomnia and sleep apnea. Journal of Sleep Disorders: Treatment and Care 2013;2:1-10.
  7. Krakow B, Ulibarri VA, McIver ND, Nadorff MR.A Novel Therapy for Chronic Sleep-Onset Insomnia: A Retrospective, Nonrandomized Controlled Study of Auto-Adjusting, Dual-Level, Positive Airway Pressure Technology. Prim Care Companion CNS Disord. 2016 Sep 29;18(5).
  8. Krakow B, McIver ND, Ulibarri VA, Nadorff MR. Retrospective, nonrandomized controlled study on autoadjusting, dual-pressure positive airway pressure therapy for a consecutive series of complex insomnia disorder patients. Nat Sci Sleep. 2017 Mar 10;9:81-95.