Changing outcomes: trauma, disordered sleep, and suicide

Most of us will experience significant trauma at some point in our lives. It remains unclear as to which individuals experiencing major trauma will develop acute stress disorder and the debilitating diagnosis of posttraumatic stress disorder (PTSD). The lifetime prevalence of PTSD now approaches 8.0% in the general population.¹ Debate persists as to whether PTSD is a disorder of human stress response or a psychodynamic response to extreme trauma. Efficacious treatment modalities have been developed using both perspectives. The most common symptoms of PTSD are disordered sleep and recurrent nightmares. These major PTSD diagnostic criteria are under the purview of the field of Sleep Medicine. PTSD is a diagnosis with well-defined criteria; the time since trauma differentiates between the diagnoses of acute stress disorder and PTSD (PTSD requires a chronicity of symptomatology for at least 3 months). Excellent treatment modalities exist for PTSD, each reported to have a > 80% positive response rate. These proven treatment modalities include prolonged exposure, eye movement desensitization and reprocessing, imagery rehearsal therapy, and continuous positive airway pressure therapy in individuals proven to have obstructive sleep apnea.² It is less clear as to what acute treatment is indicated after the experience of severe trauma.

Suicide is one of the world’s leading causes of death. For multiple reasons the robust association between PTSD and suicide is an understudied area. Any contribution to the very limited research addressing this association should be applauded, even when limited to the diffuse construct of suicidal ideation. Successful approaches to suicide prevention include an emphasis on social and family support, limiting access to lethal methods, and the treatment of underlying comorbid disorders. Currently in the United States, social support systems have limited monetary and political backing. Whereas most US suicides involve firearms, there has been a limited capacity for controlling access to firearms, even for individuals known to be actively involved in life termination. In the United States, the primary approach available for suicide prevention is the treatment of contributing and comorbid disorders.³

In this issue of the Journal of Clinical Sleep Medicine, the study by Reffi et al is a small assessment of the effects of major trauma on an understudied civilian intercity population.⁴ Such a longitudinal study can be used to help determine which acutely traumatized individuals are most likely to develop acute stress disorder/PTSD and their negative outcomes, including the most negative sequalae of suicide.⁵ These data indicate that severe trauma associated with symptoms of nightmares and insomnia potentiates suicidal ideation. Reported nightmares and insomnia in the weeks after trauma are an apparent marker for suicide risk. This is an important finding that deserves emphasis.

The treatment of insomnia and associated distress after an episode of acute trauma has been a matter of ongoing debate. Cognitive behavioral therapy (CBT) used acutely after trauma is one of the only therapeutic approaches that has shown potential for limiting symptomatic progression to acute stress disorder/PTSD.⁶ The use of medications in the situation of acute trauma is contentious. Historically, the acute use of sedatives, narcotics, and benzodiazepines has contributed to poor outcomes. Studies utilizing modern hypnotics with high efficacy, low toxicity, and low addiction and side-effect potential are too small and limited to produce generalized treatment suggestions.⁷ Further work and emphasis are clearly indicated.

DISCLOSURE STATEMENT

The author reports no conflicts of interest.