The Impact of Integrated CBT-I and PE on Sleep and PTSD Outcomes

在越南，创伤后应激障碍（PTSD）的终生患病率约为30 退伍军人和11-17%的伊拉克和阿富汗退伍军人。创伤后应激障碍与巨大的医疗保健有关 成本，自杀倾向增加，抑郁，生活质量和功能较差，身体健康， 物质使用。长期暴露（PE）是一种有效的治疗退伍军人与PTSD，减少 避免害怕但安全的暗示尽管PE是PTSD最好的治疗方法之一，但25至 45%的PTSD患者在治疗后仍然符合诊断标准。高比例的共病疾病，如 如失眠，可能干扰PE的疗效并限制长期康复结果。 在患有创伤后应激障碍的退伍军人中，睡眠障碍几乎是普遍的，70 - 87%的人报告共病 失眠未经治疗的失眠可以持续多年，是独立与受损的健康相关的 生活质量，在PTSD治疗后不能解决，并且可以加重白天的PTSD症状。 重要的是，失眠可能会通过安全学习，习惯于恐惧， 刺激，情绪应对，情绪处理和认知能力是成功治疗所必需的。 尽管如此，失眠并不是创伤后应激障碍退伍军人的主要干预措施。考虑到这些因素， 评估在PTSD之前治疗失眠是否会改善PTSD症状和生活质量结果。 认知行为治疗失眠（CBT-I）是治疗慢性和严重失眠症的一线药物。 失眠症，这会持续改善睡眠。通过在PE之前使用CBT-I并与PE结合使用 提供了几个新的优势，将：1）增加以客户为中心的治疗，通过解决头号 创伤后应激障碍退伍军人中主观抱怨; 2）通过以下方式提高创伤后应激障碍的结果和无应答率： 解决失眠相关的因素，干扰创伤后应激障碍的治疗; 3）作为一个垫脚石，并帮助 让最初不愿意参与创伤性PE的患者参与; 4）增加康复 通过解决独立影响退伍军人生活质量的两种主要疾病的结果; 5）允许 患者在更短的时间内解决失眠和创伤后应激障碍的症状; 6）增加连续性 通过允许患者与单一提供者一起工作;以及7）减少转诊诊所之间的流失风险 和waitlists。到目前为止，还没有研究利用现有的循证CBT-I在PE之前改善 失眠、创伤后应激障碍和生活质量结果。 拟议的CDA-2随机对照试验将评估整合循证CBT-I的有效性 与非活动性睡眠成分加PE（苯妥英钠-PE）相比， 和90名退伍军人的生活质量结果。我们的研究有三个总体目标：目标1（主要成果）： 研究CBTI-PE与地塞米松-PE相比对退伍军人PTSD症状的疗效， 患有创伤后应激障碍和失眠症目标2（次要结局）：检查CBTI-PE对睡眠和 与对照组相比，患有PTSD的男性和女性退伍军人的生活质量结果 还有失眠目的3（中介）：研究睡眠是否中介治疗组之间的关系 和创伤后应激障碍症状的减少。 将失眠作为一个独立的目标与体育相结合，代表了一个逻辑的，创新的， 用于增强现有治疗和优化符合 2014-2020年VHA战略计划。拟议研究的结果将直接告知临床实践， 研究失眠与创伤后应激障碍一起治疗是否会增加失眠，创伤后应激障碍的恢复， 生活质量结果。这项研究的转化计划将帮助脆弱的退伍军人群体 实现最佳和持久的恢复结果，并为未来的研究奠定基础， 研究失眠和PTSD治疗结果以及其他共病疾病之间的机制。

The lifetime prevalence of posttraumatic stress disorder (PTSD) is approximately 30% among Vietnam Veterans and 11-17% among Iraq and Afghanistan Veterans. PTSD is associated with enormous health care costs, increased suicidality, depression, poorer quality of life and functioning, physical health, and increased substance use. Prolonged exposure (PE) is an efficacious treatment for Veterans with PTSD that decreases avoidance of feared, but safe, cues. Despite PE being one of the best available treatments for PTSD, 25 to 45% of PTSD patients still meet diagnostic criteria following treatment. High rates of comorbid disorders, such as insomnia, may interfere with the efficacy of PE and limit long-term rehabilitation outcomes. Among Veterans with PTSD, sleep disturbances are nearly universal with 70 - 87% reporting comorbid insomnia. Untreated insomnia can persist for years, is independently associated with impaired health-related quality of life, does not resolve following PTSD treatment, and can exacerbate daytime PTSD symptoms. Importantly, insomnia may interfere with the mechanisms of PE through safety learning, habituation to feared stimuli, emotional coping, emotional processing, and cognitive abilities necessary for successful treatment. Despite this, insomnia is not a primary intervention for Veterans with PTSD. Given these factors, it is critical to evaluate whether treating insomnia prior to PTSD will improve PTSD symptoms and quality of life outcomes. Cognitive behavioral treatment for insomnia (CBT-I) is the first line treatment of chronic and severe insomnia, which produces lasting improvements in sleep. By using CBT-I prior to, and integrated with, PE offers several novel advantages that will: 1) increase client-centered treatment by addressing the number one subjective complaint among Veterans with PTSD; 2) enhance PTSD outcomes and non-response rates by addressing insomnia-related factors that interfere with PTSD treatment; 3) act as a stepping stone and help to engage patients who are not initially willing to engage in trauma-focused PE; 4) increase rehabilitation outcomes by addressing the two leading disorders that independently affect quality of life for Veterans; 5) allow patients to address both symptoms of insomnia and PTSD within a shortened timeframe; 6) increase continuity by allowing patients to work with a single provider; and 7) decrease the risk of attrition between referral clinics and waitlists. To date, no studies have capitalized on available evidence-based CBT-I prior to PE to improve insomnia, PTSD, and quality of life outcomes. The proposed CDA-2 randomized control trial will evaluate the efficacy of integrating evidence based CBT-I into PE (CBTI-PE) compared to a non-active sleep component plus PE (hygiene-PE) to optimize PTSD, sleep, and quality of life outcomes in 90 Veterans. Our research has three overarching aims: Aim1 (primary outcome): Investigate the efficacy of CBTI-PE compared to hygiene-PE on PTSD symptoms among Veterans with comorbid PTSD and insomnia. Aim 2 (secondary outcomes): Examine the effects CBTI-PE on sleep and quality of life outcomes, when compared to a control group, in male and female Veterans with comorbid PTSD and insomnia. Aim 3 (Mediation): Investigate whether sleep mediates the relationship between treatment group and the decreases in PTSD symptoms. Approaching insomnia as an independent target integrated with PE represents a logical, innovative, and empirically-informed method for augmenting existing treatments and optimizing outcomes consistent with the 2014-2020 VHA Strategic Plan. Findings from the proposed study will directly inform clinical practice by investigating whether treating insomnia together with PTSD increases the recovery from insomnia, PTSD, and quality of life outcomes. This translational program of research will help vulnerable Veteran populations achieve optimal and enduring recovery outcomes as well as lay the groundwork for future studies to further investigate the mechanisms between insomnia and PTSD treatment outcomes and other comorbid disorders.