Sleep continuity disturbance (also known as insomnia) and fatigue are common complaints of individuals diagnosed with cancer. Traditionally, many have believed that sleep continuity disturbance and fatigue are caused, in large measure, by the impact of the cancer diagnosis and treatment. Recent prospective research suggests however, that sleep continuity disturbance and fatigue may actually precede a cancer diagnosis. We suggest that sleep continuity disturbance and fatigue may in fact represent prodromal symptoms of cancer. We review the current perspectives of this sequence of events and present a revised schematic that accounts for the role of biological, behavioural, and cognitive factors that contribute to the development and maintenance of sleep continuity disturbances in cancer patients. Monitoring emergent and unexplained patient-reported fatigue, sleepiness, and insomnia may serve as early warning signs of new onset cancer, providing opportunity for early detection and early intervention.

Study objectives

Examine whether cognitive behavioral therapy for insomnia (CBT-I) improves sleep in posttraumatic stress disorder (PTSD) as well as nightmares, nonsleep PTSD symptoms, depression symptoms, and psychosocial functioning.

Design

RANDOMIZED CONTROLLED TRIAL WITH TWO ARMS: CBT-I and monitor-only waitlist control.

Setting

Department of Veterans Affairs (VA) Medical Center.

Participants

Forty-five adults (31 females: [mean age 37 y (22-59 y)] with PTSD meeting research diagnostic criteria for insomnia, randomly assigned to CBT-I (n = 29; 22 females) or monitor-only waitlist control (n = 16; nine females).

Interventions

Eight-session weekly individual CBT-I delivered by a licensed clinical psychologist or a board-certified psychiatrist.

Measurements and results

Measures included continuous monitoring of sleep with diary and actigraphy; prepolysomnography and postpolysomnography and Clinician-Administered PTSD Scale (CAPS); and pre, mid, and post self-report questionnaires, with follow-up of CBT-I participants 6 mo later. CBT-I was superior to the waitlist control condition in all sleep diary outcomes and in polysomnography-measured total sleep time. Compared to waitlist participants, CBT-I participants reported improved subjective sleep (41% full remission versus 0%), disruptive nocturnal behaviors (based on the Pittsburgh Sleep Quality Index-Addendum), and overall work and interpersonal functioning. These effects were maintained at 6-mo follow-up. Both CBT-I and waitlist control participants reported reductions in PTSD symptoms and CAPS-measured nightmares.

Conclusions

Cognitive behavioral therapy for insomnia (CBT-I) improved sleep in individuals with posttraumatic stress disorder, with durable gains at 6 mo. Overall psychosocial functioning improved following CBT-I. The initial evidence regarding CBT-I and nightmares is promising but further research is needed. Results suggest that a comprehensive approach to treatment of posttraumatic stress disorder should include behavioral sleep medicine.

Clinical trial information

TRIAL NAME: Cognitive Behavioral Treatment Of Insomnia In Posttraumatic Stress Disorder. URL: http://clinicaltrials.gov/ct2/show/NCT00881647.

Registration number

NCT00881647.