Obstructive Sleep Apnea (OSA) and Posttraumatic Stress Disorder (PTSD). Two prevalent conditions among veterans, often overlap and compound each other’s effects. Veterans, due to the intense stress and experiences of combat are particularly vulnerable to these conditions.

The connection between OSA and PTSD can lead to significant health challenges. Affecting both physical and mental well-being. How exactly are these two conditions connected? And what can be done to address this critical health issue?

Prevalence of OSA Among Veterans

OSA is a sleep disorder characterized by repeated interruptions in breathing during sleep, leading to poor sleep quality and various health issues. Among veterans, OSA is particularly common due to several contributing factors. Including age, weight and lifestyle. Studies have shown that the prevalence of OSA in the veteran population is notably higher than in the general population.

The high prevalence can be attributed to risk factors such as obesity. Which is more common among veterans due to lifestyle changes post-service and the physical demands of military life.

Prevalence of PTSD Among Veterans

PTSD is a mental health condition triggered by experiencing or witnessing traumatic events, common among veterans who have been exposed to combat and other traumatic situations. The U.S. Department of Veterans Affairs reports that PTSD affects about more than 20% of veterans who served in Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) in a given year. This prevalence is considerably higher compared to the general population. Where the lifetime prevalence of PTSD is estimated to be around 4%.

The high rates of PTSD among veterans are linked to the intense and often traumatic experiences encountered during military service. Combat exposure, witnessing injuries or deaths and experiencing personal harm all contribute to the development of PTSD in this population.

Why Are Veterans at Higher Risk for Both Conditions?

Veterans are at a heightened risk for both OSA and PTSD due to unique aspects of military service and post-service life. So understanding these risk factors can help develop targeted interventions and support systems for veterans.

Risk Factors for OSA Among Veterans

Several factors contribute to the increased risk of OSA among veterans:

  1. Obesity: Weight gain is a significant risk factor for OSA. And many veterans experience weight gain after leaving the military. The transition to civilian life often involves changes in diet and physical activity contributing to obesity.
  2. Age: The risk of OSA increases with age and many veterans are middle-aged or older. Moroever, the natural aging process can lead to decreased muscle tone in the airway. Which increase the likelihood of airway obstruction during sleep.
  3. Lifestyle Factors: Veterans may have lifestyle habits that contribute to OSA. Such as smoking and alcohol use. Both smoking and alcohol can exacerbate OSA symptoms by relaxing the airway muscles or causing inflammation.

Risk Factors for PTSD Among Veterans

Additionally, the risk of PTSD among veterans is influenced by several key factors related to their military service:

  1. Combat Exposure: Veterans who have been in combat situations are at a higher risk of developing PTSD. The stress and trauma associated with combat, including exposure to life-threatening situations, witnessing deaths and experiencing injury, significantly contribute to PTSD.
  2. Military Sexual Trauma (MST): MST, which includes sexual assault or harassment experienced during military service is another critical risk factor for PTSD. The VA reports  that MST is experienced by both male and female veterans, further increasing their risk of developing PTSD.
  3. Lack of Support: The transition from military to civilian life can be challenging. And a lack of social and psychological support during this period can increase the risk of PTSD. Veterans may struggle with feelings of isolation and difficulty adjusting to civilian life which can exacerbate PTSD symptoms.

Combined Impact of OSA and PTSD

The co-occurrence of OSA and PTSD in veterans can lead to a compounded impact on their health and well-being. The presence of OSA can exacerbate PTSD symptoms by disrupting sleep, leading to increased irritability, anxiety and cognitive impairment. Conversely, PTSD can worsen OSA by increasing arousal and stress levels which can further disrupt sleep patterns.

What Does the Recent Study Reveal About the OSA-PTSD Connection Among Veterans?

A recent study titled  “Obstructive Sleep Apnea and Posttraumatic Stress Disorder among OEF/OIF/OND Veterans” provides insightful findings on the connection between Obstructive Sleep Apnea (OSA) and Posttraumatic Stress Disorder (PTSD) in veterans.

This study clears the prevalence, contributing factors and implications of OSA in veterans who have experienced PTSD. Particularly those from Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND).

Prevalence of OSA in Veterans with PTSD

The study found that 69% of OEF/OIF/OND veterans presenting to a VA outpatient PTSD clinic screened as high risk for OSA. This is slightly higher than the rates found in other similar studies, which reported rates between 61% and 67%.

These findings underline a significant overlap between PTSD and OSA in this population. Veterans with PTSD are at a notably higher risk for developing OSA compared to the general population.

Contributing Factors

Several factors contribute to the higher prevalence of OSA in veterans with PTSD. One explanation is the shared risk factors in a military population. Such as prolonged sleep deprivation, sleep fragmentation and hyperarousal due to the physical and psychological stressors of combat. These conditions can exacerbate both PTSD and OSA. Chronic stress from PTSD may increase the likelihood of developing OSA. And conversely, the sleep disturbances caused by OSA may worsen PTSD symptoms.

The study also found that greater PTSD symptom severity increased the probability of screening as high risk for OSA. This was particularly evident when considering symptoms such as trouble falling or staying asleep and disturbing dreams. Which are common in PTSD and can contribute to sleep fragmentation, a key factor in OSA.

Screening and Diagnosis

The study highlights the need for effective screening and diagnosis of OSA in veterans with PTSD. While the Berlin OSA questionnaire was used for screening, it has not been validated specifically for a PTSD population. Raising concerns about potential false positives. However the high rates of OSA found in this and other studies suggest that further validation of the Berlin questionnaire or other screening tools in this population is warranted.

Polysomnography (PSG) remains the gold standard for diagnosing OSA. And the study found that more than three-quarters of the veterans who underwent PSG had an Apnea-Hypopnea Index (AHI) greater than 5, indicating OSA.

This high rate of agreement between the Berlin questionnaire and PSG suggests that the Berlin may be a useful screening tool. But further research is needed to confirm its sensitivity and specificity in veterans with PTSD.

Implications for Clinical Practice

The study’s findings emphasize the importance of making OSA screening a standard aspect of care for returning veterans with PTSD. Given the strong association between OSA and PTSD, both primary care and mental health settings should prioritize screening for OSA. Ensuring access to diagnostic assessments such as PSG and effective OSA interventions is crucial for improving the health and quality of life of veterans with PTSD.

Future Directions

The study calls for longitudinal studies to better understand the temporal relationship between PTSD and OSA. This would help clarify whether PTSD contributes to the development of OSA, if OSA exacerbates PTSD symptoms or if both conditions interact in a bidirectional manner. Such research could inform more effective clinical interventions and improve outcomes for veterans suffering from these debilitating conditions.

What Are the Consequences of Untreated OSA and PTSD?

Untreated Obstructive Sleep Apnea (OSA) and Posttraumatic Stress Disorder (PTSD) can have profound and far-reaching consequences on a veteran’s health and well-being. Both conditions independently contribute to significant physical and psychological distress. And when left untreated, they can exacerbate each other leading to a vicious cycle of worsening symptoms.

Consequences of Untreated OSA

If untreated, OSA can lead to a range of health issues, including:

  1. Cardiovascular Problems: OSA is strongly associated with an increased risk of hypertension, heart disease, stroke, and arrhythmias. The repeated drops in blood oxygen levels during apneic episodes put significant strain on the cardiovascular system.
  2. Daytime Fatigue and Cognitive Impairment: Individuals with untreated OSA often experience excessive daytime sleepiness, reduced concentration, and memory problems. Also an overall decline in cognitive function, affecting their ability to work and engage in daily activities.
  3. Metabolic Disorders: OSA is linked to insulin resistance, type 2 diabetes, and obesity. The disruption in sleep patterns can interfere with hormone regulation, leading to weight gain and metabolic dysfunction.

Consequences of Untreated PTSD

As we mentioned earlier, veterans are particularly susceptible to PTSD due to the nature of their service. Untreated PTSD can lead to:

  1. Mental Health Deterioration: Veterans with untreated PTSD may experience worsening symptoms of anxiety, depression and emotional numbness. This can lead to social withdrawal, strained relationships, and a decreased quality of life.
  2. Increased Risk of Substance Abuse: Many veterans with untreated PTSD may turn to alcohol or drugs as a way to cope with their symptoms. This can result in substance abuse disorders, further complicating their mental health and overall well-being.
  3. Physical Health Decline: PTSD is associated with a range of physical health problems, including chronic pain, gastrointestinal issues, and an increased risk of developing chronic illnesses.

How Can Veterans Access Help for OSA and PTSD?

Fortunately, help is available for veterans struggling with OSA and PTSD. Handling these conditions early can prevent the worsening of symptoms and improve overall health outcomes.

Accessing Help for OSA

The Insomnia and Sleep Institute of Arizona specializes in diagnosing and treating Obstructive Sleep Apnea (OSA). Our fellowship-trained and board-certified sleep medicine physicians work closely with clinical psychologists who specialize in Cognitive Behavioral Therapy for Insomnia (CBT-I).

We are committed to providing personalized care tailored to each individual’s needs. Utilizing advanced diagnostic tools, we offer a range of treatment options. Including CPAP therapy, lifestyle interventions, and CBT-I. Our main goal is to effectively manage OSA and improve your overall sleep health.

So if you or a loved one is struggling with symptoms of OSA or PTSD, don’t wait to seek help. Contact us today.

Accessing Help for PTSD

And for veterans dealing with PTSD, our TMS Institute of Arizona also offer a specialized care using innovative treatments such as Transcranial Magnetic Stimulation (TMS). This FDA-approved, non-invasive therapy has shown promise in reducing PTSD symptoms and improving overall mental health. Our clinic is committed to supporting veterans through their recovery journey, providing compassionate care that addresses their unique challenges.

References:
Colvonen, P. J., Masino, T., Sean P.A. Drummond, Myers, U. S., Angkaw, A. C., & Norman, S. B. (2015). Obstructive Sleep Apnea and Posttraumatic Stress Disorder among OEF/OIF/OND Veterans. Journal of Clinical Sleep Medicine, 11(05), 513–518. https://doi.org/10.5664/jcsm.4692

Orr, N., Carter, K., Collen, J. F., Hoffman, M., Holley, A. B., & Lettieri, C. J. (2010). Prevalence of Sleep Disorders Among Soldiers With Combat-Related Posttraumatic Stress Disorder. CHEST Journal, 138(4), 704A704A. https://doi.org/10.1378/chest.10975

‌Vets, non-vets work together to understand PTSD. (2022, November 14). NSF – National Science Foundation. https://new.nsf.gov/science-matters/vets-non-vets-work-together-understand-ptsd

What is MST? Military Sexual Trauma. (2024, March 5). DAV. https://www.dav.org/get-help-now/veteran-topics-resources/military-sexual-trauma-mst/

World. (2024, May 27). Post-traumatic stress disorder. Who.int; World Health Organization: WHO. https://www.who.int/news-room/fact-sheets/detail/post-traumatic-stress-disorder

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