Persistence of sleep disturbances following cognitive-behavior therapy for posttraumatic stress disorder

Efficacy of Imagery Rehearsal Therapy and Cognitive Behavioral Therapy in Sexual Assault Victims With Posttraumatic Stress Disorder: A Randomized Controlled Trial

Sleep disturbances are common among sexual assault victims with posttraumatic stress disorder (PTSD), but cognitive behavioral therapy (CBT) for PTSD does not directly address sleep-related symptoms. Trauma-related sleep disturbances are associated with more impairment and contribute to the maintenance of PTSD. In this study, we evaluated the efficacy of a combination of CBT and nightmare therapy (imagery rehearsal therapy; IRT) compared to CBT alone for the treatment of PTSD. We recruited 42 adult victims of sexual assault who were suffering from PTSD and randomly assigned them to either the experimental (IRT + CBT) or control condition (waiting period followed by CBT). After CBT, both groups demonstrated significant decreases in nighttime symptoms (except nightmare frequency) and PTSD symptoms and showed improvements in functional impairment and mental health, ds = 0.13-0.83, ps = .005-.008. Outcomes between the two groups did not differ significantly after CBT; however, we observed medium to medium-large differences between the control group and experimental group in terms of nighttime symptoms, ds = 0.45-0.63. Although results did not clearly establish the superiority of IRT + CBT over CBT alone, they demonstrated that IRT yielded greater improvement in nighttime symptoms than the waiting period, ds = 0.72-1.13, ps = .006-.047 for all interaction effects. Findings suggest that targeting nightmares at the beginning of treatment for PTSD may yield rapid improvement in nighttime symptoms. This strategy could be useful for patients with time or resource constraints or those for whom nightmares are the primary complaint.

Sleep disturbances, posttraumatic stress, and psychological distress among survivors of the 2013 Super Typhoon Haiyan

Sleep disturbances and their relation with posttraumatic stress and general psychological distress were examined after the 2013 Super Typhoon Haiyan. Sleep disturbances were hypothesized to be associated with posttraumatic stress and general psychological distress in two samples of survivors across two time points (N = 361) in the Philippines. Sample 1 (n = 223) and Sample 2 (n = 138) were collected 18 months and 30 months after the storm, respectively. Results from structural regression modeling indicated that insomnia was associated with both posttraumatic stress and general psychological distress. Poor sleep quality was associated with posttraumatic stress but not with general psychological distress. Findings underscore the longer-term relationship between sleep disturbances and overall sleep quality to posttraumatic stress in the context of a natural disaster. Implications for public mental health interventions in disaster settings are discussed.

Cognitive Behavioral Therapy for Insomnia Reduces Fear of Sleep in Individuals With Posttraumatic Stress Disorder

STUDY OBJECTIVES

Our study aims were to examine (1) the association between fear of sleep and posttraumatic stress disorder (PTSD) symptoms, (2) the association between fear of sleep and subjective and objective insomnia symptoms and disruptive behaviors during sleep, and (3) whether fear of sleep decreases following cognitive behavioral therapy for insomnia (CBT-I).

METHODS

Forty-five adults with PTSD and insomnia participated in the study. Fear of sleep was assessed using the Fear of Sleep Inventory; PTSD symptoms were assessed using the Clinician Administered PTSD Scale; and sleep disturbance symptoms were assessed using the Insomnia Severity Index, polysomnography, sleep diaries, and the Pittsburgh Sleep Quality Index Addendum for PTSD. Participants were randomly assigned to 8 weeks of CBT-I (n = 29) or a waitlist control condition (n = 16).

RESULTS

Greater fear of sleep was associated with greater PTSD symptom severity, greater nightmare frequency, and greater hypervigilance intensity. Greater fear of sleep was associated with decreased wake after sleep onset (WASO), reduced total sleep time, and greater disruptive nocturnal behaviors. Following CBT-I, there was a significant reduction in fear of sleep compared to the waitlist condition. These improvements persisted 6 months later.

CONCLUSIONS

Fear of sleep was related to sleep disturbances specific to trauma rather than "classic" insomnia symptoms. Unexpectedly, greater fear of sleep was associated with reduced WASO. These results may be related to having a truncated sleep period and thus more consolidated sleep. Fear of sleep deceased following CBT-I despite not being a permissible target for this research protocol and not being related to insomnia symptoms.

CLINICAL TRIAL REGISTRATION

Registry: CinicalTrials.gov; Name: Treating People with Post-traumatic Stress Disorder with Cognitive Behavioral Therapy for Insomnia; Identifier: NCT00881647; URL: https://clinicaltrials.gov/ct2/show/NCT00881647.

Impact of Traumatic Stress on Sleep and Management Options in Women

After exposure to traumatic stress, women are at greater risk than men for developing symptoms of some psychiatric disorders, including insomnia and nightmares. Sleep disturbance is one of the most refractory symptoms of posttraumatic stress disorder. Women were included in a few studies that examined efficacy of psychological or pharmacologic interventions for trauma-related sleep disturbances. Studies demonstrated preliminary evidence for efficacy of cognitive behavioral therapy for insomnia, imagery rehearsal therapy, and combinations of these techniques in treating insomnia and nightmares in trauma-exposed women. Prazosin as an adjunct to ongoing treatment is a potentially efficacious strategy for treating trauma-related nightmares in women.

Recent Advancements in Treating Sleep Disorders in Co-Occurring PTSD

PURPOSE OF REVIEW

Comorbidity of posttraumatic stress disorder (PTSD) and insomnia, nightmares, and obstructive sleep apnea (OSA) is high. We review recent research on psychotherapeutic and pharmacological interventions for sleep disorders in PTSD.

RECENT FINDINGS

PTSD treatments decrease PTSD severity and nightmare frequency, but do not resolve OSA or insomnia. Research on whether insomnia hinders PTSD treatment shows mixed results; untreated OSA does interfere with PTSD treatment. Cognitive behavioral therapy for insomnia is the recommended treatment for insomnia; however, optimal ordering with PTSD treatment is unclear. PTSD treatment may be most useful for PTSD-related nightmares. CPAP therapy is recommended for OSA but adherence can be low. Targeted treatment of sleep disorders in the context of PTSD offers a unique and underutilized opportunity to advance clinical care and research. Research is needed to create screening protocols, determine optimal order of treatment, and elucidate mechanisms between sleep and PTSD treatments.

Sleep disturbances as predictors of prolonged exposure therapy effectiveness among veterans with PTSD

Sleep disturbances (SD) are pronounced in Veterans with posttraumatic stress disorder (PTSD). In clinical trials, SD have been shown to limit the effectiveness of evidence-based treatments for non-PTSD disorders. The purpose of this study was to investigate the relationships between pretreatment SD and the effectiveness of Prolonged Exposure (PE) therapy for Veterans with PTSD. Twenty-one Veterans completed the Pittsburgh Sleep Quality Index (PSQI) and the Clinician Administered PTSD Scale upon presenting to a PTSD specialty clinic. Veterans completed the PTSD Symptom Checklist-Civilian (PCL-C) at the initiation of PE and biweekly thereafter for the duration of treatment (96 total assessments). Correlations and hierarchical linear modeling were utilized to examine the potential impact of baseline sleep variables on the slope and magnitude of treatment outcomes. Higher PSQI total scores, and higher sleep latency and sleep medication use subscale scores were associated with higher PCL-C scores at baseline. Veterans evidenced significant reductions in PTSD symptoms during the course of the treatment study. Total PSQI scores and composites were not associated with reduced effectiveness of PE treatment or the slope of PTSD symptom changes. Sleep disturbances do not preclude Veterans from benefits derived from engagement in this gold standard PTSD intervention.

Effects of psychotherapies for posttraumatic stress disorder on sleep disturbances: Results from a randomized clinical trial

The effectiveness and mechanisms of psychotherapies for posttraumatic stress disorder (PTSD) in treating sleep problems is of interest. This study compared the effects of a trauma-focused and a non-trauma-focused psychotherapy on sleep, to investigate whether 1) sleep improves with psychotherapy for PTSD; 2) the degree of sleep improvement depends on whether the intervention is trauma or nontrauma-focused; 3) the memory-updating procedure in cognitive therapy for PTSD (CT-PTSD) is associated with sleep improvements; 4) initial sleep duration affects PTSD treatment outcome; and 5) which symptom changes are associated with sleep duration improvements. Self-reported sleep was assessed during a randomized controlled trial (Ehlers et al., 2014) comparing CT-PTSD (delivered weekly or intensively over 7-days) with emotion-focused supportive therapy, and a waitlist. Sleep duration was reported daily in sleep diaries during intensive CT-PTSD. CT-PTSD led to greater increases in sleep duration (55.2 min) and reductions in insomnia symptoms and nightmares than supportive therapy and the waitlist. In intensive CT-PTSD, sleep duration improved within 7 days, and sleep diaries indicated a 40-min sleep duration increase after updating trauma memories. Initial sleep duration was not related to CT-PTSD treatment outcome when initial PTSD symptom severity was controlled. The results suggest that trauma-focused psychotherapy for PTSD is more effective than nontrauma-focused therapy in improving self-reported sleep, and that CT-PTSD can still be effective in the presence of reduced sleep duration.

Pilot study comparing telephone to in-person delivery of cognitive-behavioural therapy for trauma-related insomnia for rural veterans

Introduction

It is estimated that 70% of patients with posttraumatic stress disorder (PTSD) have chronic insomnia. A recent meta-analysis examined cognitive-behavioural therapy for insomnia (CBT-I) in veterans with and without PTSD, and suggested that most studies had questionable methodology, but generally supported its effectiveness in this population. Further, while CBT-I via telehealth (i.e. using telecommunication and information technology to deliver health services) has shown effectiveness for primary insomnia, it has not been applied to PTSD-related insomnia.

Methods

Veterans with insomnia who were diagnosed with PTSD ( n = 12) or having significant subthreshold PTSD symptoms ( n = 6) on the Clinician Administered PTSD Scale were randomly assigned to receive CBT-I in-person ( n = 7) or by telephone ( n = 11), to pilot test the potential effectiveness, acceptability, and feasibility of administering CBT-I in rural veterans. A six-week CBT-I protocol was delivered, and the veteran’s insomnia was assessed at post-treatment and follow-up.

Results

Given the small sample size, Cohen’s d was used to detect group differences, finding large effect sizes favouring the in-person delivery, until three-months post-treatment when this difference diminished. Most veterans found the treatment acceptable, regardless of mode of delivery. Based on the results, a larger project is feasible. Feasibility for a larger project is favourable.

Discussion

In summary, our findings uphold and extend previous research. Specifically, current pilot data suggest that telephone-delivered CBT-I may be able to reduce trauma-related insomnia symptoms. Future trials are needed to assess the effectiveness of CBT-I delivered to rural veterans with posttraumatic insomnia.

Clinical, hemispheric, and autonomic changes associated with use of closed-loop, allostatic neurotechnology by a case series of individuals with self-reported symptoms of post-traumatic stress

BACKGROUND

The objective of this pilot study was to explore the use of a closed-loop, allostatic, acoustic stimulation neurotechnology for individuals with self-reported symptoms of post-traumatic stress, as a potential means to impact symptomatology, temporal lobe high frequency asymmetry, heart rate variability (HRV), and baroreflex sensitivity (BRS).

METHODS

From a cohort of individuals participating in a naturalistic study to evaluate use of allostatic neurotechnology for diverse clinical conditions, a subset was identified who reported high scores on the Posttraumatic Stress Disorder Checklist (PCL). The intervention entailed a series of sessions wherein brain electrical activity was monitored noninvasively at high spectral resolutions, with software algorithms translating selected brain frequencies into acoustic stimuli (audible tones) that were delivered back to the user in real time, to support auto-calibration of neural oscillations. Participants completed symptom inventories before and after the intervention, and a subset underwent short-term blood pressure recordings for HRV and BRS. Changes in temporal lobe high frequency asymmetry were analyzed from baseline assessment through the first four sessions, and for the last four sessions.

RESULTS

Nineteen individuals (mean age 47, 11 women) were enrolled, and the majority also reported symptom scores that exceeded inventory thresholds for depression. They undertook a median of 16 sessions over 16.5 days, and 18 completed the number of sessions recommended. After the intervention, 89% of the completers reported clinically significant decreases in post-traumatic stress symptoms, indicated by a change of at least 10 points on the PCL. At a group level, individuals with either rightward (n = 7) or leftward (n = 7) dominant baseline asymmetry in temporal lobe high frequency (23-36 Hz) activity demonstrated statistically significant reductions in their asymmetry scores over the course of their first four sessions. For 12 individuals who underwent short-term blood pressure recordings, there were statistically significant increases in HRV in the time domain and BRS (Sequence Up). There were no adverse events.

CONCLUSION

Closed-loop, allostatic neurotechnology for auto-calibration of neural oscillations appears promising as an innovative therapeutic strategy for individuals with symptoms of post-traumatic stress.

TRIALS REGISTRATION

ClinicalTrials.gov #NCT02709369 , retrospectively registered on March 4, 2016.

Nightmares and Suicide in Posttraumatic Stress Disorder: The Mediating Role of Defeat, Entrapment, and Hopelessness

STUDY OBJECTIVES

Although nightmares appear to be related to suicidal behaviors, the mechanisms which underpin this relationship are unknown. We sought to address this gap by examining a multiple mediation hypothesis whereby nightmares were predicted to have an indirect effect on suicidal behaviors through perceptions of defeat, entrapment, and hopelessness.

METHODS

Data were collected from 91 participants who had experienced trauma and symptoms of posttraumatic stress disorder (PTSD). Nightmares were measured by summing the frequency and intensity ratings of relevant items on the Clinician-Administered PTSD Scale. Participants also completed questionnaire measures of suicidal behavior, hopelessness, defeat, and entrapment. Given the interrelations between insomnia, PTSD, and suicide, a measure of insomnia was included as a covariate. Furthermore, analyses were conducted with and without those participants who had comorbid depression.

RESULTS

Suicidal behaviors were higher in those participants who experienced nightmares (62%), in comparison to those who did not (20%). Bootstrapped analyses provided support for the hypothesized multistep mediational model. Specifically, nightmares were both directly and indirectly associated with suicidal behaviors, through perceptions of defeat, entrapment, and hopelessness, independent of comorbid insomnia and depression.

CONCLUSIONS

For the first time we show that the relationship between nightmares and suicidal behaviors is partially mediated by a multistep pathway via defeat, entrapment, and hopelessness. Clinically, our work highlights the importance of monitoring and targeting nightmares and perceptions of defeat, entrapment, and hopelessness when working with clients who have experienced trauma.

COMMENTARY

A commentary on this article appears in this issue on page 289.

Influence of Sleep Disturbance on Global Functioning After Posttraumatic Stress Disorder Treatment

Chronic insomnia and recurrent nightmares are prominent features of posttraumatic stress disorder (PTSD). Evidence from adult research indicates that these sleep disturbances do not respond as well to cognitive-behavioral therapies for PTSD and are associated with poorer functional outcomes. This study examined the effect of prolonged exposure therapy for adolescents versus client-centered therapy on posttraumatic sleep disturbance, and the extent to which sleep symptoms impacted global functioning among adolescents with sexual abuse-related PTSD. Participants included 61 adolescent girls seeking treatment at a rape crisis center. The Child PTSD Symptom Scale-Interview (Foa, Johnson, Feeny, & Treadwell, 2001) was used to assess PTSD diagnosis and severity of symptoms, including insomnia and nightmares. The Children's Global Assessment Scale (Shaffer et al., 1983) was used to assess global functioning. There were significant main effects of time and treatment on insomnia symptoms. Additionally, there was a main effect of time on nightmares. Results also showed that insomnia and nightmares significantly predicted poorer global functioning posttreatment (R² = .21). Despite significant improvements in posttraumatic sleep disturbance, there were still clinically significant insomnia symptoms after treatment, suggesting that additional interventions may be warranted to address residual sleep disturbance in PTSD.

Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the future

Post-traumatic stress disorder (PTSD) is a serious psychiatric consequence of trauma that occurs in a proportion of individuals exposed to life-threatening events. Trauma-focused psychotherapy is often recommended as first choice for those who do not recover spontaneously. But many individuals require medications. In the US, only paroxetine (PRX) and sertraline (SRT) are FDA approved for PTSD. But response and remission rates with these medications are low, so numerous other pharmacologic interventions have been tried. To date, there has not been a systematic review of the data on what are the best next-step pharmacologic strategies for individuals who fail standard treatments. To that end, we review 168 published trials of medications other than PRX or SRT and provide a detailed analysis of the 88/168 studies that describe alternative pharmacologic interventions in patients refractory to other treatment. We also review clinical factors relevant to treatment-refractory PTSD; the neurobiology of extinction, as well as evidence-based psychotherapy and neuromodulation strategies for this condition.

Potential pleiotropic beneficial effects of adjuvant melatonergic treatment in posttraumatic stress disorder

Loss of circadian rhythmicity fundamentally affects the neuroendocrine, immune, and autonomic system, similar to chronic stress and may play a central role in the development of stress-related disorders. Recent articles have focused on the role of sleep and circadian disruption in the pathophysiology of posttraumatic stress disorder (PTSD), suggesting that chronodisruption plays a causal role in PTSD development. Direct and indirect human and animal PTSD research suggests circadian system-linked neuroendocrine, immune, metabolic and autonomic dysregulation, linking circadian misalignment to PTSD pathophysiology. Recent experimental findings also support a specific role of the fundamental synchronizing pineal hormone melatonin in mechanisms of sleep, cognition and memory, metabolism, pain, neuroimmunomodulation, stress endocrinology and physiology, circadian gene expression, oxidative stress and epigenetics, all processes affected in PTSD. In the current paper, we review available literature underpinning a potentially beneficiary role of an add-on melatonergic treatment in PTSD pathophysiology and PTSD-related symptoms. The literature is presented as a narrative review, providing an overview on the most important and clinically relevant publications. We conclude that adjuvant melatonergic treatment could provide a potentially promising treatment strategy in the management of PTSD and especially PTSD-related syndromes and comorbidities. Rigorous preclinical and clinical studies are needed to validate this hypothesis.

Nightmare Frequency, Nightmare Distress and the Efficiency of Trauma-Focused Cognitive Behavioral Therapy for Post-Traumatic Stress Disorder

Background

Up to 71% of trauma victims diagnosed with PTSD have frequent nightmares (NM), compared to only 2% to 5% of the general population.

Objectives

The present study examined whether nightmares before the beginning of cognitive behavior therapy (CBT) for post-traumatic stress disorder (PTSD) could influence overall PTSD symptom reduction for 71 individuals with PTSD and different types of traumatic events.

Patients and Methods

Participants received a validated CBT of 20 weekly individual sessions. They were evaluated at five measurement times: at pre-treatment, after the third and ninth session, at post-treatment, and at 6 months follow-up.

Results

The presence of nightmares did not impact overall CBT efficiency. Specific CBT components were efficient in reducing the frequency and distress of nightmares.

Conclusions

Most participants no longer had PTSD but some still had nightmares.

A systematic review of sleep disturbance in anxiety and related disorders

Recent research suggests that sleep disturbance may be a transdiagnostic process, and there is increasing interest in examining how sleep disturbance may contribute to anxiety and related disorders. The current review summarizes and synthesizes the extant research assessing sleep in anxiety and related disorders. The findings suggest that sleep disturbance exacerbates symptom severity in the majority of anxiety and related disorders. However, the nature of sleep disturbance often varies as a function of objective versus subjective assessment. Although sleep disturbance is a correlate of most anxiety and related disorders, a causal role for sleep disturbance is less clear. A model of potential mechanisms by which sleep disturbance may confer risk for the development of anxiety and related disorders is discussed. Future research integrating findings from basic sleep research with current knowledge of anxiety and related disorders may facilitate the development of novel treatments for comorbid sleep disturbance and clinical anxiety.

Augmenting cognitive processing therapy to improve sleep impairment in PTSD: A randomized controlled trial

OBJECTIVE

Despite the success of empirically supported treatments for posttraumatic stress disorder (PTSD), sleep impairment frequently remains refractory after treatment. This single-site, randomized controlled trial examined the effectiveness of sleep-directed hypnosis as a complement to an empirically supported psychotherapy for PTSD (cognitive processing therapy [CPT]).

METHOD

Participants completed either 3 weeks of hypnosis (n = 52) or a symptom monitoring control condition (n = 56) before beginning standard CPT. Multilevel modeling was used to investigate differential patterns of change to determine whether hypnosis resulted in improvements in sleep, PTSD, and depression. An intervening variable approach was then used to determine whether improvements in sleep achieved during hypnosis augmented change in PTSD and depression during CPT.

RESULTS

After the initial phase of treatment (hypnosis or symptom monitoring), the hypnosis condition showed significantly greater improvement than the control condition in sleep and depression, but not PTSD. After CPT, both conditions demonstrated significant improvement in sleep and PTSD; however, the hypnosis condition demonstrated greater improvement in depressive symptoms. As sleep improved, there were corresponding improvements in PTSD and depression, with a stronger relationship between sleep and PTSD.

CONCLUSION

Hypnosis was effective in improving sleep impairment, but those improvements did not augment gains in PTSD recovery during the trauma-focused intervention. (PsycINFO Database Record

Sleep diaries of Vietnam War veterans with chronic PTSD: the relationships among insomnia symptoms, psychosocial stress, and nightmares

Impaired sleep and nightmares are known symptoms of posttraumatic stress disorder (PTSD) in the veteran population. In order to assess prospectively the sleep disturbances in this population, sleep diaries are an effective way to obtain information over an extended period of time. In this investigation, a sample of veterans (N = 105) completed daily sleep diaries for a 6-week period. Greater PTSD severity and nightmare-related distress were correlated with more awakenings, shorter duration of sleep, longer sleep latency, and greater frequency of nightmares. Perceived frequency of daytime stressors was associated with an increased number of nightmares, nightmare-related distress, and longer sleep latency. The use of sleep diaries in future investigations may allow targeted treatments for veteran populations with PTSD and sleep disturbances.

Cognitive Behavioral Therapy for Insomnia and Imagery Rehearsal in Combat Veterans with Comorbid Posttraumatic Stress: A Case Series

Disrupted sleep is common among combat veterans and can negatively impact response to mental health treatments. A trial of cognitive behavioral therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT) for nightmares was conducted with 14 combat veterans diagnosed with insomnia, and who were experiencing posttraumatic stress and/or depression. In the case-series that follows veterans experienced clinically significant changes in sleep, and statistically significant reductions in insomnia, nightmare, depression and posttraumatic stress severity following treatment. Combined CBT-I and IRT is a promising treatment for patients with combat-related trauma and psychiatric morbidity.

Cognitive-behavioral therapy for sleep disturbances in treating posttraumatic stress disorder symptoms: A meta-analysis of randomized controlled trials

Sleep disturbances are frequently reported in patients with posttraumatic stress disorder (PTSD). There is evidence that sleep disturbance is not only a secondary symptom but also a risk factor for PTSD. Sleep-specific psychological treatments provide an alternative to conventional trauma-focused psychological treatments. The current meta-analysis evaluated the efficacy of sleep-specific cognitive-behavioral therapy (CBT) in mitigating PTSD, sleep, and depressive symptoms. A total of 11 randomized controlled trials were included in the meta-analytic comparisons between sleep-specific CBT and waiting-list control groups at posttreatment. Random effects models showed significant reduction in self-report PTSD and depressive symptoms and insomnia severity in the sleep-specific CBT group. The corresponding effect sizes, measured in Hedges' g, were 0.58, 0.44, and 1.15, respectively. The effect sizes for sleep diary-derived sleep onset latency, wake after sleep onset, and sleep efficiency were 0.83, 1.02 and 1.15, respectively. The average study attrition rate of sleep-specific CBT was relatively low (12.8%), with no significant difference from the control group (9.4%). In conclusion, sleep-specific CBT appears to be efficacious and feasible in treating PTSD symptoms. Due to the relatively small number of randomized controlled trials available, further research is warranted to confirm its efficacy and acceptability, especially in comparison to trauma-specific psychological treatments.

Breathing exercise combined with cognitive behavioural intervention improves sleep quality and heart rate variability in major depression

AIMS AND OBJECTIVES

The aim of this study was to investigate the effects of a cognitive behavioural intervention combined with a breathing relaxation exercise on sleep quality and heart rate variability in patients with major depression.

BACKGROUND

Depression is a long-lasting illness with significant effects not only in individuals themselves, but on their family, work and social relationships as well. Cognitive behavioural therapy is considered to be an effective treatment for major depression. Breathing relaxation may improve heart rate variability, but few studies have comprehensively examined the effect of a cognitive behavioural intervention combined with relaxing breathing on patients with major depression.

DESIGN

An experimental research design with a repeated measure was used.

METHODS

Eighty-nine participants completed this study and entered data analysed. The experimental group (n = 43) received the cognitive behavioural intervention combined with a breathing relaxation exercise for four weeks, whereas the control group (n = 46) did not. Sleep quality and heart rate variability were measured at baseline, posttest1, posttest2 and follow-up. Data were examined by chi-square tests, t-tests and generalised estimating equations.

RESULTS

After adjusting for age, socioeconomic status, severity of disease and psychiatric history, the quality of sleep of the experimental group improved, with the results at posttest achieving significance. Heart rate variability parameters were also significantly improved.

CONCLUSIONS

This study supported the hypothesis that the cognitive behavioural intervention combined with a breathing relaxation exercise could improve sleep quality and heart rate variability in patients with major depression, and the effectiveness was lasting.

RELEVANCE TO CLINICAL PRACTICE

The cognitive behavioural intervention combined with a breathing relaxation exercise that included muscle relaxation, deep breathing and sleep hygiene could be provided with major depression during hospitalisation. Through group practice and experience sharing, participants could modulate their heart rate variability and share feeling about good sleep as well relaxation.

Responding to the need for sleep among survivors of interpersonal violence: A randomized controlled trial of a cognitive-behavioral insomnia intervention followed by PTSD treatment

Sleep disturbance is a common feature of posttraumatic stress disorder (PTSD), but is not a focus of standard PTSD treatments. Psychological trauma exposure is associated with considerable physical and mental health morbidity, possibly due to the alterations in neuroendocrine function and inflammation observed in trauma exposed individuals. Although PTSD treatments are efficacious, they are associated with high drop-out rates in clinical trials and clinical practice. Finally, individuals with PTSD stemming from exposure to interpersonal violence represent an especially under-treated population with significant sleep disturbance. Community-based participatory research was utilized to design and prepare a clinical trial that randomizes recent survivors of interpersonal violence who have PTSD, depression, and insomnia to receive either: (1) Cognitive Behavioral Therapy for Insomnia (CBTi) followed by Cognitive Processing Therapy (CPT) for trauma, or (2) attention control followed by CPT. Outcome measures include subjective and objective measures of sleep, clinician-administered PTSD and depression scales, inflammatory cytokines, and salivary cortisol. Assessments are conducted at baseline, following the sleep or control intervention, and again following CPT. The design allows for: (1) the first test of a sleep intervention in this population; (2) the comparison of sequenced CBTi and CPT to attention control followed by CPT, and (3) assessing the roles of neuroendocrine function, inflammatory processes, and objective sleep markers in mediating treatment outcomes. The study's overarching hypothesis is that treating insomnia will produce reduction in insomnia, PTSD, and depression severity, allowing patients to more fully engage in, and derive optimal benefits from, cognitive processing therapy.

Clarifying Heterogeneity of Daytime and Nighttime Symptoms of Post-traumatic Stress in Combat Veterans with Insomnia

Daytime and nighttime symptoms of posttraumatic stress disorder (PTSD) are common among combat veterans and military service members. However, there is a great deal of heterogeneity in how symptoms are expressed. Clarifying the heterogeneity of daytime and nighttime PTSD symptoms through exploratory clustering may generate hypotheses regarding ways to optimally match evidence-based treatments to PTSD symptom profiles. We used mixture modeling to reveal clusters based on six daytime and nighttime symptoms of 154 combat veterans with insomnia and varying levels of PTSD symptoms. Three clusters with increasing symptom severity were identified (N1=50, N2=70, N3=34). These results suggest that, among veterans with insomnia, PTSD symptoms tend to exist on a continuum of severity, rather than as a categorical PTSD diagnosis. Hypotheses regarding possible targeted treatment strategies for veterans within each identified cluster, as well as ways to generalize these methods to other groups within the military, are discussed.

Sleep disturbances, TBI and PTSD: Implications for treatment and recovery

Post-Traumatic Stress Disorder (PTSD), traumatic brain injury (TBI), and sleep problems significantly affect recovery and functional status in military personnel and Veterans returning from combat. Despite recent attention, sleep is understudied in the Veteran population. Few treatments and rehabilitation protocols target sleep, although poor sleep remains at clinical levels and continues to adversely impact functioning even after the resolution of PTSD or mild TBI symptoms. Recent developments in non-pharmacologic sleep treatments have proven efficacious as stand-alone interventions and have potential to improve treatment outcomes by augmenting traditional behavioral and cognitive therapies. This review discusses the extensive scope of work in the area of sleep as it relates to TBI and PTSD, including pathophysiology and neurobiology of sleep; existing and emerging treatment options; as well as methodological issues in sleep measurements for TBI and PTSD. Understanding sleep problems and their role in the development and maintenance of PTSD and TBI symptoms may lead to improvement in overall treatment outcomes while offering a non-stigmatizing entry in mental health services and make current treatments more comprehensive by helping to address a broader spectrum of difficulties.

Anxiety disorders and comorbid sleep problems in school-aged youth: review and future research directions

This review examines the relationship between anxiety disorders and sleep related problems (SRPs) in school-aged youth. Following an overview of normative sleep patterns and maturational sleep changes, the review addresses issues related to sleep measurement. SRPs are reviewed in relation to executive functions (e.g. affect regulation) as is the shared role of neurological regions in the regulation of anxiety and sleep. Studies of the association between SRPs and anxiety in anxiety-disordered samples are reviewed with explicit consideration of the potential mechanisms underlying the sleep-anxiety relationship (e.g., arousal, sleep hygiene, parental accommodation). Specific cognitive-behavioral treatments for SRPs and anxiety are reviewed with regard to their impact on comorbid anxiety or SRPs. Methodological limitations are noted and recommendations for future research are proposed.

Treatment of Sleep Disturbances in Post-Traumatic Stress Disorder: A Review of the Literature

Sleep disturbances are among the most commonly endorsed symptoms of post-traumatic stress disorder (PTSD). Treatment modalities that are effective for the waking symptoms of PTSD may have limited efficacy for post-traumatic sleep problems. The aim of this review is to summarize the evidence for empirically supported and/or utilized psychotherapeutic and pharmacological treatments for post-traumatic nightmares and insomnia. While there are few controlled studies of the applicability of general sleep-focused interventions to the management of the sleep disturbances in PTSD, evidence is growing to support several psychotherapeutic and pharmacological treatments. Future investigations should include trials that combine treatments focused on sleep with treatments effective in managing the waking symptoms of PTSD.

Sleep outcomes in youth with chronic pain participating in a randomized controlled trial of online cognitive-behavioral therapy for pain management

Sleep disturbances are commonly reported in youth with chronic pain. We examined whether online cognitive-behavioral therapy (CBT) for pain management would impact youth's sleep. Subjective sleep quality and actigraphic sleep were evaluated in 33 youth (M = 14.8 years; 70% female) with chronic pain participating in a larger randomized controlled trial of online-CBT. The Internet treatment condition (n = 17) received 8-10 weeks of online-CBT + standard care, and the wait-list control condition (n = 16) continued with standard care. Although pain improved with online-CBT, no changes were observed in sleep outcomes. Shorter pretreatment sleep duration was associated with less improvement in posttreatment functioning. Findings underscore the need for further development in psychological therapies to more intensively target sleep loss in youth with chronic pain.

A psychometric study of the Fear of Sleep Inventory-Short Form (FoSI-SF)

STUDY OBJECTIVES

Fear of sleep may play a significant role in sleep disturbances in individuals with posttraumatic stress disorder (PTSD). This report describes a psychometric study of the Fear of Sleep Inventory (FoSI), which was developed to measure this construct.

METHODS

The psychometric properties of the FoSI were examined in a non-clinical sample of 292 college students (Study I) and in a clinical sample of 67 trauma-exposed adults experiencing chronic nightmares (Study II). Data on the 23 items of the FoSI were subjected to exploratory factor analyses (EFA) to identify items uniquely assessing fear of sleep. Next, reliability and validity of a 13-item version of the FoSI was examined in both samples.

RESULTS

A 13-item Short-Form version (FoSI-SF) was identified as having a clear 2-factor structure with high internal consistency in both the non-clinical (α = 0.76-0.94) and clinical (α = 0.88-0.91) samples. Both studies demonstrated good convergent validity with measures of PTSD (0.48-0.61) and insomnia (0.39-0.48) and discriminant validity with a measure of sleep hygiene (0.19-0.27). The total score on the FoSI-SF was significantly higher in the clinical sample (mean = 17.90, SD = 12.56) than in the non-clinical sample (mean = 4.80, SD = 7.72); t(357) = 8.85 p < 0.001.

CONCLUSIONS

Although all items are recommended for clinical purposes, the data support the use of the 13-item FoSI-SF for research purposes. Replication of the factor structure in clinical samples is needed. Results are discussed in terms of limitations of this study and directions for further research.

Comparative meta-analysis of prazosin and imagery rehearsal therapy for nightmare frequency, sleep quality, and posttraumatic stress

STUDY OBJECTIVE

In this meta-analysis, we compare the short-term efficacy of prazosin vs. IRT on nightmares, sleep quality, and posttraumatic stress symptoms (PTSS).

METHODS

Reference databases were searched for randomized controlled trials using IRT or prazosin for nightmares, sleep disturbance, and/or PTSS. Effect sizes were calculated by subtracting the mean posttest score in the control group from the mean posttest score in the treatment group, and dividing the result by the pooled standard deviation of both groups. Mixed effects models were performed to evaluate effects of treatment characteristics, as well as sample characteristics (veteran vs. civilian) on treatment efficacy.

RESULTS

Four studies used prazosin, 10 used IRT alone or in combination with another psychological treatment, and 1 included a group receiving prazosin and another group receiving IRT. Overall effect sizes of both treatments were of moderate magnitude for nightmare frequency, sleep quality, and PTSS (p < 0.01). Effect size was not significantly different with type of treatment (psychological vs. pharmacological) on nightmare frequency (p = 0.79), sleep quality (p = 0.65), or PTSS, (p = 0.52). IRT combined with CBT for insomnia showed more improvement in sleep quality compared to prazosin (p = 0.03), IRT alone (p = 0.03), or IRT combined with another psychological intervention, (p < 0.01).

CONCLUSION

Although IRT interventions and prazosin yield comparable acute effects for the treatment of nightmares, adding CBT for insomnia to IRT seems to enhance treatment outcomes pertaining to sleep quality and PTSS. More randomized clinical trials with long-term follow-up are warranted.

COMMENTARY

A commentary on this article appears in this issue on page 9.

Exploring the role of insomnia in the relation between PTSD and pain in veterans with polytrauma injuries

BACKGROUND

Soldiers returning from Operation Enduring Freedom/Operation Iraqi Freedom experience polytrauma injuries including traumatic brain injury. Traumatic brain injury is often complicated by symptoms of insomnia, posttraumatic stress disorder (PTSD), and pain that can impact treatment and rehabilitation.

METHODS

The medical records of 137 veterans seen at a Veterans Affairs Medical Center Polytrauma clinic who sustained traumatic brain injury in combat were reviewed for this study. Demographic variables include age, sex, ethnicity, military branch, and service connection. Outcome measures include PTSD, pain, and insomnia.

RESULTS

Analyses revealed a high prevalence of PTSD, insomnia, and pain co-occurring in 51.8% of veterans. Increased PTSD symptomatology was significantly correlated with reports of more pain severity (r = 0.53), pain interference (r = 0.61), and insomnia (r = 0.67). Further analyses, controlling for service connection, indicated that insomnia partially mediated the relation between PTSD and both pain severity and interference.

CONCLUSIONS

These results highlight the overlap and complexity of presenting complaints in veterans and help identify the role of sleep disturbances in complicating diagnosis and treatment of veterans. As sleep problems reduce pain tolerance and exacerbate other symptoms, such as cognitive deficits and irritability, failure to address sleep disturbances may compromise rehabilitation efforts, suggesting the importance of a multidisciplinary team approach to assessing and treating these veterans.

When time stands still: an integrative review on the role of chronodisruption in posttraumatic stress disorder

PURPOSE OF REVIEW

The human circadian system creates and maintains cellular and systemic rhythmicity essential to homeostasis. Loss of circadian rhythmicity fundamentally affects the neuroendocrine, immune and autonomic system, similar to chronic stress and, thus, may play a central role in the development of stress-related disorders. This article focuses on the role of circadian misalignment in the pathophysiology of posttraumatic stress disorder (PTSD).

RECENT FINDINGS

Sleep disruption is a core feature of PTSD supporting the important supraordinate pathophysiological role of circadian system in PTSD. Furthermore, direct and indirect human and animal PTSD research suggests circadian system linked neuroendocrine, immune, metabolic and autonomic dysregulation with blunted diurnal rhythms, specific sleep pattern pathologies and cognitive deficits, as well as endocannabinoid and neuropeptide Y system alterations and altered circadian gene expression, linking circadian misalignment to PTSD pathophysiology.

SUMMARY

PTSD development is associated with chronodisruption findings. Evaluation and treatment of sleep and circadian disruption should be the first steps in PTSD management. State-of-the-art methods of circadian rhythm assessment should be applied to bridge the gap between clinical significance and limited understanding of the relationship between traumatic stress, sleep and circadian system.

Improvement of mood and sleep alterations in posttraumatic stress disorder patients by eye movement desensitization and reprocessing

Posttraumatic stress disorder (PTSD) patients exhibit depressive and anxiety symptoms, in addition to nightmares, which interfere with sleep continuity. Pharmacologic treatment of these sleep problems improves PTSD symptoms, but very few studies have used psychotherapeutic interventions to treat PTSD and examined their effects on sleep quality. Therefore, in the present study, we sought to investigate the effects of Eye Movement Desensitization Reprocessing therapy on indices of mood, anxiety, subjective, and objective sleep. The sample was composed of 11 healthy controls and 13 PTSD patients that were victims of assault and/or kidnapping. All participants were assessed before, and 1 day after, the end of treatment for depressive and anxiety profile, general well-being and subjective sleep by filling out specific questionnaires. In addition, objective sleep patterns were evaluated by polysomnographic recording. Healthy volunteers were submitted to the therapy for three weekly sessions, whereas PTSD patients underwent five sessions, on average. Before treatment, PTSD patients exhibited high levels of anxiety and depression, poor quality of life and poor sleep, assessed both subjectively and objectively; the latter was reflected by increased time of waking after sleep onset. After completion of treatment, patients exhibited improvement in depression and anxiety symptoms, and in quality of life; with indices that were no longer different from control volunteers. Moreover, these patients showed more consolidated sleep, with reduction of time spent awake after sleep onset. In conclusion, Eye Movement Desensitization and Reprocessing was an effective treatment of PTSD patients and improved the associated sleep and psychological symptoms.

Cognitive and behavioural therapy for insomnia (CBT-I) in psychiatric populations: a systematic review

Insomnia is highly co-morbid with psychiatric disorders, making it a frequent issue in treatment planning in psychiatric clinics. Research has also shown that although insomnia may originally precede or be a consequence of a psychiatric disorder, insomnia likely becomes semi-independent, and may exacerbate those disorders if it is not addressed, leading to reduced treatment response. Cognitive behavioural therapy for insomnia (CBT-I) is now recommended as the first line of treatment of primary insomnia. The research reviewed below indicates that CBT-I in patients with co-morbid depression, anxiety, post-traumatic stress disorder (PTSD), and substance abuse disorders is generally effective for insomnia and sometimes the co-morbid disorder as well. Although more research is needed before definitive recommendations can be made, it appears as though CBT-I is a viable approach to treating the patient with co-morbid insomnia and psychiatric disorders.

Changes in sleep disruption in the treatment of co-occurring posttraumatic stress disorder and substance use disorders

Sleep disruption appears not only to reflect a symptom of posttraumatic stress disorder (PTSD), but also a unique vulnerability for its development and maintenance. Studies examining the impact of psychosocial treatments for PTSD on sleep symptoms are few and no studies to date of which we are aware have examined this question in samples with co-occurring substance use disorders. The current study is a secondary analysis of a large clinical trial comparing 2 psychological treatments for co-occurring PTSD and substance use disorders. Women (N = 353) completed measures of PTSD at baseline, end of treatment, and 3-, 6-, and 12-month follow-ups. Results indicated that the prevalence of insomnia, but not nightmares, decreased during treatment, and that 63.8% of participants reported at least 1 clinical-level sleep symptom at the end of treatment. Improvement in sleep symptoms during treatment was associated with better overall PTSD outcomes over time, χ(2) (1) = 33.81, p < .001. These results extend the existing literature to suggest that residual sleep disruption following PTSD treatment is common in women with co-occurring PTSD and substance use disorders. Research on the benefits of adding sleep-specific intervention for those with residual sleep disruption in this population may be a promising future direction.

Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial

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.

Validation of the Fear of Sleep Inventory (FOSI) in an urban young adult African American sample

The Fear of Sleep Inventory (FOSI) was developed to identify factors that contribute to sleep disturbances in individuals exposed to trauma. This investigation examined the psychometric properties of the FOSI in a sample of African American young adults residing in urban areas. A 5-factor structure was derived from an exploratory factor analysis and then verified by confirmatory factor analysis. FOSI factors were positively correlated with the severity of PTSD (rs = .30 to .58, all ps < .001) and insomnia symptoms (rs = .36 to .64, all ps < .001). Individuals with probable PTSD or insomnia had higher scores on the total FOSI and each of the factors compared to those without probable PTSD (all ps < .001; effect sizes: r = .32 to .62) or insomnia (all ps < .001; effect sizes: r = .42 to .70). These data expand the evidence that the FOSI identifies factors contributing to sleep disturbances in trauma-exposed individuals.

Longitudinal relationships of insomnia, nightmares, and PTSD severity in recent combat veterans

OBJECTIVE

This observational, longitudinal study of veterans with recent combat exposure describes the prevalence, severity and associations of posttraumatic stress disorder (PTSD), insomnia, and nightmares over time.

METHODS

Eighty recent combat veterans recruited from Veterans Health Administration primary care settings met inclusion criteria including hazardous alcohol use and at least subthreshold PTSD. Insomnia status and nightmare status were assigned based on the Insomnia Severity Index total score and the PTSD Checklist nightmare item, respectively. Participants were re-assessed six months following their baseline assessment. Analyses of variance compared insomnia and nightmare groups on PTSD, depression, and alcohol use severity. Analyses of covariance (controlling for baseline differences) examined whether insomnia and/or nightmares were associated with the clinical course of PTSD. Persistence of conditions was also examined.

RESULTS

At baseline, 74% presented with insomnia and 61% endorsed distressing nightmares. Insomnia was associated with significantly higher PTSD and depression severity at both baseline and six months. The presence of nightmares was associated with significantly higher PTSD severity at both time points and with depression severity at baseline only. Despite decreases in PTSD and depression severity, insomnia severity was relatively unchanged after six months. The prevalence and severity of nightmare complaints diminished modestly over time.

CONCLUSION

Among this sample of recent combat veterans, insomnia and nightmares were each strongly associated with the severity of both PTSD and depressive symptoms. Over time, insomnia in particular did not appear to resolve spontaneously and was associated with ongoing PTSD. Addressing insomnia early, therefore, may be a strategy to alter the course of PTSD.

Change in sleep symptoms across Cognitive Processing Therapy and Prolonged Exposure: a longitudinal perspective

Sleep disturbance is a core component in posttraumatic stress disorder (PTSD). Although cognitive-behavioral treatments for PTSD reduce the severity of sleep symptoms, they do not lead to complete remission. The present study examines the impact of Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) on subjective measures of sleep disturbance from treatment randomization through long-term follow-up (LTFU). Participants were 171 female rape victims with PTSD who were randomly assigned to CPT, PE, or Minimal Attention (MA). After 6-weeks, the MA group was randomized to CPT or PE. Sleep symptoms were assessed at baseline, post-MA, post-treatment, 3-months, 9-months and LTFU using the Pittsburgh Sleep Quality Index (PSQI) and nightmare and insomnia items from the Clinician Administered PTSD Scale. Change in sleep during MA, from pre- to post-treatment for CPT and PE, and from post-treatment through LTFU was assessed using piecewise hierarchical linear modeling with the intent-to-treat sample. Controlling for medication, sleep improved during CPT and PE compared to MA, and treatment gains were maintained through LTFU. CPT and PE were equally efficacious and improvements persist over LTFU, yet, neither produced remission of sleep disturbance. Overall, sleep symptoms do not remit and may warrant sleep-specific treatments.

Sleep disturbances predict later trauma-related distress: cross-panel investigation amidst violent turmoil

OBJECTIVE

Sleep disturbances, including trouble falling and remaining asleep and recurrent nightmares, are symptoms of posttraumatic stress. A growing body of literature indicates that sleep disturbance may also convey vulnerability for the continuation of other symptoms of posttraumatic stress, including fear, anxiety, and heightened arousal. However, longitudinal research, which could help understand how these relationships unfold over time, has been limited.

METHOD

The longitudinal relationships between sleep disturbance and posttraumatic stress were investigated in 779 Palestinian adults randomly selected and interviewed twice during the period from April 2008 to November 2008, amid ongoing violent political turmoil. The recruitment method produced a representative sample and excellent retention. Cross-panel structural equation modeling was used to examine relationships between sleep and distress across two study periods.

RESULTS

Results indicated that initial sleep problems were associated with increased posttraumatic stress disorder (PTSD), depression, and intrapersonal resource loss at follow-up 6 months later, but initial PTSD, depression, and intrapersonal resource loss were not associated with increased sleep problems at follow-up.

CONCLUSIONS

Sleep problems may confer vulnerability to longer-term distress in the presence of ongoing political violence. Future research should examine whether interventions targeting trauma-related sleep problems may improve prevention and treatment for PTSD and related disorders.

Nightmares that mislead to diagnosis of reactivation of PTSD

BACKGROUND

Sleep disturbance is a common characteristic of patients with post-traumatic stress disorder (PTSD). Besides the clinical descriptions of nightmares and insomnia, periodic limb movements (PLMs) are reported to co-occur in PTSD. Although the causal relationship between sleep disturbance and PTSD is not fully understood, sleep disturbance is an independent risk factor for the development and reactivation of PTSD. In contrast, the link between PTSD and REM sleep behaviour disorder (RBD) is less clear.

METHOD

A case report is presented to illustrate differential diagnosis and time course of sleep disturbance in the context of PTSD.

RESULT

A 63-year-old man who had been successfully treated for PTSD but who suffered the re-occurrence of disturbed sleep due to RBD and PLM, which was misdiagnosed as reactivation of PTSD.

CONCLUSIONS

RBD can mimic PTSD-related nightmares. Accurate diagnosis of sleep disturbance in PTSD is relevant for treatment and prognostic evaluation.

Sleep quality among U.S. military veterans with PTSD: a factor analysis and structural model of symptoms

Poor sleep quality among individuals with posttraumatic stress disorder (PTSD) is associated with poorer prognosis and outcomes. The factor structure of the most commonly employed measure of self-reported sleep quality, the Pittsburgh Sleep Quality Index (PSQI), has yet to be evaluated among individuals with PTSD. The current study sought to fill this gap among a sample of 226 U.S. military veterans with PTSD (90% with co-occurring mood disorders, 73.5% with substance use disorders). We evaluated the factor structure of the PSQI by conducting an exploratory factor analysis (EFA) in approximately half of the sample (n = 111). We then conducted a second EFA in the other split half (n = 115). Lastly, we conducted a path analysis to investigate the relations between sleep factors and PTSD symptom severity, after accounting for the relation with depression. Results suggested sleep quality can best be conceptualized, among those with PTSD, as a multidimensional construct consisting of 2 factors, Perceived Sleep Quality and Efficiency/Duration. After accounting for the association between both factors and depression, only the Perceived Sleep Quality factor was associated with PTSD (β = .51). The results provide a recommended structure that improves precision in measuring sleep quality among veterans with PTSD.

A Mechanism-Based Approach to Prevention of and Therapy for Fibromyalgia

Fibromyalgia syndrome (FMS) is characterized by pain referred to deep tissues. Diagnosis and treatment of FMS are complicated by a variable coexistence with regional pain, fatigue, sleep disruption, difficulty with mentation, and depression. The widespread, deep pain of FMS can be a consequence of chronic psychological stress with autonomic dysregulation. Stress acts centrally to facilitate pain and acts peripherally, via sympathetic vasoconstriction, to establish painful muscular ischemia. FMS pain, with or without a coexistent regional pain condition, is stressful, setting up a vicious circle of reciprocal interaction. Also, stress interacts reciprocally with systems of control over depression, mentation, and sleep, establishing FMS as a multiple-system disorder. Thus, stress and the ischemic pain it generates are fundamental to the multiple disorders of FMS, and a therapeutic procedure that attenuates stress and peripheral vasoconstriction should be highly beneficial for FMS. Physical exercise has been shown to counteract peripheral vasoconstriction and to attenuate stress, depression, and fatigue and improve mentation and sleep quality. Thus, exercise can interrupt the reciprocal interactions between psychological stress and each of the multiple-system disorders of FMS. The large literature supporting these conclusions indicates that exercise should be considered strongly as a first-line approach to FMS therapy.

A meta-analysis of imagery rehearsal for post-trauma nightmares: effects on nightmare frequency, sleep quality, and posttraumatic stress

This meta-analysis evaluates the efficacy of imagery rehearsal as a treatment for nightmares, general sleep disturbance, and symptoms of post-traumatic stress. Bibliographic databases and cited references were searched to identify clinical trials of imagery rehearsal in individuals with post-trauma nightmares. Thirteen studies met inclusion criteria and reported sleep and post-traumatic stress outcomes in sufficient detail to calculate effect sizes. Results indicate that imagery rehearsal had large effects on nightmare frequency, sleep quality, and PTSD symptoms from the initial to post-treatment assessments. These effects were sustained through 6 to 12 months follow-up. Furthermore, interventions that included both imagery rehearsal and cognitive behavioral therapy for insomnia resulted in greater treatment-related improvement in sleep quality than imagery rehearsal alone. Combined treatment did not improve outcomes for PTSD or nightmares. Notably, effect sizes were small in the single study that included an active-treatment control condition. Future research should identify necessary and sufficient components of interventions for trauma-related sleep disturbance and post-traumatic stress (e.g., exposure, cognitive reappraisal, sleep and circadian regulation).

Associations between Pittsburgh Sleep Quality Index factors and health outcomes in women with posttraumatic stress disorder

OBJECTIVE

The Pittsburgh Sleep Quality Index (PSQI) is a widely used measure of subjective sleep disturbance in clinical populations, including individuals with posttraumatic stress disorder (PTSD). Although the severity of sleep disturbance is generally represented by a global symptom score, recent factor analytic studies suggest that the PSQI is better characterized by a two- or three-factor model than a one-factor model. This study examined the replicability of two- and three-factor models of the PSQI, as well as the relationship between PSQI factors and health outcomes, in a female sample with PTSD.

METHODS

The PSQI was administered to 319 women with PTSD related to sexual or physical assault. Confirmatory factor analyses tested the relative fit of one-, two-, and three-factor solutions. Bivariate correlations were performed to examine the shared variance between PSQI sleep factors and measures of PTSD, depression, anger, and physical symptoms.

RESULTS

Confirmatory factor analyses supported a three-factor model with Sleep Efficiency, Perceived Sleep Quality, and Daily Disturbances as separate indices of sleep quality. The severity of symptoms represented by the PSQI factors was positively associated with the severity of PTSD, depression, and physical symptoms. However, these health outcomes correlated as much or more with the global PSQI score as with PSQI factor scores.

CONCLUSIONS

These results support the multidimensional structure of the PSQI. Despite this, the global PSQI score has as much or more explanatory power as individual PSQI factors in predicting health outcomes.

Transdiagnostic processes in emotional disorders and insomnia: results from a sample of adult outpatients with anxiety and mood disorders

Conceptual similarities between recent models of insomnia and emotional disorders suggest there may be common factors that underlie or maintain these difficulties. Maladaptive cognitive and behavioral processes similar to those described in connection with emotional disorders have been cited as key mechanisms in the maintenance of primary insomnia. Unfortunately, research on this potential overlap is lacking. The present study examined the relationship among anxiety sensitivity (AS), dysfunctional beliefs, fatigue, safety behaviors, and insomnia severity in 59 outpatients with anxiety and mood disorders. Key insomnia processes (dysfunctional beliefs, fatigue, safety behaviors) were all related to insomnia severity in the comorbid sample, although AS was not. However, as hypothesized, AS did moderate the relationship of both dysfunctional beliefs and fatigue with insomnia severity. The relationships between key insomnia processes and insomnia severity was strongest among individuals high in AS. Results support the hypothesis that common mechanisms are involved for insomnia and emotional disorders. AS might function as a mechanism for the maintenance of sleep disturbance in the context of anxiety and mood disorders, suggesting a promising avenue for future research.