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Hamilton NA, Russell JA, Youngren WA, Gallegos AM, Crean HF, Cerulli C, Bishop TM, Hamadah K, Schulte M, Pigeon WR, Heffner KL. Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares. J Clin Sleep Med 2023; 19:1913-1921. [PMID: 37421316 PMCID: PMC10620662 DOI: 10.5664/jcsm.10710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/10/2023]
Abstract
STUDY OBJECTIVES This study's objective was to evaluate the effect of nightmares (NMs) on attrition and symptom change following cognitive behavioral therapy for insomnia (CBT-I) treatment using data from a successful CBT-I randomized controlled trial delivered to participants with recent interpersonal violence exposure. METHODS The study randomized 110 participants (107 women; mean age: 35.5 years) to CBT-I or to an attention-control group. Participants were assessed at 3 time periods: baseline, post-CBT-I (or attention control), and at time 3 (T3) post-cognitive processing therapy received by all participants. NM reports were extracted from the Fear of Sleep Inventory. Participants with weekly NMs were compared with those with fewer than weekly NMs on outcomes including attrition, insomnia, posttraumatic stress disorder, and depression. Change in NM frequency was examined. RESULTS Participants with weekly NMs (55%) were significantly more likely to be lost to follow-up post-CBT-I (37%) compared with participants with infrequent NMs (15.6%) and were less likely to complete T3 (43%) than patients with less frequent NMs (62.5%). NMs were unrelated to differential treatment response in insomnia, depression, or posttraumatic stress disorder. Treatment with CBT-I was not associated with reduced NM frequency; however, change in sleep-onset latency from post-CBT-I to T3 predicted fewer NMs at T3. CONCLUSIONS Weekly NMs were associated with attrition but not a reduced change in insomnia symptoms following CBT-I. NM symptoms did not change as a function of CBT-I, but change in sleep-onset latency predicted lower NM frequency. CBT-I trials should screen for NMs and consider augmenting CBT-I to specifically address NMs. CITATION Hamilton NA, Russell JA, Youngren WA, et al. Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares. J Clin Sleep Med. 2023;19(11):1913-1921.
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Affiliation(s)
| | | | - Westley A. Youngren
- U.S. Department of Veterans Affairs Center of Excellence for Suicide Prevention, Finger Lakes Health Care System, Canandaigua, New York
| | - Autumn M. Gallegos
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | - Hugh F. Crean
- U.S. Department of Veterans Affairs Center of Excellence for Suicide Prevention, Finger Lakes Health Care System, Canandaigua, New York
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester Medical Center, Rochester, New York
| | - Catherine Cerulli
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
- Susan B. Anthony Center and Laboratory of Interpersonal Violence and Victimization, University of Rochester Medical Center, Rochester, New York
| | - Todd M. Bishop
- U.S. Department of Veterans Affairs Center of Excellence for Suicide Prevention, Finger Lakes Health Care System, Canandaigua, New York
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | | | | | - Wilfred R. Pigeon
- U.S. Department of Veterans Affairs Center of Excellence for Suicide Prevention, Finger Lakes Health Care System, Canandaigua, New York
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | - Kathi L. Heffner
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester Medical Center, Rochester, New York
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York
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2
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Gill P, Fraser E, Tran TTD, De Sena Collier G, Jago A, Losinno J, Ganci M. Psychosocial treatments for nightmares in adults and children: a systematic review. BMC Psychiatry 2023; 23:283. [PMID: 37085821 PMCID: PMC10122409 DOI: 10.1186/s12888-023-04703-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/21/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND As nightmares may be a risk factor for, or symptom of, multiple psychological disorders, some researchers suggest that nightmares should be screened, diagnosed, and treated. Treatments for nightmares include trauma-focused Cognitive Behavioural Therapy and Image Rehearsal Therapy, and pharmacological interventions such as prazosin and nitrazepam. As recent research has put into question our current understanding of treatment efficacy, there is a need to systematically review findings related to the effectiveness of nightmare treatments to inform best practice. The current review assessed the efficacy of psychosocial treatments of nightmare in all cohorts. METHODS A systematic search of four databases for peer reviewed journal articles from 2000 onwards produced 69 (35 RCTs, 34 non-RCTs) eligible articles that underwent narrative synthesis. RESULTS The results provide strong evidence for exposure and image rehearsal treatments for the reduction of nightmare frequency, severity, and distress, in civilian, military, idiopathic, and posttraumatic stress disorder (PTSD) cohorts. There is emerging evidence that self-guided and brief treatment modalities offer efficient and effective treatment options. There is an urgent need for clinical trials of treatment effectiveness in children. CONCLUSIONS The results suggest that treatments for nightmares are most effective when they facilitate a sense of control or mastery by directly targeting the nightmare content and/or the client's emotional responses to the nightmare content. TRIAL REGISTRATION A review protocol was registered with PROSPERO (CRD42020204861).
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Affiliation(s)
- Peter Gill
- Institute for Health and Sport, Victoria University Australia, Footscray Park, Ballarat Rd, Melbourne, VIC, Australia.
| | - Emily Fraser
- Institute for Health and Sport, Victoria University Australia, Footscray Park, Ballarat Rd, Melbourne, VIC, Australia
| | - Thong Thai Diep Tran
- Institute for Health and Sport, Victoria University Australia, Footscray Park, Ballarat Rd, Melbourne, VIC, Australia
| | - Gabriel De Sena Collier
- Institute for Health and Sport, Victoria University Australia, Footscray Park, Ballarat Rd, Melbourne, VIC, Australia
| | - Andrew Jago
- Institute for Health and Sport, Victoria University Australia, Footscray Park, Ballarat Rd, Melbourne, VIC, Australia
| | - Joe Losinno
- Institute for Health and Sport, Victoria University Australia, Footscray Park, Ballarat Rd, Melbourne, VIC, Australia
| | - Michael Ganci
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
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3
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Brownlow JA, Miller KE, Gehrman PR. Treatment of Sleep Comorbidities in Posttraumatic Stress Disorder. ACTA ACUST UNITED AC 2021; 7:301-316. [PMID: 33552844 DOI: 10.1007/s40501-020-00222-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of the review Sleep disturbances, insomnia and recurrent nightmares in particular, are among the most frequently endorsed symptoms of posttraumatic stress disorder (PTSD). The present review provides a summary of the prevalence estimates and methodological challenges presented by sleep disturbances in PTSD, highlights the recent evidence for empirically supported psychotherapeutic and pharmacological interventions for comorbid sleep disturbances implicated in PTSD, and provides a summary of recent findings on integrated and sequential treatment approaches to ameliorate comorbid sleep disturbances in PTSD. Recent Findings Insomnia, recurrent nightmares, and other sleep disorders are commonly endorsed among individuals with PTSD; however, several methodological challenges contribute to the varying prevalence estimates. Targeted sleep-focused therapeutic interventions can improve sleep symptoms and mitigate daytime PTSD symptoms. Recently, attention has focused on the role of integrated and sequential approaches, suggesting that comprehensively treating sleep disturbances in PTSD is likely to require novel treatment modalities. Summary Evidence is growing on the development, course, and treatment of comorbid sleep disturbances in PTSD. Further, interventions targeting sleep disturbances in PTSD show promise in reducing symptoms. However, longitudinal investigations and additional rigorous controlled trials with diverse populations are needed to identify key features associated with treatment response in order to alleviate symptoms.
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Affiliation(s)
- Janeese A Brownlow
- Department of Psychology, College of Health & Behavioral Sciences, Delaware State University, Dover, Delaware, USA.,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine E Miller
- Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Philip R Gehrman
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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4
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Gromatsky M, Sullivan SR, Spears AP, Mitchell E, Walsh S, Kimbrel NA, Goodman M. Ecological momentary assessment (EMA) of mental health outcomes in veterans and servicemembers: A scoping review. Psychiatry Res 2020; 292:113359. [PMID: 32777594 DOI: 10.1016/j.psychres.2020.113359] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/20/2020] [Accepted: 08/01/2020] [Indexed: 12/11/2022]
Abstract
This PRISMA scoping review explores existing research conducted with United States military samples utilizing ecological momentary assessment (EMA) to evaluate mental health outcomes. EMA facilitates understanding of temporal changes of dynamic variables subject to change difficult to capture in standard laboratory assessment. It also elucidates understanding of complex etiology of mental illness in military and veteran samples and treatment approaches. Thirty-two articles published between 1995 and 2019 met inclusion criteria. Most (68.7%) included studies examined mental health symptoms and their temporal relationship to other outcomes among servicemembers and/or veterans, particularly posttraumatic stress disorder and substance use disorders. EMA was frequently employed to better understand underlying mechanisms of mental illness, predict symptom changes, assess feasibility among special populations, and assess treatment outcomes. Considerable variability existed in assessment period duration, number of daily assessments, and EMA modalities utilized. Several research gaps were identified, including underutilization of EMA to study suicide risk in veterans/servicemembers. EMA has great potential for increasing understanding of an array of complex mental health problems; however, this highly promising approach has been largely underutilized to study mental health issues among veteran and military populations to date, perhaps due to institutional delays in its adoption secondary to privacy/data security concerns.
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Affiliation(s)
- Molly Gromatsky
- VISN 2 Mental Illness Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, United States; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - Sarah R Sullivan
- VISN 2 Mental Illness Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, United States; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Angela Page Spears
- VISN 2 Mental Illness Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, United States
| | - Emily Mitchell
- VISN 2 Mental Illness Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, United States
| | - Samantha Walsh
- Levy Library, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nathan A Kimbrel
- Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States; VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, United States; VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, United States; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Marianne Goodman
- VISN 2 Mental Illness Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, United States; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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5
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Melton H, Meader N, Dale H, Wright K, Jones-Diette J, Temple M, Shah I, Lovell K, McMillan D, Churchill R, Barbui C, Gilbody S, Coventry P. Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review. Health Technol Assess 2020; 24:1-312. [PMID: 32924926 DOI: 10.3310/hta24430] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people. OBJECTIVE To identify candidate psychological and non-pharmacological treatments for future research. DESIGN Mixed-methods systematic review. PARTICIPANTS Adults aged ≥ 18 years with a history of complex traumatic events. INTERVENTIONS Psychological interventions versus control or active control; pharmacological interventions versus placebo. MAIN OUTCOME MEASURES Post-traumatic stress disorder symptoms, common mental health problems and attrition. DATA SOURCES Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017. REVIEW METHODS Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist. RESULTS One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs. LIMITATIONS Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented. CONCLUSIONS Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder. FUTURE WORK Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities. STUDY REGISTRATION This study is registered as PROSPERO CRD42017055523. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hollie Melton
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Nick Meader
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Holly Dale
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | | | | | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Rachel Churchill
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Peter Coventry
- Centre for Reviews and Dissemination, University of York, York, UK.,Department of Health Sciences, University of York, York, UK
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6
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Fear of sleep and trauma-induced insomnia: A review and conceptual model. Sleep Med Rev 2020; 55:101383. [PMID: 32992229 DOI: 10.1016/j.smrv.2020.101383] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 07/01/2020] [Accepted: 07/01/2020] [Indexed: 02/06/2023]
Abstract
Trauma-induced insomnia is a symptom of posttraumatic stress disorder (PTSD), and is reported to be particularly distressing and often persists even after remission of the core symptoms of PTSD. Recently, it has been suggested that fear of sleep plays an important role in the development and maintenance of trauma-induced insomnia. The aim of this review is to propose a conceptual model of fear of sleep as a maintaining factor of trauma-induced insomnia. After a brief overview of the role of sleep in PTSD, the concept of fear of sleep is introduced. Theoretical considerations and empirical findings on the role of fear of sleep for trauma-induced insomnia in the context of PTSD are summarized and integrated. Specifically, links between PTSD symptoms and fear of sleep are presented, as well as possible consequences of fear of sleep leading to trauma-induced insomnia. Finally, we highlight methodological issues, identify areas for future research, and discuss potential clinical implications.
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7
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Abstract
Sleep disturbances, including not being able to fall asleep easily/difficulty falling asleep, waking up frequently, or waking up too early and being unable to fall asleep again/resume sleep are diagnosed as insomnia if they cause significant disruption to daily life and are not caused by other sleep disorders such as pain or sleep apnea. Although insomnia is not considered a serious life-threatening condition, it has not only a high prevalence rate but also a high recurrence rate and tends to become chronic. Chronic insomnia patients tend to show common behavioral and cognitive patterns, typical of which are worrying about not being able to fall or stay asleep, excessive awakening because of this worry, limiting and reducing daytime activities or attempting to stay in bed for long periods to compensate for lack of sleep. These cognitive and behavioral characteristics are important contributing factors for the continuation of insomnia. To date, the most popular and effective treatment option/approach recommended by experts for insomnia is cognitive behavior therapy (CBT). CBT for insomnia consists of the following three non-pharmaceutical treatment elements: 1) behavioral elements such as stimulus control therapy, sleep restriction therapy, and muscle relaxation, 2) cognitive elements, and 3) educational elements focusing on sleep hygiene. However, there are barriers to insomnia patients receiving this treatment including accessibility and cost, despite the abundance of evidence demonstrating their effectiveness. Recently, online CBT for insomnia has become available as an alternative, and its emergence is providing a solution to the barriers to access.
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8
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Werner GG, Danböck SK, Metodiev S, Kunze AE. Pre-Sleep Arousal and Fear of Sleep in Trauma-Related Sleep Disturbances: A Cluster-Analytic Approach. CLINICAL PSYCHOLOGY IN EUROPE 2020; 2:e2699. [PMID: 36397829 PMCID: PMC9645493 DOI: 10.32872/cpe.v2i2.2699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/05/2019] [Indexed: 11/25/2022] Open
Abstract
Background Trauma-related sleep disturbances constitute critical symptoms of posttraumatic stress disorder (PTSD), but sleep symptoms often reside even after successful trauma-focused psychotherapy. Therefore, currently unattended factors - like fear of sleep (FoS) - might play a crucial role in the development and maintenance of residual sleep disturbances. However, it is unclear whether trauma-exposed individuals exhibit different symptomatic profiles of sleep disturbances that could inform individualized therapeutic approaches and eventually enhance treatment efficacy. Method In a large online study, a two-step cluster analysis and a hierarchical cluster analysis using Ward's method were performed to explore subgroups among trauma-exposed individuals (N = 471) in terms of FoS, different aspects of trauma-related sleep disturbances (e.g., insomnia symptoms, nightmares, arousal), and PTSD symptoms. These variables were compared between resulting clusters using ANOVAs and Scheffé's post-hoc tests. Results The hierarchical cluster analysis supported 3- and 4-cluster solutions. The 3-cluster solution consisted of one "healthy" (n = 199), one "subclinical" (n = 223), and one "clinical" (n = 49) cluster, with overall low, medium, and high symptomatology on all used variables. In the 4-cluster solution, the clinical cluster was further divided into two subgroups (n = 38, n = 11), where one cluster was specifically characterized by elevated somatic pre-sleep arousal and high levels of FoS. Conclusions A subgroup of trauma-exposed individuals with PTSD and sleep disturbances suffers from increased pre-sleep arousal and FoS, which has been suggested as one possible explanation for residual sleep disturbances. In these patients, FoS might be a relevant treatment target.
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Affiliation(s)
- Gabriela G. Werner
- Department of Psychology, LMU Munich [study institution], Munich, Germany
| | - Sarah K. Danböck
- Department of Psychology, LMU Munich [study institution], Munich, Germany
- Department of Psychology, University of Salzburg, Salzburg, Austria
| | - Stanislav Metodiev
- Department of Psychology, LMU Munich [study institution], Munich, Germany
| | - Anna E. Kunze
- Department of Psychology, LMU Munich [study institution], Munich, Germany
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9
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Reilly ED, Robinson SA, Petrakis BA, Kuhn E, Pigeon WR, Wiener RS, McInnes DK, Quigley KS. Mobile App Use for Insomnia Self-Management: Pilot Findings on Sleep Outcomes in Veterans. Interact J Med Res 2019; 8:e12408. [PMID: 31342904 PMCID: PMC6685127 DOI: 10.2196/12408] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/21/2018] [Accepted: 04/09/2019] [Indexed: 01/20/2023] Open
Abstract
Background Sleep disturbance is a major health concern among US veterans who have served since 2001 in a combat theater in Iraq or Afghanistan. We report subjective and objective sleep results from a pilot trial assessing self-management–guided use of a mobile app (CBT-i Coach, which is based on cognitive behavioral therapy for insomnia) as an intervention for insomnia in military veterans. Objective The primary aim of this study was to evaluate changes in subjective and objective sleep outcomes from pre to postintervention. Methods Subjective outcomes included the Insomnia Severity Index, the Pittsburgh Sleep Quality Inventory, and sleep-related functional status. A wearable sleep monitor (WatchPAT) measured objective sleep outcomes, including sleep efficiency, percent rapid eye movement (REM) during sleep, sleep time, and sleep apnea. A total of 38 participants were enrolled in the study, with 18 participants being withdrawn per the protocol because of moderate or severe sleep apnea and 9 others who dropped out or withdrew. Thus, 11 participants completed the full 6-week CBT-i Coach self-management intervention (ie, completers). Results Completer results indicated significant changes in subjective sleep measures, including reduced reports of insomnia (Z=–2.68, P=.007) from pre (mean 16.63, SD 5.55) to postintervention (mean 12.82, SD 3.74), improved sleep quality (Z=–2.37, P=.02) from pre (mean 12.82, SD 4.60) to postintervention (mean 10.73, SD 3.32), and sleep-related functioning (Z=2.675, P=.007) from pre (mean 13.86, SD 3.69) to postintervention (mean 15.379, SD 2.94). Among the objective measures, unexpectedly, objective sleep time significantly decreased from pre to postintervention (χ22=7.8, P=.02). There were no significant changes in percent REM sleep or sleep efficiency. Conclusions These findings suggest that the CBT-i Coach app can improve subjective sleep and that incorporating objective sleep measures into future, larger clinical trials or clinical practice may yield important information, particularly by detecting previously undetected sleep apnea. Trial Registration ClinicalTrials.gov NCT02392000; http://clinicaltrials.gov/ct2/show/NCT02392000
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Affiliation(s)
- Erin D Reilly
- Center for Social and Community Reintegration Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, United States
| | - Stephanie A Robinson
- Center for Healthcare Outcomes and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, United States
| | - Beth Ann Petrakis
- Center for Healthcare Outcomes and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, United States
| | - Eric Kuhn
- National Center for PTSD, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States.,Stanford University School of Medicine, Standford, CA, United States
| | - Wilfred R Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, United States.,University of Rochester Medical Center, Rochester, NY, United States
| | - Renda Soylemez Wiener
- Center for Healthcare Outcomes and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, United States.,Boston University School of Medicine, Boston, MA, United States
| | - D Keith McInnes
- Center for Healthcare Outcomes and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, United States.,Boston University School of Public Health, Boston, MA, United States
| | - Karen S Quigley
- Center for Social and Community Reintegration Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, United States.,Center for Healthcare Outcomes and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, United States.,Northeastern University, Boston, MA, United States
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10
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Abstract
Insomnia is commonly reported by military populations, especially those with comorbid mental and physical health conditions. Co-occurring conditions result in an altered presentation of insomnia symptoms, and complicate provision of cognitive-behavioral therapy for insomnia (CBT-I), requiring supplementary assessment or modifications to traditional techniques. CBT-I has consistently demonstrated positive outcomes for active-duty service members and veterans, even in the context of significant comorbidities such as post-traumatic stress disorder, depression, sleep apnea, and chronic pain. Despite its promise, studies of CBT-I in some populations, including women and individuals with substance use disorders, remain relatively understudied in active-duty and veteran populations.
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11
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Dedert EA, Dennis PA, Cunningham KC, Ulmer CS, Calhoun PS, Kimbrel N, Hicks TA, Neal JM, Beckham JC. Roles of Guilt Cognitions in Trauma-Related Sleep Disturbance in Military Veterans With Posttraumatic Stress Disorder. Behav Sleep Med 2019; 17:595-604. [PMID: 29482385 PMCID: PMC6109613 DOI: 10.1080/15402002.2018.1435544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Objective/Background: Despite a well-established role of guilt cognitions in the maintenance and treatment of posttraumatic stress disorder (PTSD), relationships of guilt cognitions to nightmares are not well understood. This study investigated the ways in which guilt cognitions, related to traumatic events, influenced the relationship between combat exposure and trauma-related sleep disturbance in military Veterans with PTSD. Participants: We recruited a sample of 50 Veterans with PTSD who completed study measures at a screening session. Methods: Participants completed self-report measures of exposure to potentially traumatic events, trauma-related guilt (hindsight bias, wrongdoing, and lack of justification) and trauma-related sleep disturbance as measured by a self-report scale and clinician ratings of nightmare severity. Results: Bivariate regression analyses established a relationship of combat exposure to wrongdoing (β = .31, p = .031), and a relationship of wrongdoing with self-reported trauma-related sleep disturbance (β = .27, p = .049) and clinician-rated nightmare severity (β = .36, p = .009). Bootstrapping analysis that included years of education as a covariate found a significant overall indirect effect of combat exposure on clinician-rated nightmare severity exerted through wrongdoing (β = .10, 95% CI [.004, .246]). Conclusions: Results suggest the association of combat exposure with trauma-related sleep disturbance is significantly influenced by perceived wrongdoing related to a traumatic event. Targeting cognitions related to wrongdoing and moral injury during a traumatic event in PTSD treatment may help ameliorate trauma-related sleep disturbance.
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Affiliation(s)
- Eric A. Dedert
- Durham VA Medical Center, Durham, NC, United States,Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Durham, NC, United States,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, United States,Correspondence concerning this article should be addressed to Eric Dedert, Durham VA Health Care System, 3022 Croasdaile Drive, Durham, NC 27705. Phone: (919) 384-8582, ext. 4055. Fax: (919) 681-7347,
| | - Paul A. Dennis
- Durham VA Medical Center, Durham, NC, United States,Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Durham, NC, United States
| | - Katherine C. Cunningham
- Durham VA Medical Center, Durham, NC, United States,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, United States
| | - Christi S. Ulmer
- Durham VA Medical Center, Durham, NC, United States,Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Durham, NC, United States
| | - Patrick S. Calhoun
- Durham VA Medical Center, Durham, NC, United States,Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Durham, NC, United States,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, United States
| | - Nathan Kimbrel
- Durham VA Medical Center, Durham, NC, United States,Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Durham, NC, United States,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, United States
| | - Terrell A. Hicks
- Virginia Commonwealth University, Virginia Institute of Psychiatric and Behavioral Genetics, Department of Psychiatry, Richmond, VA, United States
| | | | - Jean C. Beckham
- Durham VA Medical Center, Durham, NC, United States,Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Durham, NC, United States,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, United States
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12
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Mantua J, Helms SM, Weymann KB, Capaldi VF, Lim MM. Sleep Quality and Emotion Regulation Interact to Predict Anxiety in Veterans with PTSD. Behav Neurol 2018; 2018:7940832. [PMID: 29971139 PMCID: PMC6008674 DOI: 10.1155/2018/7940832] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 04/23/2018] [Accepted: 05/13/2018] [Indexed: 11/17/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) is a debilitating and common consequence of military service. PTSD is associated with increased incidence of mood disturbances (e.g., anxiety). Additionally, veterans with PTSD often have poor-quality sleep and poor emotion regulation ability. We sought to assess whether such sleep and emotion regulation deficits contribute to mood disturbances. In 144 veterans, using a double moderation model, we tested the relationship between PTSD and anxiety and examined whether sleep quality and emotion regulation interact to moderate this relationship. We found that PTSD predicts higher anxiety in veterans with poor and average sleep quality who utilize maladaptive emotion regulation strategies. However, there was no relationship between PTSD and anxiety in individuals with good sleep quality, regardless of emotion regulation. Similarly, there was no relationship between PTSD and anxiety in individuals with better emotion regulation, regardless of sleep quality. Results were unchanged when controlling for history of traumatic brain injury (TBI), despite the fact that those with both PTSD and TBI had the poorest emotion regulation overall. Taken together, these results suggest that good-quality sleep may be protective against poor emotion regulation in veterans with PTSD. Sleep may therefore be a target for therapeutic intervention in veterans with PTSD and heightened anxiety.
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Affiliation(s)
- Janna Mantua
- Neuroscience & Behavior Program, University of Massachusetts, Amherst, Amherst, MA 01003, USA
- Behavioral Biology Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Steven M. Helms
- VA Portland Health Care System, Portland, OR 97239, USA
- Oregon Health & Science University, Portland, OR 97239, USA
| | - Kris B. Weymann
- VA Portland Health Care System, Portland, OR 97239, USA
- Oregon Health & Science University, Portland, OR 97239, USA
| | - Vincent F. Capaldi
- Behavioral Biology Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Miranda M. Lim
- VA Portland Health Care System, Portland, OR 97239, USA
- Oregon Health & Science University, Portland, OR 97239, USA
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13
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Sleep Disorders in Patients With Posttraumatic Stress Disorder. Chest 2018; 154:427-439. [PMID: 29684315 DOI: 10.1016/j.chest.2018.04.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/27/2018] [Accepted: 04/03/2018] [Indexed: 02/05/2023] Open
Abstract
A growing body of evidence supports a bidirectional relationship between posttraumatic stress disorder (PTSD) and sleep disturbances. Fragmented sleep induced by sleep-related breathing disorders, insomnia, and nightmares impacts recovery and treatment outcomes and worsens PTSD symptoms. Despite recent attention, management of these disorders has been unrewarding in the setting of PTSD. This review summarizes the evidence for empirically supported treatments of these sleep ailments, including psychotherapeutic and pharmacologic interventions, as it relates to PTSD. Recent advances in positive airway pressure technology have made treatment of OSA more acceptable; however, adherence to CPAP therapy presents a substantial challenge. Concomitant insomnia, which engenders psychiatric and medical conditions, including depression, suicide, and alcohol and substance abuse, can be managed with cognitive behavioral therapy. Hypnotic agents are considered an alternative therapy, but concerns about adverse events and lack of high-level evidence supporting their efficacy in PTSD treatment have limited their use to resistant cases or as adjuncts to behavioral therapy when the response is less than desirable. Intrusion of nightmares can complicate PTSD treatment and exert serious strain on social, occupational, and marital relations. Imagery rehearsal therapy has shown significant reduction in nightmare intensity and frequency. The success of noradrenergic blocking agents has not been consistent among studies, with one-half reporting treatment failure. An integrated stepped care approach that includes components of both behavioral and pharmacologic interventions customized to patients' sleep-maladaptive behaviors may offer a solution to delivering accessible, effective, and efficient services for individuals with PTSD.
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14
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Sexton MB, Avallone KM, Smith ER, Porter KE, Ashrafioun L, Todd Arnedt J, Rauch SAM. Sleep disturbances as predictors of prolonged exposure therapy effectiveness among veterans with PTSD. Psychiatry Res 2017. [PMID: 28628792 DOI: 10.1016/j.psychres.2017.06.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Minden B Sexton
- Ann Arbor Veterans Healthcare System, Mental Health Service (116C), 2215 Fuller Rd., Ann Arbor, MI 48105, USA; University of Michigan Medical School, Departments of Psychiatry and Neurology, 4250 Plymouth Rd., Ann Arbor, MI 48109, USA.
| | - Kimberly M Avallone
- Ann Arbor Veterans Healthcare System, Mental Health Service (116C), 2215 Fuller Rd., Ann Arbor, MI 48105, USA
| | - Erin R Smith
- Ann Arbor Veterans Healthcare System, Mental Health Service (116C), 2215 Fuller Rd., Ann Arbor, MI 48105, USA; University of Michigan Medical School, Departments of Psychiatry and Neurology, 4250 Plymouth Rd., Ann Arbor, MI 48109, USA
| | - Katherine E Porter
- Ann Arbor Veterans Healthcare System, Mental Health Service (116C), 2215 Fuller Rd., Ann Arbor, MI 48105, USA; University of Michigan Medical School, Departments of Psychiatry and Neurology, 4250 Plymouth Rd., Ann Arbor, MI 48109, USA
| | - Lisham Ashrafioun
- Ann Arbor Veterans Healthcare System, Mental Health Service (116C), 2215 Fuller Rd., Ann Arbor, MI 48105, USA
| | - J Todd Arnedt
- University of Michigan Medical School, Departments of Psychiatry and Neurology, 4250 Plymouth Rd., Ann Arbor, MI 48109, USA
| | - Sheila A M Rauch
- Ann Arbor Veterans Healthcare System, Mental Health Service (116C), 2215 Fuller Rd., Ann Arbor, MI 48105, USA; University of Michigan Medical School, Departments of Psychiatry and Neurology, 4250 Plymouth Rd., Ann Arbor, MI 48109, USA; Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Atlanta, GA, USA
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15
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Abstract
PURPOSE OF REVIEW Sleep disturbances are core features of posttraumatic stress disorder (PTSD). This review aims to characterize sleep disturbances, summarize the knowledge regarding the relationships between trauma exposure and sleep difficulties, and highlight empirically supported and/or utilized treatments for trauma-related nightmares and insomnia. RECENT FINDINGS Trauma-related nightmares and insomnia, and other sleep disorders, are frequently reported among trauma survivors. The roles of fear of sleep, REM density, and decreased parasympathetic activity are beginning to inform the relationship between trauma exposure and sleep difficulties. Additionally, the potential adaptive role of sleep loss immediately following a traumatic experience is being recognized. Interventions targeting these sleep disturbances show promise in reducing symptoms. Research in understanding the role of sleep on the development, course, and treatment of PTSD is expanding. Longitudinal investigations are needed to further elucidate these relationships and identify treatments most effective in ameliorating symptoms.
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Cognitive Behavioral Social Rhythm Group Therapy for Veterans with posttraumatic stress disorder, depression, and sleep disturbance: Results from an open trial. J Affect Disord 2016; 192:234-43. [PMID: 26748739 DOI: 10.1016/j.jad.2015.12.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/09/2015] [Accepted: 12/11/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Cognitive Behavioral Social Rhythm Therapy (CBSRT) is a group psychotherapy tailored for Veterans with Posttraumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), and sleep disturbances. The aims of this study were to introduce and present initial outcomes of Cognitive Behavioral Social Rhythm Therapy (CBSRT), a 12-week skills group therapy designed to improve sleep and mood by reducing chaotic or isolated lifestyles in Veterans with PTSD. METHODS Twenty-four male Veterans with at least moderate PTSD and MDD participated in this open trial. Main outcomes were the daily sleep diary for sleep disturbances, the Clinician-Administered PTSD Scale (CAPS) for PTSD, and the Hamilton Depression Rating scale for MDD. RESULTS Veterans improved on all measures (a) with large within subject effects on PTSD symptoms, MDD symptoms, and sleep quality, and (b) with 46-58% of the sample receiving clinically significant benefits on MDD and PTSD symptoms respectively. The consistency of social rhythms was associated with the average reduction in global CAPS scores over time. Only 13% of participants dropped-out of the group therapy prematurely suggesting that this new group therapy is relatively well-tolerated by Veterans. LIMITATIONS Future research that employs a control condition is necessary to establish efficacy of CBSRT. CONCLUSIONS Data from this initial pilot study demonstrate that CBSRT may be an effective group treatment option for Veterans presenting with all three symptom complaints. These data also suggest that daily routine may be an important mechanism to consider in the treatment of PTSD symptoms comorbid with depression.
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Erford BT, Gunther C, Duncan K, Bardhoshi G, Dummett B, Kraft J, Deferio K, Falco M, Ross M. Meta-Analysis of Counseling Outcomes for the Treatment of Posttraumatic Stress Disorder. JOURNAL OF COUNSELING AND DEVELOPMENT 2016. [DOI: 10.1002/jcad.12058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Chelsea Gunther
- Education Specialties Department; Loyola University Maryland
| | - Kelly Duncan
- Division of Counseling and Psychology; University of South Dakota
- Now at School of Education; Northern University
| | - Gerta Bardhoshi
- Division of Counseling and Psychology; University of South Dakota
- Now at Department of Rehabilitation and Counselor Education; University of Iowa
| | - Beth Dummett
- Education Specialties Department; Loyola University Maryland
| | - Jennifer Kraft
- Education Specialties Department; Loyola University Maryland
| | - Katie Deferio
- Education Specialties Department; Loyola University Maryland
| | - Michelle Falco
- Education Specialties Department; Loyola University Maryland
| | - Margaret Ross
- Education Specialties Department; Loyola University Maryland
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18
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Bishop TM, Britton PC, Knox KL, Pigeon WR. Cognitive Behavioral Therapy for Insomnia and Imagery Rehearsal in Combat Veterans with Comorbid Posttraumatic Stress: A Case Series. ACTA ACUST UNITED AC 2015; 4:58-64. [PMID: 27695657 DOI: 10.1080/21635781.2015.1100564] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Todd M Bishop
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY; Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
| | - Peter C Britton
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY; Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
| | - Kerry L Knox
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY; Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
| | - Wilfred R Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY; Department of Psychiatry, University of Rochester Medical Center, Rochester, NY; Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY
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19
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Pigeon WR, Heffner KL, Crean H, Gallegos AM, Walsh P, Seehuus M, Cerulli C. 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. Contemp Clin Trials 2015; 45:252-260. [PMID: 26343743 DOI: 10.1016/j.cct.2015.08.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 08/27/2015] [Accepted: 08/30/2015] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Wilfred R Pigeon
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY USA; U.S. Department of Veterans Affairs Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY USA.
| | - Kathi L Heffner
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY USA
| | - Hugh Crean
- School of Nursing, University of Rochester Medical Center, Rochester, NY USA
| | - Autumn M Gallegos
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY USA
| | - Patrick Walsh
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY USA
| | - Martin Seehuus
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY USA
| | - Catherine Cerulli
- Susan B. Anthony Center and Laboratory of Interpersonal Violence and Victimization, University of Rochester Medical Center, Rochester, NY USA
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20
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Suh S. Cognitive Behavioral Therapy for Insomnia: Is it Effective in Treating Symptoms of Comorbid Psychiatric and Medical Disorders? A Review. SLEEP MEDICINE RESEARCH 2015. [DOI: 10.17241/smr.2015.6.1.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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Abstract
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.
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22
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23
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A systematic scoping review of complementary and alternative medicine mind and body practices to improve the health of veterans and military personnel. Med Care 2015; 52:S70-82. [PMID: 25397827 DOI: 10.1097/mlr.0000000000000228] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Meditation, imagery, acupuncture, and yoga are the most frequently offered mind and body practices in the Department of Veterans Affairs. Yet, the research on mind and body practices has been critiqued as being too limited in evidence and scope to inform clinical treatment. OBJECTIVES We conducted a systematic scoping review of mind and body practices used with veterans or active duty military personnel to identify gaps in the literature and make recommendations for future primary research. RESEARCH DESIGN Following systematic literature review methodology, we searched 5 databases using 27 different National Center for Complementary and Alternative Medicine-defined mind and body practices as text words, keywords, and MeSH terms through June 30, 2014. We also conducted handsearches of 4 previous reviews. SUBJECTS Active duty military members or veterans 18 years or older participating in mind and body practice interventions globally. MEASURES Data were extracted from studies meeting 5 inclusion criteria. The quality of randomized controlled trials (RCTs) was assessed using an existing checklist. RESULTS Of 1819 studies identified, 89 interventions (50 RCTs) published between 1976 and 2014, conducted in 9 countries, using 152 different measures to assess 65 health and well-being outcomes met our inclusion criteria. Most interventions took place in the United States (n=78). Meditation practices (n=25), relaxation techniques including imagery (n=20), spinal manipulation including physical therapy (n=16), and acupuncture (n=11) were the most frequently studied practices. Methodological quality of most RCTs was rated poorly. CONCLUSIONS Meditation and acupuncture practices are among the most frequently offered and studied mind and body practices. Future research should include yoga as it is currently understudied among veterans and military personnel. A repository of mind and body intervention outcome measures may further future research efforts, as would conducting pragmatic trials and more robust RCTs.
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24
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Exploring the role of insomnia in the relation between PTSD and pain in veterans with polytrauma injuries. J Head Trauma Rehabil 2014; 29:44-53. [PMID: 23835878 DOI: 10.1097/htr.0b013e31829c85d0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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25
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Abstract
Insomnia is a major public health concern, and is highly comorbid with a broad range of psychiatric disorders. Although insomnia has historically been considered a symptom of other disorders, this perspective has shifted. Epidemiological and experimental studies suggest that insomnia is related to the onset and course of several psychiatric disorders. Furthermore, several randomized controlled trials show that cognitive behavioral therapy for insomnia delivered to individuals who meet diagnostic criteria for insomnia and another psychiatric disorder improves the insomnia as well as the symptoms of the comorbid psychiatric disorder. Taken together, these results encompassing a range of methodologies have provided encouraging evidence and point toward insomnia as a transdiagnostic process in psychiatric disorders.
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26
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Pigeon WR, Funderburk J. Delivering a Brief Insomnia Intervention to Depressed VA Primary Care Patients. COGNITIVE AND BEHAVIORAL PRACTICE 2014. [DOI: 10.1016/j.cbpra.2013.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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27
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Vandrey R, Babson KA, Herrmann ES, Bonn-Miller MO. Interactions between disordered sleep, post-traumatic stress disorder, and substance use disorders. Int Rev Psychiatry 2014; 26:237-47. [PMID: 24892898 PMCID: PMC4052373 DOI: 10.3109/09540261.2014.901300] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Disordered sleep is associated with a number of adverse health consequences and is an integral component of many psychiatric disorders. Rates of substance use disorders (SUDs) are markedly higher among individuals with post-traumatic stress disorder (PTSD), and this relationship may be partly mediated by disturbed sleep. Sleep disturbances (e.g. insomnia, daytime sleepiness, vivid nightmares) are hallmark features of PTSD and there is evidence that individuals with PTSD engage in substance use as a means of coping with these symptoms. However, prolonged substance use can lead to more severe sleep disturbances due to the development of tolerance and withdrawal. Behavioural or pharmacological treatment of disordered sleep is associated with improved daytime symptoms and psychosocial functioning among individuals who have developed PTSD. Initial research also suggests that improving sleep could be similarly beneficial in reducing coping oriented substance use and preventing relapse among those seeking treatment for SUDs. Together, these findings suggest that ameliorating sleep disturbance among at-risk individuals would be a viable target for the prevention and treatment of PTSD and associated SUDs, but prospective research is needed to examine this hypothesis. Enhanced understanding of the interrelation between sleep, PTSD, and SUDs may yield novel prevention and intervention approaches for these costly, prevalent and frequently co-occurring disorders.
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Affiliation(s)
- Ryan Vandrey
- Johns Hopkins University School of Medicine, University of Pennsylvania
| | - Kimberly A. Babson
- Center for Innovation to Implementation, VA Palo Alto Health Care System, University of Pennsylvania
- Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, University of Pennsylvania
| | - Evan S. Herrmann
- Johns Hopkins University School of Medicine, University of Pennsylvania
| | - Marcel O. Bonn-Miller
- Center for Innovation to Implementation, VA Palo Alto Health Care System, University of Pennsylvania
- Center of Excellence in Substance Abuse Treatment and Education, Philadelphia VAMC; Department of Psychiatry, University of Pennsylvania
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28
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Abstract
PURPOSE OF REVIEW The present review provides a conceptual introduction to sleep and circadian research in psychiatric illness, and discusses recent experimental and intervention findings in this area. RECENT FINDINGS In this review, studies published since January 2011 on circadian disturbance and psychiatric illness have been summarized. SUMMARY Exciting new results have increasingly utilized objective and validated instruments to measure the circadian system in experimental studies. Since 2011, treatment research has still predominantly utilized self-report measures as outcome variables. However, research in the treatment domain for sleep/circadian disturbances comorbid with psychiatric illness has advanced the field in its work to broaden the validation of existing sleep treatments to additional patient populations with comorbid sleep/circadian disruptions and address how to increase access to and affordability of treatment for sleep and circadian dysfunction for patients with psychiatric disorders, and how to combine psychosocial treatments with psychopharmacology to optimize treatment outcomes.
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29
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Harb GC, Phelps AJ, Forbes D, Ross RJ, Gehrman PR, Cook JM. A critical review of the evidence base of imagery rehearsal for posttraumatic nightmares: pointing the way for future research. J Trauma Stress 2013; 26:570-9. [PMID: 24114887 DOI: 10.1002/jts.21854] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In this article, the authors provide information on key characteristics of imagery rehearsal treatment protocols and examine the quality of reporting of randomized controlled and uncontrolled trials of imagery rehearsal for treating posttraumatic nightmares. Using a reliable and valid scale, two independent psychologists rated 16 trials. Most reports provided insufficient information on a range of variables including the definition of treatment delivery (e.g., therapist supervision, treatment fidelity), description of the participant sample, data analysis (e.g., determination of sample size), and treatment assignment (e.g., randomization procedures). Low methodological quality and poor reporting can lead to inflation of estimates of treatment effects and inadequately substantiated conclusions, such as inflated effect sizes in meta-analytic studies. Numerous imagery rehearsal protocols exist, but in some cases are given different names and tested in pilot studies, slowing progression in the field. Randomized controlled trials of imagery rehearsal with credible comparison conditions, examination of predictors of dropout and outcome, as well as dismantling studies of imagery rehearsal treatment components are needed.
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Affiliation(s)
- Gerlinde C Harb
- Behavioral Health Service, Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA
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30
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Brown CA, Berry R, Schmidt A. Sleep and military members: emerging issues and nonpharmacological intervention. SLEEP DISORDERS 2013; 2013:160374. [PMID: 23956864 PMCID: PMC3728519 DOI: 10.1155/2013/160374] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 06/24/2013] [Accepted: 06/26/2013] [Indexed: 11/30/2022]
Abstract
Background. Many individuals who work in the military experience sleep deficiency which presents a significant problem given the nature of their work. The cause of their sleep problems is likely multifactorial, stemming from the interplay between their personal health, habits and lifestyle juxtaposed with the stress of their military work such as emotional and physical trauma experienced in service. Objective. To present an overview of sleep deficiency in military members (MMs) and review of nonpharmacological treatment options. Discussion. Although there are a number of promising nonpharmacological treatment options available for people working in the military who experience problems sleeping, testing interventions within the context of the military are still in the early stages. Further research utilizing rigorous design and standardized, context appropriate outcome measures is needed to help treat this burgeoning problem.
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Affiliation(s)
- Cary A. Brown
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 2-64 Corbett Hall, Edmonton, AB, Canada T6G 2G4
| | - Robyn Berry
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 2-64 Corbett Hall, Edmonton, AB, Canada T6G 2G4
| | - Ashley Schmidt
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 2-64 Corbett Hall, Edmonton, AB, Canada T6G 2G4
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31
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Margolies SO, Rybarczyk B, Vrana SR, Leszczyszyn DJ, Lynch J. Efficacy of a cognitive-behavioral treatment for insomnia and nightmares in Afghanistan and Iraq veterans with PTSD. J Clin Psychol 2013; 69:1026-42. [PMID: 23629959 DOI: 10.1002/jclp.21970] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Sleep disturbances are a core and salient feature of posttraumatic stress disorder (PTSD). Pilot studies have indicated that combined cognitive-behavioral therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT) for nightmares improves sleep as well as PTSD symptoms. METHOD The present study randomized 40 combat veterans (mean age 37.7 years; 90% male and 60% African American) who served in Afghanistan and/or Iraq (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]) to 4 sessions of CBT-I with adjunctive IRT or a waitlist control group. Two thirds of participants had nightmares at least once per week and received the optional IRT module. RESULTS At posttreatment, veterans who participated in CBT-I/IRT reported improved subjectively and objectively measured sleep, a reduction in PTSD symptom severity and PTSD-related nighttime symptoms, and a reduction in depression and distressed mood compared to the waitlist control group. CONCLUSION The findings from this first controlled study with OEF/OIF veterans suggest that CBT-I combined with adjunctive IRT may hold promise for reducing both insomnia and PTSD symptoms. Given the fact that only half of the patients with nightmares fully implemented the brief IRT protocol, future studies should determine if this supplement adds differential efficacy to CBT-I alone.
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Hansen K, Höfling V, Kröner-Borowik T, Stangier U, Steil R. Efficacy of psychological interventions aiming to reduce chronic nightmares: a meta-analysis. Clin Psychol Rev 2012. [PMID: 23186732 DOI: 10.1016/j.cpr.2012.10.012] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This study presents a meta-analysis of the effectiveness of psychological treatments for chronic nightmares using imaginal confrontation with nightmare contents (ICNC) or imagery rescripting and rehearsal (IRR). Pre-post effect sizes (Hedges' g) were calculated for the outcome measures of nightmare frequency, nights per week with nightmares, sleep quality, depression, anxiety, and PTSD severity. Fixed-effects and random-effects models were applied. High effect sizes were found for nightmare frequency (g=1.04), nights per week with nightmares (g=0.99), and PTSD severity (g=0.92). Most of the effect sizes for the secondary outcomes were moderate. One objective was to clarify whether ICNC or IRR is more important for nightmare reduction. The results indicate that a higher duration of time for ICNC is associated with greater improvements: The minutes of applied ICNC moderate the effect sizes for nightmare frequency at follow-up 2 and for nights per week with nightmares at post and follow-up 1. The percentage of applied ICNC moderates the effect sizes for nightmare frequency and nights per week with nightmares at follow-up 1. Thus, dismantling studies are necessary to draw conclusions regarding whether ICNC or IRR is the most effective in the psychological treatment of chronic nightmares.
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Affiliation(s)
- Kathrin Hansen
- Department of Clinical Psychology and Psychotherapy, Johann Wolfgang Goethe University, Frankfurt, Germany.
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Abstract
Two case studies are presented to demonstrate that children who experience trauma-related nightmares may benefit from cognitive-behavioral therapy for this sleep problem. The treatment was adapted from the empirically supported adult treatment for chronic trauma-related nightmares: exposure, relaxation, and rescripting therapy (ERRT). Pretreatment and posttreatment nightmare frequency and severity were measured in addition to subjective nightmare-related distress, behavioral problems, sleep quality and quantity, and symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression. Improvement in nightmare and sleep disturbance frequencies were found as well as reductions in parents’ reports of child behavior problems. This study provides preliminary support for the use of ERRT with children.
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Sánchez-Ortuño MM, Edinger JD. Cognitive-behavioral therapy for the management of insomnia comorbid with mental disorders. Curr Psychiatry Rep 2012; 14:519-28. [PMID: 22865156 DOI: 10.1007/s11920-012-0312-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Insomnia is frequently comorbid with psychiatric conditions, mostly depression and anxiety disorders. Because disturbed sleep is a symptom of most major mental disorders, it has been traditionally assumed that effective treatment of the psychiatric condition will resolve the coincident insomnia also. However, insomnia often persists after successful treatment of the comorbid mental disorder, suggesting that insomnia often warrants separate treatment attention. Cognitive-behavioral therapy (CBT) is a well established and efficacious treatment for insomnia. Most evidence supporting the efficacy of CBT comes from studies conducted with patients suffering from primary insomnia, yet over the past 20 years there has been growing support for the use of cognitive-behavioral insomnia intervention for patients with comorbid psychiatric conditions. Overall, promising results have been obtained from these studies, not only with regard to insomnia improvement but also concurrent improvements in comorbid psychiatric conditions. In this article we review recent studies in this area with particular focus on treatment of insomnia in the context of depression, post-traumatic stress disorder, and alcohol dependence.
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Nocturnal time monitoring behavior ("clock-watching") in patients presenting to a sleep medical center with insomnia and posttraumatic stress symptoms. J Nerv Ment Dis 2012; 200:821-5. [PMID: 22932731 DOI: 10.1097/nmd.0b013e318266bba3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Time monitoring behavior (TMB) commonly occurs among insomnia patients, often leads to frustration about sleeplessness, and perpetuates insomnia symptoms. Few studies have explored relationships between time monitoring and insomnia, and none have studied the potential relationships between insomnia, TMB, and posttraumatic stress symptoms (PSSs). In this retrospective chart review of 1078 patients seeking care at a sleep medical center, the patients presented with one of three chief sleep complaints (poor sleep quality, 51%; sleep-disordered breathing, 26%; and insomnia, 24%), and 32% reported moderate to severe PSSs. Both insomnia and time monitoring severity were greater in the 350 patients with PSSs compared with the 728 patients with minimal or no such symptoms. Insomnia and time monitoring severity correlated significantly with total posttraumatic stress scores and most strongly with the arousal subscale. Research on interventions to treat TMB may inform relationships between insomnia and posttraumatic stress.
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Casement MD, Swanson LM. A meta-analysis of imagery rehearsal for post-trauma nightmares: effects on nightmare frequency, sleep quality, and posttraumatic stress. Clin Psychol Rev 2012; 32:566-74. [PMID: 22819998 PMCID: PMC4120639 DOI: 10.1016/j.cpr.2012.06.002] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Revised: 02/03/2012] [Accepted: 06/11/2012] [Indexed: 12/11/2022]
Abstract
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).
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Affiliation(s)
- Melynda D Casement
- National Center for Posttraumatic Stress Disorder at VA Boston Healthcare System and Boston University Medical Center, Boston, MA, USA.
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Cranston CC, Davis JL, Rhudy JL, Favorite TK. Replication and expansion of "Best Practice Guide for the Treatment of Nightmare Disorder in Adults". J Clin Sleep Med 2012; 7:549-53; discussion 554-6. [PMID: 22003352 DOI: 10.5664/jcsm.1330] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The August 2010 issue of Journal of Clinical Sleep Medicine (Vol. 6, No. 4) included an article suggesting treatment recommendations for adult nightmare disorder. Although we appreciate the work by the authors, we were left with three basic concerns about the methodology utilized and results found. First, works providing evidence for some of the treatments were not reported in the original article. Second, search methodology in the original article was not used consistently at updated time points. Third, the original article only utilized results obtained from PubMed and did not consider other databases. The current study sought to replicate the methodology and compare findings as well as expand by equalizing search methodology across updated time points. The present study expands the original efforts further by conducting article searches again on PsycINFO. Consequent changes to evidence levels and recommendations are discussed.
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Nakamura Y, Lipschitz DL, Landward R, Kuhn R, West G. Two sessions of sleep-focused mind-body bridging improve self-reported symptoms of sleep and PTSD in veterans: A pilot randomized controlled trial. J Psychosom Res 2011; 70:335-45. [PMID: 21414453 DOI: 10.1016/j.jpsychores.2010.09.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Sleep disturbance is highly prevalent among veterans. As an alternative to sleep medications with their undesirable side effects, nonpharmacological mind-body interventions may be beneficial for sleep management in primary care. The aim of this pilot study was to investigate whether a novel mind-body intervention, mind-body bridging (MBB), focusing on sleep, could improve self-reported sleep disturbance and comorbid symptoms in veterans. METHODS This pilot study was a randomized controlled trial at the Veterans Affairs Salt Lake City Health Care System in which 63 veterans with self-reported sleep disturbance received MBB or an active sleep education control. Both interventions were conducted in two sessions, once per week. Patient-reported outcomes included the following: primary-Medical Outcomes Study (MOS) Sleep Survey, MOS Short Form-36V; secondary-Center for Epidemiological Studies-Depression, PTSD Check List-Military, Five-Factor Mindfulness Questionnaire. RESULTS At both Week 1 (1 week after the first session) and post-intervention assessments, while sleep disturbance decreased in both groups, MBB performed significantly better than did the control group. Furthermore, self-reported PTSD symptoms improved in MBB, while they remained unchanged in the control. Overall mindfulness increased in MBB, while it remained unchanged in the control. CONCLUSIONS This study provides preliminary evidence that a brief sleep-focused MBB could be a promising intervention for sleep and potentially other comorbid symptoms (e.g., PTSD). MBB could help patients develop awareness skills to deal with sleep-related symptoms. Integration of MBB into primary care settings may enhance care of patients with sleep disturbance and co-morbid symptoms.
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Affiliation(s)
- Yoshio Nakamura
- Utah Center for Exploring Mind-Body Interactions (UCEMBI), Pain Research Center, Department Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT 84108, USA.
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Treating nightmares and insomnia in posttraumatic stress disorder: a review of current evidence. Neuropharmacology 2011; 62:576-85. [PMID: 21396945 DOI: 10.1016/j.neuropharm.2011.02.029] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 02/27/2011] [Accepted: 02/28/2011] [Indexed: 11/22/2022]
Abstract
Emerging evidence supports the notion of disrupted sleep as a core component of Posttraumatic Stress Disorder (PTSD). Effective treatments for nighttime PTSD symptoms are critical because sleep disruption may be mechanistically linked to development and maintenance of PTSD and is associated with significant distress, functional impairment, and poor health. This review aimed to describe the state of science with respect to the impact of the latest behavioral and pharmacological interventions on posttraumatic nightmares and insomnia. Published studies that examined evidence for therapeutic effects upon sleep were included. Some behavioral and pharmacological interventions show promise, especially for nightmares, but there is a need for controlled trials that include valid sleep measures and are designed to identify treatment mechanisms. Our ability to treat PTSD-related sleep disturbances may be improved by moving away from considering sleep symptoms in isolation and instead conducting integrative studies that examine sequential or combined behavioral and/or pharmacological treatments targeting both the daytime and nighttime aspects of PTSD. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.
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Siebern AT, Manber R. New developments in cognitive behavioral therapy as the first-line treatment of insomnia. Psychol Res Behav Manag 2011; 4:21-8. [PMID: 22114532 PMCID: PMC3218784 DOI: 10.2147/prbm.s10041] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Insomnia is the most common sleep disorder. Psychological, behavioral, and biological factors are implicated in the development and maintenance of insomnia as a disorder, although the etiology of insomnia remains under investigation, as it is still not fully understood. Cognitive behavioral therapy for insomnia (CBTI) is a treatment for insomnia that is grounded in the science of behavior change, psychological theories, and the science of sleep. There is strong empirical evidence that CBTI is effective. Recognition of CBTI as the first-line treatment for chronic insomnia (National Institutes of Health consensus, British Medical Association) was based largely on evidence of its efficacy in primary insomnia. The aim of this article is to provide background information and review recent developments in CBTI, focusing on three domains: promising data on the use of CBTI when insomnia is experienced in the presence of comorbid conditions, new data on the use of CBTI as maintenance therapy, and emerging data on the delivery of CBTI through the use of technology and in primary care settings.
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Affiliation(s)
- Allison T Siebern
- Sleep Medicine Center, Stanford University School of Medicine, Redwood City, California, USA
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