Somatosensory Amplification Is a Predictor of Self-Reported Side Effects in the Treatment of Primary Hypertension: a Pilot Study

The Amplification of Symptoms in the Medically Ill

The mechanism of symptom amplification, developed in the study of somatization, may be helpful in caring for patients with symptoms that, while they have a demonstrable medical basis, are nonetheless disproportionately severe and distressing. Amplified medical symptoms are marked by disproportionate physical suffering, unduly negative thoughts and concerns about them, and elevated levels of health-related anxiety. They are accompanied by extensive and sustained illness behaviors, disproportionate difficulty compartmentalizing them and circumscribing their impact, and consequent problems and dissatisfaction with their medical care. A distinction has long been made between "medically explained" and "medically unexplained" symptoms. However, a more comprehensive view of symptom phenomenology undermines this distinction and places all symptoms along a smooth continuum regardless of cause: Recent findings in cognitive neuroscience suggest that all symptoms-regardless of origin-are processed through convergent pathways. The complete conscious experience of both medically "explained" and "unexplained" symptoms is an amalgam of a viscerosomatic sensation fused with its ascribed salience and the patient's ideas, expectations, and concerns about the sensation. This emerging empirical evidence furnishes a basis for viewing persistent, disproportionately distressing symptoms of demonstrable disease along a continuum with medically unexplained symptoms. Thus, therapeutic modalities developed for somatization and medically unexplained symptoms can be helpful in the care of seriously ill medical patients with amplified symptoms. These interventions include educational groups for coping with chronic illness, cognitive therapies for dysfunctional thoughts, behavioral strategies for maladaptive illness behaviors, psychotherapy for associated emotional distress, and consultation with mental health professionals to assist the primary care physician with difficulties in medical management.

Changes in insomnia severity with advanced PAP therapy in patients with posttraumatic stress symptoms and comorbid sleep apnea: a retrospective, nonrandomized controlled study

BACKGROUND

Sleep disorders frequently occur in posttraumatic stress disorder (PTSD) patients. Chronic insomnia is a common feature of and criteria for the diagnosis of PTSD. Another sleep disorder, obstructive sleep apnea (OSA), also occurs frequently in PTSD, and emerging research indicates OSA fuels chronic insomnia. Scant research has investigated the impact of OSA treatment on insomnia outcomes (Insomnia Severity Index, ISI) in trauma survivors.

METHODS

OSA patients with moderately severe posttraumatic stress symptoms were studied in a retrospective chart review. Ninety-six patients who failed CPAP therapy due to expiratory pressure intolerance or complex sleep apnea or both underwent manual titration with advanced PAP modes [autobilevel (ABPAP); adaptive servo-ventilation (ASV)], which were subsequently prescribed. PAP use measured by objective data downloads divided the sample into three groups: compliant regular users (C-RU): n = 68; subthreshold users (SC-RU): n = 12; and noncompliant users (NC-MU): n = 16. The average follow-up was 11.89 ± 12.22 months. Baseline and posttreatment ISI scores were analyzed to assess residual insomnia symptoms as well as cure rates.

RESULTS

The C-RU group showed significant improvements in insomnia with very large effects compared to those in the NC-MU reference group (P = 0.019). Insomnia severity significantly decreased in all three groups with large effects (C-RU, P = 0.001; SC-RU, P = 0.027; NC-MU, P = 0.007). Hours of weekly PAP use and insomnia severity were inversely correlated (P = 0.001, r = - 0.321). However, residual insomnia symptoms based on established ISI cut-offs were quite common, even among the C-RU group. Post hoc analysis showed that several categories of sedating medications reported at baseline (hypnotics, anti-epileptic, opiates) as well as actual use of any sedating medication (prescription or nonprescription) were associated with smaller insomnia improvements than those in patients not using any sedating agents.

CONCLUSIONS

In a retrospective, nonrandomized analysis of a select sample of sleep clinic patients with OSA and PTSD symptoms, advanced PAP therapy was associated with significant improvement in insomnia severity for both compliant and partial users. However, residual insomnia symptoms persisted, indicating that PAP therapy provides only limited treatment. RCTs are warranted to assess the effect of ABPAP and ASV modes of therapy on adherence and sleep outcomes, and their potential impact on posttraumatic stress symptoms. Treatment arms that combine PAP with CBT-I would be expected to yield the greatest potency.