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Correia ATL, Lipinska G, Rauch HGL, Forshaw PE, Roden LC, Rae DE. Associations between sleep-related heart rate variability and both sleep and symptoms of depression and anxiety: A systematic review. Sleep Med 2023; 101:106-117. [PMID: 36370515 DOI: 10.1016/j.sleep.2022.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/05/2022] [Accepted: 10/20/2022] [Indexed: 11/07/2022]
Abstract
There is a bidirectional relationship between poor sleep and both mood- and anxiety-related disorders, which are among leading global health concerns. Additionally, both disordered sleep and these psychiatric disorders appear to be independently associated with altered autonomic nervous system (ANS) function. We hypothesise that ANS dysregulation during sleep may explain part of the relationship between poor sleep and mood- and anxiety-related disorders. Heart rate variability (HRV) is a frequently used marker of ANS function and gives an indication of ANS input to the heart - in particular, of the relative contributions of sympathetic and parasympathetic activity. A systematic review of PubMed, Scopus and Web of Science yielded 41 studies dealing with sleep, mood- and anxiety-related disorders and sleep-related HRV. Hyperarousal during sleep, reflecting a predominance of sympathetic activation and indicative of ANS dysregulation, may be an important factor in the association between poor sleep and mood-related disorders. Longitudinal studies and mediation analyses are necessary to further understand the potential mediating role of ANS dysregulation on the relationship between poor sleep and mood- and anxiety-related disorders.
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Affiliation(s)
- Arron T L Correia
- Health Through Physical Activity, Lifestyle and Sport Research Centre & Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - Gosia Lipinska
- Department of Psychology, Faculty of Humanities, University of Cape Town, South Africa
| | - H G Laurie Rauch
- Health Through Physical Activity, Lifestyle and Sport Research Centre & Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Philippa E Forshaw
- Health Through Physical Activity, Lifestyle and Sport Research Centre & Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Laura C Roden
- Health Through Physical Activity, Lifestyle and Sport Research Centre & Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa; Research Centre for Sport, Exercise and Life Sciences, Faculty of Health and Life Sciences, Coventry University, United Kingdom
| | - Dale E Rae
- Health Through Physical Activity, Lifestyle and Sport Research Centre & Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa
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Hargrave AS, Sumner JA, Ebrahimi R, Cohen BE. Posttraumatic Stress Disorder (PTSD) as a Risk Factor for Cardiovascular Disease: Implications for Future Research and Clinical Care. Curr Cardiol Rep 2022; 24:2067-2079. [PMID: 36306020 DOI: 10.1007/s11886-022-01809-y] [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] [Accepted: 10/11/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Posttraumatic stress disorder (PTSD) may be an important risk factor for cardiovascular disease (CVD). We explore the literature linking PTSD to CVD, potential mechanisms, interventions, and clinical implications. We outline gaps in current literature and highlight necessary future research. RECENT FINDINGS PTSD has been independently associated with deleterious effects on cardiovascular health through biological, behavioral, and societal pathways. There are evidence-based psychotherapeutic interventions and pharmacotherapies for PTSD that may mitigate its impact on CVD. However, there are limited studies that rigorously analyze the impact of treating PTSD on cardiovascular outcomes. Trauma-informed CVD risk stratification, education, and treatment offer opportunities to improve patient care. These approaches can include a brief validated screening tool for PTSD identification and treatment. Pragmatic trials are needed to test PTSD interventions among people with CVD and evaluate for improved outcomes.
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Affiliation(s)
- Anita S Hargrave
- Department of Internal Medicine, University of California San Francisco (UCSF), San Francisco, CA, 94110, USA. .,Medical Service, San Francisco VA Health Care System, San Francisco, CA, 94121, USA.
| | - Jennifer A Sumner
- Department of Psychology, University of California Los Angeles (UCLA), Los Angeles, CA, 90095-1563, USA
| | - Ramin Ebrahimi
- Department of Medicine, Cardiology Section, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, CA, USA.,Department of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, 90095, USA
| | - Beth E Cohen
- Department of Internal Medicine, University of California San Francisco (UCSF), San Francisco, CA, 94110, USA.,Medical Service, San Francisco VA Health Care System, San Francisco, CA, 94121, USA
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Bourassa KJ, Hendrickson RC, Reger GM, Norr AM. Posttraumatic Stress Disorder Treatment Effects on Cardiovascular Physiology: A Systematic Review and Agenda for Future Research. J Trauma Stress 2021; 34:384-393. [PMID: 33277952 PMCID: PMC8035275 DOI: 10.1002/jts.22637] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 10/01/2020] [Accepted: 10/26/2020] [Indexed: 11/06/2022]
Abstract
Posttraumatic stress disorder (PTSD) is linked to both altered physiological functioning and poorer cardiovascular health outcomes, including an increased risk for cardiovascular disease and cardiovascular-related mortality. An important question is whether interventions for PTSD might ameliorate the risk for poorer health by improving cardiovascular physiological intermediaries. To begin to characterize the literature addressing this question, we conducted a systematic review of empirical studies examining the impact of PTSD interventions on cardiovascular physiological intermediaries, including blood pressure (BP), heart rate (HR), cardiac impedance, and subclinical atherosclerosis. Outcomes included both tonic (i.e., resting) cardiovascular functioning and cardiovascular reactivity (CVR). A total of 44 studies met the inclusion criteria. There was mixed evidence regarding whether PTSD treatment improved tonic cardiovascular functioning. There was stronger evidence that PTSD treatments reduced CVR to trauma-related stressors, particularly for higher-quality studies of cognitive behavioral interventions. No studies examined cardiac impedance or subclinical atherosclerosis. The studies had a high degree of heterogeneity in the populations sampled and interventions tested. Moreover, they generally included small sample sizes and lacked control conditions. Interventions for PTSD may improve cardiovascular physiological outcomes, particularly CVR to trauma cues, although additional methodologically rigorous studies are needed. We outline changes to future research that would improve the literature regarding this important question, including the more frequent use of control groups and larger sample sizes.
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Affiliation(s)
- Kyle J. Bourassa
- VA Puget Sound Healthcare System, Seattle, Washington USA,Duke University Medical Center, Center for Aging and Human Development, Durham, North Carolina, USA
| | - Rebecca C. Hendrickson
- VISN 20 Northwest Network Mental Illness Research, Education and Clinical Center (MIRECC) Seattle, Washington USA,University of Washington School of Medicine, Department of Psychiatry Seattle, Washington, USA
| | - Greg M. Reger
- VA Puget Sound Healthcare System, Seattle, Washington USA,University of Washington School of Medicine, Department of Psychiatry Seattle, Washington, USA
| | - Aaron M. Norr
- VISN 20 Northwest Network Mental Illness Research, Education and Clinical Center (MIRECC) Seattle, Washington USA,University of Washington School of Medicine, Department of Psychiatry Seattle, Washington, USA
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LoSavio ST, Beckham JC, Wells SY, Resick PA, Sherwood A, Coffman CJ, Kirby AC, Beaver TA, Dennis MF, Watkins LL. The effect of reducing posttraumatic stress disorder symptoms on cardiovascular risk: Design and methodology of a randomized clinical trial. Contemp Clin Trials 2021; 102:106269. [PMID: 33429088 PMCID: PMC8009821 DOI: 10.1016/j.cct.2021.106269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/19/2020] [Accepted: 12/31/2020] [Indexed: 12/19/2022]
Abstract
Posttraumatic stress disorder (PTSD) has been associated with accelerated progression of coronary heart disease (CHD). However, the underlying pathophysiological pathway has remained elusive and it is unclear whether there is a direct link between PTSD and CHD risk. This paper describes the methods of a randomized controlled trial developed to examine how changes in PTSD symptoms affect CHD disease pathways. One hundred twenty participants with current PTSD and who are free of known CHD will be randomized to receive either an evidence-based treatment for PTSD (Cognitive Processing Therapy; CPT) or a waitlist control (WL). Before and after CPT/WL, participants undergo assessment of CHD risk biomarkers reflecting autonomic nervous system dysregulation, systemic inflammation, and vascular endothelial dysfunction. The primary hypothesis is that individuals who show improvement in PTSD symptoms will show improvement in CHD risk biomarkers, whereas individuals who fail to improve or show worsening PTSD symptoms will have no change or worsening in CHD biomarkers. This study is expected to provide knowledge of the role of both the direct impact of PTSD symptoms on CHD risk pathways and the role of these systems as candidate mechanisms underlying the relationship between PTSD and CHD risk. Further, results will provide guidance on the utility of cognitive therapy as a tool to mitigate the accelerated progression of CHD in PTSD. Clinical Trials Registration: https://clinicaltrials.gov/ct2/show/NCT02736929; Unique identifier: NCT02736929.
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Affiliation(s)
| | - Jean C Beckham
- Duke University Medical Center, Durham, NC, USA; Durham VA Healthcare System, Durham, NC, USA
| | - Stephanie Y Wells
- Duke University Medical Center, Durham, NC, USA; Durham VA Healthcare System, Durham, NC, USA; VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, United States of America
| | | | | | - Cynthia J Coffman
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, United States of America; Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, NC, United States of America
| | - Angela C Kirby
- Duke University Medical Center, Durham, NC, USA; Durham VA Healthcare System, Durham, NC, USA; VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, United States of America
| | - Tiffany A Beaver
- Duke University Medical Center, Durham, NC, USA; Durham VA Healthcare System, Durham, NC, USA
| | - Michelle F Dennis
- Duke University Medical Center, Durham, NC, USA; Durham VA Healthcare System, Durham, NC, USA
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Badour CL, Cox KS, Goodnight JR, Flores J, Tuerk PW, Rauch SA. Sexual Desire among Veterans Receiving Prolonged Exposure Therapy for PTSD: Does Successful PTSD Treatment Also Yield Improvements in Sexual Desire? Psychiatry 2020; 83:70-83. [PMID: 31577915 PMCID: PMC7083685 DOI: 10.1080/00332747.2019.1672439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: People with posttraumatic stress disorder (PTSD) commonly report difficulties with sexual desire and other aspects of sexual functioning, but it is currently unknown if people who respond to psychotherapy for PTSD also report improvements in sexual desire. Method: One hundred and eighty-seven veterans with PTSD received prolonged exposure (PE) therapy at two outpatient PTSD specialty clinics and completed measures of PTSD symptoms (the PTSD Checklist - Military Version) and sexual desire (item 21 of the Beck Depression Inventory - Second Edition) repeatedly throughout the course of treatment. Results: The results of a conditional generalized mixed ordinal regression model showed a significant interaction between weeks in treatment and PTSD treatment response in predicting change in sexual desire across the course of treatment. Specifically, PTSD treatment responders reported improvement in sexual desire over the course of treatment, whereas nonresponders did not show changes in sexual desire over time. However, the effect of PTSD treatment response was no longer significant when accounting for severity of depression at the start of treatment. Participants reporting more severe depression at the start of treatment reported less improvement in sexual desire, regardless of PTSD symptom response. Conclusions: People with PTSD who respond to PE also report improvements in sexual desire over time, indicating that response to PE is associated with improved sexual desire, but the effect is complicated by the presence of co-occurring depression symptomatology.
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Affiliation(s)
| | - Keith S. Cox
- University of North Carolina, Asheville, Department of Psychology
| | | | | | | | - Sheila A.M. Rauch
- Emory University, Department of Psychiatry and Behavioral Sciences,VA Atlanta Healthcare System, Mental Health Service Line
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Campbell AA, Wisco BE, Silvia PJ, Gay NG. Resting respiratory sinus arrhythmia and posttraumatic stress disorder: A meta-analysis. Biol Psychol 2019; 144:125-135. [DOI: 10.1016/j.biopsycho.2019.02.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 02/10/2019] [Accepted: 02/10/2019] [Indexed: 12/31/2022]
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Paul F, Alpers GW, Reinhard I, Schredl M. Nightmares do result in psychophysiological arousal: A multimeasure ambulatory assessment study. Psychophysiology 2019; 56:e13366. [DOI: 10.1111/psyp.13366] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 01/18/2019] [Accepted: 02/22/2019] [Indexed: 01/23/2023]
Affiliation(s)
- Franc Paul
- Central Institute of Mental Health Medical Faculty Mannheim/Heidelberg University Mannheim Germany
- Department of Psychology, Clinical and Biological Psychology and Psychotherapy, School of Social Sciences University of Mannheim Mannheim Germany
| | - Georg W. Alpers
- Department of Psychology, Clinical and Biological Psychology and Psychotherapy, School of Social Sciences University of Mannheim Mannheim Germany
| | - Iris Reinhard
- Central Institute of Mental Health Medical Faculty Mannheim/Heidelberg University Mannheim Germany
| | - Michael Schredl
- Central Institute of Mental Health Medical Faculty Mannheim/Heidelberg University Mannheim Germany
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The effectiveness of eye movement desensitisation and reprocessing with refugees experiencing symptoms of posttraumatic stress disorder. EUROPEAN JOURNAL OF TRAUMA & DISSOCIATION 2019. [DOI: 10.1016/j.ejtd.2018.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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9
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Pronociceptive effects mediated by adenosinergic A2A activity at the nucleus accumbens, but what about the autonomic nervous system? Pain 2018; 159:997. [PMID: 29672454 DOI: 10.1097/j.pain.0000000000001179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Woodward E, Hackmann A, Wild J, Grey N, Clark DM, Ehlers A. Effects of psychotherapies for posttraumatic stress disorder on sleep disturbances: Results from a randomized clinical trial. Behav Res Ther 2017; 97:75-85. [PMID: 28732289 PMCID: PMC5608018 DOI: 10.1016/j.brat.2017.07.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 05/16/2017] [Accepted: 07/05/2017] [Indexed: 12/04/2022]
Abstract
The effectiveness and mechanisms of psychotherapies for posttraumatic stress disorder (PTSD) in treating sleep problems is of interest. This study compared the effects of a trauma-focused and a non-trauma-focused psychotherapy on sleep, to investigate whether 1) sleep improves with psychotherapy for PTSD; 2) the degree of sleep improvement depends on whether the intervention is trauma or nontrauma-focused; 3) the memory-updating procedure in cognitive therapy for PTSD (CT-PTSD) is associated with sleep improvements; 4) initial sleep duration affects PTSD treatment outcome; and 5) which symptom changes are associated with sleep duration improvements. Self-reported sleep was assessed during a randomized controlled trial (Ehlers et al., 2014) comparing CT-PTSD (delivered weekly or intensively over 7-days) with emotion-focused supportive therapy, and a waitlist. Sleep duration was reported daily in sleep diaries during intensive CT-PTSD. CT-PTSD led to greater increases in sleep duration (55.2 min) and reductions in insomnia symptoms and nightmares than supportive therapy and the waitlist. In intensive CT-PTSD, sleep duration improved within 7 days, and sleep diaries indicated a 40-min sleep duration increase after updating trauma memories. Initial sleep duration was not related to CT-PTSD treatment outcome when initial PTSD symptom severity was controlled. The results suggest that trauma-focused psychotherapy for PTSD is more effective than nontrauma-focused therapy in improving self-reported sleep, and that CT-PTSD can still be effective in the presence of reduced sleep duration.
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Affiliation(s)
- Elizabeth Woodward
- Department of Experimental Psychology, University of Oxford, UK; National Institute for Health Research (NIHR), Oxford Health Biomedical Research Centre, Oxford, UK.
| | - Ann Hackmann
- National Institute for Health Research (NIHR), Oxford Health Biomedical Research Centre, Oxford, UK
| | - Jennifer Wild
- Department of Experimental Psychology, University of Oxford, UK; National Institute for Health Research (NIHR), Oxford Health Biomedical Research Centre, Oxford, UK
| | - Nick Grey
- National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre, South London Maudsley NHS Foundation Trust, King's College London, UK
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, UK; National Institute for Health Research (NIHR), Oxford Health Biomedical Research Centre, Oxford, UK; National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre, South London Maudsley NHS Foundation Trust, King's College London, UK
| | - Anke Ehlers
- Department of Experimental Psychology, University of Oxford, UK; National Institute for Health Research (NIHR), Oxford Health Biomedical Research Centre, Oxford, UK; National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre, South London Maudsley NHS Foundation Trust, King's College London, UK.
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11
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Tegeler CH, Cook JF, Tegeler CL, Hirsch JR, Shaltout HA, Simpson SL, Fidali BC, Gerdes L, Lee SW. Clinical, hemispheric, and autonomic changes associated with use of closed-loop, allostatic neurotechnology by a case series of individuals with self-reported symptoms of post-traumatic stress. BMC Psychiatry 2017; 17:141. [PMID: 28420362 PMCID: PMC5395741 DOI: 10.1186/s12888-017-1299-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 04/01/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The objective of this pilot study was to explore the use of a closed-loop, allostatic, acoustic stimulation neurotechnology for individuals with self-reported symptoms of post-traumatic stress, as a potential means to impact symptomatology, temporal lobe high frequency asymmetry, heart rate variability (HRV), and baroreflex sensitivity (BRS). METHODS From a cohort of individuals participating in a naturalistic study to evaluate use of allostatic neurotechnology for diverse clinical conditions, a subset was identified who reported high scores on the Posttraumatic Stress Disorder Checklist (PCL). The intervention entailed a series of sessions wherein brain electrical activity was monitored noninvasively at high spectral resolutions, with software algorithms translating selected brain frequencies into acoustic stimuli (audible tones) that were delivered back to the user in real time, to support auto-calibration of neural oscillations. Participants completed symptom inventories before and after the intervention, and a subset underwent short-term blood pressure recordings for HRV and BRS. Changes in temporal lobe high frequency asymmetry were analyzed from baseline assessment through the first four sessions, and for the last four sessions. RESULTS Nineteen individuals (mean age 47, 11 women) were enrolled, and the majority also reported symptom scores that exceeded inventory thresholds for depression. They undertook a median of 16 sessions over 16.5 days, and 18 completed the number of sessions recommended. After the intervention, 89% of the completers reported clinically significant decreases in post-traumatic stress symptoms, indicated by a change of at least 10 points on the PCL. At a group level, individuals with either rightward (n = 7) or leftward (n = 7) dominant baseline asymmetry in temporal lobe high frequency (23-36 Hz) activity demonstrated statistically significant reductions in their asymmetry scores over the course of their first four sessions. For 12 individuals who underwent short-term blood pressure recordings, there were statistically significant increases in HRV in the time domain and BRS (Sequence Up). There were no adverse events. CONCLUSION Closed-loop, allostatic neurotechnology for auto-calibration of neural oscillations appears promising as an innovative therapeutic strategy for individuals with symptoms of post-traumatic stress. TRIALS REGISTRATION ClinicalTrials.gov #NCT02709369 , retrospectively registered on March 4, 2016.
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Affiliation(s)
- Charles H. Tegeler
- Department of Neurology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA
| | - Jared F. Cook
- Department of Neurology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA
| | - Catherine L. Tegeler
- Department of Neurology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA
| | - Joshua R. Hirsch
- Department of Neurology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA
| | - Hossam A. Shaltout
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA
| | - Sean L. Simpson
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA
| | - Brian C. Fidali
- Department of Neurology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA
| | - Lee Gerdes
- Brain State Technologies, 15150 North Hayden Road, Suite 106, Scottsdale, Arizona 85260 USA
| | - Sung W. Lee
- Brain State Technologies, 15150 North Hayden Road, Suite 106, Scottsdale, Arizona 85260 USA
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Posttraumatic Stress Disorder (PTSD) Patients Exhibit a Blunted Parasympathetic Response to an Emotional Stressor. Appl Psychophysiol Biofeedback 2016; 41:395-404. [DOI: 10.1007/s10484-016-9341-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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13
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Lerma C, Martinez-Martinez LA, Ruiz N, Vargas A, Infante O, Martinez-Lavin M. Fibromyalgia beyond reductionism. Heart rhythm fractal analysis to assess autonomic nervous system resilience. Scand J Rheumatol 2015; 45:151-7. [PMID: 26375423 DOI: 10.3109/03009742.2015.1055299] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The prevailing linear reductionist medical model seems unable to explain complex multisymptomatic illnesses such as fibromyalgia (FM) and similar maladies. Paradigms derived from the complexity theory may provide a coherent framework for these elusive illnesses. Along these lines is the proposal that FM represents a degradation of our main complex adaptive system (the autonomic nervous system, ANS), in a failed effort to adjust to a hostile environment. Healthy complex systems have fractal structures. Heart rate fractal-like variability reflects resilient ANS performance. Our aim was to measure the heart rate variability (HRV) fractal scaling index in FM patients and to correlate this index with clinical symptoms. METHOD We studied 30 women with FM and 30 controls. All participants filled out questionnaires assessing the severity of FM. The HRV fractal scaling index was estimated during 24 h using detrended fluctuation analysis (DFA). RESULTS The fractal scaling index alpha-1 was higher in FM patients than in controls (mean ± sd: 1.22 ± 0.10 vs. 1.16 ± 0.09; p = 0.031). There was a positive correlation between the fractal scaling index alpha-1 and the visual analogue scale (VAS) for depression (Spearman's ρ = 0.36, p = 0.04). CONCLUSIONS The heart rate fractal exponent alpha-1 is altered in FM patients, suggesting a rigid ANS performance. This tangible non-linear finding supports the notion that FM may represent a degradation of our main complex adaptive system, namely the ANS.
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Affiliation(s)
- C Lerma
- a National Institute of Cardiology , Mexico City , Mexico
| | | | - N Ruiz
- a National Institute of Cardiology , Mexico City , Mexico
| | - A Vargas
- a National Institute of Cardiology , Mexico City , Mexico
| | - O Infante
- a National Institute of Cardiology , Mexico City , Mexico
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Abstract
Evolution has endowed all humans with a continuum of innate, hard-wired, automatically activated defense behaviors, termed the defense cascade. Arousal is the first step in activating the defense cascade; flight or fight is an active defense response for dealing with threat; freezing is a flight-or-fight response put on hold; tonic immobility and collapsed immobility are responses of last resort to inescapable threat, when active defense responses have failed; and quiescent immobility is a state of quiescence that promotes rest and healing. Each of these defense reactions has a distinctive neural pattern mediated by a common neural pathway: activation and inhibition of particular functional components in the amygdala, hypothalamus, periaqueductal gray, and sympathetic and vagal nuclei. Unlike animals, which generally are able to restore their standard mode of functioning once the danger is past, humans often are not, and they may find themselves locked into the same, recurring pattern of response tied in with the original danger or trauma. Understanding the signature patterns of these innate responses--the particular components that combine to yield the given pattern of defense-is important for developing treatment interventions. Effective interventions aim to activate or deactivate one or more components of the signature neural pattern, thereby producing a shift in the neural pattern and, with it, in mind-body state. The process of shifting the neural pattern is the necessary first step in unlocking the patient's trauma response, in breaking the cycle of suffering, and in helping the patient to adapt to, and overcome, past trauma.
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Ragen BJ, Seidel J, Chollak C, Pietrzak RH, Neumeister A. Investigational drugs under development for the treatment of PTSD. Expert Opin Investig Drugs 2015; 24:659-72. [PMID: 25773140 DOI: 10.1517/13543784.2015.1020109] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Posttraumatic stress disorder (PTSD) is a prevalent, chronic and disabling anxiety disorder that may develop following exposure to a traumatic event. There is currently no effective pharmacotherapy for PTSD and therefore the discovery of novel, evidence-based treatments is particularly important. This review of potential novel treatments could act as a catalyst for further drug investigation. AREAS COVERED In this review, the authors discuss the heterogeneity of PTSD and why this provides a challenge for discovering effective treatments for this disorder. By searching for the neurobiological systems that are disrupted in individuals with PTSD and their correlation with different symptoms, the authors propose potential pharmacological treatments that could target these symptoms. They discuss drugs such as nabilone, d-cycloserine, nor-BNI, 7,8-dihydroxyflavone and oxytocin (OT) to target systems such as cannabinoids, glutamate, opioids, brain-derived neurotrophic factor and the OT receptor, respectively. While not conclusive, the authors believe that these brain systems include promising targets for drug discovery. Finally, the authors review animal studies, proof-of-concept studies and case studies that support our proposed treatments. EXPERT OPINION A mechanism-based approach utilizing techniques such as in vivo neuroimaging will allow for the determination of treatments. Due to the heterogeneity of the PTSD phenotype, focusing on symptomology rather than a categorical diagnosis will allow for more personalized treatment. Furthermore, there appears to be a promise in drugs as cognitive enhancers, the use of drug cocktails and novel compounds that target specific pathways linked to the etiology of PTSD.
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Affiliation(s)
- Benjamin J Ragen
- New York University School of Medicine, Department of Psychiatry , New York, NY , USA
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Mohsenin S, Mohsenin V. Diagnosis and management of sleep disorders in posttraumatic stress disorder:a review of the literature. Prim Care Companion CNS Disord 2014; 16:14r01663. [PMID: 25834768 DOI: 10.4088/pcc.14r01663] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 08/04/2014] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE International and societal conflicts and natural disasters can leave physical and mental scars in people who are directly affected by these traumatic experiences. Posttraumatic stress disorder (PTSD) is the clinical manifestation of these experiences in the form of re-experiencing the trauma, avoidance of trauma-related stimuli, and persistent symptoms of hyperarousal. There is growing evidence that sleep disruption that occurs following trauma exposure may in fact contribute to the pathophysiology of PTSD and poor clinical outcomes. The purpose of this review is to highlight the importance of recognition and management of sleep disorders in patients with PTSD. DATA SOURCES English-language, adult research studies published between 1985 and April 2014 were identified via the PubMed database. The search terms used were PTSD AND sleep disorders. STUDY SELECTION The search identified 792 original and review articles. Of these, 53 articles that discussed or researched sleep disorders in PTSD were selected. Fourteen randomized controlled trials of therapy for PTSD are included in this review. RESULTS Impaired sleep is a common complaint mainly in the form of nightmares and insomnia among people with PTSD. Sleep apnea and periodic limb movement disorder are particularly prevalent in patients with PTSD and, yet, remain unrecognized. Although selective serotonin reuptake inhibitors are effective in improving PTSD global symptoms, they have a variable and modest effect on sleep disorder symptoms. Cognitive-behavioral treatment targeted to sleep and/or the use of the centrally acting selective α1 antagonist prazosin have been more successful in treating insomnia and nightmares in PTSD than other classes of medications. In view of the high occurrence of sleep apnea and periodic leg movement disorder, a thorough sleep evaluation and treatment are warranted. CONCLUSIONS Patients with PTSD have a high prevalence of sleep disorders and should be queried for insomnia, nightmares, periodic limb movement disorder, and sleep-disordered breathing.
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Affiliation(s)
- Shahla Mohsenin
- Private Practice Psychiatry, New Haven, Connecticut (Dr S. Mohsenin) and Section of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut (Dr V. Mohsenin)
| | - Vahid Mohsenin
- Private Practice Psychiatry, New Haven, Connecticut (Dr S. Mohsenin) and Section of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut (Dr V. Mohsenin)
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Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) has been linked to reduced heart rate variability (HRV), which is in turn a risk factor for cardiovascular disease and death. Although hyperarousal and anxiety are thought to underlie this association, behavioral health risks, including smoking, alcohol dependence, obesity, and sleep disturbance, represent potential mechanisms linking PTSD and HRV. METHODS To test this hypothesis, short-term laboratory-based and 24-hour ambulatory measures of HRV were collected from 227 young adults (18-39 years), 107 of whom were diagnosed as having PTSD. Latent variable modeling was used to assess the relationship of PTSD symptoms with HRV along with potential behavioral health mediators. RESULTS PTSD symptoms were associated with reduced HRV (β = -0.21, p = .002). However, this association was reduced in models that adjusted for cigarette consumption and history of alcohol dependence and was rendered nonsignificant in a model adjusting for sleep disturbance. Independent mediation effects were deemed significant via bootstrapping analysis. Together, the three behavioral health factors (cigarette consumption, history of alcohol dependence, and sleep disturbance) accounted for 94% of the shared variance between PTSD symptoms and HRV. Abdominal obesity was not a significant mediator. CONCLUSIONS These results indicate that behavioral factors-specifically smoking, alcohol overuse, and sleep disturbance-mediate the association between PTSD and HRV-based indices of autonomic nervous system dysregulation. Benefits from psychiatric and psychological interventions in PTSD may therefore be enhanced by including modification of health behaviors.
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Norte CE, Souza GGL, Vilete L, Marques-Portella C, Coutinho ESF, Figueira I, Volchan E. They know their trauma by heart: an assessment of psychophysiological failure to recover in PTSD. J Affect Disord 2013; 150:136-41. [PMID: 23273551 DOI: 10.1016/j.jad.2012.11.039] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 11/20/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) develops following exposure to atraumatic event and is characterized by persistent intense reactivity to trauma related cues. Equally important, but less studied, is the failure to restore physiological homeostasis after these excessive reactions. This study investigates psychophysiological markers of sustained cardiac activity after exposure to reminders of traumatic event in PTSD patients. METHODS Participants passively listened to neutral and personal traumatic event while electrocardiogram was continuously recorded. Heart rate (HR) and heart rate variability (HRV) were analyzed in 19 PTSD patients and 16 trauma-exposed controls. RESULTS Both PTSD patients and trauma exposed controls exhibited a significant increase in HR to the exposure of their personal trauma. PTSD patients sustained the increase of HR while controls recovered to basal levels. In PTSD patients, sustained HR was positively associated with re-experiencing symptoms. The PTSD group also showed a reduced HRV (a measure of parasympathetic influence on the heart) during personal trauma exposure and lack of recovery. LIMITATIONS The sample size was small and PTSD patients were under medication. CONCLUSIONS Our findings provide an experimental account of the failure of PTSD patients to exhibit physiological recovery after exposure to trauma-related stimuli. PTSD patients exhibited a sustained tachycardia with attenuation of HRV that persisted even after cessation of the stressor. Re-experiencing symptoms facilitated engagement in the trauma cues, suggesting that, in their daily-life, patients most likely present repeated episodes of sustained over-reactivity, which may underpin the emotional dysregulation characteristic of PTSD.
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Affiliation(s)
- Carlos Eduardo Norte
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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19
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Lee EAD, Bissett JK, Carter MA, Cowan PA, Pyne JM, Speck PM, Theus SA, Tolley EA. Preliminary findings of the relationship of lower heart rate variability with military sexual trauma and presumed posttraumatic stress disorder. J Trauma Stress 2013; 26:249-56. [PMID: 23568414 DOI: 10.1002/jts.21797] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Decreased heart rate variability (HRV) occurs with physical and psychological disorders and is a predictor of cardiac and all-cause mortality. This study was the first of which we are aware to examine and report the relationship between military sexual trauma (MST) and HRV measures. In a historical cohort study of female veterans with (n = 27) and without (n = 99) MST who received Holter and electrocardiogram evaluation at a Veteran Affairs medical center during 2007-2010, we examined the relationship between MST and the standard deviation of all R-R intervals (SDNN) and the square root of the mean of the sum of the squares of differences between adjacent R-R intervals (RMSSD). Female veterans with MST were younger, p = .002, frequently had a probable posttraumatic stress disorder diagnosis, 80% versus 15%, p = < .0001, and had lower SDNN, p = .0001, and RMSSD, p = .001, than those without MST. The SDNN and RMSSD of a 25-year-old female veteran with MST were comparable to that of female veterans aged 69 to 81 years without MST. Further research is needed to evaluate relationships between MST and HRV measures.
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Affiliation(s)
- Elizabeth A D Lee
- Department of Research and Development, Central Arkansas Veterans Healthcare System (CAVHS), Little Rock, Arkansas, USA.
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20
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Belleville G, Guay S, Marchand A. Persistence of sleep disturbances following cognitive-behavior therapy for posttraumatic stress disorder. J Psychosom Res 2011; 70:318-27. [PMID: 21414451 DOI: 10.1016/j.jpsychores.2010.09.022] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 08/10/2010] [Accepted: 09/30/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The objectives of the present study were (1) to assess the impact of cognitive-behavior therapy (CBT) for posttraumatic stress disorder (PTSD) on associated sleep disturbances and (2) to explore the correlates of persistent sleep difficulties in terms of anxiety and depression symptoms and perceived health. METHOD Fifty-five individuals with PTSD were administered a series of assessments designed to evaluate sleep, PTSD symptoms, symptoms of anxiety and depression, and perceived health before and after individual CBT for PTSD and at 6-month follow-up. RESULTS Significant improvements were observed on sleep quality, sleep onset latency, sleep efficiency, and sleep disturbances. These changes were not fully maintained after 6 months, and 70% of people who reported baseline sleep difficulties (Pittsburgh Sleep Quality Index >5) still reported significant problems with sleep after treatment. Persistent sleep difficulties were associated with more severe posttraumatic, anxious, and depressive symptoms as well as poorer health. CONCLUSION Although CBT for PTSD had a favorable impact on sleep, the majority of participants suffered from residual sleep difficulties. Individuals with persistent sleep difficulties posttreatment may experience more residual posttraumatic, depression, and anxiety symptoms and poorer mental and physical health than those who do not report sleep problems posttreatment. Further research in this area will allow clinicians to treat sleep problems in these individuals more effectively.
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Affiliation(s)
- Geneviève Belleville
- Centre d'Étude du Trauma, Centre de Recherche Fernand-Seguin, Hôpital Louis-H. Lafontaine, Montreal, Québec (Québec), Canada H1N 3V2.
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21
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Kar N. Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review. Neuropsychiatr Dis Treat 2011; 7:167-81. [PMID: 21552319 PMCID: PMC3083990 DOI: 10.2147/ndt.s10389] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is a psychiatric sequel to a stressful event or situation of an exceptionally threatening or catastrophic nature. Cognitive behavioral therapy (CBT) has been used in the management of PTSD for many years. This paper reviews the effectiveness of CBT for the treatment of PTSD following various types of trauma, its potential to prevent PTSD, methods used in CBT, and reflects on the mechanisms of action of CBT in PTSD. METHODS Electronic databases, including PubMed, were searched for articles on CBT and PTSD. Manual searches were conducted for cross-references in the relevant journal sites. RESULTS The current literature reveals robust evidence that CBT is a safe and effective intervention for both acute and chronic PTSD following a range of traumatic experiences in adults, children, and adolescents. However, nonresponse to CBT by PTSD can be as high as 50%, contributed to by various factors, including comorbidity and the nature of the study population. CBT has been validated and used across many cultures, and has been used successfully by community therapists following brief training in individual and group settings. There has been effective use of Internet-based CBT in PTSD. CBT has been found to have a preventive role in some studies, but evidence for definitive recommendations is inadequate. The effect of CBT has been mediated mostly by the change in maladaptive cognitive distortions associated with PTSD. Many studies also report physiological, functional neuroimaging, and electroencephalographic changes correlating with response to CBT. CONCLUSION There is scope for further research on implementation of CBT following major disasters, its preventive potential following various traumas, and the neuropsychological mechanisms of action.
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Affiliation(s)
- Nilamadhab Kar
- Department of Psychiatry, Wolverhampton City Primary Care Trust, Wolverhampton, UK
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22
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Dedert EA, Calhoun PS, Watkins LL, Sherwood A, Beckham JC. Posttraumatic stress disorder, cardiovascular, and metabolic disease: a review of the evidence. Ann Behav Med 2010; 39:61-78. [PMID: 20174903 DOI: 10.1007/s12160-010-9165-9] [Citation(s) in RCA: 179] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) is a significant risk factor for cardiovascular and metabolic disease. PURPOSE The purpose of the current review is to evaluate the evidence suggesting that PTSD increases cardiovascular and metabolic risk factors, and to identify possible biomarkers and psychosocial characteristics and behavioral variables that are associated with these outcomes. METHODS A systematic literature search in the period of 2002-2009 for PTSD, cardiovascular disease, and metabolic disease was conducted. RESULTS The literature search yielded 78 studies on PTSD and cardiovascular/metabolic disease and biomarkers. CONCLUSIONS Although the available literature suggests an association of PTSD with cardiovascular disease and biomarkers, further research must consider potential confounds, incorporate longitudinal designs, and conduct careful PTSD assessments in diverse samples to address gaps in the research literature. Research on metabolic disease and biomarkers suggests an association with PTSD, but has not progressed as far as the cardiovascular research.
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Affiliation(s)
- Eric A Dedert
- VA Research Service, Department of Psychiatry and Behavioral Sciences, Durham Veterans Affairs and Duke University Medical Centers, Durham, NC, USA.
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23
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Charuvastra A, Cloitre M. Safe enough to sleep: sleep disruptions associated with trauma, posttraumatic stress, and anxiety in children and adolescents. Child Adolesc Psychiatr Clin N Am 2009; 18:877-91. [PMID: 19836694 DOI: 10.1016/j.chc.2009.04.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Sleep disturbance is an essential symptom of posttraumatic stress disorder, and recent evidence suggests that disrupted sleep may play an important role in the development of posttraumatic stress disorder following traumatic stress. The authors review several aspects of sleep as it relates to posttraumatic stress disorder. First, there is an association between traumatic stress and different components of disrupted sleep in children and adolescents. Second, sleep disruption appears to be a core feature of other pediatric anxiety disorders, and the authors consider if this preexisting sleep vulnerability may explain in part why preexisting anxiety disorders are a risk factor for developing posttraumatic stress disorder following a traumatic event. Third, the authors consider attachment theory and the social context of trauma and sleep disruption. This article concludes with a consideration of the therapeutic implications of these findings.
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Affiliation(s)
- Anthony Charuvastra
- Department of Child and Adolescent Psychiatry, Institute for Trauma and Resilience, The Trauma and Resilience Program, NYU Child Study Center, 16th Floor, 215 Lexington Avenue, New York, NY 10016, USA
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24
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Geenen R, Jacobs JW, Bijlsma JW. A Psychoneuroendocrine Perspective on the Management of Fibromyalgia Syndrome. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/10582450902816521] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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25
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Zucker TL, Samuelson KW, Muench F, Greenberg MA, Gevirtz RN. The Effects of Respiratory Sinus Arrhythmia Biofeedback on Heart Rate Variability and Posttraumatic Stress Disorder Symptoms: A Pilot Study. Appl Psychophysiol Biofeedback 2009; 34:135-43. [DOI: 10.1007/s10484-009-9085-2] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 04/07/2009] [Indexed: 10/20/2022]
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26
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Friedman BH. An autonomic flexibility–neurovisceral integration model of anxiety and cardiac vagal tone. Biol Psychol 2007; 74:185-99. [PMID: 17069959 DOI: 10.1016/j.biopsycho.2005.08.009] [Citation(s) in RCA: 487] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2005] [Indexed: 11/22/2022]
Abstract
Research on heart rate variability (HRV), cardiac vagal tone, and their relationship to anxiety is reviewed in the context of the autonomic flexibility and neurovisceral integration models of adaptive functioning. These perspectives address the qualities of response flexibility and inhibition across multiple levels, incorporating central and autonomic nervous system mechanisms of environmental engagement, as well as principles derived from non-linear dynamics. These models predict reduced HRV and vagal tone in anxiety, and the literature has generally supported this prediction, with exceptions as are noted. State, trait, and clinical expressions of anxiety are considered, along with the clinical, methodological, and theoretical implications of this research. A portrayal of anxiety as a restricted response range across biological and behavioral realms of functioning is drawn from the literature on anxiety and HRV.
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Affiliation(s)
- Bruce H Friedman
- Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061-0436, USA.
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27
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Maher MJ, Rego SA, Asnis GM. Sleep disturbances in patients with post-traumatic stress disorder: epidemiology, impact and approaches to management. CNS Drugs 2006; 20:567-90. [PMID: 16800716 DOI: 10.2165/00023210-200620070-00003] [Citation(s) in RCA: 210] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Subjective reports of sleep disturbance indicate that 70-91% of patients with post-traumatic stress disorder (PTSD) have difficulty falling or staying asleep. Nightmares are reported by 19-71% of patients, depending on the severity of their PTSD and their exposure to physical aggression. Objective measures of sleep disturbance are inconsistent, with some studies that used these measures indicating poor sleep and others finding no differences compared with non-PTSD controls. Future research in this area may benefit from examining measures of instability in the microstructure of sleep. Additionally, recent findings suggest that sleep disordered breathing (SDB) and sleep movement disorders are more common in patients with PTSD than in the general population and that these disorders may contribute to the brief awakenings, insomnia and daytime fatigue in patients with PTSD. Overall, sleep problems have an impact on the development and symptom severity of PTSD and on the quality of life and functioning of patients. In terms of treatments, SSRIs are commonly used to treat PTSD, and evidence suggests that they have a small but significant positive effect on sleep disruption. Studies of serotonin-potentiating non-SSRIs suggest that nefazodone and trazodone lead to significant reductions in insomnia and nightmares, whereas cyproheptadine may exacerbate sleep problems in patients with PTSD. Prazosin, a centrally acting alpha1-adrenoceptor antagonist, has led to large reductions in nightmares and insomnia in small studies of patients with PTSD. Augmentation of SSRIs with olanzapine, an atypical antipsychotic, may be effective for treatment-resistant nightmares and insomnia, although adverse effects can be significant. Additional medications, including zolpidem, buspirone, gabapentin and mirtazapine, have been found to improve sleep in patients with PTSD. Large randomised, placebo-controlled trials are needed to confirm the above findings. In contrast, evidence suggests that benzodiazepines, TCAs and MAOIs are not useful for the treatment of PTSD-related sleep disorders, and their adverse effect profiles make further studies unlikely. Cognitive behavioural interventions for sleep disruption in patients with PTSD include strategies targeting insomnia and imagery rehearsal therapy (IRT) for nightmares. One large randomised controlled trial of group IRT demonstrated significant reductions in nightmares and insomnia. Similarly, uncontrolled studies combining IRT and insomnia strategies have demonstrated good outcomes. Uncontrolled studies of continuous positive airway pressure for SDB in patients with PTSD show that this treatment led to significant decreases in nightmares, insomnia and PTSD symptoms. Controlled studies are needed to confirm these promising findings.
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Affiliation(s)
- Michael J Maher
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York 10467, USA
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28
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Mitani S, Fujita M, Sakamoto S, Shirakawa T. Effect of autogenic training on cardiac autonomic nervous activity in high-risk fire service workers for posttraumatic stress disorder. J Psychosom Res 2006; 60:439-44. [PMID: 16650583 DOI: 10.1016/j.jpsychores.2005.09.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2004] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We investigated the effect of autogenic training (AT) on cardiac autonomic nervous activity in fire services workers with the use of the questionnaire of the Japanese-language version of Impact of Event Scale-Revised (IES-R-J) and indexes of heart rate variability. METHODS We studied 22 male fire services workers who were divided into posttraumatic stress disorder (PTSD)-related stress group (n=10) and control group (n=12). They underwent AT twice or three times a week for 2 months. RESULTS Posttraumatic stress disorder-related stress group showed a significantly higher cardiac sympathetic nervous activity and a significantly lower cardiac parasympathetic nervous activity than control group at baseline. Autogenic training significantly decreased cardiac sympathetic nervous activity and significantly increased cardiac parasympathetic nervous activity in both groups. These changes were accompanied by a significant decrease in the total points of IES-R-J. CONCLUSION Autogenic training is effective for ameliorating the disturbance of cardiac autonomic nervous activity and psychological issues secondary to PTSD.
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Affiliation(s)
- Satoko Mitani
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Public Health, Yoshida-Konoe cho, Sakyo-ku, Kyoto 606-8501, Japan
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29
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Cotter G, Milo-Cotter O, Rubinstein D, Shemesh E. Posttraumatic stress disorder: a missed link between psychiatric and cardiovascular morbidity? CNS Spectr 2006; 11:129-36. [PMID: 16520690 DOI: 10.1017/s109285290001066x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Posttraumatic stress disorder (PTSD) symptoms may develop as a result of an acute, life-threatening traumatic event. Such acute events are quite common in patients with cardiovascular illnesses (ie, a myocardial infarction, acute exacerbations of heart failure or edema). Indeed, PTSD symptoms have been described in a substantial minority of patients who had such events (10% to 25%), and have been shown to be associated with medical morbidity and with non-adherence to medications. This review summarizes available information about these symptoms in patients with cardiovascular illnesses. It also describes the importance of recognizing PTSD as a distinct psychiatric disorder (that can be addressed by specific treatments) and as an important compounding factor in studies of psychopathology in cardiovascular patients. In particular, an argument is made that the understanding of depressive disorders in patients with cardiovascular illnesses should incorporate conceptual and treatment information from the emotional trauma literature if indeed depressive and anxiety disorders are to be successfully treated in these patients. The authors conclude with a description of the challenges and promise of an effort to implement a clinical program to screen for PTSD symptoms in patients with cardiovascular illnesses, and with recommendations for future efforts.
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Affiliation(s)
- Gad Cotter
- Department of Medicine, Division of Cardiovascular Medicine, Duke University Medical Center, Durham, North Carolina 27715, USA.
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30
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Sakata M, Sei H, Eguchi N, Morita Y, Urade Y. Arterial pressure and heart rate increase during REM sleep in adenosine A2A-receptor knockout mice, but not in wild-type mice. Neuropsychopharmacology 2005; 30:1856-60. [PMID: 15827570 DOI: 10.1038/sj.npp.1300727] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Rapid eye movement (REM)-sleep related changes in arterial pressure (AP) and heart rate (HR) were observed in homozygous and heterozygous adenosine A(2A) receptor (A2AR) knockout (KO) mice, and the corresponding wild-type mice. During REM sleep, the mean AP (MAP) and HR were clearly increased in the homozygous A2AR KO mice, while, in the wild-type mice, they were decreased or maintained at the same level. Neither homozygous nor heterozygous A2AR KO mice showed significant difference in diurnal pattern and the hourly values of MAP and HR compared to the wild-type mice. From these findings, it is likely that the adenosine A2AR is involved in autonomic regulation during REM sleep.
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Affiliation(s)
- Mie Sakata
- Department of Molecular Behavioral Biology, Osaka Bioscience Institute, Osaka, Japan
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31
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Siepmann M, Joraschky P, Rebensburg M, Rittger H, Mösler T, Agelink MW, Mück-Weymann M. Ist die autonome kardiale Regulation bei Patienten mit Depression und Koronarer Herzkrankheit gestört? ZEITSCHRIFT FUR KLINISCHE PSYCHOLOGIE UND PSYCHOTHERAPIE 2005. [DOI: 10.1026/1616-3443.34.4.277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Zusammenfassung. Hintergrund und Zielsetzung: Beeinträchtigung der Herzratenvariabilität ist ein Indikator für eine erhöhte kardiovaskuläre Mortalität. Geprüft werden sollte, ob depressive Symptome die Herzratenvariabilität beeinflussen können. Methode: Die Herzratenvariabilität wurde bei 22 ambulanten nicht behandelten Patienten (16 w, 6 m) und bei 11 gesunden Kontrollpersonen (8 w, 3 m) gemessen. Darüber hinaus wurden 41 Patienten mit koronarangiographisch gesicherter KHK (5 w, 36 m) untersucht. Ergebnisse: Die Herzratenvariabilität war bei herzgesunden Patienten mit Depression um 50% vermindert im Vergleich zu Kontrollpersonen (p < 0,05) während das Vorhandensein depressiver Symptome bei Patienten mit KHK keinen signifikanten Einfluss auf die Herzratenvariabilität hatte. Schlussfolgerungen: Störung der autonomen kardialen Regulation konnte für herzgesunde Patienten mit Depression nachgewiesen werden.
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Affiliation(s)
- Martin Siepmann
- Institut für Klinische Pharmakologie, Medizinische Fakultät der Technischen Universität Dresden
| | - Peter Joraschky
- Klinik für Psychotherapie und Psychosomatik, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden
| | - Max Rebensburg
- Klinik für Psychotherapie und Psychosomatik, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden
| | - Harald Rittger
- Klinik für Psychotherapie und Psychosomatik, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden
| | - Thomas Mösler
- Institut für Verhaltenstherapie, Verhaltensmedizin und Sexuologie, Nürnberg
| | - Marcus W. Agelink
- Klinik für Psychiatrie, Psychotherapie und Psychosomatik am Klinikum Herford/MH Hannover
| | - Michael Mück-Weymann
- Klinik für Psychotherapie und Psychosomatik, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden
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32
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Osuch E, Engel CC. Research on the Treatment of Trauma Spectrum Responses: The Role of the Optimal Healing Environment and Neurobiology. J Altern Complement Med 2004. [DOI: 10.1089/acm.2004.10.s-211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Elizabeth Osuch
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Charles C. Engel
- Deployment Health Clinical Center, Walter Reed Army Center, Washington, DC
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Mellman TA, Knorr BR, Pigeon WR, Leiter JC, Akay M. Heart rate variability during sleep and the early development of posttraumatic stress disorder. Biol Psychiatry 2004; 55:953-6. [PMID: 15110740 DOI: 10.1016/j.biopsych.2003.12.018] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2003] [Revised: 12/18/2003] [Accepted: 12/20/2003] [Indexed: 01/12/2023]
Abstract
BACKGROUND Noradrenergic function has been linked to posttraumatic stress disorder (PTSD) and might have a role in mediating sleep disturbances of the disorder. Our objective was to relate a peripheral manifestation of noradrenergic function, sympathetic nervous system activity as indexed by heart rate variability during sleep, to the development of PTSD in subjects with recent traumatic injuries. METHODS Subjects who had recall of life-threatening experiences were recruited from one of two regional trauma centers. Select subjects received a polysomnographic recording within 1 month of the trauma. Digitized electrocardiogram recordings were extracted from early and late rapid-eye-movement (REM) and preceding non-REM sleep periods. Autoregression was applied to R-R interval time series to calculate the ratios of low-frequency to high-frequency spectral densities (LF/HF ratios), which index sympathetic activation. Posttraumatic stress disorder status was determined at 2 months. RESULTS There was a significant state x group interaction: LF/HF ratios were higher during the REM sleep of the nine subjects who were positive for PTSD symptoms, compared with the 10 subjects who were PTSD negative. CONCLUSIONS Our findings are consistent with the possibility that increased noradrenergic activity during REM sleep contributes to the development of PTSD.
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Affiliation(s)
- Thomas A Mellman
- Department of Psychiatry, Dartmouth Medical School, Lebanon, New Hampshire, USA
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