Management of nightmares in patients with posttraumatic stress disorder: current perspectives

An overview of the differences in the pharmacological management of post-traumatic stress disorder between women and men

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a disabling psychiatric condition with a worldwide prevalence between 6% and 9%, and more common in the female than in the male sex. The aim of this paper is to review and comment on the different factors that might explain the discrepancies in the pharmacological management of women and men.

AREAS COVERED

The available literature shows that there exists a vulnerability of women to develop PTSD that may depend on neurobiological as well as environmental/cultural factors. These variables might influence the clinical picture, the outcome and the response to specific treatments, given their consequences on the pharmacokinetics of commonly prescribed drugs. Women suffering from PTSD are more prone to consult and receive more prescriptions of psychotropic drugs than men. However, it is evident that the particular stages of a women's life such as pregnancy or breastfeeding might require a specific evaluation and care.

EXPERT OPINION

It is necessary to explore the pharmacokinetics of compounds highlighting sex-related differences, and their safety during pregnancy and lactation. Taking care of differences between women and men should represent a main focus of research, while being a primary target towards a really tailored pharmacological treatment of PTSD.

Drawing your way out: Imagery rehearsal based art therapy (IR-AT) for post-traumatic nightmares in borderline personality disorder

Posttraumatic nightmares (PTN) are a frequent symptom after a traumatic event and often play part in the psychopathology of patients with borderline personality disorder (BPD). Imagery rehearsal therapy (IRT) currently offers the best evidence for an effective treatment to reduce PTNs, although high drop-out rates are common. Art therapy in IRT may counteract this, by its indirect, nonverbal, and often playful approach that helps to break through avoidance. This case study focusses on the perception of a patient with BPD in an art therapy based IRT treatment for patients with PTNs. It tells the story of Aurelia, a 40-year-old woman who, within this treatment, processes traumatic contents of her childhood like physical and sexual violence, but also current interactional problems that manifest themselves in her nightmares. Following the IR-AT treatment for PTNs Aurelia noticed a reduction in her nightmares, was less afraid of them and felt calmer towards her trauma. She expressed herself in the art medium and by this developed more self-efficacy. Her process resulted in an integration of the trauma and a perceived decrease in borderline symptoms. Future research can build on this basis to further explore the mechanisms and effects of IR-AT for PTNs.

Nightmare experiences and perceived ethnic discrimination amongst female university students in the United Arab Emirates: a cross-sectional study

Perceived ethnic discrimination is known to be associated with anxiety and depression, and in turn, anxiety and depression are known to be associated with nightmare frequency and distress. This elicits a question: is perceived ethnic discrimination associated with nightmare frequency and distress? In this study, 179 female university students from the United Arab Emirates were assessed to answer that question. Results showed that while anxiety and depression were related to nightmare experiences, perceived ethnic discrimination was a stronger predictor of nightmare experiences. We posit two explanations for this finding: one based on psychoanalytical insights, and the other based on the Disposition-Stress model with neurobiological correlates. No significant differences were found across ethnicity when it comes to nightmare experiences or perceived ethnic discrimination. This is an encouraging sign of optimal societal integration in the United Arab Emirates.

The effectiveness of lucid dreaming therapy in patients with nightmares: A systematic review

OBJECTIVES

Nightmares can be defined as "an unpleasant dream with anxiety and oppression". They represent a symptom possibly leading to serious psychiatric and physical consequences. It occurs to 2% to 8% of the general population. Lucid dreaming therapy (LDT) is an interesting upcoming psychotherapy for the treatment of nightmares. The aim of this study was to evaluate the efficacy of LDT in the treatment of nightmares in adults and children.

METHODS

We performed a systematic review of the literature, based on the Cochrane organisation's methodology. We explored the PubMed, Cochrane library, PsycINFO via Ovid and Embase databases and clinical trial registries (CTR), namely clinicaltrials.gov, EU clinical trials and the WHO clinical trials registry platform.

RESULTS

Four randomized controlled trials (RCT), 2 case series and 5 case reports were included. Most of the included studies found LDT effective in reducing nightmare frequency among adults with chronic and recurring nightmares. We did not identify any reports in children.

CONCLUSIONS

Despite a limited internal validity for the included studies, these first results are encouraging. Nonetheless, larger and more rigorous studies would allow to better assess the utility of LDT for nightmares.

Novel Pharmacological Targets of Post-Traumatic Stress Disorders

Post-traumatic stress disorder (PTSD) is a psychopathological condition with a heterogeneous clinical picture that is complex and challenging to treat. Its multifaceted pathophysiology still remains an unresolved question and certainly contributes to this issue. The pharmacological treatment of PTSD is mainly empirical and centered on the serotonergic system. Since the therapeutic response to prescribed drugs targeting single symptoms is generally inconsistent, there is an urgent need for novel pathogenetic hypotheses, including different mediators and pathways. This paper was conceived as a narrative review with the aim of debating the current pharmacological treatment of PTSD and further highlighting prospective targets for future drugs. The authors accessed some of the main databases of scientific literature available and selected all the papers that fulfilled the purpose of the present work. The results showed that most of the current pharmacological treatments for PTSD are symptom-based and show only partial benefits; this largely reflects the limited knowledge of its neurobiology. Growing, albeit limited, data suggests that the hypothalamic-pituitary-adrenal axis, opioids, glutamate, cannabinoids, oxytocin, neuropeptide Y, and microRNA may play a role in the development of PTSD and could be targeted for novel treatments. Indeed, recent research indicates that examining different pathways might result in the development of novel and more efficient drugs.

Nightmare disorder in active-duty US military personnel

STUDY OBJECTIVES

Military personnel experience high rates of traumatic experiences. Despite this, few studies have examined the presence of nightmare disorder in military personnel. The primary aim of this study was to examine diagnoses of nightmare disorder across the 4 largest branches of the active-duty US military.

DESIGN & PARTICIPANTS

Data and service branch densities used to derive the expected rates of diagnoses of nightmare disorder were drawn from the Defense Medical Epidemiology Database. The branches examined included all active-duty services members in the US Army, Navy, Marine Corps, and Air Force, who served between 2016 and 2021. Single-sample chi-square goodness of fit tests were conducted to examine within-variable differences for military relevant variables.

RESULTS

Between 2016 and 2019, the incidence rates of nightmare disorder (per 10,000 service members) in the US Department of Defense ranged from 11.3 in 2016 to a low of 6.9 in 2018. Service members who were classified as non-white, female, over the age of 35, married, in the Army, and/or a noncommissioned officer, were diagnosed at greater rates relative to their representation in the military population (p < .001).

CONCLUSION

Our findings of higher than expected rates of nightmare disorder in older, senior service members as well as those in the Army align with the known precipitant of nightmares, and trauma. However, the reason for the finding that female and Black service members have higher than expected rates is not readily apparent.

Antipsychotic-induced bone loss: the role of dopamine, serotonin and adrenergic receptor signalling

Antipsychotics are commonly used in treating psychiatric disorders. These medications primarily target dopamine the serotonin receptors, they have some affinity to adrenergic, histamine, glutamate and muscarinic receptors. There is clinical evidence that antipsychotic use decreases BMD and increases fracture risk, with dopamine, serotonin and adrenergic receptor-signalling becoming an increasing area of focus where the presence of these receptors in osteoclasts and osteoblasts have been demonstrated. Osteoclasts and osteoblasts are the most important cells in the bone remodelling and the bone regeneration process where the activity of these cells determine the bone resorption and formation process in order to maintain healthy bone. However, an imbalance in osteoclast and osteoblast activity can lead to decreased BMD and increased fracture risk, which is also believed to be exacerbated by antipsychotics use. Therefore, the aim of this review is to provide an overview of the mechanisms of action of first, second and third generation antipsychotics and the expression profiles of dopamine, serotonin and adrenergic receptors during osteoclastogenesis and osteoblastogenesis.

The Sleep Parameters of Paralympic Athletes: Characteristics and Assessment Instruments

CONTEXT

Sleep serves many important functions for athletes, particularly in the processes of learning, memory, recovery, and cognition.

OBJECTIVES

Define the sleep parameters of Paralympic athletes and identify the instruments used to assess and monitor sleep Paralympic athletes.

EVIDENCE ACQUISITION

This systematic review was carried out based on the PRISMA guidelines. The survey was conducted in April 2020, the searches were carried out again in September 2021 to check whether there were new scientific publications in the area of sleep and Paralympic sport, searches were performed in the following databases: PubMed, Web of Science, Scopus, SPORTDiscus, Virtual Health Library (BIREME), and SciELO. This systematic review has included studies that investigated at least one of the following sleep parameters: total sleep time, sleep latency, sleep efficiency, number of awakenings, quality of sleep, daytime sleepiness, and chronotype; the participants were comprised of athletes with disabilities. Studies published at any time in English, Portuguese, and Spanish, were included.

EVIDENCE SYNTHESIS

Data extraction and study selection were performed by 2 researchers independently, and a third author was consulted as necessary. The search returned a total of 407 studies. Following the screening based on exclusion and inclusion criteria, a total of 13 studies were considered. Paralympic athletes have a low amount (7.06 h) of sleep with poor quality and sleep latency (28.05 min), and 57.2% have daytime sleepiness, with the majority belonging to the indifferent chronotype (53, 5%). Moreover, 11 studies assess sleep using subjective instruments (questionnaires), and 2 studies used an objective instrument (actigraphy).

CONCLUSIONS

Sleep disorders are common among Paralympic athletes, poor sleep quality and quantity, and high rates of daytime sleepiness. Subjective methods are most commonly used to assess sleep.

Cannabis-assisted psychotherapy for complex dissociative posttraumatic stress disorder: A case report

BACKGROUND

A dissociative subtype of posttraumatic stress disorder, known as "D-PTSD", has been included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. In addition to meeting criteria for PTSD, patients endorse prominent dissociative symptoms, namely depersonalization and derealization, or detachment from one's self and surroundings. At present, this population is supported by a highly heterogeneous and undeveloped literature. Targeted interventions are therefore lacking, and those indicated for PTSD are limited by poor efficacy, delayed onset of action, and low patient engagement. Here, we introduce cannabis-assisted psychotherapy (CAP) as a novel treatment for D-PTSD, drawing parallels to psychedelic therapy.

CASE PRESENTATION

A 28-year-old female presented with complex D-PTSD. In a naturalistic setting, she underwent 10 sessions of CAP, scheduled twice monthly over 5 months, coupled with integrative cognitive behavioral therapy. An autonomic and relational approach to CAP was leveraged, specifically psychedelic somatic interactional psychotherapy. Acute effects included oceanic boundlessness, ego dissolution, and emotional breakthrough. From baseline to post-treatment, the patient showed a 98.5% reduction in pathological dissociation, as measured by the Multidimensional Inventory of Dissociation, no longer meeting criteria for D-PTSD. This was accompanied by decreased cognitive distractibility and emotional suffering, as well as increased psychosocial functioning. Anecdotally, the patient has sustained improvements for over 2 years to date.

CONCLUSIONS

There is urgency to identify treatments for D-PTSD. The present case, while inherently limited, underscores the potential of CAP as a therapeutic option, leading to robust and sustained improvement. Subjective effects were comparable to those produced by classic and non-classic psychedelics, such as psilocybin and ketamine. Further research is warranted to explore, establish, and optimize CAP in D-PTSD, and to characterize its role in the pharmacological landscape.

Call to action: Addressing sleep disturbances, a hallmark symptom of PTSD, for refugees, asylum seekers, and internally displaced persons

Sleep difficulty is a recognized hallmark symptom of post-traumatic stress disorder (PTSD) yet often remains an enduring and neglected problem post-treatment. Around 4.4%- 88.0% of refugees, asylum seekers, and internally displaced persons report PTSD, of which 39%- 99% report sleep difficulties. These percentages substantially exceed those of the general population. Yet there has been a lack of research examining evidence-based stand-alone and add-on treatments for PTSD and related sleep disturbances among this population. Barriers to treatment encountered by this population often vary by their legal status or location, but generally include lack of access due to insufficient evidence-based treatments or mental health practitioner shortages, lack of psychoeducation on mental health, cultural stigma, language barriers, situational instability, and racial bias. The refugee population has been on the rise over the past 10 years, and the United Nations estimated the recent Ukraine-Russia conflict would lead to an additional 12 million people needing humanitarian assistance inside Ukraine and more than 6.9 million refugees fleeing to neighboring countries in the coming months. Given that refugees, asylum seekers, and internally displaced persons repeatedly encounter barriers to mental health care specific to their predicament, interventions designed to accommodate their situation are imperative for improving their sleep and mental health. We therefore call for there to be more research on integrative programs incorporating evidence-based treatments that allow for scalability, adaptability, and rapid dissemination to maximize impact in this population. Further, we encourage trainings among clinicians and researchers to increase knowledge and confidence in working with this population.

Role of Occupational Therapy in Pain Management

This new position statement from the American Occupational Therapy Association (AOTA) describes occupational therapy's role in pain management. AOTA asserts that occupational therapy practitioners are distinctly prepared to work independently and to contribute to interprofessional teams in the treatment of pain. Practitioners strive to ensure active engagement in meaningful occupations for clients at risk for and affected by pain.

The Nightmare Quality of Life Questionnaire

RATIONALE

Patient-centered outcomes are increasingly sought to evaluate social interactions and healthcare interventions in patients with sleep disorders. Yet, measures to assess quality of life (QoL) are lacking for those who experience nightmares.

OBJECTIVE

The aim of the study is to describe the development and validation of a new health-related quality of life (HRQoL) instrument for patients with nightmares.

METHODS

Attributes obtained from a focus group of patients (n = 113) with established nightmares were analyzed using exploratory factor analysis to elicit salient QoL themes for the new instrument. A validation cohort (n = 34) was used to determine the psychometric performance of the 16-item questionnaire including item-scaling, concurrent validity, and test-retest reliability tested four weeks apart.

RESULTS

Four factors (sleep health, emotional and psychological well-being, social interaction, and motivation) explained 53.9% of the total variance. The Nightmare Quality of Life (NQoL) showed good internal consistency (Cronbach's alpha 0.85) and test-retest reliability (ICC = 0.89). Concurrent validity was evidenced by a strong correlation with the Nightmare Distress Questionnaire (r = 0.87; p < .001) and more modest associations with the Nightmare Frequency Questionnaire (r = , 0.69; p < .001), SF-36 (r = -0.68; p < .001), and PSQI (r = 0.45; p = .007).

CONCLUSIONS

The NQoL has demonstrable construct validity and reliability and represents a promising multi-dimensional instrument to assess outcome measures for quality of life in patients with nightmares.

Role of Occupational Therapy in Pain Management

The American Occupational Therapy Association (AOTA) asserts that occupational therapists and occupational therapy assistants, collectively referred to as occupational therapy practitioners (AOTA, 2020b), are distinctly prepared to work independently and to contribute to interprofessional teams in the treatment of pain. Occupational therapy practitioners work to ensure active engagement in meaningful occupations for "persons, groups, or populations (i.e., the client)" (AOTA, 2020b, p. 1) at risk for and affected by pain.

Pharmacological Management of Nightmares Associated with Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) can be a chronic and disabling condition. Post-traumatic nightmares (PTNs) form a core component of PTSD and are highly prevalent in this patient population. Nightmares in PTSD have been associated with significant distress, functional impairment, poor health outcomes, and decreased quality of life. Nightmares in PTSD are also an independent risk factor for suicide. Nightmare cessation can lead to improved quality of life, fewer hospital admissions, lower healthcare costs, and reduced all-cause mortality. Effective treatment of nightmares is critical and often leads to improvement of other PTSD symptomatology. However, approved pharmacological agents for the treatment of PTSD have modest effects on sleep and nightmares, and may cause adverse effects. No pharmacological agent has been approved specifically for the treatment of PTNs, but multiple agents have been studied. This current narrative review aimed to critically appraise proven as well as novel pharmacological agents used in the treatment of PTNs. Evidence of varying quality exists for the use of prazosin, doxazosin, clonidine, tricyclic antidepressants, trazodone, mirtazapine, atypical antipsychotics (especially risperidone, olanzapine and quetiapine), gabapentin, topiramate, and cyproheptadine. Evidence does not support the use of venlafaxine, β-blockers, benzodiazepines, or sedative hypnotics. Novel agents such as ramelteon, cannabinoids, ketamine, psychedelic agents, and trihexyphenidyl have shown promising results. Large randomized controlled trials (RCTs) are needed to evaluate the use of these novel agents. Future research directions are identified to optimize the treatment of nightmares in patients with PTSD.

Memory reconsolidation impairment using the β-adrenergic receptor blocker propranolol reduces nightmare severity in patients with post-traumatic stress disorder: a preliminary study

STUDY OBJECTIVES

Post-traumatic nightmares may exacerbate and perpetuate the daytime symptoms of post-traumatic stress disorder (PTSD) and might represent a therapeutic target. The therapeutic strategy of memory reconsolidation using the β-adrenergic receptor blocker propranolol associated with re-exposure psychotherapy is a promising treatment in PTSD patients. Previous studies have established this therapy is effective in reducing overall clinician-assessed PTSD symptoms but to date no previous study has specifically focused on posttraumatic nightmares in this therapy. This study provides a preliminary assessment of the evolution of nightmares severity during this therapy protocol, compared with the decrease of the other PTSD symptoms. It evaluates the incidence of side effects and examines the relative effects on posttraumatic nightmares.

METHODS

Patients were recruited as part of the Paris Mémoire Vive study. Data were collected using a prospective longitudinal design including one baseline visit, six therapeutic visits, and two follow-up visits. During the six therapeutic visits, propranolol was administered orally 60 to 75 minutes prior to the psychotherapeutic session.

RESULTS

On average, nightmare severity decreased from "severe" to "mild" during the protocol and remained stable two months after the last session. Whereas 85% of patients reported nightmares at baseline, only 50% still had them after the protocol. The protocol was generally well tolerated and, did not increase nightmare severity for any patient in the study.

CONCLUSIONS

Memory reconsolidation therapy with propranolol seems promising in reducing nightmare severity, up to and including remission. However, research using a randomized controlled design, and assessing maintenance of nightmare extinction, is warranted.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Using Reconsolidation Blockade to Treat Trauma Related Disorders After Paris Attacks: An Effectiveness Study (PARIS-MEM); Identifier: NCT02789982; URL: https://www.clinicaltrials.gov/ct2/show/NCT02789982.

Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs)

Psychiatric drugs have primacy for off-label prescribing. Among those, selective serotonin reuptake inhibitors (SSRIs) are highly versatile and, therefore, widely prescribed. Moreover, they are commonly considered as having a better safety profile compared to other antidepressants. Thus, when it comes to off-label prescribing, SSRIs rank among the top positions. In this review, we present the state of the art of off-label applications of selective serotonin reuptake inhibitors, ranging from migraine prophylaxis to SARS-CoV-2 antiviral properties. Research on SSRIs provided significant evidence in the treatment of premature ejaculation, both with the on-label dapoxetine 30 mg and the off-label paroxetine 20 mg. However, other than a serotoninergic syndrome, serious conditions like increased bleeding rates, hyponatremia, hepatoxicity, and post-SSRIs sexual dysfunctions, are consistently more prominent when using such compounds. These insidious side effects might be frequently underestimated during common clinical practice, especially by nonpsychiatrists. Thus, some points must be addressed when using SSRIs. Among these, a psychiatric evaluation before every administration that falls outside the regulatory agencies-approved guidelines has to be considered mandatory. For these reasons, we aim with the present article to identify the risks of inappropriate uses and to advocate the need to actively boost research encouraging future clinical trials on this topic.

Trauma Immediately Preceding REM-Behavior Disorder: A Valuable Prognostic Marker?

Background: The definition of rapid eye movement (REM) sleep behavior disorder (RBD) has varied over the years. Rapid eye movement sleep behavior disorder can be considered isolated or idiopathic or can occur in the context of other disorders, including trauma-associated sleep disorder (TSD) and overlap parasomnia. However, whether trauma in RBD carries any prognostic specificity is currently unknown.

Study Objectives: To test the hypothesis that RBD secondary to trauma is less likely to result in the development of neurodegeneration compared to idiopathic RBD (iRBD) without trauma in the general population.

Methods: A retrospective cohort study of 122 consecutive RBD patients (103 males) at two tertiary sleep clinics in Europe between 2005 and 2020 was studied. Patients were diagnosed as having iRBD by video polysomnography (vPSG) and had a semi-structured interview at presentation, including specifically eliciting any history of trauma. Patients with secondary RBD to recognized causes were excluded from the study. Patients with iRBD were categorized into three groups according to reported trauma history: (1) No history of trauma, (2) traumatic experience at least 12 months prior to RBD symptom onset, and (3) traumatic experience within 12 months of RBD symptom onset. Idiopathic RBD duration was defined as the interval between estimated onset of RBD symptoms and last hospital visit or death. Follow-up duration was defined as the interval between iRBD diagnosis and last hospital visit or death.

Results: In a follow-up period of up to 18 years, no patient who experienced trauma within 12 months preceding their iRBD diagnosis received a diagnosis of a neurodegenerative disorder (n = 35), whereas 38% of patients without trauma within the 12 months of symptom onset developed a neurodegenerative illness. These patients were also significantly more likely to have a family history of α-synucleinopathy or tauopathy.

Conclusions: The development of RBD within 12 months of experiencing a traumatic life event, indistinguishable clinically from iRBD, did not lead to phenoconversion to a neurodegenerative disorder even after 18 years (mean follow up 6 years). We suggest that a sub-type of RBD be established and classified as secondary RBD due to trauma. Additionally, we advocate that a thorough psychological and trauma history be undertaken in all patients presenting with dream enactment behaviors (DEB).

Sleep Disorders and Mood, Anxiety, and Post-Traumatic Stress Disorders: Overview of Clinical Treatments in the Context of Sleep Disturbances

Sleep disruptions are frequently reported by persons with mood, anxiety, and post-traumatic stress disorders, and co-occur with psychiatric disorders. There is evidence that sleep disorders can predict the likelihood of developing a future psychiatric disorder and exacerbate existing symptoms. Understanding the inter-relationships between sleep and psychiatric disorders is important. The primary goals of this article are to describe the interactions between psychiatric and sleep disorders in the context of sleep disturbances, underscore the bidirectional effects of mental health treatments on sleep disorder outcomes, and provide general recommendations to optimize treatment in the context of sleep disturbances.

Dream Recall/Affect and the Hypothalamic-Pituitary-Adrenal Axis

In this concise review, we present an overview of research on dream recall/affect and of the hypothalamic–pituitary–adrenal (HPA) axis, discussing caveats regarding the action of hormones of the HPA axis (mainly cortisol and its free form, cortisol-binding globulin and glucocorticoid receptors). We present results of studies regarding dream recall/affect and the HPA axis under physiological (such as waking) or pathological conditions (such as in Cushing’s syndrome or stressful situations). Finally, we try to integrate the effect of the current COVID-19 situation with dream recall/affect vis-à-vis the HPA axis.

Trauma and post-traumatic stress disorder in patients treated for opioid use disorder: findings from a 12-month cohort study

BACKGROUND

Exposure to traumatic events is both a risk factor for substance use and an adverse outcome of substance use disorders. Identifying and managing post-traumatic stress disorder (PTSD) in patients with addiction requires attention.

AIMS

To examine the lifetime prevalence of traumatic events and past-month prevalence of PSTD in patients treated for opioid use disorder, and explore the association between trauma, PTSD and treatment outcomes.

METHOD

Participants (n = 674) receiving methadone treatment in 20 community clinics across Ontario, Canada, were administered the Mini-International Neuropsychiatric Interview to identify self-reported traumatic events and PTSD. Drug use was measured for 12 months by urine drug screens.

RESULTS

Eleven per cent of participants met past-month criteria for PTSD (n = 72), and 48% reported history of traumatic events with no current PTSD (n = 323). Participants with PTSD were more likely to be female (odds ratio 2.13, 95% CI 1.20-3.76) and less likely to be employed (odds ratio 0.31, 95% CI 0.16-0.61) or married (odds ratio 0.51, 95% CI 0.26-0.90) than those with no trauma history. Antidepressants (39 v. 24%) and benzodiazepines (36 v. 18%) were differentially prescribed to patients with and without PTSD. Length of time in treatment and opioid use were not associated with trauma; however, suicidal ideation was more common in PTSD (odds ratio 2.29, 95% CI 1.04-5.01).

CONCLUSIONS

Trauma and PTSD are prevalent among patients with opioid use disorder, and consideration of trauma symptoms and associated characteristics is warranted. Patients with and without comorbid PTSD differ clinically and psychosocially, highlighting the relevance of integrating addiction and mental health services for this population.

Using Prazosin to Treat Posttraumatic Stress Disorder and Associations: A Systematic Review

OBJECTIVE

A central adrenergic hyperactivation is described in the neurobiology of posttraumatic stress disorder (PTSD) with probable variable symptomatic impact. Few studies have evaluated using the alpha-1 adrenergic antagonist prazosin for such symptoms; however, given the likely pathophysiology involved, this drug may play an important role in the pharmacological approach to PTSD.

METHODS

This study assessed articles already published on the use of prazosin through a systematic review along a timeline in view of the symptomatic target of difficult access by standardized treatments. The impact of using this medication for the general symptoms of PTSD is also discussed. Several databases were searched for articles in the literature on the use of prazosin to treat PTSD.

RESULTS

A total of 168 articles were found containing search terms in the title or abstract. Overall, 85 articles met the criteria described, and 48 studies were explored to conduct the present systematic review. Most articles showed some improvement after prazosin administration, especially in relation to sleep symptoms (nightmares and night waking). Only one article demonstrated no improvement after the use of this drug. More randomized studies are needed.

CONCLUSION

Several clinical studies demonstrated the relevant role of prazosin for treating PTSD symptoms. Prazosin is an affordable and cost-effective pharmacological option compared to other drugs used to treat PTSD.

Neuropsychiatric Complications after Stroke

Neuropsychiatric disturbances represent a common and uniquely challenging consequence of stroke. These disorders arise at the intersection of lesion-related brain dysfunction and psychological distress related to the event and its aftermath, making it difficult to identify what symptom is a direct physiological consequence of the stroke. Depression, anxiety, fatigue, apathy, emotionalism, and anger are the most common of these syndromes, and posttraumatic stress disorder related to the stroke event has become increasingly recognized as a relevant entity. Mania, obsessive-compulsive disorder, and psychosis are less commonly encountered but potentially highly debilitating conditions that may be underrecognized. Early identification and treatment may mitigate functional impairment and improve quality of life. Evidence-based guidelines from the general population are often relied upon to guide treatment. Further research is needed to understand and tailor treatment of these disorders in the poststroke population.

Sleep disturbance in patients in an inpatient hospital mediates relationship between PTSD and suicidal ideation

A common reason for admission to inpatient psychiatric units is suicidal ideation. Growing evidence of the link between sleep disturbance and suicidal ideation brings an interest in greater clarity of the pathways; this paper focused on post-traumatic stress disorder (PTSD), which carries increased risk for both sleep disturbance and suicidal ideation, as well as sex differences in those pathways. Patients were 2822 inpatients studied at admission to an inpatient psychiatric hospital and mediation analyses were used to examine pathways of interest. There was an indirect effect of PTSD on suicidal ideation through sleep disturbances for the entire sample and for men and women separately. The effect for men was larger than that for women, suggesting a stronger effect for sleep disturbance in the relationship for men. For women only, the direct effect between PTSD and suicidal ideation remained significant after mediation. Sleep disturbance plays an important role in the relationship between PTSD and suicidal ideation. Early identification of sleep disturbance in inpatients and targeted focus of sleep in conjunction with resolving trauma-related symptoms may help reduce suicidal ideation. This may be especially true of men; the indirect effect was smaller for women, suggesting that sleep disturbance should be addressed in conjunction with other PTSD symptoms likely leading to suicidal ideation.

Hospitalized Medical Patients With Posttraumatic Stress Disorder (PTSD): Review of the Literature and a Roadmap for Improved Care

Posttraumatic stress disorder (PTSD) is common in the United States, with a prevalence of nearly 8% in the general population and between 10% and 30% in veterans. Despite how common PTSD is, inpatient providers may not be familiar with its manifestations or feel comfortable taking care of patients who may exhibit symptoms related to it. In our combined experience as VA-based hospital medicine care providers, we have cared for thousands of patients hospitalized for a primary medical condition who also have PTSD as a comorbidity. We have noticed in our practices that we only focus our attention on PTSD if a related problem arises during a patient's hospitalization (eg, confrontations with the care team or high levels of anxiety). We contend that a more proactive approach could lead to better care, but little evidence about best practices exists to inform the interdisciplinary team how to optimally care for hospitalized medical patients with PTSD. In this narrative review, we present a synthesis of existing literature, describe how trauma-informed care could be used to guide the approach to patients with PTSD, and generate ideas for changes that inpatient providers could implement now, such as engaging patients to prevent PTSD exacerbations and promoting better sleep in the hospital.

Efficacy of yokukansan compared with clonazepam for rapid eye movement sleep behaviour disorder: a preliminary retrospective study

AIM

Rapid eye movement sleep behaviour disorder (RBD) is characterized by abnormal behaviours accordant with nightmares during rapid eye movement sleep and is considered a prodromal marker of dementia with Lewy body. Most common in the elderly population, RBD is generally treated with clonazepam (CZP), a long-term acting benzodiazepine antiepileptic. As such, alternative drugs for RBD are urgently needed to minimize the adverse effects peculiar to benzodiazepines. The efficacy of yokukansan (YKS), a traditional Japanese herbal medicine, on RBD was initially reported by Shinno et al. in 2008. However, no study has compared YKS with CZP. Therefore, this study aimed to clarify the possibility of using YKS as an alternative to CZP.

METHODS

This was a retrospective cohort study conducted at Jikei University Affiliated Hospital. The subjects were selected from 36 outpatients who had been diagnosed with RBD based on the International Classification of Sleep Disorders, third edition. Of the 23 who met the inclusion criteria but not the exclusion criteria, 11 were treated with YKS monotherapy, and 12 were treated with CZP monotherapy. The primary outcome was the total score on the Japanese version of the Rapid Eye Movement Sleep Behaviour Disorder Questionnaire (RBDQ-JP), and the secondary outcomes were the scores from the eight-item Short-Form Health Survey and factors 1 and 2 of the RBDQ-JP.

RESULTS

The mean total RBDQ-JP score significantly improved from 52.5 to 21.7 (P = 0.002) after treatment with YKS (mean dosage: 3.0 g/day), which was similar to the change after CZP treatment (from 43.8 to 21.3). On RBDQ-JP factor 1 (dream content), the mean score on five of six items significantly improved after treatment with YKS. There was no significant change in Short-Form Health Survey scores after treatment with either drug. Potassium concentrations were within the normal range in patients treated with YKS.

CONCLUSIONS

The present results suggest that a small amount of YKS may be an alternative to CZP for RBD, without remarkable adverse events. Further study is needed to prospectively clarify the efficacy and safety of YKS in more detail.

Cannabis and Complex Posttraumatic Stress Disorder: A Narrative Review With Considerations of Benefits and Harms

Despite substantial controversies concerning patients' reports of benefits from cannabis for posttraumatic stress disorder (PTSD) and inconsistent research findings regarding its efficacy and adverse risks, some states have already recognized PTSD as a qualifying condition for medical cannabis. Consequently, medical cannabis can also be provided for patients with complex PTSD who experience additional posttraumatic symptoms of affective dysregulation, negative perception of the self, and difficulties in relationships due to a history of repetitive trauma. In this article, we explore cannabis use in relation to benefits versus harms that might occur relative to specific complex PTSD symptoms and comorbidities. Whereas some symptoms related to PTSD per se (e.g., anxiety, insomnia, nightmares) may be benefited, others that are more characteristic of complex PTSD (e.g., dissociation, reckless behavior, and substance abuse associated with dysregulated affect) may be aggravated. Therefore, clinicians treating patients with complex PTSD who use or seek cannabis should carefully assess patients' motivations and the impacts of particular use patterns on specific symptoms. Clinicians and patients should be aware of and fully discuss the significant number of potential adverse effects of cannabis use, several of which might impede patients' participation in beneficial psychotherapeutic, social, and medical interventions.

Clinical Data for the Use of Cannabis-Based Treatments: A Comprehensive Review of the Literature

Objective:

To compile and synthesize the available literature describing medical cannabis use across various disease states.

Data Sources:

PubMed, EBSCO, and Google Scholar searches were conducted using MeSH and/or keywords.

Study Selection and Data Extraction:

Studies were included if they described the use of cannabis-based products and medications in the treatment of a predefined list of disease states in humans and were published in English. The extraction period had no historical limit and spanned through April 2019.

Data Synthesis:

Evidence was compiled and summarized for the following medical conditions: Alzheimer disease, amyotrophic lateral sclerosis, autism, cancer and cancer-associated adverse effects, seizure disorders, human immunodeficiency virus, inflammatory bowel disease, multiple sclerosis (MS), nausea, pain, posttraumatic stress disorder, and hospice care.

Relevance to Patient Care and Clinical Practice:

Based on identified data, the most robust evidence suggests that medical cannabis may be effective in the treatment of chemotherapy-induced nausea and vomiting, seizure disorders, MS-related spasticity, and pain (excluding diabetic neuropathy). Overall, the evidence is inconsistent and generally limited by poor quality. The large variation in cannabis-based products evaluated in studies limits the ability to make direct comparisons. Regardless of the product, a gradual dose titration was utilized in most studies. Cannabis-based therapies were typically well tolerated, with the most common adverse effects being dizziness, somnolence, dry mouth, nausea, and euphoria.

Conclusions:

As more states authorize medical cannabis use, there is an increasing need for high-quality clinical evidence describing its efficacy and safety. This review is intended to serve as a reference for clinicians, so that the risks and realistic benefits of medical cannabis are better understood.

A novel theory on the predictive value of variation in the β-endorphin system on the risk and severity of PTSD

Despite growing interest in genetic and psychosocial indicators of heightened susceptibility to posttraumatic stress disorder (PTSD), a predictive model, which explains why some individuals develop PTSD in response to life-threatening traumatic events, while others, when faced with the same or similar experiences, do not, has thus far remained out of reach. In this paper, we review the literature on gene-environment interactions in β-endorphin system functioning with regard to PTSD and suggest that variation, both genetic and with regard to environmental stimuli, in systems which, like the β-endorphin system, distort human perception of life-threatening traumatic experiences may account for some of the variance in resilience to the disorder. Given the role of β-endorphin in both social connections and physical exercise, this becomes especially relevant with regard to military selection, training, and leadership processes.

Passive Coping Strategies During Repeated Social Defeat Are Associated With Long-Lasting Changes in Sleep in Rats

Exposure to severe stress has immediate and prolonged neuropsychiatric consequences and increases the risk of developing Posttraumatic Stress Disorder (PTSD). Importantly, PTSD develops in only a subset of individuals after exposure to a traumatic event, with the understanding of this selective vulnerability being very limited. Individuals who go on to develop PTSD after a traumatic experience typically demonstrate sleep disturbances including persistent insomnia and recurrent trauma-related nightmares. We previously established a repeated social defeat paradigm in which rats segregate into either passively or actively coping subpopulations, and we found that this distinction correlates with measures of vulnerability or resilience to stress. In this study, we examined differences between these two behavioral phenotypes in sleep changes resulting from repeated social defeat stress. Our data indicate that, compared to control and actively coping rats, passively coping rats have less slow-wave sleep (SWS) for at least 2 weeks after the end of a series of exposures to social defeat. Furthermore, resilient rats show less exaggerated motor activation at awakenings from rapid eye movement (REM) sleep and less fragmentation of REM sleep compared to control and passively coping rats. Together, these data associate a passive coping strategy in response to repeated social defeat stress with persisting sleep disturbances. Conversely, an active coping strategy may be associated with resilience to sleep disturbances. These findings may have both prognostic and therapeutic applications to stress-associated neuropsychiatric disorders, including PTSD.

Mental Violence: The COVID-19 Nightmare

The year 2020 has generated profound changes in personal and working relations, and in dreams of millions of people worldwide. The aim of this study was to investigate the frequency and content of nightmares during the COVID-19 pandemic in Brazil, evaluating its associations with sociodemographic, occupational, and clinical factors. Cross-sectional exploratory study, including 1,057 participants who responded to an online survey about mental violence and nightmares during the pandemic, between May 25 and June 1, 2020. A descriptive analysis of the results was done to obtain frequency tables. McNemar's non-parametric test was used to compare the frequency of nightmares before and after the pandemic, and logistic regression models, to identify factors most strongly associated with the pandemic nightmares. Participants were from 21 Brazilian states, with a mean age of 38 ± 14 years, and 78% women. Half of them (n = 529) reported at least one nightmare episode during the pandemic, and 32.9% (n = 348) described a pandemic content. There was nearly a 3-fold increase in the occurrence of nightmares "once a week or more" during the pandemic, 9% before vs. 25% after. Prior psychiatric care, suicidal ideation, sleep medication, increased pandemic alcohol consumption, perceiving high risk of contamination, being woman, and of younger age were factors associated with having nightmares during the pandemic. Prior psychiatric care, sleep medication, and age remained significant after excluding participants without nightmares and comparing between individuals with and without a pandemic content. We conclude the COVID-19 pandemic has affected people's dreams. The increase in the frequency of nightmares, their pandemic content, and association with previous conditions are a concerning public mental health issue and should be taken into consideration by authorities and policy makers.

Dreams and Nightmares in Patients With Obstructive Sleep Apnea: A Review

Obstructive sleep apnea (OSA) can present with or provoke various psychological symptoms. In this article, we critically review studies that have examined dreams, dream recall, and dream content in patients with OSA. Obstructive events induce recurrent sleep fragmentation and intermittent desaturations in patients with OSA, which may trigger different parasomnias, including nightmares. Contradictory results have been reported concerning dreams in patients with OSA; while some investigators have reported less dreams in OSA patients, others have described that patients with OSA have increased dreams with emotional content, mainly violent and hostile content. Although there are reports of respiratory-related dream content in patients with OSA, most studies that have assessed the dream content of patients with OSA revealed that respiratory-related dream content was unusual. A clear association between post-traumatic stress disorders, comorbid OSA, and nightmares has been reported in several studies. Furthermore, an improvement in nightmare frequency with continuous positive airway pressure (CPAP) treatment has been shown. An inverse relationship between the severity of OSA reflected by the apnea-hypopnea index and dream recall has been demonstrated in several studies. Future studies should differentiate between patients with non-stage specific OSA and patients with rapid eye movement (REM) predominant OSA.

Use of Medicinal Cannabis and Synthetic Cannabinoids in Post-Traumatic Stress Disorder (PTSD): A Systematic Review

Background and Objectives: Post-traumatic stress disorder (PTSD) is a common psychiatric disorder resulting from a traumatic event, is manifested through hyperarousal, anxiety, depressive symptoms, and sleep disturbances. Despite several therapeutic approaches being available, both pharmacological and psychological, recently a growing interest has developed in using cannabis and synthetic cannabinoids stems from their consideration as more efficient and better tolerated alternatives for the treatment of this condition. The present paper aims to evaluate the clinical and therapeutic potentials of medical cannabis and synthetic cannabinoids in treating PTSD patients. Methods: A systematic electronic search was performed, including all papers published up to May 2019, using the following keywords (((cannabis[Title/Abstract]) OR (synthetic cannabinoids [Title/Abstract])) AND ((PTSD[Title/Abstract]) OR (Posttraumatic stress disorder[Title/Abstract]))) for the topics ‘Cannabis’, ‘Synthetic Cannabinoids’, ‘PTSD’, and MESH terms, on the PubMed, Cochrane Library, and Web of Science online databases. For data gathering purposes, PRISMA guidelines were followed. Results were organized into two groups, considering cannabis and synthetic cannabinoids as different therapeutic approaches for PTSD. Results: Present data show that cannabis and synthetic cannabinoids, both acting on the endocannabinoids system, may have a potential therapeutic use for improving PTSD symptoms, e.g., reducing anxiety, modulating memory-related processes, and improving sleep. Conclusions: Even though the current literature suggests that cannabis and synthetic cannabinoids may have a role in the treatment of PTSD, there is currently limited evidence regarding their safety and efficacy. Therefore, additional research is needed in order to better understand the effectiveness and therapeutic usage of these drug classes and monitor their safety.

Trauma Associated Sleep Disorder: Clinical Developments 5 Years After Discovery

PURPOSE OF REVIEW

We review recent and growing evidence that provides support for a novel parasomnia, trauma associated sleep disorder (TASD). Based on these findings, we further develop the clinical and polysomnographic (PSG) characteristics of TASD. We also address factors that precipitate TASD, develop a differential diagnosis, discuss therapy, and propose future directions for research.

RECENT FINDINGS

Nightmares, classically a REM phenomenon, are prevalent and underreported, even in individuals with trauma exposure. When specifically queried, trauma-related nightmares (TRN) are frequently associated with disruptive nocturnal behaviors (DNB), consistent with TASD. Capture of DNB in the lab is rare but ambulatory monitoring reveals dynamic autonomic concomitants associated with disturbed dreaming. TRN may be reported in NREM as well as REM sleep, though associated respiratory events may confound this finding. Further, dream content is more distressing in REM. Therapy for this complex disorder likely requires addressing not only the specific TASD components of TRN and DNB but comorbid sleep disorders. TASD is a unique parasomnia developing after trauma. Trauma-exposed individuals should be specifically asked about their sleep and if they have nightmares with or without DNB. Patients who report TRN warrant in-lab PSG as part of their evaluation.

Post Traumatic Stress Disorder and Substance Use Disorder as Two Pathologies Affecting Memory Reactivation: Implications for New Therapeutic Approaches

In the present review, we provide evidence indicating that although post traumatic stress disorder (PTSD) and substance use disorder (SUD) are two distinct pathologies with very different impacts on people affected by these chronic illnesses, they share numerous common characteristics, present high rates of co-morbidity, and may result from common physiological dysfunctions. We propose that these pathologies result from hyper reactivity to reminders, and thus should be considered as two disorders of memory, treated as such. We review the different possibilities to intervene on pathological memories such as extinction therapy and reconsolidation blockade. We also introduce new therapeutic avenues directly indicate by our recent proposal to replace the consolidation/reconsolidation hypothesis by the integration concept. State dependency and emotional remodeling are two innovative treatments that have already provided encouraging results. In summary, this review shows that the discovery of reactivation-dependent memory malleability has open new therapeutic avenues based on the reprocessing of pathological memories, which constitute promising approaches to treat PTSD and SUD.