Unfolded Von Willebrand Factor Binds Protein S and Reduces Anticoagulant Activity

Protein S (PS), the critical plasma cofactor for the anticoagulants tissue factor (TF) pathway inhibitor (TFPI) and activated protein C (APC), circulates in two functionally distinct pools: free (anticoagulant) or bound to complement component 4b-binding protein (C4BP) (anti-inflammatory). Acquired free PS deficiency is detected in several viral infections, but its cause is unclear. Here, we identified a shear-dependent interaction between PS and von Willebrand Factor (VWF) by mass spectrometry. Consistently, plasma PS and VWF comigrated in both native and agarose gel electrophoresis. The PS/VWF interaction was blocked by TFPI but not APC, suggesting an interaction with the C-terminal sex hormone binding globulin (SHBG) region of PS. Microfluidic systems, mimicking arterial laminar flow or disrupted turbulent flow, demonstrated that PS stably binds VWF as VWF unfolds under turbulent flow. PS/VWF complexes also localized to platelet thrombi under laminar arterial flow. In thrombin generation-based assays, shearing plasma decreased PS activity, an effect not seen in the absence of VWF. Finally, free PS deficiency in COVID-19 patients, measured using an antibody that binds near the C4BP binding site in SHBG, correlated with changes in VWF, but not C4BP, and with thrombin generation. Our data suggest that PS binds to a shear-exposed site on VWF, thus sequestering free PS and decreasing its anticoagulant activity, which would account for the increased thrombin generation potential. As many viral infections present with free PS deficiency, elevated circulating VWF, and increased vascular shear, we propose that the PS/VWF interaction reported here is a likely contributor to virus-associated thrombotic risk.

Dendritic cells influence the altered neonatal CD8 T cell immunodominance hierarchy during influenza virus infection

Neonates are more susceptible to influenza virus infection than adults, resulting in increased morbidity and mortality as well as delayed clearance of the virus. Previous work has indicated that decreased T cell and dendritic cell function underlies some of this vulnerability. We sought to understand CD8 T cell specificity and immunodominance during neonatal influenza infection as well as how any differences from the adult hierarchy might impact immunodominance and protection in subsequent infections. We found that neonatal C57BL/6 mice display an altered CD8 T cell immunodominance hierarchy, preferentially responding to an epitope in the influenza protein PA rather than the co-dominant adult response to NP and PA. Additionally, upon secondary infection, mice first infected as pups display inconsistent immunodominance and suffer increased morbidity compared to mice infected previously as adults. Finally, transfer of influenza infected adult dendritic cells to pups resulted in increased T cell activation and enhanced viral clearance as well as a slight induction of NP specific CD8 T cells. Taken together, these data suggest that infection early in life alters the specificity of memory responses to that pathogen and that dendritic cells may play a role in mediating this process. Additionally, vaccines targeting T cells should consider epitope usage and age specific dendritic cell physiology if the intended patient population includes infants as well as adults.

Neonatal dendritic cells alter the immunodominance hierarchy of the CD8 T cell response during influenza infection

Neonates are more susceptible to influenza virus infection than adults, resulting in increased morbidity and mortality as well as delayed clearance of the virus. Multiple differences between the adult and neonatal immune response to influenza help explain this vulnerability. Dendritic cells are of particular interest in this process as their decreased function in neonates results in the poor T cell activation observed during neonatal influenza infections. We sought to understand how differences in neonatal dendritic cells shape CD8 T cell specificity and immunodominance during influenza infection as well as how this may affect memory formation and viral clearance. We found that neonatal C57BL/6 mice display an altered CD8 T cell immunodominance hierarchy, preferentially responding to the influenza protein PA rather than the dominant adult epitope in the NP protein. Additionally, upon secondary infection, mice first infected as pups suffered increased morbidity compared to mice infected previously as adults. Finally, transfer of influenza infected adult dendritic cells to pups resulted in increased T cell activation and enhanced viral clearance. Taken together, these data suggest that neonatal dendritic cells alter CD8 immunodominance, and this may compromise viral clearance and memory formation.

Differential Tbet, Gata3 and RORγt expression in mature and neonatal regulatory T cells during influenza virus infection

Neonates respond poorly to influenza infection and have trouble clearing the virus. In contrast to adult mice, pups display reduced cytokine production and poor migration of cells into the alveolar space during infection, resulting in an interstitial pneumonia and delayed clearance of virus. Pups also have a large population of regulatory T cells (Tregs) in their lungs compared to adults. Tregs suppress immune reactions and their abundance in pups could explain the poor response to infection. However, we found that pups that lacked Tregs failed to clear influenza infection, suggesting that pups require Tregs to clear the virus. We hypothesize that there is a functional difference between adult and pup Tregs that may explain this finding.

Tregs express the transcription factor Foxp3, and it is essential for their function, but they may also express T helper subset transcription factors such as Tbet, Gata3 or RORγt. The function of this co-expression is incompletely understood, but they may play a role in establishing functional subsets of Tregs. We investigated whether Tregs from adult mice expressed different transcription factors than Tregs from pups during infection.

We performed flow cytometry on cells from the lungs of neonatal and adult mice infected with influenza virus to examine the prevalence of Tregs that co-expressed Foxp3 with Tbet, Gata3 or RORγt. We found that Tregs in pups tended to express Gata3 more frequently than Tregs from adults. In contrast, adult Tregs were more likely to express Tbet or RORγt than pups. We are investigating whether this differential expression of transcription factors has functional consequences in modulating the response to influenza virus.

Altered activation of neonatal alveolar macrophages affects the immune response to Pneumocystis. (56.10)

Postnatal lung development renders a different lung environment and composition in neonates as compared to adults, making the neonatal immune response to lung pathogens, such as Pneumocystis (PC), less efficient than adults. Alveolar macrophages (AMs) are the major effector cells in the immune response to PC, and a proper AM activation phenotype is imperative for clearance of infection. Following peak infection, alternative markers (arginase, mannose receptor and CD23) are increased on adult AMs, suggesting a role for this phenotype in PC resolution. A more robust increase in these alternative markers is observed in neonates following peak infection. Additionally, naïve neonatal AMs constitutively express FIZZ1 and Ym1 at levels comparable to infected counterparts. It is possible that adult AMs develop a classical phenotype in the initial response to PC, and that this phenotype cannot be obtained by neonatal AMs early in infection due to increased expression of alternative markers. Additionally, increases in these alternative markers on neonatal AMs late in infection may suppress an efficient response to PC, thus resulting in delayed clearance as compared to adults. We hypothesize that delayed AM activation and increased expression of alternative markers during resolution results in an insufficient immune response to PC infection in neonates.

The migration of T cells in response to influenza virus is altered in neonatal mice

Influenza virus is a significant cause of mortality and morbidity in children; however, little is known about the T cell response in infant lungs. Neonatal mice are highly vulnerable to influenza and only control very low doses of virus. We compared the T cell response to influenza virus infection between mice infected as adults or at 2 d old and observed defective migration into the lungs of the neonatal mice. In the adult mice, the numbers of T cells in the lung interstitia peaked at 10 d postinfection, whereas neonatal T cell infiltration, activation, and expression of TNF-alpha was delayed until 2 wk postinfection. Although T cell numbers ultimately reached adult levels in the interstitia, they were not detected in the alveoli of neonatal lungs. Instead, the alveoli contained eosinophils and neutrophils. This altered infiltrate was consistent with reduced or delayed expression of type 1 cytokines in the neonatal lung and differential chemokine expression. In influenza-infected neonates, CXCL2, CCL5, and CCL3 were expressed at adult levels, whereas the chemokines CXCL1, CXCL9, and CCL2 remained at baseline levels, and CCL11 was highly elevated. Intranasal administration of CCL2, IFN-gamma, or CXCL9 was unable to draw the neonatal T cells into the airways. Together, these data suggest that the T cell response to influenza virus is qualitatively different in neonatal mice and may contribute to an increased morbidity.

Elevated Bcl2 expression in mice decreases CD4 lymphocyte apoptosis and facilitates clearance of Pneumocystis in mice (40.6)

Lymphocyte and TNF deficiency leads to susceptibility to opportunistic infections such as Pneumocystis carinii (PC). This strongly indicates that protection against the fungal pathogen PC is dependent upon B cells, T cells and TNF. Although it has been documented that macrophage derived TNF is essential for PC clearance, the role played by TNF produced by lymphocytes has not been addressed. Furthermore, the functional role of B cells in the T cell-mediated protection against PC Pneumonia (PCP) has not been determined. In this study we report that B cells produce TNF in response to PC predominantly in the TBLN. B cells enhanced expansion of CD4 T cells and secretion of TNF in the lungs of adoptive transfer recipients and hence clearance of the organisms. Importantly, the presence of B cells resulted in upregulation of Bcl2 in CD4 T cells and down regulation of Fas and Fas Ligand consistent with a decrease in apoptotic cells as determined by annexin V staining. Lastly, we observed that T cell-derived TNF is critical for PC clearance. Taken together, our data suggest that B cells are essential for CD4 T cell survival and increased expansion leading to protection against PCP in mouse models.

Molecules involved in the NFκB signaling pathway are down regulated in neonatal alveolar macrophages resulting in reduced response to Pneumocystis infection (37.7)

Neonates are unable to clear Pneumocystis (PC) infection with the same efficiency as adults. The alveolar macrophage (AM) phenotype of neonates during infection varies from that of adults, leading to a delayed inflammatory response and a slower clearance of infection. Upon infection with PC, neonatal AMs appear to maintain an alternatively activated phenotype, where as adults tend to adopt a classical AM phenotype. Previous data from our lab has shown that an elevated expression of TGFβ in neonatal lungs suppresses the ability of AMs to respond to PC. Use of a conditional smad4 KO model in which TGFβ signaling is defective in macrophages allowed us to show that blocking the TGFβ signaling pathway improves clearance of PC in neonatal mice. To further examine the response of neonatal AMs, in vitro immunoflourescence assays were performed to examine NFκB translocation to the nucleus. We found that, while neonatal AMs translocate NFκB in response to zymosan, they remain unresponsive to PC cysts. This data suggests that the unresponsiveness of neonatal AMs to PC infection may be due in part to reduced response of macrophages to PC cysts, in addition to the immunosuppressed lung environment. We hypothesize that the down regulation of molecules involved with NFκB translocation to the nucleus results in the reduced response of AMs to PC.

Scavenger receptor A dampens induction of inflammation in response to the fungal pathogen Pneumocystis carinii

Alveolar macrophages are the effector cells largely responsible for clearance of Pneumocystis carinii from the lungs. Binding of organisms to beta-glucan and mannose receptors has been shown to stimulate phagocytosis of the organisms. To further define the mechanisms used by alveolar macrophages for clearance of P. carinii, mice deficient in the expression of scavenger receptor A (SRA) were infected with P. carinii, and clearance of organisms was monitored over time. SRA-deficient (SRAKO) mice consistently cleared P. carinii faster than did wild-type control mice. Expedited clearance corresponded to elevated numbers of activated CD4(+) T cells in the alveolar spaces of SRAKO mice compared to wild-type mice. Alveolar macrophages from SRAKO mice had increased expression of CD11b on their surfaces, consistent with an activated phenotype. However, they were not more phagocytic than macrophages expressing SRA, as measured by an in vivo phagocytosis assay. SRAKO alveolar macrophages produced significantly more tumor necrosis factor alpha (TNF-alpha) than wild-type macrophages when stimulated with lipopolysaccharide in vitro but less TNF-alpha in response to P. carinii in vitro. However, upon in vivo stimulation, SRAKO mice produced significantly more TNF-alpha, interleukin 12 (IL-12), and IL-18 in response to P. carinii infection than did wild-type mice. Together, these data indicate that SRA controls inflammatory cytokines produced by alveolar macrophages in the context of P. carinii infection.

Exogenous heat-killed Escherichia coli improves alveolar macrophage activity and reduces Pneumocystis carinii lung burden in infant mice

Pneumocystis carinii is an opportunistic fungal pathogen that causes life-threatening pneumonia in immunocompromised individuals. Infants appear to be particularly susceptible to Pneumocystis pulmonary infections. We have previously demonstrated that there is approximately a 3-week delay in the clearance of Pneumocystis organisms from pup mouse lungs compared to that in adults. We have further shown that there is approximately a 1-week delay in alveolar macrophage activation in pups versus adult mice. Alveolar macrophages are the primary effector cells responsible for the killing and clearance of Pneumocystis, suggesting that pup alveolar macrophages may be involved in the delayed clearance of this organism. Alveolar macrophages cultured in vitro with Pneumocystis alone demonstrate little to no activation, as indicated by a lack of cytokine production. However, when cultured with lipopolysaccharide (LPS) or zymosan, cytokine production was markedly increased, suggesting that pup alveolar macrophages are specifically unresponsive to Pneumocystis organisms rather than being intrinsically unable to become activated. Furthermore, pup mice treated with aerosolized, heat-killed Escherichia coli in vivo were able to clear Pneumocystis more efficiently than were control mice. Together, these data suggest that while pup alveolar macrophages are unresponsive to P. carinii f. sp. muris organisms, they are capable of activation by heat-killed E. coli in vivo, as well as LPS and zymosan in vitro. The lack of response of pup mice to P. carinii f. sp. muris may reflect protective mechanisms specific to the developing pup lung, but ultimately it results in insufficient clearance of Pneumocystis organisms.

The T Cell Response to Influenza in Neonates (43.29)

Influenza is a significant cause of mortality and morbidity in children. However, very little data exists on the neonatal immune response to influenza. We have found that neonatal mice are highly vulnerable to influenza and only control much reduced doses of virus.

In this study, the T cell response to intranasal influenza infection was compared between mice infected as adults or at 2 days old. In neonates, despite significant expansion of T cells in draining lymph nodes, entry of T cells into the lungs was defective. In adults, high numbers of CD4 and CD8 T cells peaked in the lung interstitium and alveolar spaces by 10 days post infection. However, in neonates, CD8 T cells entered the lungs by day 10 post-infection, but not to high levels, while CD4 T cell entry was delayed until 3 weeks of age. Interestingly, while CD4 T cells reached adult levels in the interstitia, they were unable to cross the epithelial barrier into the alveoli. The delayed entry of CD4 T cells corresponded with a delay in TNFα production and a lack of IFNγ which may consequently lead to delayed upregulation of adhesion molecules and chemokines.

Despite the poor response to influenza as neonates, mice infected at 2 days old with the PR8 strain of influenza did develop T cell memory. Mice were protected when subsequently infected as adults with a lethal dose of HKx31, a strain that shares only the internal T cell antigens with PR8. These data suggest that the acute sensitivity of neonates to influenza may be a consequence of defective T cell migration.

Delayed production of TNF-α in neonatal mice in response to Pneumocystis carinii infection corresponds to increased TGF-β levels in the lungs (51.11)

Neonatal mice challenged with Pneumocystis carinii (PC) exhibit a three week delay in clearance as compared to adults, corresponding to a delayed CD4+ T cell infiltration into the alveolar spaces. We have published that messenger RNA levels of transforming growth factor (TGF)-β and interleukin (IL)-10 are constitutively expressed in neonatal lungs, suggesting that the lung environment is not adequate to recruit circulating lymphocytes. We have since found that pups have increased TGF-β1 protein levels compared to adults until three weeks of age. The infiltration of CD4+ T cells corresponded to decreasing lung TGF-β levels. Moreover, production of TNF–α by CD4+ T cells was also delayed in pups compared to adults. Ongoing experiments will determine whether TGF-β dampens the proinflammatory response until it is developmentally downregulated or if decreased TGF-β levels follow lung infiltration by activated CD4+ T cells.

This research was supported by PHS grant HL062053.

B cells are required for generation of protective effector and memory CD4 cells in response to Pneumocystis lung infection

B cell-deficient mice are susceptible to infection by Pneumocystis carinii f. sp. muris (PC). To determine whether this susceptibility is due to a requirement for B cells to prime T cells, we compared CD4 T cell responses to PC in bone marrow chimeric mice that express MHC class II (MHCII) on all APCs (wild-type (WT) chimeras) and in bone marrow chimeric mice that express MHCII on all APCs except B cells (MHCII(-/-) chimeras). Although PC was rapidly cleared by WT chimeric mice, PC levels remained high in chimeric mice that lacked MHCII on B cells. In addition, although T cells were primed in the draining lymph nodes of MHCII(-/-) chimeric mice, the number of activated CD4 T cells infiltrating the lungs of these mice was reduced relative to the number in the lungs of WT chimeras. We also adoptively transferred purified CD4 T cells from the draining lymph nodes of PC-infected normal or B cell-deficient mice into SCID mice. Mice that received CD4 cells from normal mice were able to mount a response to infection in the lungs and clear PC. However, mice that received CD4 cells from B cell-deficient mice had a delayed T cell response in the lungs and failed to control the infection. These data indicate that B cells play a vital role in generation of CD4(+) memory T cells in response to PC infection in the lungs.

Passive immunization of neonatal mice against Pneumocystis carinii f. sp. muris enhances control of infection without stimulating inflammation

Pneumocystis carinii is an opportunistic fungal pathogen that causes life-threatening pneumonia in immunocompromised individuals. Infants appear to be particularly susceptible to infection with Pneumocystis. We have previously shown that there is a significant delay in clearance of the organisms from the lungs of neonatal mice compared to adults. Since alveolar macrophages are the effector cells responsible for killing and clearance of Pneumocystis, we have examined alveolar macrophage activity in neonatal mice. We found that alveolar macrophage activation is delayed about 1 week in Pneumocystis-infected neonates compared to adults. Opsonization of the organism by Pneumocystis-specific antibody resulted in increased clearance of the organism in neonatal mice; however, there was decreased expression of activation markers on neonatal alveolar macrophages and reduced levels of cytokines associated with macrophage activation. Mice born to immunized dams had significant amounts of Pneumocystis-specific immunoglobulin G in their lungs and serum at day 7 postinfection, whereas mice born to naive dams had merely detectable levels. This difference correlated with enhanced Pneumocystis clearance in mice born to immunized dams. The increase in specific antibody, however, did not result in significant inflammation in the lungs, as no differences in numbers of activated CD4+ cells were observed. Furthermore, there was no difference in cytokine or chemokine concentrations in the lungs of pups born to immune compared to naive dams. These findings indicate that specific antibody plays an important role in Pneumocystis clearance from lungs of infected neonates; moreover, this process occurs without inducing inflammation in the lungs.

Clearance of Pneumocystis carinii in mice is dependent on B cells but not on P carinii-specific antibody

Both CD4(+) T cells and B cells are critical for defense against Pneumocystis carinii infection; however, the mechanism by which B cells mediate protection is unknown. We show that P. carinii-specific IgM is not sufficient to mediate clearance of P. carinii from the lungs since CD40-deficient mice produced normal levels of specific IgM, but were unable to clear the organisms. Using chimeric mice in which the B cells were deficient in CD40 (CD40KO chimeras) we found that clearance of P. carinii infection is delayed compared with wild-type controls. These CD40KO chimeric mice produced normal levels of P. carinii-specific IgM, but did not produce class-switched IgG or IgA. Similarly, clearance of P. carinii was delayed in mice deficient in FcgammaRI and III (FcgammaRKO), indicating that P. carinii-specific IgG partially mediates opsonization and clearance of P. carinii. Opsonization of organisms by complement did not compensate for the lack of specific IgG or FcgammaR, since C3-deficient and C3-depleted FcgammaRKO mice were still able to clear P. carinii. Finally, micro MT and CD40KO chimeric mice had reduced numbers of activated CD4(+) T cells in the lungs and lymph nodes compared with wild-type mice, suggesting that B cells are important for activation of T cells in response to P. carinii. Together these data indicate that P. carinii-specific IgG plays an important, but not critical, role in defense against P. carinii. Moreover, these data suggest that B cells also mediate host defense against P. carinii by facilitating CD4(+) T cell activation or expansion.

An open-label trial of evidence-based cognitive behavior therapy for nightmares and insomnia in crime victims with PTSD

OBJECTIVE

Insomnia and nightmares are perceived as secondary phenomena in posttraumatic stress disorder (PTSD). Scant treatment research has targeted these two sleep disturbances. This study reports on an open-label trial of cognitive behavior therapy for insomnia and disturbing dreams in crime victims with PTSD. The relationship among nightmares, sleep disturbances, and PTSD symptoms is discussed.

METHOD

Sixty-two participants completed a 10-hour group treatment consisting of imagery rehearsal for nightmares and sleep hygiene, stimulus control, and sleep restriction for insomnia. Nightmare frequency, sleep quality, sleep impairment, and ratings for PTSD, anxiety, and depression symptoms were assessed at baseline and at the 3-month follow-up.

RESULTS

All measures demonstrated improvement that was roughly equivalent to changes in clinical severity from severe to moderate for sleep quality, sleep impairment, and nightmare frequency, from borderline severe to borderline moderate for PTSD symptoms, and from extremely severe to borderline severe for anxiety and depression symptoms.

CONCLUSIONS

In this uncontrolled study, successful treatment for insomnia and nightmares in crime victims was associated with improvement in symptoms of PTSD, anxiety, and depression. Participants with clinical improvements in PTSD symptoms demonstrated significantly greater improvement in sleep quality and nightmare frequency than those whose PTSD symptoms did not improve.

The relationship of sleep quality and posttraumatic stress to potential sleep disorders in sexual assault survivors with nightmares, insomnia, and PTSD

Sleep quality and posttraumatic stress disorder (PTSD) were examined in 151 sexual assault survivors, 77% of whom had previously reported symptoms of sleep-disordered breathing (SDB) or sleep movement disorders (SMD) or both. Participants completed the Pittsburgh Sleep Quality Index (PSQI) and the Posttraumatic Stress Scale (PSS). High PSQI scores reflected extremely poor sleep quality and correlated with PSS scores. PSQI scores were greater in participants with potential SDB or SMD or both. PSQI or PSS scores coupled with body-mass index and use of antidepressants or anxiolytics predicted potential sleep disorders. The relationship between sleep and posttraumatic stress appears to be more complex than can be explained by the current PTSD paradigm; and, sleep breathing and sleep movement disorders may be associated with this complexity.

Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial

CONTEXT

Chronic nightmares occur frequently in patients with posttraumatic stress disorder (PTSD) but are not usually a primary target of treatment.

OBJECTIVE

To determine if treating chronic nightmares with imagery rehearsal therapy (IRT) reduces the frequency of disturbing dreams, improves sleep quality, and decreases PTSD symptom severity.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial conducted from 1995 to 1999 among 168 women in New Mexico; 95% had moderate-to-severe PTSD, 97% had experienced rape or other sexual assault, 77% reported life-threatening sexual assault, and 58% reported repeated exposure to sexual abuse in childhood or adolescence.

INTERVENTION

Participants were randomized to receive treatment (n = 88) or to the wait-list control group (n = 80). The treatment group received IRT in 3 sessions; controls received no additional intervention, but continued any ongoing treatment.

MAIN OUTCOME MEASURES

Scores on the Nightmare Frequency Questionnaire (NFQ), Pittsburgh Sleep Quality Index (PSQI), PTSD Symptom Scale (PSS), and Clinician-Administered PTSD Scale (CAPS) at 3- and 6-month follow-up.

RESULTS

A total of 114 participants completed follow-up at 3 and/or 6 months. Comparing baseline to follow-up (n = 97-114), treatment significantly reduced nights per week with nightmares (Cohen d = 1.24; P<.001) and number of nightmares per week (Cohen d = 0.85; P<.001) on the NFQ and improved sleep (on the PSQI, Cohen d = 0.67; P<.001) and PTSD symptoms (on the PSS, Cohen d = 1.00; P<.001 and on the CAPS, Cohen d = 1.53; P<.001). Control participants showed small, nonsignificant improvements for the same measures (mean Cohen d = 0.21). In a 3-point analysis (n = 66-77), improvements occurred in the treatment group at 3-month follow-up (treatment vs control group, Cohen d = 1.15 vs 0.07 for nights per week with nightmares; 0.95 vs -0.06 for nightmares per week; 0.77 vs 0.31 on the PSQI, and 1.06 vs 0.31 on the PSS) and were sustained without further intervention or contact between 3 and 6 months. An intent-to-treat analysis (n = 168) confirmed significant differences between treatment and control groups for nightmares, sleep, and PTSD (all P<.02) with moderate effect sizes for treatment (mean Cohen d = 0.60) and small effect sizes for controls (mean Cohen d = 0.14). Posttraumatic stress symptoms decreased by at least 1 level of clinical severity in 65% of the treatment group compared with symptoms worsening or not changing in 69% of controls (chi(2)(1) = 12.80; P<.001).

CONCLUSIONS

Imagery rehearsal therapy is a brief, well-tolerated treatment that appears to decrease chronic nightmares, improve sleep quality, and decrease PTSD symptom severity.

Sleep disorder, depression, and suicidality in female sexual assault survivors

The role of sleep in psychiatric illness in general, and depression and suicidality in particular, is poorly understood and has not been well researched despite the pervasiveness of sleep complaints in these conditions. As an exploratory, hypothesis-generating study, female sexual assault survivors with posttraumatic stress disorder (n = 153) who had enrolled in a nightmare-treatment program were assessed for subjectively determined sleep breathing and sleep movement disorders. Diagnoses of potential disorders were based on clinical practice parameters and research algorithms from thefield of sleep disorders medicine. Potential sleep breathing and sleep movement disorders were present in 80% of the participants (n = 123) and included three subgroups: sleep-disordered breathing only (n = 23); sleep movement disorder only (n = 45); and both sleep disorders (n = 55). Based on the Hamilton Depression Rating Scale and Suicide subscale, participants with potential sleep disorders suffered greater depression (Cohen's d = .73-.96; p < .01) and greater suicidality (Cohen's d = .57-.78; p < .05) in comparison to participants without potential sleep disorders. The group with both sleep disorders suffered from the most severe depression and suicidality. A provisional hypothesis is formulated that describes how sleep disorders may exacerbate depression and suicidality through the effects of chronic sleep fragmentation.

Complex insomnia: insomnia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD

BACKGROUND

Sleep disturbance in posttraumatic stress disorder is very common. However, no previous posttraumatic stress disorder studies systematically examined sleep breathing disturbances, which might influence nightmares, insomnia, and posttraumatic stress disorder symptoms.

METHODS

Forty-four consecutive crime victims with nightmares and insomnia underwent standard polysomnography coupled with a nasal pressure transducer to measure airflow limitation diagnostic of obstructive sleep apnea and upper airway resistance syndrome.

RESULTS

Forty of 44 participants tested positive on objective sleep studies based on conservative respiratory disturbance indices of more than 15 events per hour; 22 patients suffered from obstructive sleep apnea and 18 suffered from upper airway resistance syndrome.

CONCLUSIONS

In an uncontrolled study, insomnia and sleep-disordered breathing were extremely prevalent in this small and select sample of crime victims. Research is needed to study 1) prevalence of sleep-disordered breathing in other posttraumatic stress disorder populations using appropriate controls and nasal pressure transducers and 2) effects of sleep treatment on posttraumatic stress symptoms in trauma survivors with comorbid obstructive sleep apnea or upper airway resistance syndrome. In the interim, some posttraumatic stress disorder patients may benefit from sleep medicine evaluations.

A retrospective study on improvements in nightmares and post-traumatic stress disorder following treatment for co-morbid sleep-disordered breathing

OBJECTIVE

To assess the impact of treatment for co-morbid sleep-disordered breathing (SDB) on patients with nightmares and post-traumatic stress.

METHODS

Twenty-three chronic nightmare sufferers (15 with post-traumatic stress disorder, PTSD) who also suffered co-morbid SDB (obstructive sleep apnea, OSA, n=16; upper airway resistance syndrome, UARS, n=7) completed a telephone interview, on average, 21 months after having been offered treatment for SDB at a university sleep disorders clinic.

RESULTS

At follow-up, 14 reported maintaining treatment (Treatment Group) and 9 reported discontinuing treatment (No-Treatment Group). More patients in the Treatment Group reported improvement in sleep (93% vs. 33%) and in daytime well being (93% vs. 33%) compared with those in the No-Treatment group. The Treatment Group reported a median improvement in nightmares of 85% compared with a median 10% worsening in the No-Treatment Group. In the PTSD subset (n=15), nine in the Treatment Group reported a median 75% improvement in PTSD symptoms whereas six in the No-Treatment Group reported a median 43% worsening.

CONCLUSION

In this small sample of patients, treatment of SDB was associated with improvements in nightmares and PTSD. Relationships between nightmares, PTSD and SDB are discussed.

A controlled study of imagery rehearsal for chronic nightmares in sexual assault survivors with PTSD: a preliminary report

Imagery-rehearsal therapy for chronic nightmares was assessed in a randomized, controlled study of sexual assault survivors with posttraumatic stress disorder (PTSD). Nightmares, sleep quality, and PTSD were assessed at baseline for 169 women, who were randomized into two groups: treatment (n = 87) and wait-list control (n = 82). Treatment consisted of two 3-hr sessions and one 1-hr session conducted over 5 weeks. Of 169 participants, 91 women (Treatment, n = 43, Control, n = 48) completed a 3-month follow-up and 78 did not. At follow-up, nightmare frequency and PTSD severity decreased and sleep quality improved in the treatment group with small to minimal changes in the control group. Treatment effects were moderate to high (Cohen's d ranged from 0.57 to 1.26). Notwithstanding the large dropout rate, imagery-rehearsal therapy is an effective treatment for chronic nightmares in sexual assault survivors with PTSD and is associated with improvement in sleep quality and decreases in PTSD severity.

Sleep breathing and sleep movement disorders masquerading as insomnia in sexual-assault survivors

A descriptive, hypothesis-generating study was performed with 156 female sexual-assault survivors who suffered from insomnia, nightmares, and posttraumatic stress disorder (PTSD). They completed 2 self-report sleep questionnaires to assess the potential presence of intrinsic sleep disorders. Seventy-seven percent of the sample (120 of 156) endorsed additional sleep complaints, besides their insomnia symptoms, that indicate the potential presence of sleep-disordered breathing ([SDB] 81 of 156, 52%) and sleep-related movement disorders ([SMD] 94 of 156, 60%). The potential for SDB was strongly correlated with the body mass index (BMI), an increase in arousal symptoms, and greater total PTSD severity. In some sexual-assault survivors, the relationship between sleeplessness and posttraumatic stress may be caused or exacerbated by intrinsic sleep disorders, and not be solely a function of psychophysiological insomnia--the traditional diagnostic term usually offered to explain the sleep problems associated with PTSD. Prevalence studies that use objective diagnostic evaluations such as polysomnography (PSG) are needed to test these hypotheses.

Hypochondriasis, somatization, and perceived health and utilization of health care services

The authors determined the different effects of hypochondriasis and somatization on health perceptions, health status, and service utilization in a primary care population. The subjects with hypochondriacal responses (HR) on the Illness Attitudes Scales or high somatic concern (HSC) on the Symptom Questionnaire had a worse perception of health and variably used more health services than the control subjects, even though the HR and HSC subjects had the same level of chronic medical disorders. Regression analyses determined that somatization contributed more to negative health perception and service utilization than did hypochondriasis, although an interaction between the two contributed to the use of psychiatric care. The authors discuss the boundary between hypochondriasis and somatization for its implications for research and clinical practice.

Hypochondriasis and somatization related to personality and attitudes toward self

Better definition of the boundary between hypochondriasis and somatization was determined by measuring attitudes to self and personality dimensions associated with these syndromes. In this study, the primary care patients with hypochondriacal responses (HR) on the Illness Attitudes Scales or high somatic concern (HSC) on the Symptom Questionnaire had more negative attitudes to self and more psychological distress than the matched group of primary care control subjects. The HR subjects were different from the non-HR subjects on two of five personality domains on the NEO Personality Inventory (NEO)-Five-Factor Inventory, and the HSC subjects were different from the non-HSC subjects on four of five NEO domains. Analysis of variance demonstrated that somatization explained most of the variance in attitudes, personality, and psychological distress, but hypochondriasis uniquely contributed only to thanatophobia. The authors discuss the boundary between hypochondriasis and somatization and offer a descriptive model of this relationship.

Functional impairment associated with psychological distress and medical severity in rural primary care patients

OBJECTIVE

The study examined functional impairment associated with psychological distress and severity of medical illness in a rural primary care population and explored how functional impairment varied with psychological distress and chronic medical illness.

METHODS

Fifty-eight patients recruited from three rural primary care clinics completed the 36-item Short Form Health Survey (SF-36) and the Typology of Psychic Distress (PsyDis). The chronic disease score, a measure of the severity of chronic medical illness, was calculated from data on use of prescription medications over a six-month period. T tests were used to determine the level of functional impairment associated with various levels of psychological distress and medical illness. Regression analyses were used to determine the proportion of variance in impairment that was explained by level of psychological distress and severity of medical illness.

RESULTS

High levels of psychological distress explained the variance in impairment in several domains measured by the SF-36, including general health, social functioning, emotional role, and mental health, whereas a high level of severity of chronic medical illness explained the variance in impairment in physical functioning. Both high psychological distress and high severity of chronic medical illness explained the variance in impairment in vitality, and neither variable explained variance in impairment in physical role or bodily pain.

CONCLUSIONS

In this rural outpatient primary care population, functional impairment was explained more by psychological distress than by severity of medical illness. Decreasing the burden of psychological distress among primary care patients may improve functioning.

Health promotion lifestyles of women experiencing crises

Women who are experiencing crisis situations, including homelessness, are often perceived as passive victims of their social, economic, and personal circumstances. A few studies have challenged the stereotype of homeless women as passive victims and demonstrated that they are active in seeking solutions to their problems (Hodnicki, Horner, & Boyle, 1992; Montgomery, 1994; Thrasher & Mowbray, 1995). This study surveyed women receiving assistance at a nurse-managed clinic that serves a homeless population to determine their health promotion strategies. On the basis of this study's findings, health care providers are encouraged to recognize and build on the strengths of women in crises at both the individual and community levels of care.

Panic disorder and quality of life: variables predictive of functional impairment

OBJECTIVE

The authors sought to characterize the functional impairment in patients with panic disorder, specifically the variance in impairment explained by demographic and clinical variables.

METHOD

Sixty-two patients with panic disorder and 61 comparison subjects from three primary care clinic sites were assessed with an adapted form of the Structured Clinical Interview for DSM-III-R. Impairment was assessed according to three measures from the 36-item Short-Form Health Survey (general health perception, mental health, and physical functioning) as well as a principal component factor of the survey. Subjects were also compared with respect to personality variables, presence and severity of chronic medical illness, and demographic characteristics. Stepwise multiple regressions with and without pairwise interactions were used to construct models of disability in the patients with panic disorder.

RESULTS

The patients with panic disorder were more impaired than comparison subjects on each measure of the Short-Form Health Survey. The panic disorder diagnosis combined with major depression, increasing neuroticism and age, less education, and an interaction between panic disorder and age accounted for 48%-77% of the variance in impairment scores. Gender and ethnicity contributed modestly to the variance in impairment in physical functioning, whereas no contribution was demonstrated for chronic medical illness or city of residence.

CONCLUSIONS

Factors in addition to panic phenomena contribute to the severe impairment seen in patients with panic disorder. Further research about factors that affect impairment may help improve clinical approaches to this illness.

The DSM-IV panic disorder field trial: panic attack frequency and functional disability

The goal of the DSM-IV panic disorder field trial was to provide an empirical basis for choosing between alternate proposals (DSM-III-R and proposed DSM-IV) for the diagnostic threshold for panic disorder, in particular the number and frequency of panic attacks required for diagnosis. The two criteria sets were compared with respect to their ability to identify individuals whose panic attacks were associated with distress, impairment, or help-seeking. Subjects were a convenience sample screened in three geographically diverse primary care clinics for presence (past 6 months) or absence (lifetime) of panic attacks. Each underwent a clinician-administered semistructured interview which included assessment of panic frequency, panic-related impairment, psychiatric diagnosis, health services utilization, and medical illness. Self-perceived health-related quality of life was assessed using the Medical Outcome Study SF-36 Health Survey Questionnaire. Although both proposals diagnosed the same proportion of panic-impaired individuals, they were not completely overlapping. Twenty percent of subjects diagnosed by each criteria set were excluded by the other. Subjects who had been excluded by the DSM-III-R but included by the DSM-IV proposal were those with fewer than 4 attacks in 4 weeks who also denied worry about the "next" attack. Broadening the worry criterion to include concerns about the health implications of attacks enabled diagnosis of this group. Subjects who met DSM-III-R, but not the proposed DSM-IV criteria, had 4 attacks in 4 weeks but denied any panic related worry. Modification of the DSM-IV proposal to include a month of worry or "a significant change in behavior related to the attacks" allowed inclusion of this group in the diagnostic category. These data suggest that the finalized DSM-IV panic disorder criteria will diagnose a greater proportion of individuals whose panic attacks are associated with impairment without inflating the diagnostic category or significantly reducing specificity.

Infrequent panic attacks: psychiatric comorbidity, personality characteristics and functional disability

Primary care patients with infrequent panic attacks were found to have similar levels of disability in their social, family and vocational functioning to patients who met DSM-III-R criteria for panic disorder. Both panic subgroups had significantly more functional disability than controls. Patients with panic and infrequent panic had significantly more Axis I psychiatric comorbidity than primary care controls but similar levels of medical comorbidity. Patients with panic disorder had a significantly higher prevalence of one or more other lifetime psychiatric diagnoses, current major depression, and current DSM-III-R depressive symptoms compared to patients with infrequent panic. Patients with infrequent panic scored as high on the NEO personality measure of neuroticism as patients with panic disorder, and both panic subgroups had significantly higher neuroticism levels than controls.

Anxiety and depression in an outpatient clinic in Lesotho, Africa

OBJECTIVE

Past studies of psychiatric disorders in primary care in developing countries have utilized measures to determine conspicuous psychiatric morbidity (CPM) rather than diagnoses. Our goal was to determine the prevalence of DSM-III major depression (DEP), panic disorder (PD), and generalized anxiety disorder (GAD) in an outpatient clinic in Lesotho, Africa.

METHODS

As part of a larger community study, we utilized a translated version of the N.I.M.H. Diagnostic Interview Schedule to determine the prevalence of DEP, PD, and GAD in 126 randomly selected outpatients (response rate = 77%) attending a general hospital clinic. We compared these data to information about demographics and symptom presentation.

RESULTS

We found twenty-nine (23%) patients with DEP, thirty (24%) with PD, and thirty-six (29%) with GAD. Forty-six (36%) had either DEP or PD, with thirteen (45%) having concurrent illness. Patients with DEP and/or PD presented with a significantly higher number of physical symptoms, and a higher percentage of symptoms that were pain or autonomic nervous system related than patients with no disorder ever.

CONCLUSION

There is significant psychiatric morbidity of common diagnoses in outpatient clinic in Lesotho, and patients present primarily with somatic symptoms, as in developed countries. There is a need for better elucidation of cross-cultural phenomenology, medical co-morbidity as a confounder, and help-seeking and treatment patterns in the developing world.

Memory sources of REM and NREM dreams

Sixteen male volunteers slept 4 nonconsecutive nights each in a sleep laboratory. They were awakened for one dream report per night. Awakenings were made, in counterbalanced order, from early-night and late-night rapid-eye movement (REM) and non-REM (NREM) sleep. Following dream reporting, subjects were asked to identify memory sources of their dream imagery. Two independent judges reliably rated mentation reports for temporal units and categorized memory sources as autobiographical episodes, abstract self-references, or semantic knowledge. We replicated earlier findings that semantic knowledge is more frequently mentioned as a dream source for REM than for NREM reports. However, with controls for length of reports, the REM-NREM difference disappeared, indicating that the stage difference in memory sources was not independent of stage difference in report lengths. There was a significant effect of time of night on source class, but only in REM sleep: Both without and with controls for report length, more semantic sources were cited for late than for early REM dreams.

Anxiety and depression in a village in Lesotho, Africa: a comparison with the United States

Adults in a village in Lesotho, Africa, were interviewed to determine the community prevalence of major depression, panic disorder, and generalised anxiety disorder. The prevalence data were compared with data from a large epidemiological study in the United States utilising the same research instrument. There was a significantly higher prevalence of all three diagnoses in Lesotho as compared with the United States. As in the United States, women were at an increased risk for these disorders, although statistical significance was not demonstrated for depression. The majority of people (77%) who had experienced panic attacks said they had sought help for their symptoms, with the majority attending Western-trained doctors. The relationship between explanatory models and help-seeking behaviour was explored in people who had had panic attacks. Less than 40% of those with generalised anxiety disorder said they sought help.

Processing of memories and knowledge in REM and NREM dreams

Over 4 nights, 16 young-adult males each reported 2 REM and 2 nonREM dreams. They then identified possible sources of dream imagery in their waking memory and/or knowledge. A judge, naive as to conditions of data collection, reliably judged the closeness of correspondence of dream event to identified source. Correspondence was lower for REM than for nonREM reports and for longer than for shorter reports from either stage.

Chest pain with negative cardiac diagnostic studies. Relationship to psychiatric illness

A total of 98 patients with chest pain and no prior history of organic heart disease underwent a structured psychiatric interview at the time of cardiac diagnostic testing, either coronary arteriography or exercise treadmill. Patients with negative cardiac test results were significantly younger and more likely to be female, endorsed a greater number of autonomic symptoms with their chest pain, and were more likely to report atypical chest pain. These patients had significantly higher scores on measures of anxiety and negative life events and significantly greater prevalences of DSM-III panic disorder (47% vs. 6%), major depression (39% vs. 8%), and two or more simple phobias (43% vs. 12%) than did patients with cardiac test results demonstrating coronary artery disease. Using logistic regression, a model was developed to estimate the probability of negative cardiac test results from patient characteristics and psychiatric diagnoses.

Chest pain: relationship of psychiatric illness to coronary arteriographic results

Seventy-four patients with chest pain and no prior history of organic heart disease were interviewed with a structured psychiatric interview immediately after coronary arteriography. The majority of patients with both negative and positive coronary angiographies had undergone previous exercise tolerance tests, but the patients with angiographic coronary artery disease were significantly more likely to have had positive results on a treadmill test. Patients with chest pain and negative coronary arteriograms were significantly younger; more likely to be female; more apt to have a higher number of autonomic symptoms (tachycardia, dyspnea, dizziness, and paresthesias) associated with chest pain, and more likely to describe atypical chest pain. Patients with chest pain and normal coronary arteriographic results also had significantly higher psychologic scores on indices of anxiety and depression and were significantly more likely to meet criteria of the Diagnostic and Statistical Manual of Mental Disorders, third edition, for panic disorder (43 percent versus 6.5 percent), major depression (36 percent versus 4 percent), and two or more phobias (36 percent versus 15 percent) than were patients with chest pain and a coronary arteriography study demonstrating coronary artery stenosis.

Sympathetic nervous system activity in panic disorder

To assess sympathetic nervous system (SNS) activity in panic disorder, arterialized venous norepinephrine (NE) and epinephrine (EPI) were measured in 10 patients and 10 age- and weight-matched controls. In addition, arterialized plasma NE kinetics were determined using a tritiated NE isotope dilution technique. There were no significant differences between patients and controls for resting, supine plasma NE levels, plasma NE appearance rate, plasma NE clearance, or plasma cortisol. However, plasma EPI levels were significantly higher in panic patients (103 +/- 23 vs. 33 +/- 16 pg/ml). Furthermore, there was a significant correlation between anxiety ratings and plasma EPI levels in panic disorder patients. These findings suggest that during the resting state, panic disorder is associated with a selective activation of the adrenomedullary component of the SNS.