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ABSTRACT: 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.
Journal of Traumatic Stress 11/2001; 14(4):647-65. · 2.72 Impact Factor
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B Krakow,
M Hollifield,
L Johnston,
M Koss,
R Schrader,
T D Warner,
D Tandberg,
J Lauriello,
L McBride,
L Cutchen,
D Cheng,
S Emmons, A Germain,
D Melendrez,
D Sandoval,
H Prince
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ABSTRACT: Chronic nightmares occur frequently in patients with posttraumatic stress disorder (PTSD) but are not usually a primary target of treatment.
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.
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.
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.
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.
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).
Imagery rehearsal therapy is a brief, well-tolerated treatment that appears to decrease chronic nightmares, improve sleep quality, and decrease PTSD symptom severity.
JAMA The Journal of the American Medical Association 09/2001; 286(5):537-45. · 30.03 Impact Factor
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ABSTRACT: 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.
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.
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.
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.
Biological Psychiatry 07/2001; 49(11):948-53. · 8.28 Impact Factor
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ABSTRACT: To assess the impact of treatment for co-morbid sleep-disordered breathing (SDB) on patients with nightmares and post-traumatic stress.
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.
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.
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.
Journal of Psychosomatic Research 12/2000; 49(5):291-8. · 3.30 Impact Factor
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ABSTRACT: 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.
Crisis The Journal of Crisis Intervention and Suicide Prevention 02/2000; 21(4):163-170. · 1.09 Impact Factor
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ABSTRACT: 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.
Comprehensive Psychiatry 41(1):49-56. · 2.26 Impact Factor
