No full-text available
To read the full-text of this research,
you can request a copy directly from the author.
Abstract
Sleep complaints and various sleep symptoms are common in elderly persons with cardiac diseases. Nightmares are associated with profound sleep disturbances.
The present questionnaire survey with questions on sleep symptoms, nightmares and cardiac symptoms comprised 6103 elderly subjects (39.5% men).
Nightmares occurred rather often in 6.9% and very often in 2.1% of the men. The corresponding frequencies in women were 9.6 and 2.3%, respectively. Irregular heart beats were reported by 11.8% of the men and 131% of the women (NS). Spasmodic chest pain occurred in 12.9 and 10.6%, respectively (p < 0.01). Irregular heart beats increased in association with increasing nightmares in both men (p < 0.01) and women (p < 0.0001). The percentages of men and women with both irregular heart beats and spasmodic chest pain were three times and seven times higher, respectively, among those who had nightmares very often than among those who very seldom or never had nightmares. The increase in cardiac symptoms in nightmare sufferers was not attributable to an increase in medication with cardiac drugs.
In this group of elderly men and women increased nightmares were associated with an increase in irregular heart beats and spasmodic chest pain.
... Although there is no consensus on what is called dream disorder, nightmares are one of the most important subsets (8). Nightmares are related to cardiac markers such as heart rate and irregular heartbeats (9,10). Also, dream anxiety and related emotions are associated with the incidence of MI during sleep (11). ...
... The total score is between 0 and 30, with higher scores indicating greater severity of somatic symptoms. Levels of somatic symptom severity are characterized by four categories included minimal (0-4), low (5-9), medium (10)(11)(12)(13)(14), and high (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30). The scale validity was confirmed by Kocalevent et al. (19). ...
... Johansson et al. (38) founded that infarct size measured by conventional biochemical markers, left ventricle ejection fraction, and history of previous MI are not related to the sleep disturbances. Mutually, other studies have suggested an association between sleep-related disorders, dream-related factors, and nightmares with cardiac markers and symptoms (8)(9)(10). Also, Ehrhardt et al. (39) refer to a complex interaction between sleep disorders such as sleep apnea and carotid stenosis. ...
Objective:
Sleep-related disorders and rapid eye movement-sleep parasomnias such as nightmares are among the threatening factors for the quality of life in clinical populations such as myocardial infarction (MI) patients. The present study was done to investigate the correlates of sleep-related disorders, dream-related factors, and nightmares in MI patients.
Materials and Methods:
In this cross-sectional study, 222 MI patients admitted to a hospital in western Iran participated in the study during June-December 2018. Patients completed several standard tools related to sleep and dream. The stenosis severity and extent were assessed using angiography by an expert cardiologist. Data were analyzed using the Pearson correlation coefficient and multiple regression analysis.
Results:
The mean (± standard deviation) age of patients (51.8% male) was 63.6±51.3. The prevalence of poor sleep quality was 98.2%. Somatic symptoms were strongest correlates of the poor sleep quality (p<0.001), sleep self-efficacy (p<0.001), nightmare frequency and severity (p<0.001), and emotionally negative dream (p=0.006). Chest pain and stenosis severity were unable to explain any of the sleep-related disorders or dream-related factors. Somatic symptoms (p<0.001) and chest pain (p=0.029) were lower in patients with fearful dream content compared to those without fearful content.
Conclusion:
Compared to the stenosis severity or chest pain, somatic symptoms are the strongest correlates of sleep-related disorders and dream-related factors included sleep self-efficacy and emotionally negative dream along with nightmare frequency and severity. Although, the relationship between somatic symptoms and fearful dream content is a complex phenomenon. Future longitudinal studies with several follow-up stages can provide valuable findings.
... Nightmares have also been empirically demonstrated to be reactive to intense stress (Cernovsky, 1984c;Coalson, 1995;Cook, Caplan, & Wolowitz, 1990;Hartmann, 1984;Picchioni et al., 2002;Wood, Bootzin, Rosenhan, Nolen-Hoeksema, & Jourden, 1992) and often to accompany a number of chronic health problems, including migraine headaches (Levitan, 1984), bronchitis and asthma (Klink & Quan, 1987), chronic obstructive airways disorder (Krakow, Melendrez, et al., 2001;Wood et al., 1993), and cardiac disease (Asplund, 2003;Parmar & Luque-Coqui, 1998). Among the elderly, nightmares are associated with an increase in irregular heart beats and spasmodic chest pain (Asplund, 2003). ...
... Nightmares have also been empirically demonstrated to be reactive to intense stress (Cernovsky, 1984c;Coalson, 1995;Cook, Caplan, & Wolowitz, 1990;Hartmann, 1984;Picchioni et al., 2002;Wood, Bootzin, Rosenhan, Nolen-Hoeksema, & Jourden, 1992) and often to accompany a number of chronic health problems, including migraine headaches (Levitan, 1984), bronchitis and asthma (Klink & Quan, 1987), chronic obstructive airways disorder (Krakow, Melendrez, et al., 2001;Wood et al., 1993), and cardiac disease (Asplund, 2003;Parmar & Luque-Coqui, 1998). Among the elderly, nightmares are associated with an increase in irregular heart beats and spasmodic chest pain (Asplund, 2003). Frequent nightmares also afflict substance abusers (Cernovsky, 1985(Cernovsky, , 1986Greenberg & Pearlman, 1967;Gross et al., 1966;Lansky & Bley, 1992). ...
Nightmares are common, occurring weekly in 4%-10% of the population, and are associated with female gender, younger age, increased stress, psychopathology, and dispositional traits. Nightmare pathogenesis remains unexplained, as do differences between nontraumatic and posttraumatic nightmares (for those with or without posttraumatic stress disorder) and relations with waking functioning. No models adequately explain nightmares nor have they been reconciled with recent developments in cognitive neuroscience, fear acquisition, and emotional memory. The authors review the recent literature and propose a conceptual framework for understanding a spectrum of dysphoric dreaming. Central to this is the notion that variations in nightmare prevalence, frequency, severity, and psychopathological comorbidity reflect the influence of both affect load, a consequence of daily variations in emotional pressure, and affect distress, a disposition to experience events with distressing, highly reactive emotions. In a cross-state, multilevel model of dream function and nightmare production, the authors integrate findings on emotional memory structures and the brain correlates of emotion.
... 21 The primary objective of the current study was to investigate if NP accounts for independent variance in physical and psychological processes outside of distress; namely, potentially-concretized cardiac symptoms, other conditions which might affect cardiac symptoms (sleep fragmentation, Type-D personality, health behaviors, perceived stress), as well as overall perceptions of physical health, nightmares, and general dream recall. A secondary aim was to extend previous findings which related nightmares to cardiac symptoms in middle-aged and older populations 12,22 while investigating other processes which might be involved. Given the previous findings and conceptualizations of NP and distress, we expected that, outside of distress, NP would independently account for independent variance among constructs that might reflect concretization (cardiac symptoms) and nightmares. ...
Introduction Nightmare proneness, a trait-like disposition to experience frequent nightmares, has been strongly related to psychological distress. The aim of the present study was to examine if cardiac symptoms and hypothetically-related variables, nightmares, and perceived physical health could be used to differentiate nightmare proneness and psychological distress.
Materials and Methods In the present cross-sectional study, 254 young adults completed measures of nightmare proneness, psychological distress, cardiac symptoms, nonspecific and posttraumatic nightmares, nightmare distress, health behaviors, perceptions of physical health, perceived stress, Type-D personality, sleep fragmentation, and dream recall.
Results After controlling for psychological distress, nightmare proneness remained significantly correlated with nightmares, nightmare distress, cardiac symptoms, sleep fragmentation, physical health, perceived stress, and Type-D personality. After controlling for nightmare proneness, distress remained correlated with perceived stress and Type-D personality. Regression analyses indicated that after accounting for all variables, nightmare distress, physical health, and nightmare proneness predicted cardiac symptoms. Posttraumatic nightmares, sleep fragmentation, distress, perceived stress, Type-D personality, and chest pain predicted nightmare proneness.
Conclusion Nightmare proneness and psychological distress can be considered separate constructs. The findings were consistent with those of previous research and supported the theoretical propositions that nightmare proneness includes hyperarousal, vulnerability to stressors, and concretization, a mental process in which vague internal states are made more concrete.
... As for possible gender differences in the onset of acute cardiovascular events, a comprehensive review from our group on worldwide chronobiologic studies from 1996 to 2015 (n=64 studies, >650000 cases), showed that only less than one half of studies provided separate analysis by gender. However, these complete studies included 85% of total Biological correlates Working W with frequent nightmares show a blunted cortisol awakening response on a working day, compared to those without nightmares 79 After the menopause, the prevalence of spasmodic chest pain and irregular heartbeat ↑ with the number of nights a week disturbed by nightmares 88 Elderly subjects with nightmares: no gender difference for irregular heartbeats (IH), whereas spasmodic chest pain (SCP) was significantly more frequent in M. IH significantly ↑ in association with increasing nightmares in both M and W. The percentages of M and W with both IH and SCP were 3-and 7-times higher among those who had nightmares very often than among those who very seldom or never had nightmares, respectively 89 cases, so that we can now assume that morning hours represent equally critical time for both men and women 105 . ...
Objective:
The aim of this study was to review the available findings on sex-related differences for sleep disorders, dreams and nightmares.
Materials and methods:
We explored the PubMed, EMBASE and Google Scholar electronic databases, with regards to the searching terms 'sleep', 'dreams', and 'nightmares' associated with 'sex' and/or 'gender'. Moreover, other supplementary terms for the searching strategy were 'chronobiology', and 'circadian rhythm'. Due to the relative paucity of studies including separate analysis by sex, and especially to their wide heterogeneity, we decided to proceed with a narrative review, highlighting the sex-related findings of each topic into apposite boxes.
Results:
On one hand, sleep disorders seem to be more frequent in women. On the other hand, sex-related differences exist for either dreams or nightmares. As for the former, differences make reference to dream content (men: physical aggression, women family themes), self-reported perspective (men dream in third person, women in first person), dream sharing (more frequent in women), lucid dreaming (women more realistic, men more controlled), and daydreaming (young men more frequently have sexual themes). Nightmares are more frequent in women too, and they are often associated with sleep disorders and even with psychiatric disorders, such as depression and/or anxiety. In women, a strong association has been shown between nightmares and evening circadian preference.
Conclusions:
For many years, and for many reasons, laboratory experiments have been conducted mainly, if not exclusively, on male animals. Thus, a novel effort towards a new governance of scientific and research activities with a gender-specific perspective has been claimed for all areas of medicine, and more research on sex-differences is strongly needed also on this topic.
... Recent studies although have examined the relationship between dream and psychological and physical well-being included depression, insomnia, fatigue and other factors such as sex, age, the use of antidepressants or hypnotics and frequent heavy use of alcohol, cardiac symptoms among general population (14,15), less focused on the population with cardiovascular problems (13). Thus, it seems that spontaneous study on physiological and psychological factors can facilitate the perception of complex mechanisms of the dream. ...
Introduction:
Dream, as a kind of mental activity, includes various functions such as mood regulation, adjustment and integration of new information with the available memory system. The study was done for assessing the relationship between physiological and psychological components of cardiac diseases with emotionally negative dreams in cardiac rehabilitation.
Methods:
At the baseline of this cross-sectional study, 156 patients from Western Iran participated during April-November 2016. People 20 years-80 years able to recall the emotional content of dreams after cardiac surgery entered the study. The Beck depression inventory (BDI), Beck anxiety inventory (BAI), Buss and Perry's aggression questionnaire (BPAQ) and Schredl's dream emotions manual were used for collecting data. A binary logistic regression analysis used for the study of the relationship between risk factors and emotionally negative dreams.
Results:
The mean age of participants was 59 (SD = 9) years (men: 64.1%). The results showed that 25% of patients have negative emotional content. After adjustment for demographic variables, the results showed that increased anxiety [adjusted odds ratio (adj OR) = 1.08 [1.01-1.16], P = 0.020] and anger (adj OR = 1.03 [1.00-1.06], P = 0.024) and hypertension (adj OR = 2.71 [1.10-6.68], P = 0.030) can predict the dreams with negative content significantly.
Conclusion:
The increasing rates of anxiety and anger and history of hypertension are related to increasing dreams with the negative emotional load. The control of risk factors of dreams with negative emotional load can be the target of future interventions.
... Emotions in dreaming may be expressed in nightmares (Asplund, 2003;Blagrove, Farmer, & Williams, 2004;Zadra & Donderi, 2000), anxiety (Schredl, Adam, Beckmann, & Petrova, 2016), apathy (Zanasi et al., 2014), or pleasure (Freud, 1961;Perogamvros, Dang-Vu, Desseilles, & Schwartz, 2013;Perogamvros & Schwartz, 2012). Repressed emotions could lead to depression: Schredl et al. (2016) investigated the relationship between illness, health-related worries, and health-related dreams (n =178 with112 women, 66 men; ranging from 16 to 82 yrs) and found a significant relationship between dreams, health-related worries (34.09%), and illness (40.45%). ...
... 13 The Swedish study by Asplund shows that nightmares were associated with an increased risk in irregular heartbeat and spasmodic chest pain in elderly people. 21 Studies have also reported that insomnia, [22][23][24] difficulty falling asleep, 10,25 and the use of sleeping pills 26 were related to an increased risk of cardiovascular disease. Although different methods were used for evaluating sleep quality, our results are in line with the results in the findings in previous literature. ...
Study objectives:
There is limited information on the relationship between risk of cardiovascular disease and the joint effects of sleep quality and sleep duration, especially from large, prospective, cohort studies. This study is to prospectively investigate the joint effects of sleep quality and sleep duration on the development of coronary heart disease.
Methods:
This study examined 60,586 adults aged 40 years or older. A self-administered questionnaire was used to collect information on sleep quality and sleep duration as well as a wide range of potential confounders. Events of coronary heart disease were self-reported in subsequent medical examinations. Two types of Sleep Score (multiplicative and additive) were constructed to reflect the participants' sleep profiles, considering both sleep quality and sleep duration. The Cox regression model was used to estimate the hazard ratio (HR) and the 95% confidence interval (CI).
Results:
A total of 2,740 participants (4.5%) reported new events of coronary heart disease at follow-up. For sleep duration, participants in the group of < 6 h/d was significantly associated with an increased risk of coronary heart disease (HR: 1.13, 95% CI: 1.04-1.23). However, the association in the participants with long sleep duration (> 8 h/d) did not reach statistical significance (HR: 1.11, 95% CI: 0.98-1.26). For sleep quality, both dreamy sleep (HR: 1.21, 95% CI: 1.10-1.32) and difficult to fall asleep/use of sleeping pills or drugs (HR: 1.40, 95% CI: 1.25-1.56) were associated with an increased risk of the disease. Participants in the lowest quartile of multiplicative Sleep Score (HR: 1.31, 95% CI: 1.16-1.47) and of additive sleep score (HR: 1.31, 95% CI: 1.16-1.47) were associated with increased risk of coronary heart disease compared with those in the highest quartile.
Conclusions:
Both short sleep duration and poor sleep quality are associated with the risk of coronary heart disease. The association for long sleep duration does not reach statistical significance. Lower Sleep Score (poorer sleep profile) increases the risk of coronary heart disease, suggesting the importance of considering sleep duration and sleep quality together when developing strategies to improve sleep for cardiovascular disease prevention.
... This is in concordance with previous findings, showing a relationship between nightmares and certain somatic diseases like cardiac symptoms such as spasmodic chest pain and irregular heart beating . Furthermore, the association between cardiac symptoms and the prevalence of nightmares seems to be independent of the symptoms of sleep-disordered breathing (ASPLOUND 2003). Since sleep and dream disorders are relevant predictors of the development of depression, the association between dream complaints and lowered levels of well-being may indicate the presence of sub-clinical depressive states. ...
Both neurobiological and cognitive psychological evidence suggests that dreams reflect the affective concerns and emotional balance of the dreamer. Moreover, there is increasing evidence for the thesis that dreams take part in the process of emotional regulation by creating narrative structures and new associations for memories with emotional and personal relevance and giving birth to a reduced emotional arousal or balanced mood state during post-dreaming wakeful- ness. As health means a state of complete physical, mental and social well-being, it is reasonable to assume that it is reflected in the quality of dream experiences. These theoretical considerations are exemplified by significant associations between dream emotions and health indexes emerging after the preliminary analysis of the Hungarostudy epidemiological database. Results suggest that items of the Dream Quality Questionnaire correlate with self-rated health, days spent on sick leave and most prominently with well-being. Negative dream emotions are negative predictors of health, while the opposite is true for positive ones. This effect is only partially explained by the illness intrusiveness index, the effect of dreams on daytime mood or well-being as measured by the well-being scale of the World Health Organization (WHO). Our results indicate that simple practical questions regarding habitual dream-affect, nightmares and night- terror-like symptoms convey information on the general mental and physical health of the subjects, which could be useful in medical practice.
... This is in concordance with previous findings, showing a relationship between nightmares and certain somatic diseases like cardiac symptoms such as spasmodic chest pain and irregular heart beating . Furthermore, the association between cardiac symptoms and the prevalence of nightmares seems to be independent of the symptoms of sleep-disordered breathing (ASPLOUND 2003). Since sleep and dream disorders are relevant predictors of the development of depression, the association between dream complaints and lowered levels of well-being may indicate the presence of sub-clinical depressive states. ...
... Gyakori rémálmok azonban egészen eltérő klinikai állapotokat is kísérhetnek. Egyes krónikus egészségügyi panaszok, mint például a migrénes fejfájás [31], az asztmatikus hörghurut [32], valamint a szív-ér rendszeri betegségek [33] is társulhatnak gyakori rémálmokkal. Újabb kutatások eredménye szerint a rémisztő álmok ráadásul nemcsak kísérik, hanem egyes esetekben megelőzik az egészségügyi problémák megjelenését [6]. ...
Nightmares are intense and unpleasant dream experiences that characterize approximately 4 percent of the adult population at least on a weekly basis. Nightmare frequency is often co-morbid with other mental complaints; however, recent results indicate that nightmare disorder is independent from waking mental dysfunctions. Nightmare disorder is intimately related to poor subjective sleep quality, and according to polysomnographic studies nightmare subjects' sleep is characterized by increased sleep fragmentation and hyper-arousal. These findings suggest that instead of the psychopathological perspective nightmare disorder should be viewed as a specific sleep disorder that requires targeted treatment. Nevertheless, in order to choose the adequate treatment procedure clinicians should examine the co-morbid mental disorders as well taking into consideration the severity of nightmare distress, the latter supposed to be the mediator between nightmare frequency and waking mental dysfunctions. Orv. Hetil., 2013, 154, 497-502.
... The presence of a gender difference for 5-to 7-year-olds that was previously reported (Smedje et al., 1999) may not be representative of young children at large because it was based only upon participants who reported a clinically significant frequency of nightmares (at least 1 nightmare/week). Finally, the absence of a gender difference for the oldest age group in our study fails to replicate a gender difference demonstrated in a larger population study from Sweden (Asplund, 2003), a discrepancy that may reflect a low sample size for our older group (N ϭ 151). ...
Retrospective estimates of nightmare frequency for a sample of 23,990 respondents to an Internet questionnaire (female: N = 19,367, mean age = 24.9 ± 10.14 years; male: N = 4,623; mean age = 25.5 ± 10.81) were evaluated as a function of age, gender, and pre- versus post-September 11, 2001. Female respondents reported more frequent monthly nightmares (4.44 ± 6.71) than did male respondents (3.39 ± 6.07), and this result was seen for all age strata younger than 60. Also, for female respondents, nightmare frequency increased from ages 10-19 to 20-39 then decreased monotonically to ages 50-59. For male respondents, nightmare frequency was stable from ages 10-19 to 30-39 then decreased to ages 50-59. An increase in nightmare frequency was observed post-September 11 only for male respondents-particularly for 10- to 29-year-olds. This increase was sustained 2 years later. These effects were maintained when dream recall was held constant. Results replicate, in a single sample, previously published gender and age effects and provide new evidence that the nightmares of males may be differentially sensitive to traumatic events for which victims and/or perpetrators are primarily male. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
... Given that cytokines modulate sleep, an immune substrate has been considered to explain insomnia and parasomnias, such as nightmares, which may precede an acute coronary syndrome. Moreover, hypoxemia due to obstructive sleep apnea, when present, promotes the deterioration of cardiac ischemia (58). ...
Pain and sleep share mutual relations under the influence of cognitive and neuroendocrine changes. Sleep is an important homeostatic feature and, when impaired, contributes to the development or worsening of pain-related diseases. The aim of the present review is to provide a panoramic view for the generalist physician on sleep disorders that occur in pain-related diseases within the field of Internal Medicine, such as rheumatic diseases, acute coronary syndrome, digestive diseases, cancer, and headache.
... In one study of the elderly, chest pain and palpitations were more commonly noted in those with nightmares. 48 However, chest pain and palpitations are not perfect surrogates for the presence of CVD, and these symptoms might be manifestations of other conditions in some of the affected individuals. ...
Sleep disturbances are a common problem with chronic insomnia occurring in 10% of the general adult population and obstructive sleep apnea present in 4% and 2% of middle-aged men and women respectively. In addition, Americans are sleeping fewer hours per night than they did 20 years ago. There is now increasing evidence that reductions and increases in sleep duration, and various sleep disorders including obstructive sleep apnea and insomnia may be causal factors in the development of cardiovascular disease. Some of the evidence linking disturbances of sleep with cardiovascular disease is described in this review.
... En cuanto a las parasomnias del despertar, especialmente terrores nocturnos y arousals del confusionales, en adultos, están a menudo relacionadas con trastornos mentales (delirio de otra vida), condiciones médicas, tales como trabajo por turnos o necesidad excesiva del sueño (Ohayon y cols., 1999). Otros estudios han relacionado a las parasomnias con trastornos cardiacos (Asplund, 2003). En general, no se han establecido estudios acerca de la calidad de vida relacionada con la salud y las parasomnias. ...
Se describe la relación existente entre los trastornos de sueño, salud y calidad de vida desde la perspectiva de la medicina conductual del sueño, basado en evidencias empíricas, demostrándose la baja calidad de vida en función con los síntomas en cada uno de los trastornos del sueño. El artículo comprende una descripción de la medicina comportamental del sueño, la relación entre calidad de vida y sueño, patrones de sueño y salud, sueño y enfermedad crónica, insomnio, síndrome de piernas inquietas, calidad de vida y salud, somnolencia excesiva diurna, calidad de vida y salud, y parasomnias y salud.
Sleep disorders cause considerable morbidity and distress in the aging population. By highlighting the clinical diagnosis and management of sleep disorders, this volume provides a valuable resource for all those involved in health care of older individuals. The changes in sleep patterns that occur during normal aging are described, followed by authoritative chapters on the presentation of various age-related sleep disorders. The book deals with the range of therapeutic measures available for managing these disorders and gives insight to potential areas of research that have emerged in the last few years, such as the study of circadian rhythms in later life, sleep patterns associated with co-morbidities and the use of quality-of-life measurement tools to determine sleep quality as we age. This volume is relevant to sleep disorders specialists, psychiatrists, geriatricians and gerontologists, and any professionals and researchers working in the interdisciplinary areas of sleep and aging.
Objectives
Nightmares are extremely unpleasant and vivid recurring dreams that are accompanied with awakening during sleep. However, earlier studies were mostly conducted with children and adults, with very few studies on nightmares in older adults. This population-based study aims to investigate the prevalence of nightmares and its associated factors nightmares in the elderly.
Methods
This study utilized a subsample from the Korean Genome and Epidemiology Study (KoGES). Participants (n=2,940; mean age 63.71 ± 6.73) completed the questionnaires on nightmares(Disturbing Dream and Nightmare Severity Index; DDNSI), depression, suicidal ideation, sleep quality and stress.
Results
Among the sample, 2.7%(n=79) were classified into the nightmare group(NG), which was classified with DDNSI scores. In the age group over 70, prevalence of nightmares was 6.3%(n=37), which was significantly higher than other age groups. Marital status, employment status and family income were associated with nightmares. Additionally, NG reported significantly more sleep problems, higher suicidal ideation, depression and stress compared to the non-nightmare group(N-NG). Logistic regression analyses results indicated that the NG was 4.35 times at higher risk for depression, and 3.16 higher risk for stress, and 3.45 higher risk for suicidal ideation compared to the N-NG after controlling for covariates.
Conclusions
Our results indicate that psychological and demographic factors are associated with nightmares in the elderly. Furthermore, this population-based cohort study showed the prevalence of nightmares increased after age 70, which suggests the need for further studies of nightmares in older populations.
Objective: To evaluate the frequency of nightmares in inpatients without psychiatric antecedents at a general hospital compared with outpatients that consulted at the psychiatric department of the same hospital. Material and Method: 50 inpatients without psychiatric antecedents (group I) and 100 outpatients (group II) were interviewed. The presence of nightmares were asked during the admission in group I and during the previous two months of the consultation in group II. Results: Nightmares, group I: 16%, group II: 31%. Nightmares in group I: 25% surgery inpatients, 25% intensive care inpatients, 20% oncology inpatients and 6% general medicine inpatients. Nightmares in group II: 50% patients with eating disorders, 35% depressive disorders, 29% with AIDS diagnosis, 29% adjustment disorder, 26% evaluated for obesity surgery and 20% anxiety disorder. Conclusions: Psychiatric patients have nightmares more frequently than inpatients. Nightmares research is important since, if they are not treated, they may cause significant discomfort.
Disturbed dreaming has been identified as a primary or secondary symptom in many medical conditions. The quality of such dreaming can be conveniently classified as varying along a continuum of subjective intensity. At one extreme, dream recall ceases entirely (global cessation of dreaming) or is unusually impoverished in quantity or content (dream impoverishment). Impoverishment affects patients with alexithymia, posttraumatic stress disorder (PTSD), and some brain syndromes. At the other extreme, dreaming is profuse and vivid (excessive dreaming), affecting patients with epic dreaming, some brain lesions, and withdrawal from some medications, or it becomes so intense that it is confused with reality (dream-reality confusion) as is the case with bereavement or the postpartum state, intensive care unit (ICU) delirium, limbic lobe damage, and psychotic states. Intense dreaming may become rigidly repetitive (repetitive dream content). Conditions such as rapid eye movement (REM) sleep behavior disorder with or without parkinsonism, epilepsy, PTSD, migraine, and cardiac illness are affected by dream repetition. The intensity dimension of dream disturbance appears to mirror various aberrations of dreaming's normal capacity to simulate reality. Accordingly, episodic memories, which are normally absent from dream content, appear more frequently in disturbed dreams. Although effective treatments are available for several common dream disturbances, the development of new treatments might benefit from attention to intensified reality simulation and the role of episodic memory activation.
Study Objective: To estimate the prevalence rates of self-reported nightmares in a large sample of Kuwaiti children, adolescents, college students, and employees and to examine the age and gender differences. Methods: A sample of 11,334 school and college students and employees was recruited. Their ages ranged between 10 and 55 years. A self-rating scale item was used to assess frequency of nightmares. It was answered on a 5-point intensity scale with O=No, 1=A little, 2=Moderate, 3=Much, and 4=Very much. This scale has acceptable temporal stability. Point prevalence rate was computed as the summation of the percentages of responses in the two options: "Much" and Very much" during the most recent month. Results: The prevalence rates of reported nightmares ranged between 4.5% (male undergraduates and employees) and 14.3% (female adolescents). The prevalence rates of boys (12.7%) and girls (12.3%) were similar as were male undergraduates and employees (4.5%). Female adolescents obtained around double of the rate of their male counterparts (14.3% vs. 7.5%), as well as female and male undergraduates (8.3% vs. 4.5%) respectively. Nightmares decreased markedly with age in both males and females, with one exception, i.e., the highest prevalence rate was among female adolescents. The sex-related differences in reported nightmares were significant favoring females in adolescent and undergraduate groups only. However, effect sizes were small. Conclusions: Self-reported nightmares are common in a large Kuwaiti sample. There is a need for comprehensive programs of guidance, counseling, or therapeutic intervention.
The present study, a questionnaire survey, was undertaken to assess the relationship between nightmares and sleep and between nightmares and sensory organ dysfunctions in a large group of elderly persons. The survey comprised 6,103 elderly subjects (39.5% men). The ages (mean±standard deviation) of the male and female participants were 73.0±6.0 and 72.6±6.7 years, respectively. Poor sleep was reported by 14.4% of the men and 28.1% of the women (p<0.0001). Frequent nightmares were reported by 9.0 % of the men and 11.9 % of the women (p<0.05). Compared with men and women without nightmares, the sleep time to first awakening was shorter, time taken to get to sleep after nocturnal awakening was longer, longest uninterrupted sleep period was shorter and total nocturnal time in bed was longer in nightmare sufferers of both sexes. In a multiple logistic regression analysis with age, visual status, hearing and tinnitus as the independent variables and nightmares as the dependent variable, nightmares were 1.5 (1.0-2.3) times more frequent in men with than without hearing impairment and 2.2 (1.4-3.4) times more frequent in men with than without tinnitus but were unaffected by visual status and age. In women nightmares were 1.9 (1.3-2.5) times more frequent in association with visual impairment but unaffected by hearing impairment, tinnitus and age. It is concluded that the occurrence of nightmares in the elderly is associated with different kinds of sleep disturbances. Visual impairment, hearing impairment and tinnitus were all associated with increased nightmares.
Parasomnias are common clinical complaints. Formal sleep evaluation including PSG is indicated for parasomnias that are violent and potentially injurious; disruptive to the bed partner or other household members; accompanied by excessive daytime sleepiness; or associated with medical,psychiatric, or neurologic symptoms or findings [2]. Multiple sleep latency testing should be considered for patients who have complaints of excessive daytime sleepiness. An extensive history, including medical, neurologic,psychiatric, and sleep disorder, and a review of medication, alcohol, illicit drug use, and family history of parasomnias, may provide useful clues. Distinguishing between a parasomnia and a seizure may be difficult as both can present as recurrent, stereotypical behaviors. Evaluation may be aided by an expanded EEG montage during overnight PSG studies.
Chest pain is a common symptom of panic attacks, but little is known about the relationship in older women among panic attacks, chest pain, and daily life ischemia.
The authors conducted a cross-sectional survey of 3063 community-dwelling, generally healthy postmenopausal women enrolled between 1997 and 2000 in the Myocardial Ischemia and Migraine Study in 10 clinical centers of the 40-center Women's Health Initiative. Participants, ages 50 to 79 years, completed a questionnaire about occurrence of panic attacks in the previous 6 months and underwent 24-hour ambulatory electrocardiogram monitoring (AECG); 2705 women had valid AECG recordings and panic attack questionnaires. ST depression on AECG, heart rate variability (HRV), and chest pain episodes were compared among women with and without a 6-month history of panic attack.
There was no difference in overall prevalence of ischemic episodes during AECG between women with and without panic attacks. Women with a recent history of panic were more likely to experience chest pain during AECG after controlling for potential confounders (odds ratio [OR] = 2.01; 95% confidence interval [CI] = 1.40-2.88), including both nonischemic (OR = 1.83; 95% CI = 1.26-2.65) and ischemic chest pain (OR = 4.94; 95% CI = 1.41-17.30). Although mean HRV was lower in those with panic attacks (p = .017), this was not significant after controlling for confounders.
Postmenopausal women with a recent history of panic attacks do not appear to have more daily life ischemia as measured by occurrence of ST depression during 24-hour monitoring, but do have more chest pain and possibly lower HRV, suggesting that even sporadic panic attacks may be related to cardiovascular risk.
Factors precipitating nocturnal myocardial ischaemia were investigated in 10 patients with frequent daytime and nocturnal angina pectoris. Eight patients had fixed obstructive coronary artery disease or a low exercise threshold or both before the onset of ischaemia. Two patients had variant angina with normal coronary arteries and negative exercise tests. During sleep the electrocardiogram, electroencephalogram, electro-oculogram, electromyogram, chest wall movements, nasal airflow, and oxygen saturation were continuously measured. Forty two episodes of transient ST segment depression were recorded in the eight patients with coronary artery disease and 26 episodes of ST segment depression and elevation in the two patients with variant angina and normal coronary arteries. All episodes of ST segment depression in the former group of patients were preceded by an increase in heart rate as a result of arousal and lightening of sleep, bodily movements, rapid eye movement sleep, or sleep apnoea (one episode). In contrast, in the variant angina group no increase in heart rate, arousal, or apnoea preceded 23 of the 26 episodes of ST segment change. Thus increase in myocardial oxygen demand was important in precipitating nocturnal angina in patients with coronary artery disease and reduced coronary reserve. In the patients with coronary spasm these factors did not often precede the onset of nocturnal myocardial ischaemia.
Emotional stress is a recognized trigger for coronary artery spasm. An association between dreams and sudden death is described in folklore and medical history, and originates from the common experience of being awakened by vivid, frightening dreams, with racing pulse, cold sweats and other physiological responses associated with intense distress. Intense alterations in autonomic activity during dreaming can have dire consequences in patients with cardiovascular disease. Four patients with no evidence of underlying coronary artery disease, where emotional stress produced by nightmares or 'deadly dreams' caused coronary artery dissection in two and vasospasm in the other two, leading to life-threatening cardiac events, are presented. A possible mechanism is speculated.
To compile and assess the English-language literature on drug-induced nightmares, excluding nightmares secondary to drug withdrawal or drug-associated night terrors.
Published articles, letters, case reports, and abstracts in English were identified by MEDLINE (1966-May 1998) searches using the search term nightmares, chemically induced. Additional articles were obtained from bibliographies of retrieved articles.
All case reports of drug-induced nightmares were evaluated using the Naranjo algorithm for causality. Clinical studies of drugs that reported nightmares as an adverse effect were assessed for frequency of occurrence.
Nightmares, defined as nocturnal episodes of intense anxiety and fear associated with a vivid, emotionally charged dream experience, are generally classified as a parasomnia. Possible pharmacologic mechanisms for drug-induced nightmares, such as REM suppression and dopamine receptor stimulation, are reviewed. However, the vast majority of therapeutic agents implicated in causing nightmares have no obvious pharmacologic mechanism.
Assessing causality with an event such as a nightmare is difficult because of the high incidence of nightmares in the healthy population. Using qualitative, quantitative, and possible pharmacologic mechanism criteria, it appears that sedative/hypnotics, beta-blockers, and amphetamines are the therapeutic modalities most frequently associated with nightmares. These drug classes have a plausible pharmacologic mechanism to explain this effect. Dopamine agonists also have evidence of causality, with dopamine receptor stimulation as a possible pharmacologic mechanism.
This study, for the first time, distinguishes between nightmares and bad dreams, measures the frequency of each using dream logs, and separately assesses the relation between nightmares, bad dreams, and well-being. Eighty-nine participants completed 7 measures of well-being and recorded their dreams for 4 consecutive weeks. The dream logs yielded estimated mean annual nightmare and bad-dream frequencies that were significantly (ps < .01) greater than the mean 12-month and 1-month retrospective estimates. Nightmare frequency had more significant correlations than bad-dream frequency with well-being, suggesting that nightmares are a more severe expression of the same basic phenomenon. The findings confirm and extend evidence that nightmares are more prevalent than was previously believed and underscore the need to differentiate nightmares from bad dreams.
During the last decade several studies have indicated that sleep problems might belong to the risk indicators for coronary artery disease (CAD). For example, a 6-year follow-up study of >10,000 subjects revealed a risk of 2.04 for CAD in "poor" versus "good" sleepers.1 Little is known about the types of sleep complaints that are associated with future CAD. One may speculate that trouble falling asleep is associated with CAD, because this is indicative of prolonged tension. Trouble staying asleep may be predictive for the same reason, or because it is indicative of a heart failure or nocturnal angina. Waking up tired may reflect an impaired sleep or an adverse effect of medication, angina pectoris or aging, and lose its predictive power when adjusted for these factors. Waking up tired may also indicate depression. Recent meta-analyses of the vast literature of personality factors and CAD have shown that, of all personality attributes, depression is the one most strongly associated with disease outcome.2 Because early-morning tiredness is a major characteristic of depression it is predicted that problems falling asleep or staying asleep are not predictive of MI when controlled for waking up exhausted, but that the latter complaint remains predictive when controlled for complaints indicating problems in gaining or maintaining sleep (hypothesis I). Waking up exhausted may be a consequence of poor sleep. Statistically controlling for the influence of problems falling or staying asleep does not completely remove any possible effects of these problems on the feeling of being tired at waking up. To rule out any possibility that exhaustion on waking up is caused by a "bad night," we also tested the hypothesis that those who wake up exhausted but do not have problems falling or staying asleep are at increased risk of myocardial infarction (hypothesis II).
A diurnal pattern of changes in transient myocardial ischemia has been well documented in patients with coronary artery disease (CAD) with an increase in the early morning hours. To further investigate potential triggers of ischemia, certain defined and distinct episodes of waking and rising during the nighttime were examined. Of 113 patients who underwent ambulatory monitoring of the electrocardiogram, 466 episodes of ischemia lasting 3,926 minutes were detected in 67 of the patients. In 30 patients who had ischemia at night, 21 reported 36 occasions of waking and rising, and 67% of these events were associated with ST-segment depression. Frequency and duration of ischemia were similar in the nocturnal episodes versus the early morning episodes of ischemia as were the increases in heart rate at 30, 10, 5 and 1 minute before the onset. Even before waking, there was an increase in heart rate beginning approximately 30 minutes before the onset of ischemia. This increase became significant 5 minutes before onset both in the early morning and on rising at night. Patients with nocturnal ischemia had significantly worse clinical signs of CAD. This study shows that rising at night is often associated with episodes of myocardial ischemia and, like the morning events on rising, is likely an important trigger of ischemia in patients with CAD.
A deviant habitual sleep duration, sleep complaints, frequent napping and snoring have all been suggested as potential risk factors for future coronary heart disease. It has not been studied thoroughly, however, whether the association of these phenomena with coronary heart disease is confounded by Type A behaviour or by a state of vital exhaustion. The aim of the present study was to explore the association of the above sleep characteristics with the coronary risk factors, 'Type A behaviour' and 'vital exhaustion' systematically. The results indicated that Type A behaviour was not associated with any of these sleep characteristics, except with frequent waking. Exhausted subjects, however, reported chronic sleep complaints, a short sleep duration and frequent napping significantly more often than vital subjects. Type A behaviour did not confound these associations. The data support the assumption that these sleep characteristics can be considered as potential risk factors for coronary heart disease because of their association with vital exhaustion.
Of 82 subjective insomniacs aged 65-74 years identified during a community survey and classified on the basis of self-reported sleep quality, 69 (84%) continued to complain of poor sleep when re-interviewed 18-24 months later. When compared with a control group of similarly stable 'good sleepers' (n = 64) drawn from the same community sample these persistent subjective insomniacs showed significantly higher levels of constitutional (trait) and transitory (state) anxiety, and neuroticism. Discriminant analysis indicated that elevated levels of neuroticism, reduced health status (as measured by the number of drugs prescribed) and relatively high levels of tea consumption were most closely associated with persistent complaints of poor sleep. Thus, despite the existence of health problems as a major cause of sleep disturbance in later life, personality factors appear to exert a pervasive influence on subjective sleep quality among the 'younger' elderly.
Self-reported sleep data from 2238 monozygotic and 4545 dizygotic adult twin pairs indicated a significant hereditary effect on sleep length [overall heritability estimate (h2 = 0.44)] and on sleep quality (h2 = 0.44). When the data were examined in subgroups defined by sex, age (18-24 years and 25 or more years of age), and cohabitation status of the twin pair, the highest heritability estimates for sleep length were for twins living together aged 25 or older. For twins living apart the heritability estimates were statistically significant in all women and men aged 25 or older. For sleep quality significant heritability estimates were found for all groups except women living together.
The mortality risk associated with different sleeping patterns was assessed by use of the 1965 Human Population Laboratory survey of a random sample of 6928 adults in Alameda County, CA and a subsequent 9-year mortality follow-up. The analysis indicates that mortality rates from ischemic heart disease, cancer, stroke, and all causes combined were lowest for individuals sleeping 7 or 8 h per night. Men sleeping 6 h or less or 9 h or more had 1.7 times the total age-adjusted death rate of men sleeping 7 or 8 h per night. The comparable relative risk for women was 1.6. The association between sleeping patterns and all causes of mortality was found to be independent of self-reported trouble sleeping and self-reported physical health status at the time of the 1965 survey. Simultaneous adjustment for age, sex, race, socioeconomic status, physical health status, smoking history, physical inactivity, alcohol consumption, weight status, use of health services, social networks, and life satisfaction reduced the relative mortality risk associated with sleeping patterns to 1.3 (p less than or equal to 0.04).
To investigate the interrelationship between sleep complaints and cardiac symptoms.
An epidemiological survey by means of questionnaire.
Västerbotten and Norrbotten in northern Sweden.
All 10,216 members of the Swedish Pensioners' Association (SPF).
Sleep disturbances and cardiac diseases.
Of the men who slept well, 3.0% stated they were troubled by both spasmodic chest pain ('angina pectoris') and a sensation of irregular heart beats ('cardiac arrhythmia'), 9.9% had angina pectoris alone, 7.9% suffered from cardiac arrhythmia, and 79.2% had neither of these disorders. Amongst the men who slept poorly, the corresponding frequencies were 7.0%, 8.7%, 12.3% and 72.0% (P < 0.001). Amongst the women who slept well these frequencies were 2.3%, 7.0%, 8.2% and 82.5%, and among those who slept poorly 5.9%, 10.2%, 15.0% and 68.9% (P < 0.0001). Amongst those with reported sleep complaints, there was an increased occurrence of both angina pectoris and cardiac arrhythmia. This increase in cardiac disease was found in men and women; both in those with trouble falling asleep, those who frequently awoke during the night and those who had difficulty regaining sleep; and also in those with too early final awakening in the morning. Daytime sleepiness was also associated with increased cardiac symptoms.
Poor sleep was associated with both an increase in angina pectoris and cardiac arrhythmias.
In this study, insomnia in 80-year-olds was related to medical, psychological and social factors. The data were based on examinations every year in people aged between 80 and 89 years. Of 333 people living in the city of Lund and born in 1908, 67% participated. Increased severity of insomnia was significantly associated with use of diuretics, other cardiovascular drugs, hypnotics and laxatives, and with nervousness, difficulty relaxing, anorexia, nausea, constipation, backache, feeling cold, sweating, loss of weight, dizziness, depression, general fatigue, exhaustion, angina pectoris, cardiac insufficiency, worsened objective and subjective health, presence of negative T-waves on ECG, anxiety, total life satisfaction, neuroticism, disbelief in a just world, feeling lonely and lower survival rates. Thus insomnia has widespread associations with different aspects of life in 80-year-olds.
Sleep disorders are very prevalent in the general population and are associated with significant medical, psychological, and social disturbances. Insomnia is the most common. When chronic, it usually reflects psychological/behavioral disturbances. Most insomniacs can be evaluated in an office setting, and a multidimensional approach is recommended, including sleep hygiene measures, psychotherapy, and medication. The parasomnias, including sleepwalking, night terrors, and nightmares, have benign implications in childhood but often reflect psychopathology or significant stress in adolescents and adults and organicity in the elderly. Excessive daytime sleepiness is typically the most frequent complaint and often reflects organic dysfunction. Narcolepsy and idiopathic hypersomnia are chronic brain disorders with an onset at a young age, whereas sleep apnea is more common in middle age and is associated with obesity and cardiovascular problems. Therapeutic naps, medications, and supportive therapy are recommended for narcolepsy and hypersomnia; continuous positive airway pressure, weight loss, surgery, and oral devices are the common treatments for sleep apnea.
Dreams occur during all stages of sleep. Nightmares are common. They can be associated with poor sleep and diminished daytime performance. Frequent nightmares are not related to underlying psychopathology in most children and in some "creative" adults. However, recurrent nightmares are the most defining symptom of post-traumatic stress disorder and may be associated with other psychiatric illnesses. Night terrors are arousal disorders that occur most often in children and usually occur early in the sleep period. Patients with rapid-eye-movement behavior disorder often present with nocturnal injury resulting from the acting out of dreams. Dream disorders may respond to medication, but behavioral treatment approaches have shown excellent results, particularly in patients with post-traumatic stress disorder and recurrent nightmares.
The purpose of the study was to investigate the natural history of insomnia and its association with depression and mortality. In 1983, 1,870 randomly selected subjects aged 45-65 years answered a questionnaire on sleep and health. Of the 1,604 survivors in 1995, 1,244 (77.6%) answered a new questionnaire with almost identical questions. Mortality data were collected for the 266 subjects that had died during the follow-up period. Chronic insomnia was reported by 36.0% of women and 25.4% of men (chi2 = 9.7; p < .01). About 75% of subjects with insomnia at baseline continued to have insomnia at follow-up. Insomnia in women predicted subsequent depression (odds ratio [OR] = 4.1; 95% confidence interval [CI] 2.1-7.2) but was not related to mortality. In men, insomnia predicted mortality (OR = 1.7; 95% CI 1.2-2.3), but after adjustment for an array of possible risk factors, this association was no longer significant. Men with depression at baseline had an adjusted total death rate that was 1.9 times higher than in the nondepressed men (95% CI: 1.2-3.0).
The aim of this study was to evaluate the influence of somatic health, mental health and age on sleep and the use of sleep medication in a group of elderly men and women. Questionnaires were distributed to 9417 persons, and the response rate was 69%. The mean ages (s.d.) of the male and female participants were 73.9 (6.3) and 74.5 (6.8) years, respectively. Sleep disturbances were more common in women than in men at all ages and increased with age in both sexes. A stepwise regression analysis showed that in men, more severely sleep disturbances were associated with poorer somatic health (R(2)=0.089; P<0.0001), poorer mental health (R(2)=0.106; P<0.0001) and increasing age (R(2)=0.109; P<0.0001) and in the women worse somatic health (R(2)=0.087; P<0.0001), worse mental health (R(2)=0.104; P<0.0001) but no further deterioration of sleep with age. Sleep medication was more common in women than in men at all ages and increased with age in both sexes. The use of sleep medication was more strongly related to somatic health than to mental health and age in both sexes. In conclusion, both sleep complaints and sleep medication showed a stronger relation to somatic health than to mental health and age in this group of elderly men and women.
To explore possible links between sleep quality, cognitive anxiety and the effects of sleep disturbances on health, daytime functioning and quality of life, for assessment in a larger study. Hypotheses were: (a) patients with coronary artery disease have insufficient sleep as measured by self-reported sleep and by polysomnography, (b) self-reported sleep is associated with polysomnographically measured sleep, (c) reduced sleep quality is associated with physical and mental health, and interferes with quality of life as measured by means of interviews and polysomnography, (d) reduced sleep quality is associated with reduced resilience to stress.
It has become increasingly evident that poor sleep with sleep initiation difficulties is an independent risk factor for cardiac events among men, and requires more attention in clinical nursing practice.
Descriptive, correlative and explorative study.
Forty-four men, aged 45-70, about to undergo coronary artery bypass surgery at a Swedish University Hospital.
Interviews and 24-hour continuous ambulatory polysomnography were performed. For the interviews, the Uppsala Sleep Inventory, Spielberger State Anxiety Scale and the Nottingham Health Profile instruments were used.
Seventeen patients (38.6%) had insufficient sleep and 12 had sleep initiation difficulties. Logistic regressions revealed that reduced stage 3-4 sleep predicted poorer overall health, initiation of sleep difficulties, predicted insufficient sleep and involuntary thoughts predicted fragmented sleep. Poorer quality of life was predicted by reduced deep sleep. Independent predictors for emotional distress were sleep efficiency below 85%, fragmented sleep and a daytime nap longer than 15 minutes.
Objective sleep was associated with several subjective sleep variables. The results provide empirical support for significant variables included in a theoretical framework relating to sleep quality, cognitive anxiety, health and quality of life. A larger study is recommended that includes both men and women.
Sleep deprivation has experimentally been shown to adversely influence glucose metabolism, endocrine function and sympathovagal balance in young men without known serious disease. We investigated the impact of sleep problems and resting heart rate in a large sample of self-reported, healthy middle-aged men and women on long-term mortality.
In all 22,444 men and 10,902 women participated in a population-based health screening (71% mean attendance), including blood sampling and examination of blood pressure (BP) and pulse rate after 10 min supine rest, as well as a self-administered questionnaire on sleep problems. Mortality was assessed from national death registers.
Sleep disturbances were related to increased cardiovascular risk factor levels at baseline in both sexes, and predicted total and cause-specific mortality after a mean of 12 years (women) and 17 years (men) of follow-up. In men, self-reported healthy at baseline, total mortality during follow-up was independently predicted by both sleep problems and increased resting heart rate, also after adjustment for smoking, body mass index (BMI), systolic BP, cholesterol, smoking and problematic alcohol drinking habits. A step-wise increased total mortality was shown in men reporting successively worse sleep problems and higher heart rate, highest hazard ratio 2.7 [95% confidence interval (CI) = 2.1-3.4] after adjustments, compared with men free from sleep problems and with normal heart rate.
Sleep disturbance is a predictor of total and cause-specific mortality in both sexes, but only interacts with increased resting heart rate for this prediction in healthy men. Sleep problems correlated cross-sectional with disturbances in lipid and glucose metabolism, even after adjustment for degree of obesity and smoking. Sleep disturbance is a symptom for a biological pathway that is correlated to premature mortality. One possible explanation would be that it acts in concert with sympathetic nervous activation (SNA), both being consequences of chronic stress exposure.