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.     

Survey on the usefulness of trazodone in patients with PTSD with insomnia or nightmares

BACKGROUND: Trazodone is commonly used in the treatment of insonmia and nightmares in patients with PTSD. There is little evidence in the literature for this practice. METHOD: Seventy-four patients from the Palo Alto Veterans Affairs Health Care System in California who were admitted to a specialized 8 week inpatient treatment program for PTSD were surveyed regarding their use of trazodone in the treatment of insomnia or nightmares. Patients were asked to complete a questionnaire regarding trazodone's effectiveness, side effects, and optimal doses. RESULTS: Of 74 patients surveyed, 60 patients were able to maintain an effective dose of trazodone. The other 14 patients were unable to tolerate the medication. Seventy-two percent of the 60 patients assessed found trazodone helpful in decreasing nightmares, from an average of 3.3 to 1.3 nights per week (p<.005). Ninety-two percent found it helped with sleep onset, and 78% reported improvement with sleep maintenance. There was a significant correlation between the effectiveness in decreasing nightmares and improving sleep (r= .57, p < .005). The effective dose range of trazodone for 70% of patients was 50 to 200 mg nightly. Of the 74 patients surveyed, 9 (12%) reported priapism. CONCLUSION: Trazodone appears effective for the treatment of insomnia and nightmares associated with chronic PTSD. However, controlled trials are needed before any definite conclusions can be drawn. The higher than expected occurrence of priapism warrants clinicians asking directly about this side effect.     

Longitudinal relationships of insomnia,nightmares, and PTSD severity in recent combat veterans

Objective

This observational, longitudinal study of veterans with recent combat exposure describes the prevalence, severity and associations of posttraumatic stress disorder (PTSD), insomnia, and nightmares over time.

Methods

Eighty recent combat veterans recruited from Veterans Health Administration primary care settings met inclusion criteria including hazardous alcohol use and at least subthreshold PTSD. Insomnia status and nightmare status were assigned based on the Insomnia Severity Index total score and the PTSD Checklist nightmare item, respectively. Participants were re-assessed six months following their baseline assessment. Analyses of variance compared insomnia and nightmare groups on PTSD, depression, and alcohol use severity. Analyses of covariance (controlling for baseline differences) examined whether insomnia and/or nightmares were associated with the clinical course of PTSD. Persistence of conditions was also examined.

Results

At baseline, 74% presented with insomnia and 61% endorsed distressing nightmares. Insomnia was associated with significantly higher PTSD and depression severity at both baseline and six months. The presence of nightmares was associated with significantly higher PTSD severity at both time points and with depression severity at baseline only. Despite decreases in PTSD and depression severity, insomnia severity was relatively unchanged after six months. The prevalence and severity of nightmare complaints diminished modestly over time.

Conclusion

Among this sample of recent combat veterans, insomnia and nightmares were each strongly associated with the severity of both PTSD and depressive symptoms. Over time, insomnia in particular did not appear to resolve spontaneously and was associated with ongoing PTSD. Addressing insomnia early, therefore, may be a strategy to alter the course of PTSD.     

Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia

OBJECTIVE: This study evaluated the effectiveness of a supervised benzodiazepine taper, singly and combined with cognitive behavior therapy, for benzodiazepine discontinuation in older adults with chronic insomnia. METHOD: Seventy-six older adult outpatients (38 women, 38 men; mean age of 62.5 years) with chronic insomnia and prolonged use (mean duration of 19.3 years) of benzodiazepine medication for sleep were randomly assigned for a 10-week intervention consisting of a supervised benzodiazepine withdrawal program (N=25), cognitive behavior therapy for insomnia (N=24), or supervised withdrawal plus cognitive behavior therapy (N=27). Follow-up assessments were conducted at 3 and 12 months. The main outcome measures were benzodiazepine use, sleep parameters, and anxiety and depressive symptoms. RESULTS: All three interventions produced significant reductions in both the quantity (90% reduction) and frequency (80% reduction) of benzodiazepine use, and 63% of the patients were drug-free within an average of 7 weeks. More patients who received medication taper plus cognitive behavior therapy (85%) were benzodiazepine-free after the initial intervention, compared to those who received medication taper alone (48%) and cognitive behavior therapy alone (54%). The patients in the two groups that received cognitive behavior therapy perceived greater subjective sleep improvements than those who received medication taper alone. Polysomnographic data showed an increase in the amount of time spent in stages 3 and 4 sleep and REM sleep and a decrease in total sleep time across all three conditions from baseline to posttreatment. Initial benzodiazepine reductions were well maintained up to the 12-month follow-up, and sleep improvements became more noticeable over this period. No significant withdrawal symptoms or adverse events were associated with benzodiazepine tapering. CONCLUSIONS: A structured, time-limited intervention is effective in assisting chronic users of benzodiazepine medication to discontinue or reduce their use of medication. The addition of cognitive behavior therapy alleviates insomnia, but sleep improvements may become noticeable only after several months of benzodiazepine abstinence.     

Diagnostic overlap between acute stress disorder and PTSD in victims of violent crime

OBJECTIVE: In a group of crime victims, the authors investigated overlap between acute stress disorder and posttraumatic stress disorder (PTSD) diagnoses and their relative ability to predict PTSD at 6 months. METHOD: A mixed-sex group of 157 victims of violent assault were interviewed within 1 month of the crime. At the 6-month follow-up, 87.9% were reinterviewed by telephone. RESULTS: At baseline the rate of acute stress disorder was 19.1%, the rate of PTSD was 21.0%, and the percentage agreement between them was 95.5%. The two diagnoses were equally effective predictors of PTSD 6 months later. CONCLUSIONS: The high level of overlap between acute stress disorder and PTSD calls into question whether, as presently formulated, they represent distinct diagnoses.     

Clinical efficacy of individual cognitive behavior therapy for psychophysiological insomnia in 20 outpatients

Aim: Twenty patients (14 of them women) suffering from psychophysiological insomnia (PPI) were enrolled for cognitive behavior therapy (CBT). The mean age of the patients was 56.9 years, and the mean duration of insomnia morbidity was 8.9 years. Each received individual combined CBT treatments consisting of stimulus control, sleep reduction, cognitive therapy and sleep hygiene education over a period of 1 month. Methods: Just before the CBT and after its completion, sleep measurements were conducted that involved (i) sleep logs, Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), and the Pittsburgh Sleep Quality Index (PSQI); (ii) actigraphy measurement; (iii) dissociation between subjective and objective evaluation of sleep calculated from sleep logs and actigraphy results; and (iv) correlation between DBAS and the aforementioned sleep parameters. Because the intention was to focus on patients' incorrect cognition about sleep, the definition ‘changes in dissociation between the sleep log and actigraphically measured sleep’ was used as the primary outcome and ‘changes in DBAS score’ as the secondary outcome. Results: After the CBT the following was found: (i) underestimation by PPI patients of the objective evaluation of sleep; (ii) a decrease in the dissociation between the subjective and objective evaluation of sleep; (iii) improvement of the DBAS; and (iv) improvement of sleep logs and actigraphy measurements. Moreover, there was a correlation between the improvement of PSQI, sleep logs and DBAS. Conclusion: CBT for insomnia is able to redress incorrect cognition about sleep, leading to improvement of the disorder.     

Attentional and memory bias for emotional information in crime victims with acute posttraumatic stress disorder (PTSD)

A combined emotional Stroop, implicit memory (tachistoscopic identification) and explicit memory (free recall) task with three types of words (trauma-related, positive, and neutral) and two exposure conditions (subliminal and supraliminal) was administered to 39 crime victims with acute posttraumatic stress disorder (PTSD) and 39 age- and sex-matched controls. PTSD subjects showed supraliminal Stroop interference for trauma-related words and a similar effect on positive words. A specific explicit memory bias was found for trauma-related words among the PTSD subjects, but no preattentive bias on the subliminally presented words, nor any implicit memory bias. Findings suggest that acute PTSD subjects have an attentional and memory bias for threat-related material. Methodological limitations of the study are reviewed, and it is proposed that further studies are needed in order to elucidate whether acute PTSD Ss display a preattentive and implicit memory bias for trauma-related material.     

失眠的认知行为治疗对失眠障碍患者睡眠质量和认知功能的影响

背景 失眠障碍已成为当前社会的一种常见疾病,失眠的认知行为治疗（CBTI）是失眠障碍的非药物治疗方法之一,其对失眠障碍患者睡眠质量和认知功能影响的研究有限。目的 探索CBTI对失眠障碍患者睡眠质量和认知功能的影响,为失眠障碍的非药物治疗提供参考。方法 选取2021年1月-2022年10月在四川省精神卫生中心就诊、符合《精神障碍诊断与统计手册（第5版）》（DSM-5）诊断标准的47例失眠障碍患者为研究对象。患者接受为期6周的CBTI治疗。治疗前,采用汉密尔顿抑郁量表24项（HAMD-24）和汉密尔顿焦虑量表（HAMA）评定患者的抑郁和焦虑症状,在治疗前及治疗6周后采用匹兹堡睡眠质量指数量表（PSQI）和蒙特利尔认知评估量表（MoCA）评定患者的睡眠情况和认知功能。采用Spearman相关分析考查治疗后失眠障碍患者PSQI总评分减分值与MoCA总评分增分值的相关性。结果 治疗6周后,失眠障碍患者PSQI的主观睡眠质量、入睡时间、睡眠时间、睡眠效率、睡眠障碍、日间功能障碍因子评分及PSQI总评分均低于治疗前,差异均有统计学意义（t=5.569~15.290,P均<0.01）,MoCA的视空间与执行功能、命名、注意力、语言能力、抽象思维、记忆力因子评分及总评分均高于治疗前,差异均有统计学意义（t=-11.273~-4.277,P均<0.01）。Spearman相关分析显示,经6周CBTI治疗后,失眠障碍患者PSQI总评分减分值与MoCA总评分增分值呈正相关（r=0.323,P=0.027）。结论 CBTI可能有助于改善失眠障碍患者的睡眠质量和认知功能。CBTI干预后,失眠障碍患者睡眠质量的提高可能与认知功能的改善存在一定的关联。     

Open trial of cognitive behavior therapy for childhood obsessive-compulsive disorder

Examined the utility of CBT for childhood obsessive-compulsive disorder (OCD) including a preliminary exploration of predictors of response to this form of treatment. A total of 42 youngsters (mean age 11.8 years, 60% female, 52% on medication at baseline) with DSM-IV OCD were treated openly using a developmentally sensitive treatment protocol based on exposure plus response prevention (ERP). The treatment response rate (CGI < 2) was 79% with a mean decrease from baseline in NIMH global scores of 45%. Response was not related to age, gender, baseline medication status, comorbid symptomatology, or therapist experience. Poorer outcome was associated with more severe obsessions and greater OCD-related academic impairment at baseline. When presented in a developmentally appropriate manner, CBT is a useful treatment for childhood OCD. Controlled trials are needed to provide a more rigorous test of this treatment approach and provide better information regarding potential mediators and moderators of outcome.     

Quetiapine for insomnia in Parkinson disease: results from an open-label trial

Quetiapine is an atypical antipsychotic with sedative properties frequently used to treat hallucinations and psychosis in Parkinson disease (PD). The objective of this trial is to evaluate quetiapine for insomnia in nonpsychotic PD patients. Fourteen consecutive PD patients with frequent insomnia and without psychotic symptoms were treated openly for 12 weeks with a single evening dose of quetiapine. The dose was adjusted according to clinical improvement and tolerance. The severity of insomnia was assessed using the Pittsburgh Sleep Quality Index (PSQI), daytime sleepiness was evaluated with the Epworth Sleep Scale (ESS), and motor performance was evaluated using the motor section of the Unified Parkinson's Disease Rating Scale (UPDRS). All evaluations were done before and 1, 2, and 3 months after initiation of treatment. Total PSQI basal scores were 13.6 +/- 3.7 points. The PSQI score improved in 11 patients and was reduced by 3.8 +/- 3.9 points by the end of the study (P < 0.01). The ESS score was reduced by 4.3 +/- 3.7 points (P < 0.01). The mean quetiapine dose was 31.9 mg/day. No significant change was observed in the motor scale. Two patients were discontinued due to nonserious adverse effects. These results suggest that quetiapine may be a safe and effective treatment of insomnia in PD patients. Double-blind studies will probably confirm these findings.     

失眠伴抑郁与单纯失眠患者失眠认知行为治疗的疗效分析

目的分析失眠认知行为疗法(cognitive behavioral therapy on insomnia,CBT-i)对失眠伴抑郁患者以及单纯失眠患者的疗效。方法71例符合失眠症诊断的患者,根据贝克抑郁量表(Beck Depression Inventory,BDI)得分分为单纯失眠组(<14分,33例)和失眠伴抑郁组(≥14分,38例)。2组患者每天填写睡眠日记,并给予8周标准的CBT-i治疗,在治疗前(基线)、治疗第4周、治疗第8周、治疗结束后4周(第3个月)、治疗结束后16周(第6个月)采用匹兹堡睡眠质量指数(Pittsburgh Sleep Quality Index,PSQI)、失眠严重程度指数(Insomnia Severity Index,ISI)、BDI、贝克焦虑量表(Beck Anxiety Inventory,BAI)、SF-36健康调查简表对2组患者睡眠质量、抑郁焦虑程度、个人健康状况等进行评估,采用独立样本t检验进行组间比较,采用重复测量方差分析进行各时间点组内比较。结果与基线时比较,单纯失眠组和失眠伴抑郁组第8周、第3个月和6个月随访时入睡潜伏期、睡眠效率、PSQI、ISI、BDI、BAI、SF-36组内比较差异均有统计学意义。失眠伴抑郁组较单纯失眠组在基线、第8周、第3个月和6个月随访时BAI(t=-6.340、-3.301、-3.511、-2.982)、SF-36(t=4.162、3.195、2.022、3.629)评分差异有统计学意义(P<0.01或0.05),2组ISI评分在第6个月随访时差异有统计学意义[(7.3±4.6)分与(4.7±3.4)分,t=-2.044,P=0.048]。2组入睡潜伏期和睡眠效率以及PSQI的评分在第8周、第3个月和6个月随访时与基线的变化量差异均无统计学意义;而2组BAI、BDI评分在第8周与第3个月和6个月随访时与基线的变化量差异有统计学意义。结论CBT-i对失眠伴抑郁患者和单纯失眠患者均有效,且可以缓解失眠伴抑郁患者的抑郁症状以及改善患者生活质量。     

An open-label trial of combination therapy with interferon beta-1a and oral methotrexate in MS.

An open-label study was performed to evaluate the safety and efficacy of combination therapy with weekly oral methotrexate (20 mg) and interferon beta-1a (IFN beta-1a) in 15 patients with MS who had experienced exacerbations while receiving IFN beta monotherapy. Nausea was the only major side effect. A 44% reduction in the number of gadolinium-enhanced lesions seen on MRI scan was observed during combination therapy (p = 0.02). There was a trend toward fewer exacerbations. This combination therapy appears to be safe and well tolerated, and should be studied in a controlled trial.     

Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia.

OBJECTIVE: Although four meta-analytic reviews support the efficacy of pharmacotherapy and behavior therapy for the treatment of insomnia, no meta-analysis has evaluated whether these treatment modalities yield comparable outcomes during acute treatment. The authors conducted a quantitative review of the literature on the outcome of the two treatments to compare the short-term efficacy of pharmacotherapy and behavioral therapy in primary insomnia. METHOD: They identified studies from 1966 through 2000 using MEDLINE, psycINFO, and bibliographies. Investigations were limited to studies using prospective measures and within-subject designs to assess the efficacy of benzodiazepines or benzodiazepine receptor agonists or behavioral treatments for primary insomnia. Benzodiazepine receptor agonists included zolpidem, zopiclone, and zaleplon. Behavioral treatments included stimulus control and sleep restriction therapies. Twenty-one studies summarizing outcomes for 470 subjects met inclusion criteria. RESULTS: Weighted effect sizes for subjective measures of sleep latency, number of awakenings, wake time after sleep onset, total sleep time, and sleep quality before and after treatment were moderate to large. There were no differences in magnitude between pharmacological and behavioral treatments in any measures except latency to sleep onset. Behavior therapy resulted in a greater reduction in sleep latency than pharmacotherapy. CONCLUSIONS: Overall, behavior therapy and pharmacotherapy produce similar short-term treatment outcomes in primary insomnia.     

Web- vs telehealth-based delivery of cognitive behavioral therapy for insomnia: a randomized controlled trial

ObjectivesThe purpose of our study was to evaluate and compare two methods of service delivery (web-based and telehealth-based) for chronic insomnia with regard to patient preference, clinical effectiveness, and patient satisfaction.MethodsOur study was a randomized controlled trial with manualized telehealth- and web-based delivery conditions (nonblinded). The sample comprised 73 adults with chronic insomnia. Participants received web-based delivery from their homes or telehealth-based delivery from a nearby clinic. Both interventions consisted of identical psychoeducation, sleep hygiene and stimulus control instruction, sleep restriction treatment, relaxation training, cognitive therapy, mindfulness meditation, and medication-tapering assistance.ResultsUsing a linear mixed model analysis, results showed that both delivery methods produced equivalent changes in insomnia severity, with large effect sizes. Attendance patterns favored telehealth, whereas homework adherence and preference data favored web-based delivery.ConclusionsWeb- and telehealth-based delivery are both helpful in treating chronic insomnia in rural-dwelling adults.     

Clinical application of behavior therapy for insomnia

Behavior therapy procedures have led to significant improvement in insomnia in several controlled outcome studies, and provide an effective alternative to the use of hypnotics. This article highlights dangers in the pharmacologic management of sleep, provides an overview of behavioral techniques that have proven effective in the treatment of insomnia, and outlines guidelines for the implementation of behavioral techniques on a clinical level. A diagnostic approach which identifies the maintaining conditions of the insomnia through the use of behavior analysis techniques is recommended, and procedures for the development of rational, empirically-based treatment strategies are suggested.     

Insomnia and generalized anxiety disorder: effects of cognitive behavior therapy for gad on insomnia symptoms

Although clinical practice suggests that sleep complaints are frequent among patients with generalized anxiety disorder (GAD), frequency, severity, types of insomnia complaints, and relationship to GAD diagnosis severity in patients diagnosed using Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria are not well documented. Clinical data about the impact on insomnia symptoms of treating GAD worries are also lacking. The present study examined these aspects in 44 GAD patients who participated in a treatment study specifically addressing excessive worries through CBT interventions. All patients were assessed using a structured clinical interview and the Anxiety Disorder Interview Schedule-IV (ADIS-IV). They also completed anxiety and insomnia inventories, including the Insomnia Severity Index (ISI), a self-report measure which assesses insomnia type, severity and interference with daily life. Among this sample, 47.7% reported difficulties initiating sleep, 63.6% reported difficulties maintaining sleep, and 56.8% complained of waking too early in the morning. The majority of these patients (86.5%) reported never having experienced insomnia without having excessive worries. However, insomnia severity and GAD severity were not correlated. In this sample, patients with severe GAD did not necessarily report more severe insomnia symptoms. Regarding treatment impact on insomnia complaints, ISI post-treatment scores were significantly lower after treatment. Mean post-treatment scores almost reached ISI's "absence of clinical insomnia" category. Results indicate that this CBT package for GAD does have a significant impact on sleep quality even if sleep disturbances were not specifically addressed during treatment.     

PTSD in ambulant RTA victims: a randomized controlled trial of debriefing

This report examines initial distress levels, course of symptoms, incidence of posttraumatic stress disorder (PTSD), predictors of short-term outcome, and value of prophylactic counseling in a consecutive series of 40 ambulant trauma clinic attenders with minor road traffic accident (RTA) injuries. Subjects were randomly allocated to intervention and monitoring groups following assessment at a mean of 7 days posttrauma and reassessed at 3 months using a variety of standard rating scales. Seventy-five percent reported significant levels of distress at 1 week posttrauma. By 3 months this had decreased sharply to 35%, and 22% were significantly impaired by clinical assessment. Incidence of PTSD over 3 months was estimated at 19% and point prevalence at 3 months posttrauma was 9%. High initial distress, increasing age, and high levels of perceived threat were significant independent predictors of morbidity, and no significant differences in outcome were found between intervention and monitoring groups at 3 months.     

Cognitive mechanisms of sleep outcomes in a randomized clinical trial of internet-based cognitive behavioral therapy for insomnia

ObjectiveThe aim of this study was to investigate in a randomized clinical trial the role of sleep-related cognitive variables in the long-term efficacy of an online, fully automated cognitive behavioral therapy intervention for insomnia (CBT-I) (Sleep Healthy Using the Internet [SHUTi]).MethodThree hundred and three participants (M_age = 43.3 years; SD = 11.6) were randomly assigned to SHUTi or an online patient education condition and assessed at baseline, postintervention (nine weeks after baseline), and six and 12 months after the intervention period. Cognitive variables were self-reported internal and chance sleep locus of control, dysfunctional beliefs and attitudes about sleep (DBAS), sleep specific self-efficacy, and insomnia knowledge. Primary outcomes were self-reported online ratings of insomnia severity (Insomnia Severity Index), and sleep onset latency and wake after sleep onset from online sleep diaries, collected 12 months after the intervention period.ResultsThose who received SHUTi had, at postassessment, higher levels of insomnia knowledge (95% confidence interval [CI] = 0.10–0.16) and internal sleep locus of control (95% CI = 0.04–0.55) as well as lower DBAS (95% CI = 1.52–2.39) and sleep locus of control attributed to chance (95% CI = 0.15–0.71). Insomnia knowledge, chance sleep locus of control, and DBAS mediated the relationship between condition and at least one 12-month postassessment sleep outcome. Within the SHUTi condition, changes in each cognitive variable (with the exception of internal sleep locus of control) predicted improvement in at least one sleep outcome one year later.ConclusionOnline CBT-I may reduce the enormous public health burden of insomnia by changing underlying cognitive variables that lead to long-term changes in sleep outcomes.