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Psychological and Physiological Trauma Research
Seize Your Journeys
_______________________ Traumatic stress is found in many competent, healthy, strong, good people. No one can completely protect themselves from traumatic experiences. Many people have long-lasting problems following exposure to trauma. Up to 8% of persons will have PTSD at some time in their lives. People who react to traumas are not going crazy. What is happening to them is part of a set of common symptoms and problems that are connected with being in a traumatic situation, and thus, is a normal reaction to abnormal events and experiences. Having symptoms after a traumatic event is NOT a sign of personal weakness. Given exposure to a trauma that is bad enough, probably all people would develop PTSD. By understanding trauma symptoms better, a person can become less fearful of them and better able to manage them. By recognizing the effects of trauma and knowing more about symptoms, a person will be better able to decide about getting treatment. _______________________
Sleep Disorders DSMIV-R
“The sleep disorders are organized into four major sections according to presumed etiology.
Primary Sleep Disorders are those in which none of the etiologies listed below (i.e., another mental disorder, a general medical condition, or a substance) is responsible. Primary Sleep Disorders are presumed to arise from endogenous abnormalities in sleep-wake generating or timing mechanisms, often complicated by conditioning factors. Primary Sleep Disorders in turn are divided into Dyssomnias (characterized by abnormalities in the amount, quality, or timing of sleep) and Parasomnias (characterized by abnormal behavioral or physiological events occurring in association with sleep, specific sleep stages, or sleep-awake transitions). Sleep Disorder Related to Another Mental Disorder involves a prominent complaint of sleep disturbance that results from a diagnosable mental disorder (often a Mood Disorder or Anxiety Disorder) but that is sufficiently severe to warrant independent clinical attention. Presumably, the pathophysiological mechanisms responsible for the mental disorder also affect sleep-awake regulation. Sleep Disorder Due to a General Medical Condition involves a prominent complaint of sleep disturbance that results from the direct physiological effects of a general medical condition on the sleep-wake system. Substance-Induced Sleep Disorder involves prominent complaints of sleep disturbance that result from the concurrent use, or recent discontinuation of use, of a substance (including medications). That systematic assessment in individuals who present with prominent complaints of sleep disturbance includes an evaluation of the specific type of sleep complaint and a consideration of concurrent mental disorders, general medical conditions, and substance (including medication) use that may be responsible for the sleep disturbance. Five distinct sleep stages can be measured by polysomnography: rapid eye movement (REM) sleep and four stages of non-rapid eye movement (NREM) sleep (stages 1, 2, 3, and 4). Stage 1 NREM sleep is a transition from wakefulness to sleep and occupies about 5% of time spent asleep in healthy adults. Stage 2 NREM sleep, which is characterized by specific EEG waveforms (sleep spindles and K complexes), occupies about 50% of time spent asleep. Stages 3 and 4 NREM sleep (also known collectively as slow-wave sleep) are the deepest levels of sleep and occupy about 10%-20% of sleep time. REM sleep, during which the majority of typical storylike dreams occur, occupies about 20%-25% of total sleep. These sleep stages have a characteristic temporal organization across the night. NREM stages 3 and 4 tend to occur in the first one-third to one-half of the night and increase in duration in response to sleep deprivation. REM sleep occurs cyclically throughout the night, alternating with NREM sleep about every 80-100 minutes. REM sleep periods increase in duration toward the morning. Human sleep also varies characteristically across the life span. After relative stability with large amounts of slow-wave sleep in childhood and early adolescence, sleep continuity and depth deteriorate across the adult age range. This deterioration is reflected by increased wakefulness and stage 1 sleep and decreased stages 3 and 4 sleep. Because of this, age must be considered in the diagnosis of a Sleep Disorder in any individual. Polysomnography is the monitoring of multiple electrophysiological parameters during sleep and generally includes measurement of EEG activity, electroculographic activity, and electromyographic activity. Additional polysomnographic measures may include oral or nasal airflow, respiratory effort, chest and abdominal wall movement, oxyhemoglobin saturation, or exhaled carbon dioxide concentration; these measures are used to monitor respiration during sleep and to detect the presence and severity of sleep apnea. Measurement of peripheral electromyographic activity may be used to detect abnormal movements during sleep. Most polysomnographic studies are conducted during the person’s usual sleeping hours—that is, at night. However, daytime polysomnographic studies also are used to quantify daytime sleepiness. The most common daytime procedure is the Multiple Sleep Latency Test (MSLT), in which the individual is instructed to lie down in a dark room and not resist falling asleep; this protocol is repeated fives times during the day. Sleep latency (the amount of time required to fall asleep) is measured on each trial and is used as an index of physiological sleepiness. The converse of the MSLT is also used: In the Repeated Test of Sustained Wakefulness (RTSW), the individual is placed in a quiet, dimly lit room and instructed to remain awake; this protocol is repeated several times during the day. Again, sleep latency is measured, but is it used here as an index of the individual’s ability to maintain wakefulness. Standard terminology for polysomnographic measures is used throughout the test in this section. Sleep continuity refers to the overall balance of sleep and wakefulness during a night of sleep. “Better” sleep continuity indicates consolidated sleep and wakefulness; “worse” sleep continuity indicates disrupted sleep with more wakefulness. Specific sleep continuity measures include sleep latency—the amount of time required to fall asleep (expressed in minutes); intermittent wakefulness—the amount of awake time after initial sleep onset (expressed in minutes); and sleep efficiency—the ratio of actual time spent asleep to time spent in bed (expressed as a percentage, with higher numbers indicating better sleep continuity). Sleep architecture refers to the amount and distribution of specific sleep stages. Sleep architecture measures include absolute amount of REM sleep and each NREM sleep stage (in minutes), relative amount of REM seep and NREM sleep stages (expressed as a percentage of total sleep time), and latency between sleep onset and the first REM period (REM latency). The text for each of the Sleep Disorders contains a section describing its relationship to corresponding disorders in The International Classification of Sleep Disorders: (ICSD) diagnostic and Coding Manual, published in 1990 by the American Sleep Disorders Association. FUNCTIONAL NEUROANATOMY In order to best understand this atlas it is important to have a sense of the functional neuroanatomy of the brain. Over the next several pages there is a brief summary of the 5 major brain systems that relate to behavior, along with the general location seen on SPECT of these areas.
The Deep Limbic System
Functions
Problems
The Basal Ganglia System
Functions
Problems
The Prefrontal Cortex
Functions
Problems
The Cingulate Gyrus
Problems
The Temporal Lobes
Functions
Problems
Non-dominant Side (usually the right)
Secure Attachments as a Defense Against Trauma “All people mature and thrive in a social context that has profound effects on how they cope with life’s stresses. Particularly early in life, the social context plays a critical role in fuffering an individual against stressful situations, and in building the psychological and biological capacities to deal with further stresses. The primary function of parents can be thought of as helping children modulate their arousal by attuned and well-timed provision of playing, feeding, comforting, touching, looking, cleaning, and resting—in short, by teaching them skills that will gradually help them modulate their own arousal. Secure attachment bonds serve as primary defenses against trauma-induced psychopathology in both children and adults (Finkelhor & Browne, 1984). In children who have been exposed to severe stressors, the quality of the parental bond is probably the single most important determinant of long-term damage (McFarlane, 1988).” van der Kolk, Bessel, Alexander C. McFarlane, and Lars Weisaeth, eds. 1996. Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York and London: Guilford Press. .p. 185 _______________________
Sleep Disorders
“The sleep disorders are organized into four major sections according to presumed etiology. Primary Sleep Disorders are those in which none of the etiologies listed below (i.e., another mental disorder, a general medical condition, or a substance) is responsible. Primary Sleep Disorders are presumed to arise from endogenous abnormalities in sleep-wake generating or timing mechanisms, often complicated by conditioning factors. Primary Sleep Disorders in turn are divided into Dyssomnias (characterized by abnormalities in the amount, quality, or timing of sleep) and Parasomnias (characterized by abnormal behavioral or physiological events occurring in association with sleep, specific sleep stages, or sleep-awake transitions). Sleep Disorder Related to Another Mental Disorder involves a prominent complaint of sleep disturbance that results from a diagnosable mental disorder (often a Mood Disorder or Anxiety Disorder) but that is sufficiently severe to warrant independent clinical attention. Presumably, the pathophysiological mechanisms responsible for the mental disorder also affect sleep-awake regulation. Sleep Disorder Due to a General Medical Condition involves a prominent complaint of sleep disturbance that results from the direct physiological effects of a general medical condition on the sleep-wake system. Substance-Induced Sleep Disorder involves prominent complaints of sleep disturbance that result from the concurrent use, or recent discontinuation of use, of a substance (including medications). That systematic assessment in individuals who present with prominent complaints of sleep disturbance includes an evaluation of the specific type of sleep complaint and a consideration of concurrent mental disorders, general medical conditions, and substance (including medication) use that may be responsible for the sleep disturbance. Five distinct sleep stages can be measured by polysomnography: rapid eye movement (REM) sleep and four stages of non-rapid eye movement (NREM) sleep (stages 1, 2, 3, and 4). Stage 1 NREM sleep is a transition from wakefulness to sleep and occupies about 5% of time spent asleep in healthy adults. Stage 2 NREM sleep, which is characterized by specific EEG waveforms (sleep spindles and K complexes), occupies about 50% of time spent asleep. Stages 3 and 4 NREM sleep (also known collectively as slow-wave sleep) are the deepest levels of sleep and occupy about 10%-20% of sleep time. REM sleep, during which the majority of typical storylike dreams occur, occupies about 20%-25% of total sleep. These sleep stages have a characteristic temporal organization across the night. NREM stages 3 and 4 tend to occur in the first one-third to one-half of the night and increase in duration in response to sleep deprivation. REM sleep occurs cyclically throughout the night, alternating with NREM sleep about every 80-100 minutes. REM sleep periods increase in duration toward the morning. Human sleep also varies characteristically across the life span. After relative stability with large amounts of slow-wave sleep in childhood and early adolescence, sleep continuity and depth deteriorate across the adult age range. This deterioration is reflected by increased wakefulness and stage 1 sleep and decreased stages 3 and 4 sleep. Because of this, age must be considered in the diagnosis of a Sleep Disorder in any individual. Polysomnography is the monitoring of multiple electrophysiological parameters during sleep and generally includes measurement of EEG activity, electroculographic activity, and electromyographic activity. Additional polysomnographic measures may include oral or nasal airflow, respiratory effort, chest and abdominal wall movement, oxyhemoglobin saturation, or exhaled carbon dioxide concentration; these measures are used to monitor respiration during sleep and to detect the presence and severity of sleep apnea. Measurement of peripheral electromyographic activity may be used to detect abnormal movements during sleep. Most polysomnographic studies are conducted during the person’s usual sleeping hours—that is, at night. However, daytime polysomnographic studies also are used to quantify daytime sleepiness. The most common daytime procedure is the Multiple Sleep Latency Test (MSLT), in which the individual is instructed to lie down in a dark room and not resist falling asleep; this protocol is repeated fives times during the day. Sleep latency (the amount of time required to fall asleep) is measured on each trial and is used as an index of physiological sleepiness. The converse of the MSLT is also used: In the Repeated Test of Sustained Wakefulness (RTSW), the individual is placed in a quiet, dimly lit room and instructed to remain awake; this protocol is repeated several times during the day. Again, sleep latency is measured, but is it used here as an index of the individual’s ability to maintain wakefulness. Standard terminology for polysomnographic measures is used throughout the test in this section. Sleep continuity refers to the overall balance of sleep and wakefulness during a night of sleep. “Better” sleep continuity indicates consolidated sleep and wakefulness; “worse” sleep continuity indicates disrupted sleep with more wakefulness. Specific sleep continuity measures include sleep latency—the amount of time required to fall asleep (expressed in minutes); intermittent wakefulness—the amount of awake time after initial sleep onset (expressed in minutes); and sleep efficiency—the ratio of actual time spent asleep to time spent in bed (expressed as a percentage, with higher numbers indicating better sleep continuity). Sleep architecture refers to the amount and distribution of specific sleep stages. Sleep architecture measures include absolute amount of REM sleep and each NREM sleep stage (in minutes), relative amount of REM seep and NREM sleep stages (expressed as a percentage of total sleep time), and latency between sleep onset and the first REM period (REM latency). The text for each of the Sleep Disorders contains a section describing its relationship to corresponding disorders in The International Classification of Sleep Disorders: (ICSD) diagnostic and Coding Manual, published in 1990 by the American Sleep Disorders Association. _________________
Substance Dependence “Features The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is a pattern of repeated self-administration that can result in tolerance, withdrawal, and compulsive drug-taking behavior. A diagnosis of Substance Dependence can be applied to every class of substances except caffeine. The symptoms of Dependence are similar across the various categories of substances, but for certain classes some symptoms are less salient, and in a few instances not all symptoms apply (e.g., withdrawal symptoms are not specified for Hallucinogenic Dependence). Although not specifically listed as a criterion item, “craving” (a strong subjective drive to use the substance) is likely to be experienced by most (if not all) individuals with Substance Dependence. Dependence is defined as a cluster of three or more of the symptoms listed below occurring at any time in the same 12-month-period. Tolerance (Criterion 1) is the need for greatly increased amounts of the substance to achieve intoxication (or the desired effect) or a markedly diminished effect with continued use of the same amount of the substance. The degree to which tolerance develops varies greatly across substances. Furthermore, for a specific drug, varied degrees of tolerance may develop for its different central nervous system effects. For example, for opioids, tolerance to respiratory depression and tolerance to analgesia develop at different rates. Individuals with heavy use of opioids and stimulants can develop substantial (e.g., 10-f0ld) levels of tolerance, often to a dosage that would be lethal to a nonuser. Alcohol tolerance can also be pronounced, but is usually less extreme than for amphetamine. Many individuals who smoke cigarettes consume more than 20 cigarettes a day, an amount that would have produced symptoms of toxicity when they first started smoking. Individuals with heavy use of cannabis or phencyclidine (PCP) are generally not aware of having developed tolerance (although it has been demonstrated in animal studies and in some individuals). Tolerance may be difficult to determine by history alone when the substance used is illegal and perhaps mixed with various diluents or with other substances. In such situations, laboratory tests may be helpful (e.g., high blood levels of the substance coupled with little evidence of intoxication suggest that tolerance is likely). Tolerance must also be distinguished from individual variability in the initial sensitivity to the effects of particular substances. For example, some first-time drinkers show very little evidence of intoxication with three or four drink, whereas others of similar weight and drinking histories had slurred speech and incoordination. Withdrawal (Criterion 2a) is a maladaptive behavioral change, with physiological and cognitive concomitants, that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing unpleasant withdrawal symptoms, the persons is likely to take the substance to relieve or to avoid those symptoms (Criterion 2b), typically using the substance throughout the day beginning soon after awakening. Withdrawal symptoms, which are generally the opposite of the acute effects of the substance, vary greatly across the calluses of substances, and separate criteria sets for Withdrawal are provided for most of the classes. Marked and generally easily measured physiological signs of withdrawal are common with alcohol, opioids, and sedatives, hypnotics, and anxiolytics. Withdrawal signs and symptoms are often present, but may be less apparent, with stimulants such as amphetamines and cocaine, as well as with nicotine and cannabis. No significant withdrawal is seen even after repeated use of hallucinogens. Withdrawal from phencyclidine and related substances has not yet been described in humans (although it has been demonstrated in animals). Neither tolerance nor withdrawal is necessary or sufficient for a diagnosis of Substance Dependence. However, for most classes of substances, a past history of tolerance or withdrawals is associated with a more severe clinical course (i.e., an earlier onset of Dependence, higher levels of substance intake, and a greater number of substance-related problems). Some individuals (e.g., those with Cannabis Dependence) show a pattern of compulsive use without obvious signs of tolerance or withdrawal. Conversely, some general medical and postsurgical patients without Opioid Dependence may develop a tolerance to prescribed opioids and experience withdrawal symptoms without showing any signs of compulsive use. The specifiers With Physiological Dependence and Without Physiological Dependence are provided to indicate the presence or absence of tolerance or withdrawal. The following items describe the pattern of compulsive substance use that is characteristic of Dependence. The individual may take the substance in larger amounts or over a longer period than was originally intended (e.g., continuing to drink until severely intoxicated despite having set a limit of only one drink) (Criterion 3). The individual may express a persistent desire to cut down or regulate substance use. Often, there have been many unsuccessful efforts to decrease or discontinue use (Criterion 4). The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects (Criterion 5). In some instances of Substance Dependence, virtually all of the person’s daily activities revolve around the substance. Important social, occupational, ore recreational activities may be given up or reduced because of substance use (Criterion 6). The individual may withdraw from family activities and hobbies in order to use the substance in private or to spend more time with substance-using friends. Despite recognizing the contributing role of the substance to a psychological or physical problem (e.g., sever depressive symptoms or damage to organ systems), the person continues to use the substance (Criterion 7). The key issue in evaluating this criterion is not eh existence of the problem, but rather the individual’s failure to abstain from using the substance despite having evidence of the difficulty it is causing.
Specifiers Tolerance and withdrawal may be associated with a higher risk for immediate general medical problems and a higher relapse rate. Specifiers are provided to note their presence or absence: With Physiological Dependence. This specifier should be used when Substance Dependence is accompanied by evidence of tolerance (Criterion 1) or withdrawal (Criterion 2). Without Physiological Dependence. This specifier should be used when there is no evidence of tolerance (Criterion 1) or withdrawal (Criterion 2). In these individuals, Substance Dependence is characterized by a pattern of compulsive use (at least three items from Criteria 3-7).”
Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. P. 193-195.
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PTSD, DID, and EMDR Posttraumatic Stress Disorder "The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease. The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator). Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7). The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."
Dissociative Identity Disorder (DID) "The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play. Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations. Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts. The number of identities reported ranges from 2 to more than 100. Half of reported cases include the individuals with 10 or fewer identities." Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. EMDR Eye Movement Desensitization and Reprocessing "Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach. During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session. Eight Phases of Treatment The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete. In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced. In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two. The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system. After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com __________________ Major Depressive Disorder “Diagnostic Features The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (Criteria A and C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Major Depressive Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion B). The fourth digit in the diagnostic code for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes) or Recurrent. It is sometimes difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes. For purposes of this manual, an episode is considered to have ended when the full criteria for eh Major Depressive Episode have not been met for at least 2 consecutive months. During this 2-month period, there is either complete resolution of symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode (In Partial Remission). The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance. If the criteria for a Major Depressive Disorder are met, the severity of the episode is notes as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria for a Major Depressive Episode are not currently met, the fifth digit is used to indicate whether the disorder is In Partial Remission or In Full Remission. If Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive Disorder, the diagnosis is changed to a Bipolar Disorder. However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of other medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an addition diagnosis of Substance-induced Mood Disorder, With Manic features (or With Mixed Features), should be noted. Similarly, if manic or hypomanic symptoms occur as a direct effect of a general medical condition, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Medical Condition, With Manic Features (or With Mixed Features), should be noted.” p. 369 “Course Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s. Epidemiological data suggest that the age at onset is decreasing for those born more recently. The course of Major Depressive Disorder, Recurrent, is variable. Some people have isolated episodes that are separated by many years without any depressive symptoms, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older. Some evidence suggests that the periods of remission generally last longer early in the course of the disorder. The number of prior episodes predicts the likelihood of developing a subsequent Major Depressive Episode. At least 60% of individuals with Major Depresssive Disorder, Single Episode, can be expected to have a second episode. Individuals who have had tow episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance of having a fourth. About 5%-10% of individuals with Major Depressive Disorder, single Episode, subsequently develop a Manic Episode (i.e., develop Bipolar I Disorder). Major Depressive Episodes may end completely (in about two-thirds of cases), or only partially or not at all (in about one-third of cases). For individuals who have only partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern of partial interepisode recovery. The longitudinal course specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery may therefore have prognostic value. A number of individuals have pre-existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, single Episode. Some evidence suggests that these individuals are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing treatment to attain and maintain a more thorough and longer-lasting euthymic state. Follow-up naturalistic studies suggested that 1 year after the diagnosis of a major Depressive Episode, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full Major Depressive Episode, roughly 20% continue to have some symptoms that no longer meet full criteria for a Major Depressive Episode (i.e., major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episodes. Episodes of Major Depressive Disorder often follow a severe psychosocial stressor, such as the death of a loved one or divorce. Studies suggest that psychosocial events 9stressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of subsequent episodes. Chronic general medical conditions and Substance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder. It is difficult to predict whether the first episode of a Major Depressive Disorder in a young person will ultimately evolve into a Bipolar Disorder. Some data suggest that the acute onset of severe depression, especially with psychotic features and psychomotor retardation, in a young person without prepubertal psychopathology is more likely to predict a bipolar disorder. A family history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.” p. 372-373
Diagnostic and statistical manual of mental disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association.
________________ Major Depressive Disorder “Diagnostic Features The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (Criteria A and C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Major Depressive Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion B). The fourth digit in the diagnostic code for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes) or Recurrent. It is sometimes difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes. For purposes of this manual, an episode is considered to have ended when the full criteria for eh Major Depressive Episode have not been met for at least 2 consecutive months. During this 2-month period, there is either complete resolution of symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode (In Partial Remission). The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance. If the criteria for a Major Depressive Disorder are met, the severity of the episode is notes as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria for a Major Depressive Episode are not currently met, the fifth digit is used to indicate whether the disorder is In Partial Remission or In Full Remission. If Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive Disorder, the diagnosis is changed to a Bipolar Disorder. However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of other medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an addition diagnosis of Substance-induced Mood Disorder, With Manic features (or With Mixed Features), should be noted. Similarly, if manic or hypomanic symptoms occur as a direct effect of a general medical condition, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Medical Condition, With Manic Features (or With Mixed Features), should be noted.” p. 369 “Course Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s. Epidemiological data suggest that the age at onset is decreasing for those born more recently. The course of Major Depressive Disorder, Recurrent, is variable. Some people have isolated episodes that are separated by many years without any depressive symptoms, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older. Some evidence suggests that the periods of remission generally last longer early in the course of the disorder. The number of prior episodes predicts the likelihood of developing a subsequent Major Depressive Episode. At least 60% of individuals with Major Depresssive Disorder, Single Episode, can be expected to have a second episode. Individuals who have had tow episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance of having a fourth. About 5%-10% of individuals with Major Depressive Disorder, single Episode, subsequently develop a Manic Episode (i.e., develop Bipolar I Disorder). Major Depressive Episodes may end completely (in about two-thirds of cases), or only partially or not at all (in about one-third of cases). For individuals who have only partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern of partial interepisode recovery. The longitudinal course specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery may therefore have prognostic value. A number of individuals have pre-existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, single Episode. Some evidence suggests that these individuals are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing treatment to attain and maintain a more thorough and longer-lasting euthymic state. Follow-up naturalistic studies suggested that 1 year after the diagnosis of a major Depressive Episode, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full Major Depressive Episode, roughly 20% continue to have some symptoms that no longer meet full criteria for a Major Depressive Episode (i.e., major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episodes. Episodes of Major Depressive Disorder often follow a severe psychosocial stressor, such as the death of a loved one or divorce. Studies suggest that psychosocial events 9stressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of subsequent episodes. Chronic general medical conditions and Substance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder. It is difficult to predict whether the first episode of a Major Depressive Disorder in a young person will ultimately evolve into a Bipolar Disorder. Some data suggest that the acute onset of severe depression, especially with psychotic features and psychomotor retardation, in a young person without prepubertal psychopathology is more likely to predict a bipolar disorder. A family history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.” p. 372-373 Diagnostic and statistical manual of mental disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. ________________ DID-PTSD-EMDR Dissociative Identity Disorder (DID) "The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play. Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations. Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts. The number of identities reported ranges from 2 to more than 100. Half of reported cases include the individuals with 10 or fewer identities." Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. PTSD, DID, and EMDR Posttraumatic Stress Disorder "The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease. The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator). Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7). The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."
EMDR Eye Movement Desensitization and Reprocessing "Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach. During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session. Eight Phases of Treatment The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete. In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced. In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two. The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system. After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com
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NeuroBiology of Trauma
Sleep Disorders and Trauma
Title: Sleep and posttraumatic stress disorder: A review. Author(s): Harvey, Allison G., allison.harvey@psy.ox.ac.uk, U Oxford, Dept of Experimental Psychology, Oxford, England; Jones, Charlie, U Oxford, Dept of Experimental Psychology, Oxford, England; Schmidt, D. Anne, U Oxford, Dept of Experimental Psychology, Oxford, England Address: Harvey, Allison G., Dept of Experimental Psychology, U Oxford, South Parks Road, OX1 3UD, Oxford, United Kingdom, allison.harvey@psy.ox.ac.uk Source: Clinical Psychology Review , Vol 23(3), May 2003. Special Issue: Post Traumatic Stress Disorder. pp. 377-407. Publisher: United Kingdom: Elsevier Science. Abstract: Research seeking to establish the relationship between sleep and posttraumatic stress disorder (PTSD) is in its infancy. An empirically supported theory of the relationship is yet to emerge. The aims of the present paper are threefold: to summarise the literature on the prevalence and treatment of sleep disturbance characteristic of acute stress disorder (ASD) and PTSD, to critically review this literature, and to draw together the disparate theoretical perspectives that have been proposed to account for the empirical findings. After a brief overview of normal human sleep, the literature specifying the relation between sleep disturbance and PTSD is summarized. This includes studies of the prevalence of sleep disturbance and nightmares, content of nightmares, abnormalities in rapid eye movement (REM) sleep, arousal threshold during sleep, body movement during sleep, and breathing-related sleep disorders. In addition, studies of the treatment of sleep disturbance in individuals with PTSD are reviewed. We conclude that the role of sleep in PTSD is complex, but that it is an important area for further elucidating the nature and treatment of PTSD. Areas for future research are specified. In particular, a priority is to improve the methodology of the research conducted. _____
Title: The mediating effects of sleep in the relationship between traumatic stress and health symptoms in urban police officers. Author(s): Mohr, David, dmohr@itsa.ucsf.edu, Dept of Veterans Affairs Medical Ctr, San Francisco, CA, US; Vedantham, Kumar; Neylan, Thomas; Metzler, Thomas J.; Best, Suzanne; Marmar, Charles R. Address: Mohr, David, VA Medical Ctr, 4150 Clement Street (116A), San Francisco, CA, US, 94121, dmohr@itsa.ucsf.edu Source: Psychosomatic Medicine, Vol 65(3), May-Jun 2003. pp. 485-489. Publisher: US: Lippincott Williams & Wilkins. Language: English Abstract: Objective: Posttraumatic stress symptoms have been associated with increased health problems across numerous studies. Sleep disruption, one of the principal symptoms resulting from traumatic stress, has also been shown to produce health problems. This study explored the hypothesis that the relationship between posttraumatic stress symptoms and health is mediated by sleep problems. Method: A sample of 741 police officers were administered measures of traumatic stress symptoms, sleep, health functioning, and somatic symptoms. Results: Traumatic stress symptoms were significantly related to both somatic symptoms (R-sup-2=0.18, p < .001) and health functioning (R-sup-2=0.02, p < .01). The relationship between somatic symptoms and traumatic stress symptoms was partially mediated by sleep (p < .001). The relationship between traumatic stress symptoms and health functioning was fully mediated by sleep. Conclusions: Although design characteristics, such as cross-sectional sampling, limit the inferences that can be drawn, these findings suggest that sleep may serve as an important mediator between traumatic stress and somatic symptoms. _____
Title: Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: A placebo-controlled study. Author(s): Raskind, Murray A., VA Puget Sound Health Care System, Seattle, WA, US; Peskind, Elaine R.; Kanter, Evan D.; Petrie, Eric C.; Radant, Allen; Thompson, Charles E.; Dobie, Dorcas J.; Hoff, David; Rein, Rebekah J.; Straits-Troester, Kristy; Thomas, Ronald G.; McFall, Miles M. Address: Raskind, Murray A., VA Puget Sound Health Care System (116 MIRECC), 1660 S. Columbian Way, Seattle, WA, US, 98108, murray.raskind@med.va.gov Source: American Journal of Psychiatry, Vol 160(2), Feb 2003. pp. 371-373. Publisher: US: American Psychiatric Assn. Abstract: Prazosin is a centrally active alpha-sub-1 adrenergic antagonist. The authors' goal was to evaluate prazosin efficacy for nightmares, sleep disturbance, and overall posttraumatic stress disorder (PTSD) in combat veterans. Ten Vietnam combat veterans with chronic PTSD and severe trauma-related nightmares each received prazosin and placebo in a 20-week double-blind crossover protocol. Prazosin was superior to placebo for the three primary outcome measures: scores on the 1) recurrent distressing dreams item and the 2) difficulty falling/staying asleep item of the Clinician-Administered PTSD Scale and 3) change in overall PTSD severity and functional status according to the Clinical Global Impression of change. Total score and symptom cluster scores for reexperiencing, avoidance/numbing, and hyperarousal on the Clinician-Administered PTSD Scale also were significantly more improved in the prazosin condition, and prazosin was well tolerated. _____
Title: An investigation of the continuity and alternative channels hypotheses in sleep paralysis and narcolepsy. Author(s): Mcnulty, Stacey A., Carleton U., Canada Source: Dissertation Abstracts International: Section B: The Sciences & Engineering , Vol 63(9-B), 2003. pp. 4403. Publisher: US: Univ Microfilms International. Abstract: The relationship between imagery associated with sleep and waking imagery was the focus of the current research. Two studies examined the validity of applying the Continuity versus the Alternative Channels Hypotheses to understanding the association between day and night imagery among individuals who self-reported sleep paralysis or with a clinical diagnosis of narcolepsy. The Continuity Hypothesis suggests that individuals absorbed in night imagery are likely to be absorbed in daytime imagery, so those with sleep paralysis should show high levels of day and night imagery (which would be positively correlated). The Alternative Channels Hypothesis suggests that individuals experiencing trauma and psychopathology suppress daytime imagery; such imagery is channelled into night imagery. Thus, those who experience night imagery should show signs of pathology, and such imagery should be inversely correlated with day imagery. In Study 1, students reporting sleep paralysis (n = 80) were compared to controls (n = 80) on indices assessing day and night imagery, psychopathology and trauma. Sleep paralysis participants did not differ from controls on the indices. However, regressions indicated a positive relationship between day and night imagery, but this effect was moderated by psychopathology and trauma. Among individuals low in psychopathology (or trauma), high day imagery vividness scores were associated with high scores on night imagery, but not among those demonstrating high symptoms of pathology or trauma. Similarly, among individuals low in trauma, high scores on a multidimensional imagery measure were associated with high scores on the nightmare/terror index of night imagery, but not among those demonstrating high symptoms of trauma. It was suggested that while support appeared to be greater for the Continuity Hypothesis, the results were mixed due to the lack of clinical sleep pathology. In Study 2, clinically diagnosed narcoleptics (n = 26) were compared to controls (n = 26) on the same indices. However, not only was there no difference between clinical and control groups on imagery and pathology, the positive relationship between day and night imagery was not significant. A moderating effect of psychopathology and trauma was not found among narcoleptics. Thus, among a clinical sample, there was support for neither hypothesis. Methodological concerns and theoretical implications were discussed. _____
Title: Hypnotic medication in the aftermath of trauma. Author(s): Mellman, Thomas A., Dartmouth Medical School, Hanover, NH, US; Bustamante, Victoria , U Miami, School of Medicine, Miami, FL, US; David, Daniella , U Miami, School of Medicine, Miami, FL, US; Fins, Ana I., Nova Southeastern U, Ft Lauderdale, FL, US Source: Journal of Clinical Psychiatry , Vol 63(12), Dec 2002. pp. 1183-1184. Publisher: US: Physicians Postgraduate Press. Abstract: Published treatment guidelines, as well as a recent review in the New England Journal of Medicine make recommendations for short-term use of hypnotic medication for early intervention following trauma. The present authors have advocated this approach and they report here a recently followed up pilot case series with a small randomized, placebo-controlled trial. 22 subjects (Ss; males and females, mean age 36.1 yrs) who had been admitted to a level I trauma center following life-threatening incidents including motor vehicle accidents, industrial accidents, and impersonal assaults. Ss were manifesting early posttraumatic stress disorder (PTSD) symptoms and they reported at least moderate impairment of sleep initiation or maintenance, thus meeting DSM-IV criteria for PTSD. Results with temazepam treatment indicate that there was a significant interaction of increased sleep duration and having received temazepam for the first night of treatment. Results, while preliminary, do not support that early, brief treatment with hypnotics facilitated reduction of PTSD symptoms or improved sleep beyond the duration of their use. The finding related reduced awakening to improvement in PTSD suggests the possibility of a role for other interventions for reducing sleep disruption. _____
Title: Sonolencia diurna excessiva pos-traumatismo de cranio: Associacao com movimentos periodicos de pernas e disturbio de comportamento do sono REM. Translated Title: Excessive daytime sleepiness after traumatic brain injury: Association with periodic limb movements and REM behavior disorder. Author(s): Rodrigues, Raimundo Nonato D., U Brasilia, Laboratoria de Sono do Hosp Universitario, Brasilia, Brazil; Abreu e Silva, Aida A. A., U Brasilia, Laboratoria de Sono do Hosp Universitario, Brasilia, Brazil; Source: Arquivos de Neuro-Psiquiatria, Vol 60(3-A), Sep 2002. pp. 656-660. Publisher: Brazil: Arquivos de Neuro-Psiquiatria. Abstract: Presents the case of a 52-yr-old male patient reporting with a complaint of "restless sleep". His wife informed that for the past 10 yrs the patient had presented intense and aggressive body movements, and sometimes violent dreams. The patient also complained of excessive daytime sleepiness. His relevant previous medical history included a traumatic brain injury at the age of 28 which left him in coma for 2 mos. A video-polysomnography showed periodic leg movements and, during REM sleep, aggressive and agitated behavior. The multiple sleep latency test revealed extremely short latencies. Initially, the patient was treated with levodopa-benzerazide, 100/25 mg, 2 hrs before bedtime. After 10 wks his overnight behavior pattern improved and leg movements diminished. This case supports the hypothesis of an association between cranial trauma and alterations in the dopaminergic pathways represented by periodic leg movements during sleep and a sleep behavior disorder and proposes the possibility of hypothalamic hypocretin involvement in its pathophysiology. _____
Title: Sleep-disordered breathing, psychiatric distress, and quality of life impairment in sexual assault survivors. Author(s): Krakow, Barry, Sleep & Human Health Inst, Albuquerque, NM, US; Melendrez, Dominic , Sleep & Human Health Inst, Albuquerque, NM, US; Johnston, Lisa, Sleep & Human Health Inst, Albuquerque, NM, US; Warner, Teddy D., U New Mexico, Health Sciences Ctr, Albuquerque, NM, US; Clark, James O. , Sleep & Human Health Inst, Albuquerque, NM, US; Pacheco, Mary , U New Mexico, U Hosp Sleep Disorders Ctr, Albuquerque, NM, US; Pedersen, Beth , Sleep & Human Health Inst, Albuquerque, NM, US; Koss, Mary , U Arizona, Health Sciences Ctr, Tucson, AZ, US; Hollifield, Michael , U New Mexico, Health Sciences Ctr, Albuquerque, NM, US; Schrader, Ron , U New Mexico, Dept of Mathematics & Statistics, Albuquerque, NM, US Address: Krakow, Barry, Sleep & Human Health Inst, 4775 Indian School Road NE, Suite #305, Albuquerque, NM, US, 87110 Source: Journal of Nervous & Mental Disease, Vol 190(7), Jul 2002. pp. 442-452. Publisher: US: Lippincott Williams & Wilkins. Abstract: Using American Academy of Sleep Medicine research criteria, sleep-disordered breathing (SDB) was assessed in a pilot study of 187 sexual assault survivors (mean age 37 yrs) with posttraumatic stress symptoms. Nightmares, sleep quality, distress, and quality of life were also assessed along with historical accounts of prior treatments for sleep complaints. Presumptive SDB diagnoses were established for 168 Ss. 21 of 168 under-went sleep testing, and all met objective SDB diagnostic criteria. There were no clinically meaningful differences in age, body-mass index, sleep quality, distress, or quality of life measures between 21 confirmed SDB cases and 147 suspected cases not tested. Compared with 19 Ss without SDB, 168 Ss with diagnosed or suspected SDB reported significantly worse nightmares, sleep quality, anxiety, depression, posttraumatic stress, and impaired quality of life. Despite suffering from sleep problems for an average of 20 yrs, which had not responded to repeated use of psychotropic medications or psychotherapy, few Ss had been referred to sleep specialists. SDB appears widespread among sexual assault survivors seeking help for nightmares. Research is needed to clarify the associations among SDB, distress, and physical and mental health impairment in trauma patients. _____
Title: Sleep complaints as early predictors of posttraumatic stress disorder: A 1-Year prospective study of injured survivors of motor vehicle accidents. Author(s): Koren, Danny; Arnon, Issac; Lavie, Peretz; Klein, Ehud, e_klein@rambam.health.gov.il, Rambam Medical Ctr, Dept of Psychiatry, Haifa, Israel Address: Klein, Ehud, Rambam Medical Ctr, Dept of Psychiatry, Haifa, Israel, e_klein@rambam.health.gov.il Source: American Journal of Psychiatry, Vol 159(5), May 2002. pp. 855-857. Publisher: US: American Psychiatric Assn. Abstract: Disturbed sleep is a common complaint among patients with posttraumatic stress disorder (PTSD) that appears in the reexperiencing and hyperarousal symptom clusters in Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). The causal relationship between sleep complaints and PTSD is unclear. Self-reported insomnia and excessive daytime sleepiness were assessed in 102 victims (aged 18-65 yrs) of motor vehicle accidents and 19 comparison Ss 1 wk and 1, 3, 6, and 12 mo after the trauma. At 12 mo the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) was administered to determine diagnoses of PTSD. 26 of the accident victims but none of the comparison Ss met the criteria for PTSD. Logistic regression models indicated that sleep complaints from 1 mo on were significant in predicting PTSD at 1 yr. These results suggest that on the basis of sleep complaints as early as 1 mo after the trauma, it is possible to detect subjects who will later develop chronic PTSD. _____
Title: "Sleep disturbances in the wake of traumatic events." Comment. Author(s): Rothbaum, Barbara O., Emory U, School of Medicine, Atlanta, GA, US; Foa, Edna B., U Pennsylvania, School of Medicine, Philadelphia, PA, US Source: New England Journal of Medicine, Vol 346(17), Apr 2002. pp. 1334-1335. Publisher: US: Massachusetts Medical Society. Abstract: Comments on the article by P. Lavie concerning sleep disturbances and traumatic events. The authors adamantly disagree with Lavie's conclusions regarding the treatment of traumatized persons with chronic psychiatric disturbances such as posttraumatic stress disorder (PTSD). The authors believe that advising survivors to "leave traumatic memories behind" is counterproductive, and physicians should not recommend such avoidance to their patients. _____
Title: Post-traumatic stress disorder and sleep. Author(s): Van Ommeren, Mark, Transcultural Psychosocial Organization, Amsterdam, Netherlands; De Jong, Joop T. V. M., Transcultural Psychosocial Organization, Amsterdam, Netherlands; Komproe, Ivan, Transcultural Psychosocial Organization, Amsterdam, Netherlands Source: New England Journal of Medicine, Vol 346(17), Apr 2002. pp. 1334. Publisher: US: Massachusetts Medical Society. Abstract: Comments on the article by P. Lavie concerning sleep disturbances and traumatic events. The authors state that Lavie has shown that objective, sleep-laboratory measures do not consistently support the subjective reports of insomnia given by Western survivors of traumatic events and that an explanation is not given for this inconsistency. It is believed that future investigations will confirm that insomnia is not specific to posttraumatic stress disorder (PTSD) but that trauma-related nightmares are a core symptom of the disorder _____
Title: "Sleep disturbances in the wake of traumatic events." Reply. Author(s): Lavie, Peretz , Technion-Israel Inst of Technology, Haifa, Israel Source: New England Journal of Medicine, Vol 346(17), Apr 2002. pp. 1335. Publisher: US: Massachusetts Medical Society. Abstract: Replies to the comment by B. O. Rothbaum and E. B. Foa concerning the article by P. Lavie which discussed sleep disturbances and traumatic events. The author states that none of the references that Rothbaum and Foa cite in their letter provide evidence that prolonged exposure is effective in severely traumatized patients. _____
Title: Hypnosis treatment of sleeping problems in children experiencing loss. Author(s): Hawkins, Peter , U Sunderland, Psychology Div, Sunderland, United Kingdom; Polemikos, Nikitas , U Aegean, Greece Address: Hawkins, Peter, U Sunderland, Psychology Div, St Peter's Campus, Sunderland, United Kingdom, SR6 ODD Source: Contemporary Hypnosis , Vol 19(1), 2002. pp. 18-24. Publisher: England: Whurr Publishers. Abstract: Research and clinical evidence show that children who experience loss become traumatized. The results of traumatization include sleeping problems, for example difficulties in initiating sleep and sleep terrors. Psychological intervention programmes, including hypnotherapy, have been shown to have some success in helping children to overcome their sleeping problems. In this study, a new paradigm qualitative methodology was used in which a small group of children were taught self-hypnosis to manage their sleep difficulties. The group comprised six children ranging in age from 8-12 yrs. Three children had been bereaved after the death of one parent, 1 child lost a brother, and the other 2 had been referred due to parental separation. Within the group, the children's experiences of utilizing self-hypnosis at home were discussed, and a consensus reached concerning its effects. Complementary data were collected through interviews with caregivers and by completion of the Southampton Sleep Management Schedule (L. Bartlet and J. Beaumont, 1998). From the study it was concluded that young children can be taught self-hypnosis in order to manage their sleeping problems effectively. Furthermore, the present study demonstrated that children can be involved in a collaborative research group. _____
Title: Circadian rhythm sleep disorders (CRSD) in psychiatry--A review. Author(s): Dagan, Yaron , Sheba Medical Ctr, Inst for Fatigue & Sleep Medicine, Tel-Hashomer, Israel Address: Dagan, Yaron, Sheba Medical Ctr,Inst for Fatigue & Sleep Medicine, Tel-Hashomer, Israel, ydagan@post.tau.ac.il Source: Israel Journal of Psychiatry & Related Sciences, Vol 39(1), 2002. pp. 19-27. Publisher: Israel: Gefen Publishing House. Abstract: Discusses circadian rhythm sleep disorders (CRSDs), their consequences, and available treatment. CRSDs are a group of sleep disorders characterized by a de-synchronization between an individual's biological clock and the environmental 24-hr schedule. The 4 main types of CRSDs are delayed sleep phase syndrome, advanced sleep phase syndrome, non-24-hr sleep-wake syndrome, and irregular sleep wake pattern. These disorders lead to harmful psychological and functional difficulties; certain personality disorders may be related to them as well. Psychotropic drugs, including selective serotonin reuptake inhibitors and haloperidol, can cause CRSD, as can minor head trauma. Common treatments include chronotherapy, light therapy, or administration of vitamin B12 or melatonin. _____
Title: Current concepts: Sleep disturbances in the wake of traumatic events. Author(s): Lavie, Peretz , Technion-Israel Inst of Technology, Faculty of Medicine, Sleep Lab, Haifa, Israel Address: Lavie, Peretz, Technion-Israel Inst of Technology, Sleep Lab, Gutwirth Bldg., Technion City, Haifa, Israel Source: New England Journal of Medicine, Vol 345(25), Dec 2001. pp. 1825-1832. Publisher: US: Massachusetts Medical Society. Abstract: Summarizes existing knowledge about the immediate and long-term effects of traumatic events on sleep, and offers guidelines for the treatment of trauma-related sleep disturbances. Charts of sleep stages of normal sleep and 2 types of insomnia that are typically found in traumatized patients are shown. It is argued that sleep disturbances in traumatized patients are complex behavioral events. In many cases, the subjective reports are out of proportion to the frequency and severity of objective sleep-laboratory findings, and patients are generally unaware of the true nature of their sleep disturbances. In contradiction to the hypothesis that patients with posttraumatic stress disorder (PTSD) must sleep lightly, patients with PTSD appear to have deeper sleep and lower rates of dream recall than normal persons. The author maintains that sleep disturbances in traumatized patients should be treated as an independent clinical entity, and both behavioral and pharmacologic therapies can be beneficial. _____
Title: Tragedy and insomnia. Author(s): White, David P., Brigham and Women's Hosp, Boston, MA, US Source: New England Journal of Medicine, Vol 345(25), Dec 2001. pp. 1846-1847. Publisher: US: Massachusetts Medical Society. Abstract: Notes that sleep disorders are extremely common after a serious stressful or traumatic event and probably require therapy if the problem is severe enough for patients to seek medical help. The author argues that in addition to educating patients about the importance of sleep hygiene, the short-term use of hypnotic agents is probably appropriate in many of these patients, although there is no data indicating that their use will avert subsequent psychological, sleep-related, or physical problems. It is maintained that patients with persistent insomnia should be referred to appropriate specialists, although some may require long-term treatment with hypnotic agents. _____
Title: There and back again: A phenomenological inquiry of school shootings as experienced by school leaders. Author(s): Fein, Albert H., Gonzaga U., US Source: Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 62(3-B), Sep 2001. pp. 1572. Publisher: US: Univ Microfilms International. Abstract: Public shooting incidents have increased in the past decade, particularly in schools. The lack of research about the impact on leaders who managed in the aftermath of these crises led to this study, the purpose of which was to explore how school leaders perceived and described their experiences of school shooting incidents. According to trauma theory, exposure to the threat of death may lead to predictable physiological and psychological responses. School leaders included central office and building administrators and other individuals who assumed leadership roles. The methodology for this study was phenomenology, which called for participants to tell their lived experiences. Interviews were analyzed and yielded six major themes: (1) School shootings exposed leaders directly or indirectly to the threat of death. Physiological and emotional responses reported by leaders suggested they suffered from trauma. Reported responses included sleep disorders, hyper-alertness, loss of appetite; shock and disbelief, anger, guilt, helplessness and shame; and flashback experiences. (2) Leaders coped by drawing on training and past experiences, spiritual beliefs, positive self-talk, focusing on tasks, collaborating, establishing and maintaining boundaries; through humor, sharing their experiences, leaving the district, and through symbolic acts. They derived support from family, peers, victims and through counseling. Responses to shootings reflected varying degrees of recovery. (3) Leaders felt a high degree of responsibility for restoring order and for easing the pain and suffering they witnessed. Leaders experienced added load as pressure, weight, and anxiety/guilt. The media was a major contributor to their loads. Participant accounts reflect varying degrees of recovery. (4) Leaders did not have the benefit of models to guide their decisions or actions had to make sense of extremely unusual events and circumstances; they were forced to learn while leading. The need for making decisions increased exponentially, as did uncertainty. (5) Leaders experienced themselves in new ways as a result of their experiences, ranging from pride to self-doubt. Most described themselves as changed forever. (6) Leaders experienced significant changes in their views of the world. Many felt a new sense of vulnerability. Some were inspired to make a positive difference, often by publicly sharing their experiences. _____
Title: Trauma-related sleep disturbance and self-reported physical health symptoms in treatment-seeking female rape victims. Author(s): Clum, Gretchen A., U Missouri, Ctr for Trauma Recovery, St Louis, MO, US; Nishith, Pallavi; Resick, Patricia A. Source: Journal of Nervous & Mental Disease, Vol 189(9), Sep 2001. pp. 618-622. Publisher: US: Lippincott Williams & Wilkins. Abstract: The purpose of the study was to assess the relationship between trauma-related sleep disturbance and physical health symptoms in treatment-seeldng female rape victims. A total of 167 participants (aged 18-70 yrs) were assessed for posttraumatic stress disorder (PTSD) symptoms, depression, sleep disturbance, and frequency of self-reported health symptoms. Results demonstrated that trauma-related sleep disturbance predicted unique variance in physical health symptoms after other PTSD and depression symptoms were controlled. The findings suggest that trauma-related sleep disturbance is one potential factor contributing to physical health symptoms in rape victims with PTSD. _____
Title: Sleep and trauma in children. Author(s): Sadeh, Avi , Lab for Children's Sleep Disorders, Dept of Psychology, Tel Aviv U, Israel Source: Stores, Gregory (Ed); Wiggs, Luci (Ed); 2001. Sleep disturbance in children and adolescents with disorders of development: Its significance and management. Clinics in developmental medicine, No. 155. New York, NY, US: Cambridge University Press. pp. 169-173 Abstract: This short review focuses on the relationships between stress, trauma and sleep and sleep disorders in children. The research findings from studies in this field have often been incongruent and unpredictable. A theoretical model is developed to explain these findings and to create a more coherent picture. The etiology and management of sleep disorders in traumatized children are also discussed. _____
Title: Sleep disturbances and psychiatric disorders associated with posttraumatic stress disorder in the general population. Author(s): Ohayon, Maurice M., Stanford U School of Medicine, Sleep Disorders Ctr, Stanford, CA, US; Shapiro, Colin M. Source: Comprehensive Psychiatry, Vol 41(6), Nov-Dec 2000. pp. 469-478. Publisher: US: WB Saunders. Abstract: Assessed sleep disturbances in subjects with posttraumatic stress disorder (PTSD) from urban general population and identified associated psychiatric disorders in these Ss. The study was performed with a representative sample of 1,832 Ss (aged 15-90 yrs) who were surveyed by telephone. Interviewers used Sleep-EVAL, an expert system specifically designed to conduct epidemiologic studies of sleep and mental disorders in the general population. Overall, 11.6% of the sample reported having experienced a traumatic event, with no difference in the proportion of men and women. Approximately 2% of the entire sample were diagnosed by the system as having PTSD at the time of interview. The rate was higher for women (2.6%) than for men (0.9%), which translated into an odds ratio of 2.8. PTSD was strongly associated with other mental disorders: 75.7% of Ss with PTSD received at least one other diagnosis. Most concurrent disorders (80.7%) appeared after exposure to the traumatic event. Sleep disturbances also affected about 70% of the PTSD Ss. Violent or injurious behaviors during sleep, sleep paralysis, sleep talking, and hypnagogic and hypnopompic hallucinations were more frequently reported in respondents with PTSD. Moreover, complaints of rapid eye movement (REM)-related sleep symptoms could be an indication of an underlying problem stemming from PTSD. _____
Title: "PTSD, dementia, and sleep disorder: A possible association": Reply. Author(s): Johnston, Deirde , Wake Forest U, School of Medicine, Winston-Salem, NC, US Source: Journal of the American Geriatrics Society, Vol 48(9), Sep 2000. pp. 1169-1170. Publisher: US: Blackwell Science. Abstract: Responds to J. Verghese comments on the current author's article on posttraumatic stress disorder (PTSD) and dementia. In Verghese's comment he pointed out that the nature and type of dementia was not specified and suggest the possible association of PTSD, dementia and sleep disorders. The current author agrees with his comment on the need for further research to determine the type of dementia associated with the phenomenon described. The author also feels that little is known about the effects of cognitive impairment on the disorders of sleep and other behaviors in individual with PTSD or a history of extreme trauma. _____
Title: Sleep in a community sample of elderly war veterans with and without posttraumatic stress disorder. Author(s): Engdahl, Brian E., VA Medical Ctr, Psychology Service, Minneapolis, MN, US; Eberly, Raina E.; Hurwitz, Thomas D.; Mahowald, Mark W.; Blake, Julee Source: Biological Psychiatry, Vol 47(6), Mar 2000. pp. 520-525. Publisher: US: Elsevier Science. Abstract: Studied sleep in a community sample of war veterans with and without posttraumatic stress disorder (PTSD). 59 elderly males (aged 61-80 yrs) exposed to war trauma 28-50 years ago and free from sleep-affecting medications and disorders other than PTSD completed 3 nights of polysomnography. Of these Ss, 30 met criteria for current PTSD; 3 were receiving supportive outpatient psychotherapy. Two significant differences were observed: Those with PTSD had a higher percentage of REM sleep and fewer arousals from non-REM sleep. The perceptions of sleep quality among the Ss with PTSD were lower than the perceptions of non-PTSD Ss. Although Ss with untreated obstructive sleep apnea and sleep movement disorders were not included in the sample, many cases were detected on initial screening. Treatment resulted in improved sleep and increased feelings of well being. Alterations in REM and arousals characterized PTSD in this sample. When comorbid sleep disorders were ruled out, sleep was clinically similar across the groups. Trauma-related sleep disturbances that Ss reported as arising early in the course of the disorder appear to have declined over time. _____
Title: Hypersomnia after head-neck trauma: A medicolegal dilemma. Author(s): Guilleminault, Christian, Stanford U Sleep Disorders Ctr, Stanford, CA, US; Yuen, K. M.; Gulevich, M. G.; Karadeniz, D.; Leger, D.; Philip, P. Source: Neurology, Vol 54(3), Feb 2000. pp. 653-659. Publisher: US: Lippincott Williams & Wilkins. Abstract: Evaluated the severity of daytime sleepiness in patients with a history of head trauma who complained of daytime somnolence, investigated polygraphic abnormalities during sleep, and determined whether daytime sleepiness was the cause or consequence of head trauma. The authors performed a systematic evaluation of 184 patients (aged 18-54 yrs) comprised of clinical interviews, sleep disorders questionnaires, sleepiness and depression scales, medical and neurologic evaluations, sleep logs with actigraphy, nocturnal polysomnography, and the Multiple Sleep Latency Test (MSLT). Post-traumatic complaint of somnolence was associated with variable degrees of impaired daytime functioning in more than 98% of patients. Ss who were in a coma for 24 hrs, who had a head fracture, or who had immediate neurosurgical interventions were likely to have scores >16 points on the Epworth Sleepiness Scale (ESS) and <=5 minutes on the MSLT. Pain at night was an important factor in nocturnal sleep disruption and daytime sleepiness. Extensive evaluation of pretrauma behavior supported the conclusion that the onset of symptomatic sleep-disordered breathing was associated with the trauma. Ss who showed a "compulsive presleep behavior" were severely impaired in performing their daily activities. _____
Title: Screening for Traume-related sleep disturbance in women admitted for specialized inpatient treatment. Author(s): Allen, Jon G., The Menninger Clinic, Topeka, KS, US; Console, David A.; Brethour, John R. Jr.; Huntoon, Janis; Fulz, Jim; Stein, April B. Source: Journal of Trauma & Dissociation, Vol 1(3), 2000. pp. 59-86. Publisher: US: Haworth Medical Press. Abstract: The authors designed a Sleep Disturbance Screening questionnaire to assist clinicians in disentangling trauma-related factors that contribute to sleep disturbance from other common factors, such as depression. They administered the questionnaire to 129 female psychiatric inpatients (mean age 38 yrs old), most of whom were treated in a specialty program for trauma-related disorders. Confirmatory and exploratory factor analyses distinguished 4 sleep disturbance scales, 2 pertaining to sleep disturbances generally (insomnia, hypersomnia) and 2 pertaining to sleep-related fear (intrusive, phobic). Correlations of the sleep disturbance scales with the Childhood Trauma Questionnaire, Impact of Event Scale-Revised, Dissociative Experiences Scale, Beck Depression Inventory, and selected scales of the Millon Clinical Multiaxial Inventory show evidence of convergent and discriminant validity for the Sleep Disturbance Screening. The findings point to the potential diagnostic value of screening for trauma-related sleep disturbance, with the Sleep Disturbance Screening providing a small set of key questions that may be used in psychometric form or incorporated into routine diagnostic clinical interviews. _____
Title: Depressive symptoms and sleep disturbance in adults with histories of childhood abuse. Author(s): Chu, James A., McLean Hosp, Bellmont, MA, US; Dill, Diana L.; Murphy, Donna E. Source: Journal of Trauma & Dissociation, Vol 1(3), 2000. pp. 87-97. Publisher: US: Haworth Medical Press. Abstract: Depressive symptoms including sleep disturbance are clinically apparent in many patients with histories of childhood abuse. This study investigated the nature and severity of depressive symptoms, sleep disturbance, and trauma-related symptoms in a group of female participants (aged 18-60 yrs old) with abuse histories, as compared to a non-abused group of female participants with major depression. 60 participants with a history of childhood abuse and 13 participants with major depression completed several self-report instruments which examine past life experiences, depressive symptoms, post-traumatic symptoms, dissociative symptoms, and sleep problems. Both the abused and depressed groups showed high levels of depressive symptoms, but there were no significant differences between the groups. The abused group had significantly more intrusive post-traumatic symptoms and more dissociative symptoms, and were more likely to be afraid of falling asleep and more anxious upon mid-sleep awakening. Severity of depressive symptoms in the abused group was correlated with severity of intrusive post-traumatic symptomatology. Conclusions indicate that symptoms of major depression in some patients with abuse histories may have a post-traumatic etiology. _____
Title: Sleep and the pathogenesis of PTSD. Author(s): Mellman, Thomas Alan, Dartmouth Hitchcock Medical Ctr, Dept of Psychiatry, Lebanon, NH, US Source: Shalev, Arieh Y. (Ed); Yehuda, Rachel (Ed); et al; 2000. International handbook of human response to trauma. The Plenum series on stress and coping. Dordrecht, Netherlands: Kluwer Academic Publishers. pp. 299-306 Abstract: One of the prime symptoms of posttraumatic stress disorder (PTSD) is difficulty in sleep. Trauma survivors most often complain about insomnia and traumatic nightmares. This chapter provides a summary of studies of sleep in PTSD. It is argued that sleep has been one of the easier symptoms to study because it can be easily quantified by objective and relatively non-intrusive measures. However, contrasting with apparently ubiquitous clinical complaints of sleep disturbances, empirical observations have failed to observe a consistent pattern of sleep abnormalities in PTSD. The author suggests that it may be that the laboratory condition inadvertently provides a therapeutic and safe environment that lacks the normal cues that trigger disturbed sleep. Nonetheless, it is argued that the gains made in this area have direct relevance to the clinical treatment of sleep disorders associated with PTSD. _____
Title: Was Anna O.'s black snake hallucination a sleep paralysis nightmare? Dreams, memories, and trauma. Author(s): Powell, Russell A., Grant MacEwan Coll, Dept of Social Sciences, Edmonton, AB, Canada; Nielsen, Tore A. Source: Psychiatry: Interpersonal & Biological Processes, Vol 61(3), Fal 1998. pp. 239-248. Publisher: US: Guilford Publications. Abstract: This article offers a new interpretation of what J. Breuer believed was the precipitating event in Anna 0.'s illness: a terrifying hallucination of a black snake attacking her ailing father. This event has been variously interpreted as indicating an underlying psychodynamic conflict, as a temporal lobe seizure, and as an hypnotic confabulation. The authors argue, however, that the hallucination--during which Anna O.'s arm was reportedly "asleep" due to nerve blockage--was probably a sleep paralysis nightmare. Sleep paralysis nightmares continue to be overlooked or misdiagnosed in clinical practice, and, in recent years, have been implicated in the controversy surrounding memories of trauma and sexual abuse. _____
Title: Using sleep dysfunction to explore the nature of resilience in adult survivors of childhood abuse or trauma. Author(s): Chambers, Elisha, Brock U, Dept of Psychology, St Catharines, ON, Canada; Belicki, Kathy Source: Child Abuse & Neglect, Vol 22(8), Aug 1998. pp. 753-758. Abstract: In early studies, resilience to trauma was equated with psychological well-being. This study explores the possibility that such resilience is better described as social-behavioral competency and that, in turn, such competency can conceal emotional pain. A university sample of 79 women and 18 men (aged 18-24 yrs) completed measures of childhood abuse and trauma resilient characteristics, and sleep dysfunction. The measures of sleep problems could be divided into those tapping psychological well-being (e.g., nightmare frequency) and those reflecting social-behavioral functioning (e.g., measures of the impact of nightmares on waking functioning). 53 Ss reported experiencing one or more types of trauma or abuse in childhood. As a group they scored more negatively than those reporting no abuse on measures of sleep dysfunction. Resilient characteristics were only related to measures of social-behavioral functioning, not well-being. These findings are consistent with current conceptualizations of trauma/abuse recovery as involving multiple dimensions of functioning, some of which are more publicly observable than others. Therefore, some apparently resilient individuals may have good social-behavioral competency while still experiencing psychological pain. _____
Title: A variant of the Kleine-Levin syndrome following head trauma. Author(s): Kostic, Vladimir S., Clinical Ctr of Serbia, Inst of Neurology, Belgrade, Yugoslavia; Stefanova, E.; Svetel, M.; Kozic, D. Source: Behavioural Neurology , Vol 11(2), 1998. pp. 105-108. Publisher: Netherlands: IOS Press. Abstract: A 19-yr-old man developed the Kleine-Levin syndrome 3 wks after head trauma and subsequent neurosurgical evacuation of a right-sided, fronto-temporal epidural hematoma. The expression of periodic episodes was observed for hypersomnolence and, to a lesser degree, for behavioral disturbances, while the hyperphagia was constantly present during a period of 1.5 yrs. These clinical features were associated with the focal, right-sided hypothalamic lesion and ipsilateral posttraurnatic parenchymal temporal lobe damage on NMR imaging. _____
Title: Self-reported sleep disturbances: A comparison of adult female rape victims with PTSD and non-traumatized women. Author(s): Reed, Carole-Rae, U Pennsylvania, US Source: Dissertation Abstracts International: Section B: The Sciences & Engineering , Vol 58(7-B), Jan 1998. pp. 3562. Publisher: US: Univ Microfilms International. Abstract: Post-traumatic Stress Disorder (PTSD) frequently occurs as a response to rape. Rape victims and other trauma survivors frequently report sleep disturbances following the traumatic event. Responses of 23 rape victims with PTSD and 23 comparison women to sleep-related items on four standardized instruments were analyzed. The instruments used were the Impact of Events Scale (Horowitz, Wilner, Alvarez, 1979), the Symptom Checklist-90-Revised (Derogatis, 1977), the Beck Depression Inventory (Beck, Rush, Shaw, & Emery, 1979), and the PENN Inventory for Posttraumatic Stress Disorder (Hammarberg, 1990). All sleep-related items analyzed showed significant positive associations with rape and PTSD. Predictive power of each item was assessed. Being awakened from sleep during the rape was not significantly associated with self-reported sleep disturbances. Findings support the assertion that sleep disturbances are a hallmark of PTSD (Ross et al., 1989). The Information Processing of Trauma Model (Burgess & Hartman, 1988; Hartman & Burgess, 1988) was supported and its usefulness in predicting and explaining response to sexual trauma was expanded to include adult female rape victims. Future research in sleep and trauma with female populations is strongly indicated. _____
Title: Convergent validity of three posttraumatic symptoms inventories among adult sexual abuse survivors. Author(s): Gold, Jeffrey W. , Key Program, Springfield, MA, US; Cardena, Etzel Source: Journal of Traumatic Stress, Vol 11(1), Jan 1998. pp. 173-180. Publisher: US: Kluwer Academic/Plenum Publishers. Abstract: Tested the convergent validity of the Civilian Mississippi Scale for posttraumatic stress disorder (PTSD) (CM-PTSD), the Trauma Symptom Checklist-40, and the Response to Childhood Incest Questionnaire (RCIQ) among 52 20-58 yr old sexual abuse survivors. Ss completed the questionnaires used to assess posttraumatic symptomatology. Statistical analyses showed that the 3 inventories were significantly and substantially correlated with each other when RCIQ mean scores were used instead of the numerical tally of items marked other than 0. The CM-PTSD factor and RCIQ subscales that addressed core PTSD symptoms were significantly correlated with emotional dysphoria, social alienation/detachment, dissociation, sleep disorders and other symptoms commonly associated with traumatic events. The results suggest that these 3 inventories, to an extent, tap the same underlying construct and are valid measures of posttraumatic symptomatology in the sexual abuse population. _____
Title: Sleep disturbance, fears, and global adjustment in clinical samples of sexually abused and nonsexually abused children. Author(s): Larson, Elisabeth Joyce, Southern Illinois U Carbondale, US Source: Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 57(10-B), Apr 1997. pp. 6581. Publisher: US: Univ Microfilms International. Abstract: Sleep disturbance and fears have been clinically associated with the trauma of child sexual abuse, and have been linked to two prominent models for understanding sexual abuse sequelae (i.e., Post-Traumatic Stress Disorder and the Traumagenic Dynamics model proposed by Finkelhor & Browne, 1985). In addition, clinicians have often associated sleep disturbance with general anxiety and, more specifically, with fears reflective of children's life circumstances. The present study examined global adjustment, fears, sleep disturbance, and the relationships between sleep problems and fears in clinical groups of sexually abused and nonsexually abused children. Archival samples of 6-12 year-old boys and girls presenting for outpatient treatment were obtained. Child self-report measures included the Sleep Problems Checklist, Louisville Fear Survey for Children, and Sexual Abuse Fear Evaluation. Parent-report instruments included the Sleep Problems Checklist and the Child Behavior Checklist. The results provided no support for the hypothesis that sexually abused children exhibit more fears than nonsexually abused children, and only partial support for the hypothesis that victims experience more sleep disturbance than nonvictims. There was a tendency for parents of molested children to describe their children as experiencing more Externalizing symptoms than parents of nonmolested children. Gender differences in specific Internalizing symptoms were found, with girls reporting more fears and sleep problems than boys. Finally, the results did not support the hypothesis that sexually abused children's sleep disturbances are related to abuse-specific fears. Few sleep/fear correlates for victims were found, but numerous relationships between nonvictims' self-reported sleep difficulties and specific types of fears emerged. Implications of the results and suggestions for future research were discussed. _____
Title: EMDR. Eine neue Methode zur Behandlung posttraumatischer Belastungsstoerungen. Translated Title: Eye movement desensitization and reprocessing: A new treatment method for postraumatic stress-disorder. Author(s): Hofmann, Arne, Klinik Hohe Mark, Oberursel, Germany Source: Psychotherapeut, Vol 41(6), Nov 1996. pp. 368-372. Abstract: Studied the effectiveness of eye movement desensitization and reprocessing (EMDR) in the inpatient treatment of postraumatic stress-disorder (PSD). Human Ss: Eight male and female German adults (aged 26-46 yrs) (PSD). The Ss received 1-9 sessions of EMDR within the context of a psychodynamic inpatient therapy program. Subjective units of discomfort in relation to traumatic memories; other trauma-related symptoms (e.g., sleep disorders, intrusive memories, and avoidance behavior); and self-related cognitions were measured at the beginning and end of inpatient therapy and at 3-mo and 6-mo follow-ups to determine the therapeutic effects of EMDR. (English abstract) _____
Title: Stress, Trauma, and Sleep in Children. Author(s): Sadeh, Avi, Tel-Aviv U, Dept of Psychology, Tel Aviv, Israel Source: Child & Adolescent Psychiatric Clinics of North America, Vol 5(3), Jul 1996. pp. 685-700. Publisher: US: WB Saunders. Abstract: This article reviews the literature on the effects of trauma and stress on children's sleep patterns. Included are studies on "ex- perimental stress," response to separation and loss, response to war and disasters, and the consequences of child abuse. The importance of distinguishing between subjective and objective measures of sleep as well as the 2 basic modes of response of the sleep/wake system to stress are highlighted. Two case examples are provided. _____
Title: First night effects in post-traumatic stress disorder inpatients. Author(s): Woodward, Steven H., Palo Alto Dept of Veterans Affairs Medical Ctr, National Ctr for PTSD, Clinical/Education Div, Palo Alto, CA, US; Bliwise, Donald L.; Friedman, Matthew J.; Gusman, Fred D. Source: Sleep: Journal of Sleep Research & Sleep Medicine , Vol 19(4), May 1996. pp. 312-317. Publisher: US: American Sleep Disorders Assn. Abstract: Examined 1st night effects sleep data in 80 military inpatients hospitalized for post-traumatic stress disorder (PTSD), 7 nonhospitalized PTSD sufferers, 6 non-ill combat exposed Ss, and 8 non-ill trauma-free Ss. Ss schedule their own sleep within constraints imposed by the inpatient treatment program. The recording montage included electrooculogram (EOG), EEG, EMG, EKG, respiratory effort, and blood oxygen saturation. PTSD inpatients exhibited attenuated 1st night effects compared to non-hospitalized PTSD sufferers and non-trauma-exposed controls. Non-ill combat-exposed Ss also exhibited small 1st night effects. Within the inpatient sample, severity indices of PTSD, depression and anxiety failed to account for variance in 1st night effects. Results show attenuation of 1st night effects in a new inpatient population and suggest their statistical independence together with a range of relevant symptoms. Both the attenuation of 1st night effects in PTSD inpatients and their accentuation in PTSD outpatients may be indicative of enhanced sensitivity to the sleep environment. _____
Title: Circadian dysregulation in abused children. Author(s): Glod, Carol A., Boston Coll, US Source: Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 56(10-B), Apr 1996. pp. 5416. Publisher: US: Univ Microfilms International. Abstract: Childhood abuse has been associated with a variety of psychiatric sequelae, including Post-Traumatic Stress Disorder (PTSD). Several studies suggest that sleep disturbance may be a 'hallmark of PTSD' in adults. The purpose of this study is to assess whether intense averse stimulation during early development (in the form of physical and sexual abuse) leads to disruption of sleep/wake and rest/activity cycles. Methods. Sixteen hospitalized abused children (mean age 9.7 2.1; 4 females, 12 males) were compared with those of 15 healthy pediatric controls (mean age 8.3 1.9 yrs; 6 females, 9 males). All children were essentially medication-free and diagnoses were assessed via structured diagnostic interview (K-SADS-E). Abused children were one outpatient and 15 inpatients recruited from a child psychiatric unit, and had suffered substantiated episodes of either physical and/or sexual abuse. Children were studied using belt-worn ambulatory activity monitors (Motionlogger AM-16) for 72 consecutive hours, during weekdays, between day 3 and day 30 of admission. Results. The abused group reported a variety of psychological symptoms and had significantly higher scores on the Child Behavior Checklist. Abused children took over twice as long to fall asleep than controls, 27.9 22.9 vs. 11 8.8 minutes and had significantly poorer sleep efficiencies (92.9 3.8%) compared with controls (96.1 1.6%). Abused children had higher mean diurnal activity levels compared with controls, however, this just failed to reach statistical significance. Significant differences emerged in the circadian frequency, although both groups were well-entrained to a 24-hour day. The circadian acrophase occurred 62 minutes later in the abused group compared with controls. Discussion. These results are consistent with clinical observations suggesting behavioral and sleep disruption secondary to trauma. Quantifiable disturbances in sleep/wake and rest/activity cycles supports the results. _____
Title: Identifying sexual trauma histories from patterns of sleep and dreams. Author(s): Belicki, Kathryn, Brock U, St Catharines, ON, Canada; Cuddy, Marion Source: Barrett, Deirdre (Ed); 1996. Trauma and dreams. Cambridge, MA, US: Harvard University Press. pp. 46-55 Abstract: certain patterns of sleep and dream disturbance are associated with a history of sexual trauma / individuals who have been sexually abused are more likely to report frequent nightmares and sleep terrors, and they will experience greater disruption of their sleep / their nightmares will frequently involve explicit violence and are more likely to have sexual content / when sexuality appears it will usually be portrayed as involving guilt, shame, distrust, manipulation, or violence / those who have been sexually abused are more likely to dream of a threatening or evil presence, which may take human, animal/insect, or supernatural form / there is a greater tendency to describe dream characters' physical appearance or in some other context to mention physical anatomy / [suggest that it is worthwhile for therapists] to inquire into the quality of a client's sleep / to do so may assist a therapist in making an early identification of a client's history of trauma _____
Title: Sleep disturbance and its relationship to psychiatric morbidity after Hurricane Andrew. Author(s): Mellman, Thomas A., U Miami School of Medicine, Dept of Psychiatry, FL, US; David, Daniella; Kulick-Bell, Renee; Hebding, Joanne; et al. Source: American Journal of Psychiatry, Vol 152(11), Nov 1995. pp. 1659-1663. Publisher: US: American Psychiatric Assn. Abstract: Explored sleep disturbance and its relationship to post traumatic morbidity from evaluations done within a year after the trauma. Sleep and psychiatric symptoms of 54 victims of Hurricane Andrew who had no psychiatric illness in the 6 mo before the hurricane were evaluated. A subset of 10 hurricane victims with active psychiatric morbidity and 9 controls who were unaffected by the hurricane were examined in a sleep laboratory. A broad range of sleep-related complaints were rated as being greater after the hurricane, and psychiatric morbidity (most commonly post-traumatic stress disorder [PTSD], followed by depression) had a significant effect on most of the subjective sleep measures. REM density correlated positively with both the PTSD symptom of reexperiencing trauma and global distress. Ss affected by Hurricane Andrew reported sleep disturbances, particularly those Ss with psychiatric morbidity. _____
Title: Military socialization during the Vietnam era: Differentiated aspects of trauma and conditioned responses. Author(s): Alcaras, David, U California, San Diego, US Source: Dissertation Abstracts International Section A: Humanities & Social Sciences , Vol 56(4-A), Oct 1995. pp. 1530. Publisher: US: University Microfilms International. Abstract: It is popularly believed that military combat veterans of the Vietnam war suffer from a form of Post Traumatic Stress Disorder (PTSD), which is directly associated to a traumatic experience(s) related to war. This research departs from the notion that a traumatic event in and of itself changes forever the life of an individual. This study's purpose is to examine military socialization, war trauma, the social learning dynamic, and the moral conflict within the social context of the Vietnam era as a powerful influence on the outcome of the Vietnam veteran's life experience. The phenomena of the Vietnam veteran's war experience e.g. death, dying, killing, and general suffering, differs little from other veterans of other wars. How the war experience of the Vietnam veteran becomes defined by non-combatants, and more importantly how the veteran's response to the aftermath of war fall within the realm of mental illness appears to be more a function of the moral conflict surrounding the war than the effects of the war itself. Those behaviors which are attributed to PTSD, e.g. anger, rage, isolation, avoidant behaviors, intrusive recollection of the military and war, and a myriad of sleep disorders, are viewed here as ego defense mechanisms developed in military training, war, and during the re-entry period. Hence, rather than seeing the veteran's life as a series of re-enactments of the trauma in an effort to 'make it right this time', the veteran's life experience is differentiated; some behaviors owed to trauma, others to military socialization and a form of psychological conditioning unique to military training during the Vietnam era. _____
Title: Refugee stress and folk belief: Hmong sudden deaths. Author(s): Adler, Shelley R., U California, Dept of Epidemiology & Biostatistics, Div of Medical Anthropology, San Francisco, US Source: Social Science & Medicine, Vol 40(12), Jun 1995. pp. 1623-1629. Publisher: US: Elsevier Science. Abstract: Investigated the relationship between a traditional nocturnal spirit encounter and Hmong Sudden Unexpected Nocturnal Death Syndrome (SUNDS) with 118 Hmong men and women living in the US. Ss were interviewed regarding their awareness of and personal experience with the nightmare spirit, cultural beliefs and immigrant experiences. While both men and women have the nightmares, regardless of traditional or Christian religious orientation, the supranormal attack acts as a trigger for SUNDS mostly in Hmong men. The combination of powerful traditional belief in the nightmare spirit, combined with traumas of war, immigration and acculturation, crates psychological stress resulting in SUNDS. _____
Title: Ethnomedical pathogenesis and Hmong immigrants' sudden nocturnal deaths. Author(s): Adler, Shelley R. , U California, Div of Medical Anthropology, Dept of Epidemiology & Biostatistics, San Francisco, US Source: Culture, Medicine & Psychiatry, Vol 18(1), Mar 1994. pp. 23-59. Publisher: Netherlands: Kluwer Academic. Abstract: Investigated Hmong traditional beliefs to isolate the trigger event underlying sudden unexpected death syndrome (SUNDS) among Hmong refugees. Interviews with 118 Hmong Ss revealed that dab tsog or nightmare attacks on Hmong men are more frequent as a result of recent and severe sociocultural change. These attacks can result in extreme stress for the victim. Compounded with factors such as the trauma of war, migration, rapid acculturation, and the inability to practice traditional healing and ritual, the power of traditional belief in the nightmare appears to cause cataclysmic psychological stress that can result in death from SUNDS among male Hmong refugees. Case studies of 4 men (aged 31-58 yrs) are also included. _____
Title: Sleep and dreams in well-adjusted and less adjusted Holocaust survivors. Author(s): Kaminer, Hanna, Israel Inst of Technology, Faculty of Medicine, Haifa, Israel; Lavie, Peretz Source: Stroebe, Margaret S. (Ed); Stroebe, Wolfgang (Ed); et al; 1993. Handbook of bereavement: Theory, research, and intervention. New York, NY, US: Cambridge University Press. pp. 331-345 Abstract: examine the assumption that a connection exists between disturbances in sleep patterns and nightmares [of Holocaust survivors] . . . and variables of coping of trauma survivors [average age 60.2 years] / examine the mechanisms that enabled some of the survivors to cope well even though they had undergone severe trauma _____
Title: The new primal scream: Primal therapy 20 years on. Author(s): Janov, Arthur, Primal Training Ctr, Director, Los Angeles, CA, US Source: 1991. Wilmington, DE, US: Enterprise Publishing, Inc. xiii, 380 pp. Abstract: In "The New Primal Scream," Dr. Arthur Janov details exactly how ridding the mind of repressed, early childhood or infant traumas has been scientifically linked to the reduction of many serious medical problems. Problems such as stress, anxiety, depression, sleep disorders, high blood pressure, cancer, drug and alcohol addiction, sexual difficulties, phobias, obsessions, ulcers, migraines, asthma, and even arthritis. "The New Primal Scream" is the culmination of Janov's life work, featuring completely new case histories, observations, and clinical research not dealt with previously. Primal therapy is able to reduce or eliminate a host of physical and psychic ailments in a relatively short period of time with lasting results. This book is not just about psychotherapy. It is about the human condition. It is about how to detect neurosis and how we know what is normal. It is about weeping and its role in health for each of us. It is about anxiety and depression and what they really are. It is about despair and hope, and the silent scream known as illness. It is about the malignancy of hopelessness, tumorous despression, broken dreams, and ruptured relationships. It concerns the nature of love. And finally, it is about real intelligence, not about being cultured, educated, and erudite. It is about being able to love and to give, to survive, and to lead a life which is intelligent, one that is neither self-destructive nor hurts others. Table of Contents: (Abbreviated) Acknowledgements Introduction: Primal therapy twenty years later Part one: Why we get sick ..The basic human needs ..Primal pain: The great hidden secret ..Repression: The gates of the brain and the loss of feeling ..Levels of consciousness and the nature of mind ..Alietta ..How early experience is imprinted ..Acting neurotic: Symbolic acting out ..Birth trauma: Life-long consequences of birth ..The birth prototype and the later personality
Part two: The forms of neurosis ..Stress, anxiety, and tension: Symptoms of disease ..Malignant despair: Repression and the immune system ..Illness as the silent scream ..Sex, sensuality, and sexuality
Part three: How we get well ..On the nature of normal ..The role of weeping in psychotherapy ..Why do you have to relive your childhood to get well? ..Primal therapy today ..Nadine ..Conclusions: Primal therapy twenty years later Epilogue Index _____
Title: Escape stress, sleep disorders, and assimilation of refugees. Author(s): Cernovsky, Zack Z. , St Thomas Psychiatric Hosp, ON, Canada Source: Social Behavior & Personality , Vol 18(2), 1990. pp. 287-297. Publisher: New Zealand: Society for Personality Research. Abstract: 38 Czechoslovak refugees (aged 24-71 yrs) living in Switzerland completed a questionnaire that included the Gough-Sanford Rigidity Scale, an escape scale, an assimilation scale, a measure of life stress, and a measure of sleep disorders. Repetitive nightmares about escaping their homeland were more frequent in Ss who described their real life act of escape as more frightening or risky. The incidence of escape nightmares correlated significantly with the extent of stress during the S's actual escape. The level of satisfaction with life in the host country was unrelated to the incidence of escape nightmares but was inversely related to incidence of other sleep problems (restless sleep and difficulties falling asleep). _____
Title: Brother to brother: Integrating concepts of healing regarding male sexual assault survivors and Vietnam veterans. Author(s): Evans, Mark C., New Medico Highwatch, Rehabilitation Counselor, Ossipee, NH, US Source: Hunter, Mic (Ed); 1990. The sexually abused male, Vol. 2: Application of treatment strategies. Lexington, MA, England: Lexington Books/D. C. Heath and Com. pp. 57-78 Abstract: the assessment and treatment models for returning Vietnam veterans have paralleled the experience of those treating the psychological wounds of sexual assault survivors / briefly reviews both treatment models and their separation in implementation / compares the symptomatologies and treatment protocols of rape trauma and delayed stress syndrome (DSS), both of which are considered posttraumatic stress disorders (PTSDs) (American Psychiatric Association 1980) / implications for treatment and suggested protocols also are included / comparing the posttraumatic stress disorders of two syndromes / sleep disorders / social and behavioral issues / sexual dysfunction / survivor support networks / guilt _____
Title: Sleep in the dementing disorders. Author(s): Prinz, Patricia, U Washington, University Hosp, Psychiatry & Behavioral Sciences, Clinical Research Ctr, American Lake Veterans Administration Medical Ctr, Sleep & Aging Research Program, Seattle, WA, US; Poceta, J. Steven; Vitiello, Michael V. Source: Nebes, Robert D. (Ed); Corkin, S. (Ed); 1990. Handbook of neuropsychology, Vol. 4. Handbook of neuropsychology. New York, NY, US: Elsevier Science. pp. 335-347 Abstract: aged / nocturnal respiratory dysfunction (sleep apnea) / nocturnal myoclonus / sleep disturbance secondary to physical illness or toxic metabolic states / sleep disturbances secondary to psychiatric illness / sleep disturbance associated with drug and alcohol use / sleep disturbances related to circadian rhythm changes / other sleep disorders / sleep disturbance secondary to dementing conditions / brain structure and sleep-wake function / sleep change associated with AD [Alzheimer's disease] / sleep changes associated with other dementing disorders [Parkinson's disease, alcohol and alcoholic dementia, cerebrovascular disorders, head trauma, Pick's disease, Huntington's disease (HD), other degenerative disorders] _____
Title: The nightmare: A riding ghost with sexual connotations. Author(s): Haga, Eivind, Sentralsjukehuset i Rogaland, Psykiatrisk Avdeling, Stavanger, Norway Source: Nordisk Psykiatrisk Tidsskrift , Vol 43(6), 1989. pp. 515-520. Publisher: Norway: Scandinavian Univ Press. Abstract: Describes the nightmare phenomenon from folkloristic, etymologic, historical-medical, and psychological viewpoints. Victims of the nightmare (a riding ghost) feel an intense anxiety, with pressure on the chest and a helpless paralysis. Etymology and folklore stress the traumatic etiologic aspect of the nightmare phenomenon, as well as its sexual connotations. Modern sleep researchers are uncertain whether REM nightmares or sleep-terror episodes can have a traumatic origin, but adults with these disorders often display symptoms of other mental disorders. The possibility that the common features of so many nightmares reflect real sexual traumas to a greater extent than hitherto recognized is discussed. _____
Title: Sleep patterns in trauma victims with disturbed dreaming. Author(s): Kramer, Milton , Bethesda Oak Hosp, Sleep Disorders Ctr of Greater Cincinnati, OH, US; Kinney, Lois Source: Psychiatric Journal of the University of Ottawa, Vol 13(1), Mar 1988. pp. 12-16. Publisher: Canada: Canadian Medical Assn. Abstract: Investigated the sleep pattern of 8 dream-disturbed Vietnam combat veterans in the sleep laboratory and compared it with that of 8 combat veterans with alternate symptoms of posttraumatic stress disorder (PTSD). Sleep in both groups was lighter and more disrupted than normal. The dream-disturbed group was distinguished by a longer REM latency and more spontaneous awakenings during non-REM during the 1st half of the night. PTSD was diagnosed in full-blown form in each dream-disturbed S and in none of the comparison group. The possibility of PTSD in a latent form in this latter group was suggested by the sleep disturbances. A circadian rhythm disturbance is hypothesized to underlie the altered sleep and a vulnerability to a recurring PTSD. _____
Title: Passage a l'acte et fonction onirique. Translated Title: Acting out and dream function. Author(s): Baldacci, J.-L. , Ctr Hospitalier Specialise de Maison-Blanche, Neuilly-sur-Marne, France Source: Information Psychiatrique, Vol 60(10), Dec 1984. pp. 1229-1241. Publisher: France: Editions Privat. Abstract: Describes acting out and its underlying language as a consequence of a functional alteration of dream life, linked to archaic pregenital fixations and psychic traumas actually experienced in childhood. Case examples are presented, and this theory is discussed in terms of sleepwalking, dreams, nightmares, and traumatic neurosis models. (English, Spanish & Italian abstracts) (29 ref) _____
Title: Posttraumatic excessive daytime sleepiness: A review of 20 patients. Author(s): Guilleminault, Christian , Stanford U School of Medicine, Sleep Disorders Ctr; Faull, Kym F.; Miles, Laughton; Van den Hoed, Johanna Source: Neurology , Vol 33(12), Dec 1983. pp. 1584-1589. Publisher: US: Lippincott Williams & Wilkins. Abstract: 20 18-59 yr old patients complaining of excessive daylight somnolence (EDS) secondary to significant head trauma were studied objectively. Several polygraphic recording protocols were performed over the 12-yr study period. CSF analysis for specific neurotransmitter metabolites' evaluation did not differentiate posttraumatic EDS Ss from narcoleptics or other Ss with EDS. Objective testing in posttraumatic sleepiness is recommended because of the plurality of problems and medicolegal implications. (19 ref) _____
Title: Nonprocess autism in children: A comparative etiopathogenic study. Author(s): Kagan, V. E., Leningrad Specialized Dept for the Treatment of Neuroses in Children & Adolescents, USSR Source: Soviet Neurology & Psychiatry, Vol 14(1-sup-2), Spr-Sum 1981. pp. 25-30. Publisher: US: M.E. Sharpe, Inc.. Abstract: Compared etiological and developmental factors of 38 autistic children (aged 3-16 yrs) with those of 53 children with schizophrenia, 30 children with organic brain damage partially manifested as autism, and 30 children with communication difficulties secondary to neuroses. It was found that over 94% of autistic Ss had been born from a 1st pregnancy and that in a considerable number of the pregnancies the mother had experienced toxicosis, infectious or viral diseases, poisoning, trauma, or other complications. Common disorders in the autistic Ss during the 1st 3 yrs of life included hyperactivity, sleep disorders, digestive disorders, and poor coordination. The most characteristic feature of early psychomotor development was uneven and asynchronic maturation of functions such as walking and talking. Two or more signs of organic brain damage were found in over 94% of autistic Ss, and many showed disturbances in differentiation of "right" from "left." An analysis of intellectual development indicated that the average level was lower than in healthy peers but higher than in mentally retarded children of the same age. Analysis of speech behavior, memory, and thought indicated a depressed activation of the right hemisphere. The author discusses these results as supporting the theory that autism is a nonprogressive, qualitatively unique residual organic disorder since no exacerbations, remissions, or transformations were found. (14 ref) Sleep Disorders and Traumatic Stress
Title: The mediating effects of sleep in the relationship between traumatic stress and health symptoms in urban police officers. Author(s): Mohr, David, dmohr@itsa.ucsf.edu, Dept of Veterans Affairs Medical Ctr, San Francisco, CA, US; Vedantham, Kumar ; Neylan, Thomas; Metzler, Thomas J.; Best, Suzanne; Marmar, Charles R. Address: Mohr, David, VA Medical Ctr, 4150 Clement Street (116A), San Francisco, CA, US, 94121, dmohr@itsa.ucsf.edu Source: Psychosomatic Medicine, Vol 65(3), May-Jun 2003. pp.485-489. Publisher: US: Lippincott Williams & Wilkins. Abstract: Objective: Posttraumatic stress symptoms have been associated with increased health problems across numerous studies. Sleep disruption, one of the principal symptoms resulting from traumatic stress, has also been shown to produce health problems. This study explored the hypothesis that the relationship between posttraumatic stress symptoms and health is mediated by sleep problems. Method: A sample of 741 police officers were administered measures of traumatic stress symptoms, sleep, health functioning, and somatic symptoms. Results: Traumatic stress symptoms were significantly related to both somatic symptoms (R-sup-2=0.18, p < .001) and health functioning (R-sup-2=0.02, p < .01). The relationship between somatic symptoms and traumatic stress symptoms was partially mediated by sleep (p < .001). The relationship between traumatic stress symptoms and health functioning was fully mediated by sleep. Conclusions: Although design characteristics, such as cross-sectional sampling, limit the inferences that can be drawn, these findings suggest that sleep may serve as an important mediator between traumatic stress and somatic symptoms. _____
Title: Sleep in post-traumatic stress disorder and panic: Convergence and divergence. Author(s): Sheikh, Javaid I., Sheikh@stanford.edu, Veterans Affairs Palo Alto Healthcare System, Menlo Park, CA, US; Woodward, Steven H., Veterans Affairs Palo Alto Healthcare System, Menlo Park, CA, US; Leskin, Gregory A. , Veterans Affairs Palo Alto Healthcare System, Menlo Park, CA, US Address: Sheikh, Javaid I., VA Palo Alto Health Care System (116A-MP), 795 Willow Road, Menlo Park, CA, US, 94025, Sheikh@stanford.edu Source: Depression & Anxiety, Vol 18(4), 2003. Special Issue: Panic and sleep disorders. pp. 187-197. Publisher: US: John Wiley & Sons. Abstract: Disturbed sleep is a common clinical problem in anxiety disorders, particularly in patients with post-traumatic stress disorder (PTSD) and panic disorder (PD). Several studies have attempted to validate the subjective sleep complaints of these disorders using laboratory polysomnography. These attempts, typically focusing on PTSD or PD independently, have demonstrated inconsistent results. To our knowledge, no such studies have attempted to directly compare and contrast sleep disturbances in PTSD and PD together. Our review of the studies of subjective sleep disturbances, sleep architecture, and sleep-related biologic phenomena suggests that a comparative characterization of sleep disturbances in these two disorders is timely. Such an inference is based on our identification of several areas of convergence and divergence between PTSD and PD found in the published literature, as well as our own preliminary investigations. Specifically, PTSD and PD seem to converge on several sleep-related parameters, namely, sleep quality, presence of episodic parasomnias, and movement time... _____
Title: "Sleep disturbances in the wake of traumatic events." Comment. Author(s): Rothbaum, Barbara O. , Emory U, School of Medicine, Atlanta, GA, US; Foa, Edna B., U Pennsylvania, School of Medicine, Philadelphia, PA, US Source: New England Journal of Medicine, Vol 346(17), Apr 2002. pp. 1334-1335. Publisher: US: Massachusetts Medical Society. Abstract: Comments on the article by P. Lavie concerning sleep disturbances and traumatic events. The authors adamantly disagree with Lavie's conclusions regarding the treatment of traumatized persons with chronic psychiatric disturbances such as posttraumatic stress disorder (PTSD). The authors believe that advising survivors to "leave traumatic memories behind" is counterproductive, and physicians should not recommend such avoidance to their patients. _____
Title: Post-traumatic stress disorder and sleep. Author(s): Van Ommeren, Mark, Transcultural Psychosocial Organization, Amsterdam, Netherlands; De Jong, Joop T. V. M., Transcultural Psychosocial Organization, Amsterdam, Netherlands; Komproe, Ivan, Transcultural Psychosocial Organization, Amsterdam, Netherlands Source: New England Journal of Medicine, Vol 346(17), Apr 2002. pp. 1334. Publisher: US: Massachusetts Medical Society. Abstract: Comments on the article by P. Lavie concerning sleep disturbances and traumatic events. The authors state that Lavie has shown that objective, sleep-laboratory measures do not consistently support the subjective reports of insomnia given by Western survivors of traumatic events and that an explanation is not given for this inconsistency. It is believed that future investigations will confirm that insomnia is not specific to posttraumatic stress disorder (PTSD) but that trauma-related nightmares are a core symptom of the disorder _____
Title: "Sleep disturbances in the wake of traumatic events." Reply. Author(s): Lavie, Peretz , Technion-Israel Inst of Technology, Haifa, Israel Source: New England Journal of Medicine, Vol 346(17), Apr 2002. pp. 1335. Publisher: US: Massachusetts Medical Society. Abstract: Replies to the comment by B. O. Rothbaum and E. B. Foa concerning the article by P. Lavie which discussed sleep disturbances and traumatic events. The author states that none of the references that Rothbaum and Foa cite in their letter provide evidence that prolonged exposure is effective in severely traumatized patients. _____
Title: No evidence of sleep disturbance in post-traumatic stress disorder: A polysomnographic study in injured victims of traffic accidents. Author(s): Klein, Ehud, Rambam Medical Ctr, Dept of Psychiatry, Haifa, Israel; Koren, Danny, Rambam Medical Ctr, Dept of Psychiatry, Haifa, Israel; Arnon, Isaac, Rambam Medical Ctr, Dept of Psychiatry, Haifa, Israel; Lavie, Peretz , Technion-Israel Inst of Technology, Rappaport Faculty of Medicine, Sleep Lab, Haifa, Israel Address: Klein, Ehud, Rambam Medical Ctr,Dept of Psychiatry, Haifa, Israel, e_klein@rambam.health.gov.il Source: Israel Journal of Psychiatry & Related Sciences, Vol 39(1), 2002. pp. 3-10. Publisher: Israel: Gefen Publishing House. Abstract: Examined the relationship of posttraumatic stress disorder (PTSD) and sleep disturbances. 14 injured traffic accident victims (aged 18-65 yrs), some of whom were diagnosed with PTSD, completed a 3-night polysomnographic (PSG) study 1 yr following the accident. Ss also completed questionnaires concerning PTSD, insomnia, daytime sleepiness, and general psychiatric symptomatology. Results show no significant differences between PTSD and non-PTSD Ss on any of the PSG measures, nor any differences concerning awakening thresholds during REM sleep. PTSD Ss attained higher scores concerning avoidance and depression. _____
Title: Current concepts: Sleep disturbances in the wake of traumatic events. Author(s): Lavie, Peretz , Technion-Israel Inst of Technology, Faculty of Medicine, Sleep Lab, Haifa, Israel Address: Lavie, Peretz, Technion-Israel Inst of Technology, Sleep Lab, Gutwirth Bldg., Technion City, Haifa, Israel Source: New England Journal of Medicine, Vol 345(25), Dec 2001. pp. 1825-1832. Publisher: US: Massachusetts Medical Society. Abstract: Summarizes existing knowledge about the immediate and long-term effects of traumatic events on sleep, and offers guidelines for the treatment of trauma-related sleep disturbances. Charts of sleep stages of normal sleep and 2 types of insomnia that are typically found in traumatized patients are shown. It is argued that sleep disturbances in traumatized patients are complex behavioral events. In many cases, the subjective reports are out of proportion to the frequency and severity of objective sleep-laboratory findings, and patients are generally unaware of the true nature of their sleep disturbances. In contradiction to the hypothesis that patients with posttraumatic stress disorder (PTSD) must sleep lightly, patients with PTSD appear to have deeper sleep and lower rates of dream recall than normal persons. The author maintains that sleep disturbances in traumatized patients should be treated as an independent clinical entity, and both behavioral and pharmacologic therapies can be beneficial. _____
Title: A retrospective study on improvements in nightmares and post-traumatic stress disorder following treatment for co-morbid sleep-disordered breathing. Author(s): Krakow, Barry, U New Mexico Health Sciences Ctr, UNM Sleep Research, Albuquerque, NM, US; Lowry, Carmen; Germain, Anne; Gaddy, Lane; Hollifield, Michael; Koss, Mary; Tandberg, Dan; Johnston, Lisa; Melendrez, Dominic Source: Journal of Psychosomatic Research, Vol 49(5), Nov 2000. pp. 291-298. Publisher: US: Elsevier Science. Abstract: Assessed the impact of treatment for comorbid sleep-disordered breathing (SDB) on patients with nightmares and posttraumatic stress disorder (PTSD). 23 chronic nightmare sufferers (15 with PTSD) who also suffered comorbid SDB (16 with obstructive sleep apnea, OSA; 7 with upper airway resistance syndrome, UARS) completed a telephone interview, on average, 21 mos 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, 9 in the Treatment Group reported a median 75% improvement in PTSD symptoms whereas 6 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. _____
Title: Olanzapine for nightmares and sleep disturbances in posttraumatic stress disorder (PTSD). Author(s): Labbate, Lawrence A.; Douglas, Susan Source: Canadian Journal of Psychiatry, Vol 45(7), Sep 2000. pp. 667-668. Publisher: Canada: Canadian Psychiatric Assn. Abstract: Describes a case of successful olanzapine treatment of insomnia and nightmares associated with posttraumatic stress disorder (PTSD) in a 58-yr-old male combat veteran who developed symptoms of intense anxiety, nightmares, panic attacks, and avoidance of social situations following his experience as an infantryman in the Viet Nam war. The authors state that the patient's mood and anxiety were reasonably well controlled on sertaline. However because he continued to suffer frequent nightmares and sleep disturbances as well as hallucinations while falling asleep, a trial of olanzapine, at bedtime, was begun. The patient noted that after 2 nights his sleep quality improved dramatically, and after 1 wk he no longer experienced nightmares. _____
Title: Post-traumatic stress disorder as a consequence of a toxic spill in northern California. Author(s): Freed, Deborah, California School of Professional Psychology-Berkeley/Alameda, Alameda, CA, US; Bowler, Rosemarie; Fleming, India Source: Journal of Applied Social Psychology, Vol 28(3), Feb 1998. pp. 264-281. Publisher: US: VH Winston & Son. Abstract: Examined the development of PTSD and associated features among residents of Dunsmuir, California, following the 1991 railroad toxic spill of the soil fumigant sodium methyldithiocarbamate (metam sodium). Classification of PTSD was based on a cutoff score from the Impact of Event Scale. It was predicted that greater exposure to the spill would increase the risk of PTSD and associated symptoms among spill residents (SRs); that those classified with PTSD would report more symptoms than would those without PTSD and controls; and that litigants would be classified with PTSD more than would nonlitigants. Results suggest that SRs classified with PTSD had greater levels of tension, depression, anxiety, anger, fatigue, and confusion than did SRs without PTSD and control residents with and without PTSD. SRs with PTSD reported more memory problems and sleep disorders than did those without PTSD and control residents with and without PTSD. Measures of physiological arousal showed that SRs had higher systolic blood pressure several hours after a stressful interview than did control residents without PTSD. Pulse rates several hours after a stressful interview were higher for SRs with and without PTSD than for control residents with PTSD. _____
Title: Self-reported sleep disturbances: A comparison of adult female rape victims with PTSD and non-traumatized women. Author(s): Reed, Carole-Rae, U Pennsylvania, US Source: Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 58(7-B), Jan 1998. pp. 3562. Publisher: US: Univ Microfilms International. Abstract: Post-traumatic Stress Disorder (PTSD) frequently occurs as a response to rape. Rape victims and other trauma survivors frequently report sleep disturbances following the traumatic event. Responses of 23 rape victims with PTSD and 23 comparison women to sleep-related items on four standardized instruments were analyzed. The instruments used were the Impact of Events Scale (Horowitz, Wilner, Alvarez, 1979), the Symptom Checklist-90-Revised (Derogatis, 1977), the Beck Depression Inventory (Beck, Rush, Shaw, & Emery, 1979), and the PENN Inventory for Posttraumatic Stress Disorder (Hammarberg, 1990). All sleep-related items analyzed showed significant positive associations with rape and PTSD. Predictive power of each item was assessed. Being awakened from sleep during the rape was not significantly associated with self-reported sleep disturbances. Findings support the assertion that sleep disturbances are a hallmark of PTSD (Ross et al., 1989). The Information Processing of Trauma Model (Burgess & Hartman, 1988; Hartman & Burgess, 1988) was supported and its usefulness in predicting and explaining response to sexual trauma was expanded to include adult female rape victims. Future research in sleep and trauma with female populations is strongly indicated. _____
Title: Sleep disturbance, fears, and global adjustment in clinical samples of sexually abused and nonsexually abused children. Author(s): Larson, Elisabeth Joyce, Southern Illinois U Carbondale, US Source: Dissertation Abstracts International: Section B: The Sciences & Engineering , Vol 57(10-B), Apr 1997. pp. 6581. Publisher: US: Univ Microfilms International. Abstract: Sleep disturbance and fears have been clinically associated with the trauma of child sexual abuse, and have been linked to two prominent models for understanding sexual abuse sequelae (i.e., Post-Traumatic Stress Disorder and the Traumagenic Dynamics model proposed by Finkelhor & Browne, 1985). In addition, clinicians have often associated sleep disturbance with general anxiety and, more specifically, with fears reflective of children's life circumstances. The present study examined global adjustment, fears, sleep disturbance, and the relationships between sleep problems and fears in clinical groups of sexually abused and nonsexually abused children. Archival samples of 6-12 year-old boys and girls presenting for outpatient treatment were obtained. Child self-report measures included the Sleep Problems Checklist, Louisville Fear Survey for Children, and Sexual Abuse Fear Evaluation. Parent-report instruments included the Sleep Problems Checklist and the Child Behavior Checklist. The results provided no support for the hypothesis that sexually abused children exhibit more fears than nonsexually abused children, and only partial support for the hypothesis that victims experience more sleep disturbance than nonvictims. There was a tendency for parents of molested children to describe their children as experiencing more Externalizing symptoms than parents of nonmolested children. Gender differences in specific Internalizing symptoms were found, with girls reporting more fears and sleep problems than boys. Finally, the results did not support the hypothesis that sexually abused children's sleep disturbances are related to abuse-specific fears. Few sleep/fear correlates for victims were found, but numerous relationships between nonvictims' self-reported sleep difficulties and specific types of fears emerged. Implications of the results and suggestions for future research were discussed. _____
Title: Effects of trazodone on sleep in patients diagnosed with post-traumatic stress disorder (PTSD). Author(s): Ashford, J. Wesson; Miller, Thomas W. Source: Journal of Contemporary Psychotherapy, Vol 26(3), Fal 1996. pp. 221-233. Publisher: US: Kluwer Academic/Plenum Publishers. Abstract: Investigated the subjective effects and efficacy of trazodone on 48 veteran patients diagnosed with posttraumatic stress disorder (PTSD) and identified sleep disturbance as a critical factor in their diagnostic symptomology. Patients received variable dosages of trazodone ranging from prn orders (25 mg) to 500 mg at bedtime. Results show 20 of the 21 under 60 and 24 out of 27 over 60 had positive responses to bedtime trazodone doses, in that they slept better, including going to sleep more quickly, having fewer nightmares, and had less anger the next day. These benefits may be due to deepened nonREM sleep early in the night as well as delayed REM sleep onset. _____
Title: Evaluation of Parasomnias in Children. Author(s): Rosen, Gerald M., Hennepin County Medical Ctr, Minnesota Regional Sleep Disorders Ctr, Minneapolis, MN, US; Ferber, Richard; Mahowald, Mark W. Source: Child & Adolescent Psychiatric Clinics of North America, Vol 5(3), Jul 1996. pp. 601-616. Publisher: US: WB Saunders. Abstract: Discusses parasomnias among children, described as undesirable motor, autonomic, or experiential phenomena that occur exclusively or predominately during sleep. The parasomnias that most often come to the attention of medical or psychiatric care providers are unusual arousals out of sleep. The differential diagnosis for these arousals includes disorders of arousal, nocturnal dissociative states, gastroesophageal reflux, sleep apnea, conditioned arousals, nightmares, post-traumatic stress disorder, and nocturnal panic. The sleep history, sleep diary, and medical and neurologic histories are the most important tools for working through this differential. Occasionally, polysomnography is necessary in these evaluations. In the majority of cases, an accurate diagnosis can be established and an effective treatment instituted.
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Title: First night effects in post-traumatic stress disorder inpatients. Author(s): Woodward, Steven H., Palo Alto Dept of Veterans Affairs Medical Ctr, National Ctr for PTSD, Clinical/Education Div, Palo Alto, CA, US; Bliwise, Donald L.; Friedman, Matthew J.; Gusman, Fred D. Source: Sleep: Journal of Sleep Research & Sleep Medicine, Vol 19(4), May 1996. pp. 312-317. Publisher: US: American Sleep Disorders Assn. Abstract: Examined 1st night effects sleep data in 80 military inpatients hospitalized for post-traumatic stress disorder (PTSD), 7 nonhospitalized PTSD sufferers, 6 non-ill combat exposed Ss, and 8 non-ill trauma-free Ss. Ss schedule their own sleep within constraints imposed by the inpatient treatment program. The recording montage included electrooculogram (EOG), EEG, EMG, EKG, respiratory effort, and blood oxygen saturation. PTSD inpatients exhibited attenuated 1st night effects compared to non-hospitalized PTSD sufferers and non-trauma-exposed controls. Non-ill combat-exposed Ss also exhibited small 1st night effects. Within the inpatient sample, severity indices of PTSD, depression and anxiety failed to account for variance in 1st night effects. Results show attenuation of 1st night effects in a new inpatient population and suggest their statistical independence together with a range of relevant symptoms. Both the attenuation of 1st night effects in PTSD inpatients and their accentuation in PTSD outpatients may be indicative of enhanced sensitivity to the sleep environment. _____
Title: Circadian dysregulation in abused children. Author(s): Glod, Carol A., Boston Coll, US Source: Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 56(10-B), Apr 1996. pp. 5416. Publisher: US: Univ Microfilms International. Abstract: Childhood abuse has been associated with a variety of psychiatric sequelae, including Post-Traumatic Stress Disorder (PTSD). Several studies suggest that sleep disturbance may be a 'hallmark of PTSD' in adults. The purpose of this study is to assess whether intense averse stimulation during early development (in the form of physical and sexual abuse) leads to disruption of sleep/wake and rest/activity cycles. Methods. Sixteen hospitalized abused children (mean age 9.7 2.1; 4 females, 12 males) were compared with those of 15 healthy pediatric controls (mean age 8.3 1.9 yrs; 6 females, 9 males). All children were essentially medication-free and diagnoses were assessed via structured diagnostic interview (K-SADS-E). Abused children were one outpatient and 15 inpatients recruited from a child psychiatric unit, and had suffered substantiated episodes of either physical and/or sexual abuse. Children were studied using belt-worn ambulatory activity monitors (Motionlogger AM-16) for 72 consecutive hours, during weekdays, between day 3 and day 30 of admission. Results. The abused group reported a variety of psychological symptoms and had significantly higher scores on the Child Behavior Checklist. Abused children took over twice as long to fall asleep than controls, 27.9 22.9 vs. 11 8.8 minutes and had significantly poorer sleep efficiencies (92.9 3.8%) compared with controls (96.1 1.6%). Abused children had higher mean diurnal activity levels compared with controls, however, this just failed to reach statistical significance. Significant differences emerged in the circadian frequency, although both groups were well-entrained to a 24-hour day. The circadian acrophase occurred 62 minutes later in the abused group compared with controls. Discussion. These results are consistent with clinical observations suggesting behavioral and sleep disruption secondary to trauma. Quantifiable disturbances in sleep/wake and rest/activity cycles supports the results. _____
Title: Sleep disturbance and its relationship to psychiatric morbidity after Hurricane Andrew. Author(s): Mellman, Thomas A., U Miami School of Medicine, Dept of Psychiatry, FL, US; David, Daniella; Kulick-Bell, Renee; Hebding, Joanne; et al. Source: American Journal of Psychiatry, Vol 152(11), Nov 1995. pp. 1659-1663. Publisher: US: American Psychiatric Assn. Abstract: Explored sleep disturbance and its relationship to post traumatic morbidity from evaluations done within a year after the trauma. Sleep and psychiatric symptoms of 54 victims of Hurricane Andrew who had no psychiatric illness in the 6 mo before the hurricane were evaluated. A subset of 10 hurricane victims with active psychiatric morbidity and 9 controls who were unaffected by the hurricane were examined in a sleep laboratory. A broad range of sleep-related complaints were rated as being greater after the hurricane, and psychiatric morbidity (most commonly post-traumatic stress disorder [PTSD], followed by depression) had a significant effect on most of the subjective sleep measures. REM density correlated positively with both the PTSD symptom of reexperiencing trauma and global distress. Ss affected by Hurricane Andrew reported sleep disturbances, particularly those Ss with psychiatric morbidity. _____
Title: Military socialization during the Vietnam era: Differentiated aspects of trauma and conditioned responses. Author(s): Alcaras, David, U California, San Diego, US Source: Dissertation Abstracts International Section A: |
