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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 PTSD
Title: Parasomnias as neuropsychiatric complications of electrical injury. Author(s): Ghaemi, S. Nassir , Harvard Medical School, Massachusetts General Hosp, Dept of Psychiatry, Boston, US; Irizarry, Michael C. Source: Psychosomatics: Journal of Consultation Liaison Psychiatry, Vol 36(4), Jul-Aug 1995. pp. 416. Publisher: US: American Psychiatric. Abstract: Reports an unusual case of adult-onset parasomnias as neuropsychiatric complications of electrical injury. S was a 34-yr-old male who had experienced an electrical shock for 12-25 sec and later experienced vivid nightmares, symptoms of PTSD, and sleepwalking. _____
Title: The Massachusetts General Hospital Annotated Bibliography: For residents training in consultation-liaison psychiatry. Author(s): Cremens, M. Cornelia , Massachusetts General Hosp, Dept of Psychiatry, Boston, US; Calabrese, Lori Viscogliosi; Shuster, John L.; Stern, Theodore A. Source: Psychosomatics: Journal of Consultation Liaison Psychiatry, Vol 36(3), May-Jun 1995. pp. 217-235. Publisher: US: American Psychiatric. Abstract: Presents a 129-item annotated bibliography of articles published over the last decades for the resident's division of the Avery D. Weisman Psychiatry Consultation Service at the Massachusetts General Hospital. Some of the topics covered in the bibliography include delirium and agitation, forensic psychiatry, somatoform disorders, the suicidal patient, child psychiatry consultation, ECT, anxiety, depression, pain management, psychostimulants, drug withdrawal states, factitious disorder, geriatric psychiatry, posttraumatic stress disorder (PTSD), cancer, and sleep disorders. _____
Title: Neuropsychiatric syndrome and psychological symptoms in patients with advanced cancer. Author(s): Breitbart, William , Memorial Sloan-Kettering Cancer Ctr, New York, NY, US; Bruera, Eduardo; Chochinov, Harvey; Lynch, Mary Source: Journal of Pain & Symptom Management, Vol 10(2), Feb 1995. pp. 131-141. Publisher: US: Elsevier Science. Abstract: Discusses contributions of a panel of the National Cancer Institute of Canada Workshop on Symptom Control and Supportive Care in Patients with Advanced Cancer on October 28-29, 1993. Presentations focused on prevalence, assessment, and intervention in mood disorders (depression) and cognitive disorders (delirium). For future research, panelists recommended (1) an emphasis on symptom control and supportive care, (2) uniform terminology and diagnostic classification systems, (3) use of existing validated tools and measures in prevalence and intervention research, (4) development of new tools and measures more applicable and relevant to palliative care settings, and (5) prevalence and intervention studies in neuropsychiatric disorders and other areas affecting cancer patients, such as anxiety disorders, posttraumatic stress disorder (PTSD), sleep disorders, fatigue and tension, and suicidal ideation and desire for hastened death. _____
Title: Motor dysfunction during sleep in posttraumatic stress disorder. Author(s): Ross, Richard J. , Veterans Affairs Medical Ctr, Psychiatry Service, Philadelphia, PA, US; Ball, William A.; Dinges, David F.; Kribbs, Nancy B.; et al. Source: Sleep: Journal of Sleep Research & Sleep Medicine, Vol 17(8), Dec 1994. pp. 723-732. Publisher: US: American Sleep Disorders Assn. Abstract: Studied anterior tibialis muscle activity during sleep in a group of 12 Vietnam combat veterans with current posttraumatic stress disorder (PTSD) and in an age-matched normal control group. The PTSD Ss had a higher percentage of REM sleep epochs with at least 1 prolonged twitch burst; they also were more likely to have periodic limb movements in sleep, during nonrapid eye movement sleep. Both these forms of muscle activation also have been observed in REM behavior disorder (RBD), a parasomnia characterized by the actual enactment of dream sequences during REM sleep. The identification of RBD-like signs in PTSD adds to the evidence for a fundamental disturbance of REM sleep phasic mechanisms in PTSD. _____
Title: The polysomnographic effects of clonidine on sleep disorders in posttraumatic stress disorder: A pilot study with Cambodian patients. Author(s): Kinzie, J. David, Oregon Health Sciences U, Dept of Psychiatry, Portland, US; Sack, Robert L.; Riley, Crystal M. Source: Journal of Nervous & Mental Disease, Vol 182(10), Oct 1994. pp. 585-587. Publisher: US: Lippincott Williams & Wilkins. Abstract: Recorded the sleep of 4 Cambodian women with posttraumatic stress syndrome and major depressive disorder using all-night polysomnograph recordings (PR). Ss were then given clonidine and evaluated psychiatrically. Ss had frequent awakenings, reduced REM latencies, and reduced sleep efficiency. Ss also reported intrusive, disturbing nightmares in REM sleep, non-REM sleep, and wakefulness. Subjectively, clonidine had a consistent beneficial effect. Ss reported better sleep, less daytime irritability, and many fewer nightmares. However, after taking clonidine the PR recordings showed decreased sleep efficiency and there was no improvement in the number of awakenings. Further, REM sleep was eliminated in 2 patients after taking clonidine. _____
Title: Abuse of children in day care centres: Characteristics and consequences. Author(s): Kelley, Susan J., Boston Coll School of Nursing, Dept of Maternal Child Health, Chestnut Hill, MA, US Source: Child Abuse Review, Vol 3(1), Mar 1994. pp. 15-25. Publisher: US: John Wiley & Sons. Abstract: Discusses day care sexual abuse cases as warranting a specialized treatment approach. The article proposes that the characteristics of abuse in day care settings merit special attention despite commonalities shared with sexual abuse in other settings. These factors include the young age of the victims, the involvement of multiple victims and multiple perpetrators, females as perpetrators, use of extreme threats, severity of the abuse, and in some instances ritualistic activities. Literature is reviewed examining the consequences of abuse in day care. The findings suggest a negative impact on children including anxiety, excessive fearfulness, behavioral disturbances, sexual acting out and sleep disorders, and parents appear to experience psychological distress with symptoms consistent with post-traumatic stress disorder (PTSD). Implications focus on specialized treatment with a major goal of decreasing symptomatology among family members. _____
Title: Sleep disorders and stress. Author(s): Partinen, Markku, U Helsinki Kivelae Hosp, Dept of Neurology, Finland Source: Journal of Psychosomatic Research, Vol 38(Suppl 1), 1994. pp. 89-91. Publisher: US: Elsevier Science. Abstract: Reviews the relationship between stress (ST) and sleep disorders (SDs). ST is associated with SDs in 2 ways: ST provokes SDs, and disturbed sleep provokes ST and increases risk for conditions such as cardiovascular disease. The exact relationship between SD and ST is complicated, given the close relationship of ST to anxiety and depression. ST is probably the most frequent cause of transient insomnia, and various SDs are very common among patients with posttraumatic stress disorder (PTSD). Therapy for ST-related insomnia consists mainly of behavior treatment with reassurance, support, and education; the treatment of PTSD-related insomnia is similar and includes psychotherapy with reassurance and pharmacotherapy. _____
Title: Sleep disorders in the elderly: Depression and post-traumatic stress disorder. Author(s): Guerrero, Jose, U Sevilla, Spain; Crocq, Marc-Antoine Source: Journal of Psychosomatic Research, Vol 38(Suppl 1), 1994. pp. 141-150. Publisher: US: Elsevier Science. Abstract: Reports on 2 studies of sleep (SL) disorders in the elderly. The 1st study examined the interactions between age, SL complaints, severity of disease, melancholic features and somatic symptoms, and treatment response in outpatient Ss with unipolar depression. 198 Ss under age 55 yrs and 198 Ss over age 65 yrs were evaluated. SL complaints were more frequent and more severe in the elderly, and anxiety was strongly associated with initial or terminal insomnia in the elderly. The 2nd study examined SL and aging in 817 former prisoners of war (average age 67 yrs) who responded to a mailed survey. Most Ss still suffered traumatic nightmares more than 40 yrs after their imprisonment. Symptoms of posttraumatic stress disorder (PTSD) were related both to combat and to captivity where mortality exceeded 50%. _____
Title: Behandeling van chronische posttraumatische stress-stoornis met fluvoxamine. Een open onderzoek. Translated Title: Fluvoxamine treatment for chronic PTSD. Author(s): de Boer, M. C. , St. Lucas Ziekenhuis, Amsterdam, Netherlands; Op den Velde, W.; Falger, P. R. J.; Hovens, J. E.; et al. Source: Tijdschrift voor Psychiatrie , Vol 36(5), 1994. pp. 335-342. Publisher: Netherlands: Uitgeverij Boom. Abstract: Studied the effectiveness of fluvoxamine in reducing the symptoms of posttraumatic stress disorder (PTSD). Human Ss: 24 male and female Dutch adults (aged 64-69 yrs) (PTSD due to experiences in the Second World War). In particular, changes in depression, sleep problems, anxiety, and vital exhaustion were assessed. After a 2 wk washout period, Ss received daily doses of fluvoxamine, beginning with 50 mg and increasing over 4 wks to 150-300 mg. The treatment continued for 12 wks. Ss' symptoms were measured at the beginning of the treatment and after 4 and 12 wks of treatment. Tests used: The Global Clinical Impression Scale, the Self-Rating Depression Scale, the State-Trait Anxiety Inventory and the Maastricht Questionnaire for Vital Exhaustion (A. Appels et al, 1987). (English abstract) _____
Title: Clinical uses of benzodiazepines. Author(s): Hollister, Leo E., U Texas Health Science Ctr, Dept of Psychiatry, Houston, US; Mueller-Oerlinghausen, Bruno; Rickels, Karl; Shader, Richard I. Source: Journal of Clinical Psychopharmacology , Vol 13(6, Suppl 1), Dec 1993. pp. 169. Publisher: US: Lippincott Williams & Wilkins. Abstract: Reviews literature on the range of clinical applications in which benzodiazepines have been tried and evaluates evidence for their efficacy in each. Topics examined in the review include the use of benzodiazepines for treating conditions such as anxiety disorders including phobias and posttraumatic stress disorder (PTSD); sleep disorders; mood disorders; anxiety associated with medical illness; and psychotic symptoms and disorders. Also addressed is benzodiazepine treatment for conditions such as convulsive disorders, involuntary movement disorders, spastic disorders and acute muscle spasms, and intoxication and withdrawal from alcohol and other substances. Findings from the review indicate that the widespread use of benzodiazepines for the treatment of these and other conditions is justified. The use of benzodiazepines is also concluded to be of value for ECT and for medical/diagnostic procedures. _____
Title: Eye-movement desensitization: A simple treatment for post-traumatic stress disorder? Author(s): Page, Andrew C., U New South Wales, Clinical Research Unit for Anxiety Disorders-St Vincent's Hosp, Sydney, Australia; Crino, Rocco D. Source: Australian & New Zealand Journal of Psychiatry, Vol 27(2), Jun 1993. pp. 288-293. Publisher: Australia: Blackwell Science Asia. Abstract: Describes eye movement desensitization and possible therapeutic effects, provides minimal criteria for deciding whether the treatment technique is effective, and critically evaluates presently available theoretical accounts with respect to posttraumatic stress disorder (PTSD). The method involves having the patient recall a traumatic experience, while following a therapist's finger; the procedure is repeated until the patient's discomfort level decreases. A case is reported of a 35-yr-old woman who had been robbed at gunpoint, subsequently developing sleep disorders and extreme nervousness. After a series of eye movement desensitization sessions, her distress level dropped significantly. Controlled trials are recommended to determine clinical efficacy of this method. _____
Title: Recurrent nightmares in posttraumatic stress disorder: Association with sleep paralysis, hypnopompic hallucinations, and REM sleep. Author(s): Hudson, James I., McLean Hosp, Belmont, MA, US; Manoach, Dara S.; Sabo, Alex N.; Sternbach, Stephen E.; et al. Source: Journal of Nervous & Mental Disease, Vol 179(9), Sep 1991. pp. 572-573. Publisher: US: Lippincott Williams & Wilkins. Abstract: A 36-yr-old woman with posttraumatic stress disorder (PTSD) experienced recurrent nightmares associated with sleep paralysis and hypnopompic hallucinations (vivid, dream-like hallucinations upon awakening). This association has 2 implications: (1) mentations of traumatic content with sleep paralysis and hypnopompic hallucinations are more terrifying than either experience alone and (2) a possible association between PTSD and REM sleep pathology. _____
Title: Infant psychiatry: Its relevance for the general psychiatrist. Author(s): Minde, K., The Montreal Children's Hosp, Dept of Psychiatry, Westmount, PQ, Canada; Benoit, D. Source: British Journal of Psychiatry, Vol 159, Aug 1991. pp. 173-184. Publisher: England: Royal Coll of Psychiatrists. Abstract: This review discusses 4 issues that have been specially important for the development of infant psychiatry: infant competence, continuity vs discontinuity of human development, the concept of internal representation, and temperament. The disorders of infancy are addressed including attachment disorder, failure to thrive, sleep disorders, aggression, adjustment reaction, posttraumatic stress disorder (PTSD), pervasive developmental disorder, and other conditions. The review also discusses the psychiatric assessment of infants and their families and the relevance of infant psychiatry for adult psychiatrists. _____
Title: "Sleep disturbance in PTSD": Reply. Author(s): Lipper, Steven; Edinger, Jack D.; Stein, Roy M. Source: American Journal of Psychiatry, Vol 147(12), Dec 1990. pp. 1697-1698. Publisher: US: American Psychiatric Assn. Abstract: Responds to J. S. March's comments concerning the speculation by S. Lipper et al that a disturbance in the regulation of REM sleep may be at the core of posttraumatic stress disorder (PTSD). It is noted that this hypothesis was originally proposed by R. J. Ross et al. _____
Title: Sleep disturbance in PTSD. Author(s): March, John S. Source: American Journal of Psychiatry, Vol 147(12), Dec 1990. pp. 1697. Publisher: US: American Psychiatric Assn. Abstract: Presents cases of a 40-yr-old woman and a 41-yr-old man with posttraumatic stress disorder (PTSD) that provide evidence counter to the views of R. J. Ross et al (see record 1989-33165-001) and S. Lipper et al (see record 1990-12426-001), who both speculated that a disturbance in the regulation of REM sleep is at the core of PTSD. It is not reasonable to infer that a disturbance in sleep regulation is any more the hallmark of PTSD than are other features of the disorder, particularly reexperiencing and phobic avoidance. _____
Title: Sleep disturbance and computerized axial tomographic scan findings in former prisoners of war. Author(s): Peters, Jeffrey, Veterans Affairs Medical Ctr, Pittsburgh, PA, US; Van Kammen, Daniel P.; Van Kammen, Welmoet B.; Neylan, Thomas C. Source: Comprehensive Psychiatry, Vol 31(6), Nov-Dec 1990. pp. 535-539. Publisher: US: WB Saunders. Abstract: 10 drug-free former American prisoners of war, captured on Bataan and Corregidor by the Japanese in World War II, participated in a study of the relationship between structural brain abnormalities on computerized axial tomography (CAT) scans and sleep EEG findings. All Ss had complaints of sleep disturbances and other posttraumatic stress disorder (PTSD)-related symptoms. Six of 10 Ss had no Stage 4 sleep and had significantly higher mean ventricular brain ratios. _____
Title: Affective disorders, DST, and treatment in PTSD patients: Clinical observations. Author(s): Olivera, Arturo A., Western Reserve Psychiatric Hosp, Northfield, OH, US; Fero, David Source: Journal of Traumatic Stress, Vol 3(3), Jul 1990. pp. 407-414. Publisher: US: Kluwer Academic/Plenum Publishers. Abstract: Examined the occurrence of major affective disorders (MADs) in 109 chronic posttraumatic stress disorder (PTSD) patients and the usefulness of the dexamethasone suppression test (DST) in supporting clinical diagnosis in an exclusively clinical setting. 65 Ss had current MADs. Of these 65, 56 had major depression, and 9 had bipolar disorder. Nonsuppression of the DST occurred only in Ss with concurrent MAD; the incidence of nonsuppression was 32.3%. Treatment effectively attained clinical improvement (i.e., resolution of depression, panic, anxiety, sleep disorders, tolerance, isolation) and conversion of nonsuppressor to suppressor state in these cases. The DST, cortisol suppression index, and inhibition of cortisol production index were useful to support the clinical diagnosis of MADs in PTSD patients. _____
Title: Sleep disturbance in Post-Traumatic Stress Disorder: A comparison with non-PTSD insomnia. Author(s): Inman, David J., Veterans Administration Medical Ctr, Coatesville, PA, US; Silver, Steven M.; Doghramji, Karl Source: Journal of Traumatic Stress, Vol 3(3), Jul 1990. pp. 429-437. Publisher: US: Kluwer Academic/Plenum Publishers. Abstract: Compared sleep disturbance in 35 Vietnam war combat veterans (aged 25-60 yrs) having posttraumatic stress disorder (PTSD) with 37 age-matched non-PTSD (NPTSD) patients having insomnia without other PTSD symptoms. PTSD Ss reported symptoms of anxiety, agitation, and concurrent body movement that were associated with insomnia. Nightmares of these Ss were more repetitive and more disruptive to sleep than those of NPTSD insomnia Ss. PTSD Ss also reported more fatigue during daytime functioning and more anxiety during waking hours, attributable to relationship, legal, financial, and physical difficulties, than NPTSD insomnia Ss. _____
Title: Parasomnias in children. Author(s): Mahowald, Mark W., Hennepin County Medical Ctr, Minnesota Regional Sleep Disorders Ctr, Minneapolis, US; Rosen, Gerald M. Source: Pediatrician , Vol 17(1), 1990. pp. 21-31. Publisher: Switzerland: S Karger AG. Abstract: Describes a clinical classification system for parasomnia and presents guidelines for evaluation and treatment. REM disorders include dream anxiety attacks, sleep paralysis, hypnagogic or hypnopompic hallucinations, and REM sleep behavior disorder. Sleep starts, partial arousals, and sleep drunkenness characterize nonrapid eye movement (NREM) disorders. Non-sleep stage parasomnias include bruxism, enuresis, rhythmic movement disorder, posttraumatic stress disorder (PTSD), periodic movements of sleep, and somniloquy. Secondary sleep parasomnias include central nervous system (CNS) cardiopulmonary, and gastrointestinal disorders. The importance of a thorough diagnostic work-up prior to treatment is stressed. _____
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 disturbance and PTSD. Author(s): Lipper, Steven; Edinger, Jack D.; Stein, Roy M. Source: American Journal of Psychiatry, Vol 146(12), Dec 1989. pp. 1644-1645. Publisher: US: American Psychiatric Assn. Abstract: Commends R. J. Ross et al for their call for precise descriptions of actual sleep patterns in a well-defined cohort of posttraumatic stress disorder (PTSD) patients and for sleep studies with polysomnography. The work of Ross et al is supplemented by findings from double-blind, placebo-controlled studies (e.g., M. Shestatzky et al) and information on carbamazepine. _____
Title: Dr. Ross and associates reply. Author(s): Ross, Richard J.; Ball, William A.; Sullivan, Kenneth A.; Caroff, Stanley N. Source: American Journal of Psychiatry, Vol 146(12), Dec 1989. pp. 1645. Publisher: US: American Psychiatric Assn. Abstract: Responds to comments by S. Lipper et al on the work of R. J. Ross et al regarding the pathophysiology of posttraumatic stress disorder (PTSD), focusing on narcolepsy, controlled drug studies, and the role of carbamazepine. Application of pharmacological probes to polysomnographic investigations will advance the testing of the hypothesis linking PTSD to dysfunctional REM sleep mechanisms. _____
Title: Sleep disturbance as the hallmark of posttraumatic stress disorder. Author(s): Ross, Richard J., Veterans Administration Medical Ctr, Psychiatry Service, Philadelphia, PA, US; Ball, William A.; Sullivan, Kenneth A.; Caroff, Stanley N. Source: American Journal of Psychiatry, Vol 146(6), Jun 1989. pp. 697-707. Publisher: US: American Psychiatric Assn. Abstract: The reexperiencing of a traumatic event in the form of repetitive dreams, memories, or flashbacks is one of the cardinal manifestations of posttraumatic stress disorder (PTSD). The dream disturbance associated with PTSD may be relatively specific for this disorder, and dysfunctional REM sleep mechanisms may be involved in the pathogenesis of the posttraumatic anxiety dream. Neurophysiological studies in animals suggests that central nervous system (CNS) processes generating REM sleep may participate in the control of the classical startle response, which may be akin to the startle behavior commonly described in PTSD patients. In speculating that PTSD may be fundamentally a disorder of REM sleep mechanisms, the present authors suggest several strategies for future research. _____
Title: Revising the differential diagnosis of the parasomnias in DSM-III--R. Author(s): Ross, Richard J., U Pennsylvania School of Medicine, Philadelphia, US; Ball, William A.; Morrison, Adrian R. Source: Sleep: Journal of Sleep Research & Sleep Medicine, Vol 12(3), Jun 1989. pp. 287-289. Publisher: US: American Sleep Disorders Assn. Abstract: Argues that parasomnias are not handled adequately in Diagnostic and Statistical Manual of Mental Disorders-III--Revised (DSM-III--R) and suggests that posttraumatic stress disorder (PTSD) and its associated anxious dreams be mentioned in the DSM-III--R differential diagnosis section because clinicians not accustomed to including PTSD among their range of diagnostic options may not consider it when evaluating patients with prominent anxiety dreams. _____
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: Ambulante slaapwaakpolygrafie bij een patient met PTSS. Translated Title: Ambulatory sleep^wake polygraphy in a patient suffering from PTSD. Author(s): de Groen, J. H., Academisch Ziekenhuis Maastricht, Afdeling Klinische Neurofysiologie, Netherlands; Bergs, P. P.; van Ammers, V. C. Source: Tijdschrift voor Psychiatrie, Vol 30(5), 1988. pp. 327-337. Publisher: Netherlands: Uitgeverij Boom. Abstract: Describes outpatient sleep-wake polygraphy in the case of a 73-yr-old World War II posttraumatic stress disorder (PTSD) victim. It is maintained that the findings revealed a sleep-apnea syndrome and internal dissociation of the circadian rhythms of several physiologic variables. The possible relationship with REM and nonrapid eye movement (NREM) night terrors is discussed. (English abstract) _____
Title: Clinical relevance of grief and mourning among Cambodian refugees. Author(s): Boehnlein, James K., U Pennsylvania School of Medicine, Robert Wood Johnson Foundation Clinical Scholars Program, Philadelphia, US Source: Social Science & Medicine, Vol 25(7), 1987. pp. 765-772. Publisher: US: Elsevier Science. Abstract: One to 2 million Cambodians were executed or died of disease and starvation during the rule of the Pol Pot government. It is suggested that many survivors of that catastrophe have developed symptoms of posttraumatic stress disorder. There is some evidence that the intrusive symptoms of this disorder (nightmares, sleep disorders, startle reactions) can be treated with medication. But other psychosocial problems similar to those found in chronic grief (avoidance behavior, shame, decreased involvement with other individuals) are more resistive to treatment. The interpretations of, or meanings given to, specific symptoms by the patient may be influenced by culturally-specific religious beliefs, rituals, and social traditions. These cultural factors have relevance for therapeutic interventions. The case study of a 45-yr-old widow is included. _____
Sleep Disorders and PTSD II ____
Title: Sleep Pathophysiology in Posttraumatic Stress Disorder and Idiopathic Nightmare Sufferers. Author(s): Germain, Anne, Sleep Research Center, Hopital du Sacre-Coeur de Montreal, Montreal, PQ, Canada; Nielsen, Tore A. , Sleep Research Center, Hopital du Sacre-Coeur de Montreal, Montreal, PQ, Canada Address: Germain, Anne, University of Pittsburgh School of Medicine, Department of Psychiatry, 3811 O'Hara Street, Suite E-1116, Pittsburgh, PA, US, 15213 Source: Biological Psychiatry, Vol 54(10), Nov 2003. pp. 1092-1098. Publisher: United Kingdom: Elsevier Science. Abstract: Nightmares are common in posttraumatic stress disorder (PTSD), but they also frequently occur in idiopathic form. Findings associated with sleep disturbances in these two groups have been inconsistent, and sparse for idiopathic nightmares. The aim of the present study was to investigate whether sleep anomalies in PTSD sufferers with frequent nightmares (P-NM) differ from those observed in non-PTSD, idiopathic nightmare (I-NM) sufferers and healthy individuals. Sleep measures were obtained from nine P-NM sufferers, 11 I-NM sufferers, and 13 healthy control subjects. All participants slept in the laboratory for two consecutive nights where electroencephalogram, electrooculogram, chin and leg electromyogram, electrocardiogram, and respiration were recorded continuously. Posttraumatic nightmare sufferers had significantly more nocturnal awakenings than did I-NM sufferers and control subjects. Elevated indices of periodic leg movements (PLMs) during rapid eye movement (REM) and non-REM sleep characterized both P-NM and I-NM sufferers. Posttraumatic nightmare sufferers exhibit more nocturnal awakenings than do I-NM sufferers and control subjects, which supports the hypothesis of hyperarousal in sleep in PTSD sufferers; however, elevated PLM indices in both P-NM and I-NM sufferers... _____
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: 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: 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: 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: Sleep in posttraumatic stress disorder. Author(s): Singareddy, Ravi Kumar , Wayne State U School of Medicine, Dept of Psychiatry & Behavioral Neurosciences, Detroit, MI, US; Balon, Richard , Wayne State U School of Medicine, Dept of Psychiatry & Behavioral Neurosciences, Detroit, MI, US; Address: Singareddy, Ravi Kumar, U Psychiatric Ctr--Jefferson, 2751 E. Jefferson, Suite 200, Detroit, MI, US, 48207, rsingare@med.wayne.edu Source: Annals of Clinical Psychiatry, Vol 14(3), Sep 2002. pp. 183-190. Publisher: US: Kluwer Academic. Abstract: Posttraumatic stress disorder (PTSD) is often associated with sleep disturbances. In this review, we focus on the published literature on subjective and objective findings of sleep in patients with PTSD. Insomnia and nightmares are most commonly reported subjective sleep disturbances. Polysomnographic investigations have frequently reported rapid eye movement (REM) sleep abnormalities in PTSD. However, studies have not been consistent about the type of REM sleep dysfunction in PTSD patients. Antidepressants such as nefazodone, trazodone, fluvoxamine, and imagery rehearsal therapy are found to be beneficial in the treatment of PTSD associated sleep disturbances as well as core symptoms of this anxiety disorder. We propose use of such modalities of treatment in PTSD patients with predominant sleep disturbances. Further studies are required to clarify polysomnographic sleep changes especially the role of REM sleep dysregulation and treatment of sleep disturbances in PTSD. _____
Title: Sleep pathophysiology and cognitive-behavioral treatment of posttraumatic and idiopathic nightmares. Author(s): Germain, Anne, Universite De Montreal, Canada Source: Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 63(1-B), Jul 2002. pp. 581. Publisher: US: Univ Microfilms International. Abstract: Complaints of disrupted sleep and nightmares are known to be highly prevalent in patients suffering from posttraumatic stress disorder (PTSD). However, no study has investigated the relationship between these two sleep phenomena in PTSD patients. It is possible that sleep disturbances in PTSD patients may arise from an underlying mechanism related to nightmares. If so, people who suffer from non-PTSD idiopathic nightmares (I-NM) should exhibit sleep disturbances comparable to these observed in PTSD patients who report frequent nightmares (P-NM). This also implies that nightmare alleviation should be accompanied by quantifiable improvements in sleep. The efficacy of imagery rehearsal (a cognitive-behavioural technique) for alleviating nightmare frequency and associated symptoms of psychological distress has been demonstrated but never independently replicated. Moreover, polysomnographic (PSG) methods have never been used to assess sleep quality both pre- and post-treatment in P-NM and I-NM patients. The goal of the first study was thus to investigate whether I-NM and P-NM patients exhibit more sleep anomalies than healthy control (CTL) participants, and whether sleep anomalies observed in the former two groups are similar. The goals of the second study were: (1) to independently replicate the efficacy of imagery rehearsal for alleviating nightmares, and (2) to investigate whether nightmare alleviation is associated with quantifiable improvements in sleep. In the first study, we demonstrated that both P-NM and I-NM patients exhibit more periodic leg movements in sleep (PLMS) than do healthy participants, but do not differ from each other on this measure. Further, P-NM patients demonstrate more nocturnal awakenings than do either I-NM patients or CTL participants. The results suggest that increased motor activity in sleep may be a correlate of intense negative dreaming in nightmare patients, whereas the increased number of nocturnal awakenings may be related to the hyperarousal component of PTSD. In the second study, the efficacy of imagery rehearsal for alleviating nightmares and waking symptoms of psychological distress was replicated. I-NM and P-NM patients demonstrated different patterns of response to treatment however. I-NM patients reported significantly fewer nightmares and bad dreams and a slight reduction in psychological distress. P-NM patients exhibited significant reduction in symptoms of psychological distress, but only slightly fewer bad dreams. Pre/post-treatment comparisons of sleep measures revealed that I-NM had significantly fewer PLMS in REM sleep post-treatment, whereas P-NM patients had increases in both the micro-arousal index and the REM density measure. These results suggest that a reduction in REM sleep motor activity parallels the reduction in frequency of disturbing dreams in I-NM patients only, and that these patients benefit primarily from the alleviation of nightmares. P-NM patients appear to benefit primarily from the alleviation of symptoms of waking psychological distress. In P-NM patients, treatment may also facilitate emotional processing during sleep, as suggested by the increased REM density and micro-arousal measures. _____
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: 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: An overview of coexisting conditions for women with AD/HD. Author(s): Nadeau, Kathleen G., Chesapeake Ctr for Attention & Learning Disorders, Silver Spring, MD, US; Quinn, Patricia O. Source: Nadeau, Kathleen G. (Ed); Quinn, Patricia O. (Ed); 2002. Understanding women with AD/HD. Silver Spring, MD, US: Advantage Books. pp. 152-176 Abstract: Notes that a broad range of conditions commonly coexist with attention deficit hyperactivity disorder (ADHD) in women. This chapter outlines the following comorbid conditions: depression, bipolar mood disorder, anxiety disorders, posttraumatic stress disorder (PTSD), addiction, eating disorders, sleeping problems, and learning disabilities. _____
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: The relationship of sleep quality and posttraumatic stress to potential sleep disorders in sexual assault survivors with nightmares, insomnia, and PTSD. Author(s): Krakow, Barry, Sleep & Human Health Inst, Albuquerque, NM, US; Germain, Anne; Warner, Teddy D.; Schrader, Ron; Koss, Mary; Hollifield, Michael; Tandberg, Dan; Melendrez, Dominic; Johnston, Lisa Address: Krakow, Barry, Sleep & Human Health Inst, 4775 Indian School Road NE, Suite 305, Albuquerque, NM, US, 87110, bkrakow@salud.unm.edu Source: Journal of Traumatic Stress, Vol 14(4), Oct 2001. pp. 647-665. Publisher: US: Kluwer Academic/Plenum Publishers. Abstract: Sleep quality and posttraumatic stress disorder (PTSD) were examined in 151 female sexual assault survivors (aged 18-74 yrs old), 77% of whom had previously reported symptoms of sleep-disordered breathing (SDB) or sleep movement disorders (SMD) or both. Ss also experienced chronic and frequent nightmares and insomnia complaints. Participants completed the Pittsburgh Sleep Quality Index (PSQI) and the Posttraumatic Stress Scale (PSS). High PSQI scores reflected extremely poor sleep quality and correlated with PSS scores. PSQI scores were greater in participants with potential SDB or SMD or both. PSQI or PSS scores coupled with body-mass index and use of antidepressants or anxiolytics predicted potential sleep disorders. The relationship between sleep and posttraumatic stress appears to be more complex than can be explained by the current PTSD paradigm; and, sleep breathing and sleep movement disorders may be associated with this complexity. _____
Title: Gabapentin in PTSD: A retrospective, clinical series of adjunctive therapy. Author(s): Hamner, Mark B., Ralph H. Johnson Veterans Affairs Medical Ctr, Charleston, SC, US; Brodrick, Peter S.; Labbate, Lawrence A. Address: Hamner, Mark B., Ralph H. Johnson VA Medical Ctr, 109 Bee Street-116, Charleston, SC, US, 29401, hamnermb@musc.edu Source: Annals of Clinical Psychiatry, Vol 13(3), Sep 2001. pp. 141-146. Publisher: US: Kluwer Academic. Abstract: Posttraumatic stress disorder (PTSD) symptoms may improve significantly with antidepressant medications, however some phenomena often remain refractory to the most commonly used treatments. Frequently, sleep disturbances, such as insomnia and nightmares, are symptoms of PTSD that are refractory to antidepressant treatment. Gabapentin, a novel anticonvulsant agent, has been of interest as a potential anxiolytic agent, but has not been evaluated in PTSD. The authors reviewed records of 30 consecutive patients (aged 41-70 yrs) who had been diagnosed with PTSD and had received gabapentin as an adjunctive medication. For each S, the target symptoms that led to the initiation of gabapentin treatment were identified. Using the most recent clinical data available, the change in target symptom severity following treatment was rated as unimproved, mildly improved, moderately improved, or markedly improved. The gabapentin was often first prescribed to facilitate sleep. 77% of patients showed moderate or greater improvement in duration of sleep, and most noted a decrease in the frequency of nightmares. Findings suggest that gabapentin may improve sleep difficulties in particular and also other symptoms associated with chronic PTSD. _____
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 difficulties and alcohol use motives in female rape victims with posttraumatic stress disorder. Author(s): Nishith, Pallavi, U Missouri-St Louis, Dept of Psychology, Ctr for Trauma Recovery, St Louis, MO, US; Resick, Patricia A.; Mueser, Kim T. Address: Nishith, Pallavi, U Missouri-St Louis, Ctr for Trauma Recovery, U-8 Weinman Building, 8001 Natural Bridge Road, St Louis, MO, US, 63121, pnishith@umsl.edu Source: Journal of Traumatic Stress, Vol 14(3), Jul 2001. pp. 469-479. Publisher: US: Kluwer Academic/Plenum Publishers. Abstract: Assessed the relationship between sleep difficulties and drinking motives in female rape victims with posttraumatic stress disorder (PTSD). 74 participants (aged 18-72 yrs) were assessed for PTSD symptoms, depression, sleep difficulties, and drinking motives. Results demonstrate that neither PTSD symptoms nor depression are related to any motives for using alcohol. On the other hand, after controlling for education, sleep difficulties are significantly related to drinking motives for coping with negative affect, but not pleasure enhancement or socialization. The findings suggest that sleep difficulties may be an important factor contributing to alcohol use in rape victims with PTSD. _____
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. 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: 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. 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: Posttraumatic stress disorder and sleep difficulty. Author(s): Jacobs-Rebhun, Scott; Schnurr, Paula P.; Friedman, Matthew; J.; Peck, Robert; Brophy, Michael; Fuller, Dwain Source: American Journal of Psychiatry, Vol 157(9), Sep 2000. pp. 1525-1526. Publisher: US: American Psychiatric Assn. Abstract: Conducted a double-blind, randomized, placebo-controlled trial of cyproheptadine for treating sleep problems found in posttraumatic stress disorder (PTSD). 69 male Vietnam veterans who had current combat-related PTSD were enrolled in a 2-wk trial across 2 sites. Posttreatment data on the Clinician Administered PTSD Scale, the Pittsburgh Sleep Quality Index, and a nightmare questionnaire were available for 60 Ss. Results suggest that cyproheptadine does not appear to be an effective treatment for sleep problems or combat-related PTSD and may even exacerbate sleep disturbance. _____
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: "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: PTSD, dementia, and sleep disorder: A possible association. Author(s): Verghese, Joe, Albert Einstein Coll of Medicine(Bronx), Dept of Neurology/Einstein Aging Study, Bronx, NY, US Source: Journal of the American Geriatrics Society, Vol 48(9), Sep 2000. pp. 1169-1170. Publisher: US: Blackwell Science. Abstract: Comments on the article by D. Johnston (see record 2000-13202-004) which described the association of posttraumatic stress disorder (PTSD) and dementia in WWII veterans. However, the nature and type of dementia in these patients was not specified. The current author believes that the clinical feature in these patients suggest a diagnosis of possible or probable dementia with Lewy bodies (DLB). The article stresses that there is a strong association with PTSD, dementia and sleep disorders. A subjective disturbance of sleep, including the occurrence of repetitive, stereotypical anxiety dreams is characteristic of PTSD. It is possible that in some patients PTSD and/or REM sleep behavior disorders may either herald or present with cognitive impairment, which may subsequently evolve into DLB. _____
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: Sleep breathing and sleep movement disorders masquerading as insomnia in sexual-assault survivors. Author(s): Krakow, Barry , U New Mexico Sleep Research, Albuquerque, NM, US; Germain, Anne; Tandberg, Dan; Koss, Mary; Schrader, Ron; Hollifield, Michael; Cheng, Diana; Edmond, Tonya Source: Comprehensive Psychiatry , Vol 41(1), Jan-Feb 2000. pp. 49-56. Abstract: A descriptive, hypothesis-generating study was performed with 156 female sexual-assault survivors (aged 18-74 yrs) who suffered from insomnia, nightmares, and posttraumatic stress disorder (PTSD). Ss completed 2 self-report sleep questionnaires to assess the potential presence of intrinsic sleep disorders. 77% of the sample (120 of 156) endorsed additional sleep complaints, besides their insomnia symptoms, that indicate the potential presence of sleep-disordered breathing ([SDB] 81 of 156, 52%) and sleep-related movement disorders ([SMD] 94 of 156, 60%). The potential for SDB was strongly correlated with the body mass index (BMI), an increase in arousal symptoms, and greater total PTSD severity. In some sexual assault survivors, the relationship between sleeplessness and posttraumatic stress may be caused or exacerbated by intrinsic sleep disorders, and not be solely a function of psychophysiological insomnia, the traditional diagnostic term usually offered to explain the sleep problems associated with PTSD. Prevalence studies that use objective diagnostic evaluations such as polysomnography are needed to test these hypotheses. _____
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: Sleep disturbances and nightmares as symptoms of posttraumatic stress disorder. Author(s): Jukic, Vlado, Psychiatric Hosp Vrapce, Zagreb, Croatia; Sumic, Jadranka Culav; Brecic, Petra; Muzinic-Masle, Lana; Source: Psychiatria Danubina , Vol 11(1-2), Jun 1999. pp. 13-17. Publisher: Croatia: Univ of Zagreb. Abstract: Examined the connection between sleep disturbance symptoms and stressful events experienced during the war in Croatia by traumatized war survivors. 150 former prisoners of war, 150 combat veterans and 75 women refugees were studied, all of whom were in psychiatric treatment and diagnosed with posttraumatic stress disorder (PTSD). Ss underwent a detailed psychiatric interview, with special emphasis on frequency and intensity of sleep disturbances and appearance of nightmares. Results show that, among general features of the observed groups, there were statistically significant differences in age and working status; former war prisoners and refugees also differed in professional and matrimonial status. There were no group differences with respect to sleep disturbances, but there were differences in the appearance and severity of nightmares. The former war prisoners, who all had combat experience and were refugees and victims in prison camps, showed the highest frequency of nightmares. There were no statistically significant differences between combat veterans and refugees, perhaps due to the persistence of stressful factors in everyday life of women refugees. _____
Title: A scale for assessing sleep hygiene: Preliminary data. Author(s): Blake, Dudley David , Dept of Veterans Affairs Medical Ctr, Evaluation & Brief Treatment Unit/Ward 2, Boise, ID, US; Gomez, Marcella Hurtado Source: Psychological Reports, Vol 83(3, Pt 2), Dec 1998. pp. 1175-1178. Publisher: US: Psychological Reports. Abstract: No reliable measure exists for assessing the nature and scope of adherence or nonadherence to effective sleep hygiene practices. Sleep hygiene refers to practices and behaviors that promote sleep quality and quantity. This report details the creation and empirical validation of the Sleep Hygiene Self-test. 52 combat veterans, patients in a treatment program for posttraumatic stress disorder (PTSD), completed the 30-item self-test prior to and after their participation in 5 wks of group therapy for sleep hygiene. Analysis indicated good internal consistency and suitability as a pre-posttest measure. _____
Title: Polysomnographic sleep is not clinically impaired in Vietnam combat veterans with chronic posttraumatic stress disorder. Author(s): Hurwitz, Thomas D., Minneapolis Veterans Affairs Medical Ctr, Minneapolis, MN, US; Mahowald, Mark W.; Kuskowski, Michael; Engdahl, Brian E. Source: Biological Psychiatry, Vol 44(10), Nov 1998. pp. 1066-1073. Abstract: Evaluated a group of Vietnam combat veterans (VCVs) with posttraumatic stress disorder (PTSD) using clinical polysomnographic techniques. 18 VCVs (aged 38-63 yrs) with PTSD and 10 healthy non-combat Vietnam era veterans participated in 2 nights of polysomnographic study and a multiple sleep latencies test. Ss also completed measures included the Beck Depression Inventory, the Beck Anxiety Inventory, the Zung Self-Rating Anxiety Scale, the Symptom Checklist-90, and a sleep disturbances questionnaire. No significant differences between groups were noted except for greater sleep onset latency to stage 2, and lower arousals/hour from stages 3 and 4 on night 2, and lower subjectively estimated total sleep time on night 1 in the PTSD Ss. Polysomnographically recorded sleep was notably better than expected in the presence of clinically significant PTSD with typical histories of disrupted sleep . In these Ss, there was no clinically significant sleep disorder or typical pattern of REM or non-REM sleep disturbance detectable by standard polysomnography. _____
Title: Posttraumatic stress disorder and obstructive sleep apnea syndrome. Author(s): Youakim, James M., Jefferson Medical Coll, Dept of Psychiatry & Human Behavior, Sleep Disorders Ctr, Philadelphia, PA, US; Doghramji, Karl; Schutte, Sharon L. Source: Psychosomatics: Journal of Consultation Liaison Psychiatry, Vol 39(2), Mar-Apr 1998. pp. 168-171. Abstract: Reports the case of a 42-yr-old man with posttraumatic stress disorder (PTSD) and severe obstructive sleep apnea syndrome (OSAS) whose PTSD symptoms abated when his OSAS was successfully treated. This case supports the notion that treatment of PTSD will be more successful if treatment of sleep complaints is emphasized and if sleep apnea and other sleep disorders are treated aggressively. The possibility of a connection between sleep-disordered breathing and PTSD, as seen in this case, has implications for understanding the physiology and treatment of PTSD. _____
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: Victimologie de la prise d'otage: Etude aupres de 29 victimes. Translated Title: Hostages victimology: Study of 29 victims. Author(s): Bigot, T., Groupe Hospitalier Cochin, Service de Psychiatrie, Paris, France; Ferrand, I. Source: Annales Medico-Psychologiques , Vol 156(1), Jan 1998. pp. 22-27. Publisher: France: Editions Elsevier. Abstract: Using a semi-structured interview technique, 29 victims of 2 types of hostage taking incidents (criminal and terrorist) were examined 6 mo following their release. About 65% of those interviewed acknowledged the presence of psychological symptoms. Those most frequently mentioned included weakness (66.7%), flashbacks (66.7%), sleep disorders (59.3%), hypervigilance (55.6%). Symptoms of posttraumatic stress disorder (PTSD), according to DSM-III-R, were found in about 25% of the cases as were generalized anxiety, depressive symptoms, and somatic symptoms. Others reported changes in their psychosocial functioning and a loss of confidence in the social system. _____
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: Diagnosis of governmental torture. Author(s): Genefke, Inge; Vesti, Peter Source: Jaranson, James M. (Ed); Popkin, Michael K. (Ed); 1998. Caring for victims of torture. Washington, DC, US: American Psychiatric Association. pp. 43-59 Abstract: The author's detail a series of "surprises" they discovered in their work. They note that "the criteria for posttraumatic stress disorder (PTSD) are not sufficient for the categorization of the entire picture after torture," but contend that those who survive governmental torture can readily be identified. The following topics are addressed: diagnosing torture; consensus group of the rehabilitation and research centre for torture victims; does a torture syndrome exist; can a person who has suffered governmental torture be diagnosed; psychosomatic complaints in torture victims; physical abuse: specific symptoms and objective findings; and altered sleep patterns. _____
Title: A parasomnia overlap disorder involving sleepwalking, sleep terrors, and REM sleep behavior disorder in 33 polysomnographically confirmed cases. Author(s): Schenck, Carlos H., Hennepin County Medical Ctr, Dept of Psychiatry, Minneapolis, MN, US; Boyd, Jeffrey L.; Mahowald, Mark W. Source: Sleep: Journal of Sleep Research & Sleep Medicine, Vol 20(11), Nov 1997. pp. 972-981. Publisher: US: American Academy of Sleep Medicine. Abstract: 23 male and 10 female patients (mean age 34 yrs) with combined (injurious) sleepwalking, sleep terrors, and rapid REM sleep behavior disorder (parasomnia overlap disorder) were gathered over an 8-yr period. Ss underwent clinical and polysomnographic evaluations. Age of parasomnia onset was 15-16 years (range 1-66). An idiopathic subgroup (N = 22) had a significantly earlier mean age of parasomnia onset than a symptomtic subgroup, whose parasomnia began with either of the following: neurologic disorders, nocturnal paroxysmal atrial fibrillation, posttraumatic stress disorder (PTSD)/major depression, chronic ethanol/amphetamine abuse and withdrawal, or mixed disorders. The rate of Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) Axis I psychiatric disorders and group scores on psychometric tests were not elevated. 15 Ss had previously received psychologic or psychiatric therapy for their parasomnia, without benefit. Treatment outcome was available for 20 Ss; 18 Ss had substantial parasomnia control with bedtime clonazepam, alprazolam and/or carbamazepine, or self-hypnosis. It is concluded that parasomnia overlap disorder is a treatable condition that emerges in various clinical settings and can be understood within the context of current knowledge on parasomnias and motor control/dyscontrol during sleep. _____
Title: A polysomnographic comparison of veterans with combat-related PTSD, depressed men, and non-ill controls. Author(s): Mellman, Thomas A., U Miami, School of Medicine, Miami Veterans Administration Medical Ctr Psychiatry Service, Miami, FL, US; Nolan, Bruce; Hebding, Joanne; Kulick-Bell, Renee; et al. Source: Sleep: Journal of Sleep Research & Sleep Medicine , Vol 20(1), Jan 1997. pp. 46-51. Publisher: US: American Sleep Disorders Assn. Abstract: Compared the polysomnographic indices of sleep disturbance and correlates of symptomatic awakenings in 25 38-48 yr old male patients with combat-related posttraumatic stress disorder (PTSD), 16 33-50 yr old male patients with principal diagnosis of major depression, and 10 asymptomatic male controls. Data were obtained from recordings made after an accommodation night. Sleep efficiency was decreased in the PTSD compared to the major depression and control groups. Likewise, REM density was comparably increased, while the amount of REM sleep was reduced. These sleep measures were not significantly associated with comorbid depression, substance-use disorder histories, or subclinical sleep apnea or limb movements within the PTSD group. These findings support sleep maintenance being impaired in chronic PTSD patients. Divergence of REM time between the clinical groups suggests the possibility of different underlying mechanisms. _____
Title: Psychobiology of sleep disturbances in posttraumatic stress disorder. Author(s): Mellman, Thomas A., U Miami, School of Medicine, Dept of Psychiatry, Miami, FL, US Source: Yehuda, Rachel (Ed); McFarlane, Alexander C. (Ed); 1997. Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Sciences, Vol. 821. New York, NY, US: New York Academy of Sciences. pp. 142-149 Abstract: Sleep disturbances are prominent features of posttraumatic stress disorder (PTSD). Two general dimensions of sleep disturbances exist in PTSD, 1 pertaining to arousal regulation and the other to the expression of memories in dreams. In this chapter, available phenomenological and polysomnographic findings regarding arousal patterns, dreaming, and REM physiology are reviewed in adults with PTSD. Implications for pathogenesis are discussed and preliminary observations relevant to treatment are presented. _____
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. Publisher: Germany: Springer-Verlag. 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: 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: 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: Gulf War syndrome: Polysomnographic study of eight cases. Author(s): Brown, Terry Michael , U Mississippi Medical Ctr, Sleep Disorder Ctr, Jackson, MS, US; Fleishman, Sam A.; Casanova, Manuel F. Source: Journal of Chronic Fatigue Syndrome, Vol 2(1), 1996. pp. 41-51. Publisher: US: Haworth Press. Abstract: Examined whether patients complaining of the "Gulf War Syndrome" might have hidden sleep disorders, or psychiatric disorders, similar to what has been described in patients with chronic fatigue syndrome and fibromyalgia. Eight consecutive Gulf War veterans (aged 28-49 yrs) from the VA Gulf War Registry and Evaluation program complaining of fatigue and other symptoms, were psychiatrically and polysomnographically screened. One S was found to have major depression and posttraumatic stress disorder (PTSD), while another had PTSD alone. The sleep diagnoses assigned to the 8 Ss were as follows: 3 Ss had sleep apnea syndrome, one of whom also had periodic limb movements of sleep disorder. Four Ss met criteria for periodic limb movements of sleep disorder. Four Ss had clinically significant sleep state-misperceptions. All of the patients' symptoms were reported as occurring subsequent to Gulf War deployment, and not prior to deployment. It is concluded that as with the classic fatigue syndromes such as chronic fatigue syndrome and fibromyalgia, Gulf War Syndrome patients may benefit from a more thorough investigation of their sleep and psychiatric status. _____
Title: Periodic limb movements of sleep in combat veterans with posttraumatic stress disorder. Author(s): Brown, Terry M., Augusta Veteran's Administration Medical Ctr, Augusta, GA, US; Boudewyns, Patrick A. Source: Journal of Traumatic Stress , Vol 9(1), Jan 1996. pp. 129-136. Publisher: US: Kluwer Academic/Plenum Publishers. Abstract: 25 veterans (mean age 46.4 yrs) suffering from combat-related posttraumatic stress disorder (PTSD) were studied for 1-4 nights with all-night polysomnography. All Ss had sleep complaints. Analysis reveals that 19 (76%) of the patients were found to have clinically significant periodic limb movements of sleep (PLMs) by the 2nd night of study. PLMs are associated with sleep complaints in normals. For this reason, the common assumption that sleep complaints in PTSD are related only to the psychiatric disorder itself are challenged. _____
Title: Subjective versus objective sleep in Vietnam combat veterans hospitalized for PTSD. Author(s): Woodward, Steven H., National Ctr of PTSD, Clinical/Educational Div, Palo Alto, CA, US; Bliwise, Donald L.; Friedman, Matthew J.; Gusman, D. Fred Source: Journal of Traumatic Stress, Vol 9(1), Jan 1996. pp. 137-143. Publisher: US: Kluwer Academic/Plenum Publishers. Abstract: 25 Vietnam combat veterans with chronic severe posttraumatic stress disorder (PTSD) completed a sleep self-report questionnaire on admission to an inpatient treatment program. Between 1 and 2 mo later each spent 3 or more nights in the sleep laboratory. When self-report and laboratory findings were compared, significant relationships were observed between sleep schedule items such as time-to-bed/time-out-of-bed and polysomnographic measures of sleep. In contrast, global ratings of sleep quality were generally unrelated to polysomnographic measures. These findings may have implications for survey research assessing sleep quality in traumatized populations. _____
Title: Late onset of posttraumatic stress disorde |
