Effectiveness of guided imagery to improve sleep quality among young adults with post-traumatic stress disorder (PTSD)

Update on Posttraumatic Stress Disorder and Implications for Acute and Critical Care APRNs.

This study examined the prevalence of lifetime traumatic events and current symptoms of posttraumatic stress disorder (PTSD) among treatment-seeking cocaine-dependent outpatients and compared patients with and without PTSD on current substance use, psychopathology, and sociodemographic characteristics. The subjects were 122 adult cocaine-dependent outpatients participating in a treatment outcome study of psychosocial therapy. In addition to standard self-report and interview measures of psychopathology and substance use, the subjects completed the Trauma History Questionnaire and the PTSD Checklist before entering treatment. These patients experienced a large number of lifetime traumatic events (mean = 5.7); men experienced more general disasters and crime-related traumas than women, and women experienced more physical and sexual abuse than men. According to self-report measures, 20.5% of the subjects currently met the DSM-III-R criteria for PTSD; the rate of PTSD was 30.2% among women and 15.2% among men. Patients with PTSD had significantly higher rates of co-occurring axis I and axis II disorders, interpersonal problems, medical problems, resistance to treatment, and psychopathology symptoms than patients without PTSD. Psychopathology symptoms represented the most consistent difference between the two groups and provided the best prediction of PTSD status in a logistic regression. However, the groups did not differ significantly in current substance use or sociodemographic characteristics. These findings underscore the value of screening substance abusers for PTSD, because it can identify a small but substantial number who might require additional treatment. Further studies of the relationship between PTSD and substance abuse appear warranted.

EMDR therapy administered to patients with cancer has proven to be effective in the reduction of posttraumatic stress disorder (PTSD) symptoms and PTSD diagnosis remission. The main objective of this study was to measure the PTSD scores and diagnosis changes before and after the provision of the EMDR-Protocol for Recent Critical Incidents and Ongoing Traumatic Stress (EMDR-PRECI) to female patients with cancer-related PTSD diagnosis. A secondary objective was to observe the immunoglobulins and the cortisol changes pre and post-treatment. Seven female patients with different types of cancer (5 breast, 1 colon, and 1 lymphatic cancer), different cancer treatments (radiation, chemotherapy, radiation, and chemotherapy), and PTSD diagnosis related to their diagnosis and cancer treatment met the inclusion criteria. Participants’ age ranged from 40 to 57 years old (M = 52.28 years old). For PTSD diagnosis and total scores, we used the Global Assessment of Posttraumatic Stress Questionnaire validated for the Mexican population. Biomarkers (cortisol and immunoglobulins) were measured before and after EMDR treatment. For the neuroendocrine measure, we used the cortisol levels in the participant’s blood. For the immunological measure, we used the Nephelometry technique. We measured the changes in the following types of antibodies (immunoglobulins): a) Immunoglobulin A (IgA), b) Immunoglobulin G (IgG), and c) Immunoglobulin M (IgM). EMDR-PRECI was provided by three licensed EMDR clinicians formally trained in the protocol administration. Each EMDR-PRECI session lasted 50-60 minutes. The minimum number of sessions was three and the maximum ten with an average of five. Treatment focused only on the distressing memories related to diagnosis and cancer treatment. No adverse effects were reported during treatment or at six months post-treatment assessment. Results showed a full PTSD diagnosis remission in all participants with significant differences for PTSD scores, t (6) = 2.44, p < .05. These results are in concordance with Carletto et al., study in which all patients treated with EMDR no longer met criteria for PTSD [12]. No significant differences were found for immunoglobulins or cortisol. We believe that the administration of the EMDR-PRECI could be an efficient and effective component of a psychosocial approach to reduce or eliminate cancer-related PTSD symptoms and diagnosis.

Exploring Racial Disparity in Posttraumatic Stress Disorder Diagnosis: Implications for Care of African American Women

Disturbed sleep is a hallmark feature of posttraumatic stress disorder (PTSD). However, few studies have examined sleep objectively in individuals with PTSD compared to trauma-exposed controls. This study used wrist actigraphy to measure and compare sleep patterns in trauma-exposed Australian Vietnam veterans (VV) with and without PTSD. Trauma-exposed Australian VV with and without PTSD were recruited from the PTSD Initiative. VV wore wrist accelerometers over 14 days and completed daily sleep diaries. Sleep parameters were compared between groups including sleep latency (SL), time in bed (TIB), total sleep time (TST), wake after sleep onset (WASO), and movement index (MI). Night-to-night and overall within-individual variability were assessed by root mean squared successive differences and comparison of individual standard deviations. Correlations between sleep diary (self-reported) and wrist actigraphy (objective) variables were also assessed. A total of 40 male VV (20 with PTSD) participated in the study. We found no difference in sleep patterns determined by wrist actigraphy between groups with the exception of reduced SL in VV with PTSD (3.9 ± 0.9 versus 4.9 ± 1.4 minutes, P < .05). Overall within-individual variability was significantly greater in VV with PTSD for TIB, TST, WASO, and MI. Self-reported and objective TST and WASO were more strongly correlated in VV without PTSD than those with PTSD. Although there were no significant differences in sleep parameters, VV with PTSD had increased within-individual overall sleep variability and reduced correlation between self-reported and objective sleep parameters compared to trauma-exposed controls. Further evaluation of extended sleep patterns by actigraphy in VV with PTSD is warranted.

BackgroundPoor sleep quality has been associated with changes in brain volume among veterans, particularly those who have experienced mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD). This study sought to investigate (1) whether poor sleep quality is associated with decreased cortical thickness in Iraq and Afghanistan war veterans, and (2) whether these associations differ topographically depending on the presence or absence of mTBI and PTSD.MethodsA sample of 440 post-9/11 era U.S. veterans enrolled in the Translational Research Center for Traumatic Brain Injury and Stress Disorders study at VA Boston, MA from 2010 to 2022 was included in the study. We examined the relationship between sleep quality, as measured by the Pittsburgh Sleep Quality Index (PSQI), and cortical thickness in veterans with mTBI (n = 57), PTSD (n = 110), comorbid mTBI and PTSD (n = 129), and neither PTSD nor mTBI (n = 144). To determine the topographical relationship between subjective sleep quality and cortical thickness in each diagnostic group, we employed a General Linear Model (GLM) at each vertex on the cortical mantle. The extent of topographical overlap between the resulting statistical maps was assessed using Dice coefficients.ResultsThere were no significant associations between PSQI and cortical thickness in the group without PTSD or mTBI (n = 144) or in the PTSD-only group (n = 110). In the mTBI-only group (n = 57), lower sleep quality was significantly associated with reduced thickness bilaterally in frontal, cingulate, and precuneus regions, as well as in the right parietal and temporal regions (β = −0.0137, P < 0.0005). In the comorbid mTBI and PTSD group (n = 129), significant associations were observed bilaterally in frontal, precentral, and precuneus regions, in the left cingulate and the right parietal regions (β = −0.0094, P < 0.0005). Interaction analysis revealed that there was a stronger relationship between poor sleep quality and decreased cortical thickness in individuals with mTBI (n = 186) compared to those without mTBI (n = 254) specifically in the frontal and cingulate regions (β = −0.0077, P < 0.0005).ConclusionsThis study demonstrates a significant relationship between poor sleep quality and lower cortical thickness primarily within frontal regions among individuals with both isolated mTBI or comorbid diagnoses of mTBI and PTSD. Thus, if directionality is established in longitudinal and interventional studies, it may be crucial to consider addressing sleep in the treatment of veterans who have sustained mTBI.

The authors aim to delineate cognitive dysfunction associated with posttraumatic stress disorder (PTSD) by evaluating a well-defined cohort of former World War II prisoners of war (POWs) with documented trauma and minimal comorbidities. The authors studied a cross-sectional assessment of neuropsychological performance in former POWs with PTSD, PTSD with other psychiatric comorbidities, and those with no PTSD or psychiatric diagnoses. Participants who developed PTSD had average IQ, while those who did not develop PTSD after similar traumatic experiences had higher IQs than average (approximately 116). Those with PTSD performed significantly less well in tests of selective frontal lobe functions and psychomotor speed. In addition, PTSD patients with co-occurring psychiatric conditions experienced impairment in recognition memory for faces. Higher IQ appears to protect individuals who undergo a traumatic experience from developing long-term PTSD, while cognitive dysfunctions appear to develop with or subsequent to PTSD. These distinctions were supported by the negative and positive correlations of these cognitive dysfunctions with quantitative markers of trauma, respectively. There is a suggestion that some cognitive decrements occur in PTSD patients only when they have comorbid psychiatric diagnoses.

Posttraumatic Stress Disorder Symptoms During the First Six Months After Traumatic Brain Injury

Introduction The increase in violence against young women has a high impact on the prevalence of Posttraumatic stress disorder (PTSD). The lifetime prevalence of PTSD is twice as high in women. However, most studies assessing sleep disturbances in PTSD were conducted predominantly in male samples and combat veterans. Objective: To analyze the sleep of young women with and without PTSD. Hypothesis: Women with PTSD have worse sleep quality, higher arousability, and higher muscle activity during REM sleep. Methods Case-controlled study with young women. Seventy-four women who suffered sexual assault and developed PTSD (DSM-5); and 64 women from the community without PTSD. Women were recruited from the PTSD outpatient clinic (Universidade Federal de São Paulo, Brazil).Clinician-Administered Posttraumatic Stress Scale (CAPS 5), Beck Depression and Anxiety Inventories (BDI) (BAI), full in-lab Polysomnography (PSG), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Índex (PSQI), Fatigue Impact Scale (FIS), and Insomnia Severity Índex (ISI) were applied to all participants. Analysis of variance, regression models, and general linear modeling were used. Results Patients mean age was 28 vs 24 for the control group (p=0.004). CAPS mean score in PTSD-group was 42.5±9.1. BDI, BAI, FIS, PSQI, ISI scores were worse in PTSD-group (p&amp;lt;0.05, all). Pittsburgh Sleep Quality Index (PSQI) score was significantly associated with CAPS 5 independently of depression, fatigue, and sleep fragmentation. The PTSD women had lower total sleep time (p= 0.01) and lower REM sleep percentage (p=0.04). However, the control group had higher arousal index (p=.0.01) and had higher muscle activity during REM sleep (p=0.03) than PTSD. Conclusion Women with PTSD had significantly worse score in PSQI, FIS, and ISI. PSQI score was associated with PTSD severity. However, when PSG results are concerned, we found higher sleep fragmentation in the control group. We speculate that women with PTSD may have felt safer and taken care of in the lab, which might explain the difference between objective and subjective measures of sleep quality in PTSD. Support Acknowledgments: FAPESP: Fundação de Apoio à pesquisa de São Paulo, AFIP: Associação Incentivo a Pesquisa

Introduction Sleep difficulties are prevalent among individuals with posttraumatic stress disorder (PTSD). While sleep often improves following psychotherapy for PTSD, residual sleep difficulties are common. Most studies assessing sleep in the context of PTSD treatment have relied on single-item scores. This study evaluated associations between sleep difficulties and psychopathology prior to treatment and predictors of change in global and trauma-related sleep problems following PTSD treatment. Methods Participants (N=146, 75.3% Female, M Age=36) enrolled in a randomized trial of prolonged exposure (PE) and PE plus sertraline completed the Pittsburgh Sleep Quality Index (PSQI), PSQI PTSD Addendum (PSQI-PTSD), PTSD Symptom Scale Self-Report for DSM-IV (PSS-SR; re-experiencing, avoidance, and arousal subscales), and Quick Inventory of Depressive Symptomatology (QIDS-SR) at baseline, post-treatment, and 3-month follow-up. Sleep-related items were removed from PSS-SR and QIDS-SR scales. Correlations examined associations between baseline self-report measures. For treatment-completers, paired t-tests compared PSQI and PSQI-PTSD scores between baseline and post-treatment and between post-treatment and follow-up. Multivariate linear regression models assessed predictors of change in sleep from baseline to post-treatment. Results At baseline, global sleep difficulties (PSQI) were clinically elevated (M=11.77, SD=3.26) and associated with moderately higher PSS-SR avoidance (r=.26, p=.002), arousal (r=.32, p&amp;lt;.001), and QIDS-SR severity (r=.30, p&amp;lt;.001), but not PSS-SR re-experiencing. PTSD-related sleep difficulties (PSQI-PTSD) were associated with greater PSS-SR re-experiencing (r=.48, p&amp;lt;.001), avoidance (r=.35, p&amp;lt;.001), and arousal (r=.29, p&amp;lt;.001) and QIDS-SR severity (r=.44, p&amp;lt;.001). Among treatment-completers, sleep problems decreased substantially between baseline and post-treatment (PSQI: p&amp;lt;.001, d=1.09; PSQI-PTSD: p&amp;lt;.001, d=0.96); however, mean global sleep difficulty scores remained above the clinical-cutoff of 5 (M=7.90, SD=3.87). Change from post-treatment to follow-up was non-significant, suggesting maintenance of gains. When predicting change in PTSD-related, but not global, sleep difficulties, higher baseline re-experiencing symptoms (β=.38, p=.002) was the strongest predictor of improvement in trauma-related sleep difficulties (PSQI-PTSD, R-squared=.20, F(4,84)=5.18, p&amp;lt;.001). Conclusion On average, sleep difficulties decreased substantially following trauma-focused intervention, but global sleep difficulties remained elevated. This builds upon research suggesting sleep disturbance may be better conceptualized and treated as comorbid with PTSD rather than secondary. Research identifying mechanisms mediating improved sleep can inform targeted use of adjunctive, sleep-specific interventions for patients receiving trauma-focused therapy. Support (if any) R01MH066347, R01MH066348

Background: War-induced Post-Traumatic Stress Disorder (PTSD) and its complications can be passed on to patients’ family members. Objectives: This study aims to investigate PTSD symptoms and sleep quality among chronic PTSD patients and their wives. Methods: PTSD symptoms were evaluated among 14 veterans with chronic PTSD and their wives by the PTSD checklist - Military version (PCL-M). Objective and subjective sleep data were collected by actigraphy and Pittsburgh Sleep Quality Index (PSQI), respectively. Data was analyzed using t - tests, χ2, and Pearson or Spearman correlation coefficient by SPSS software version 16. Results: According to PCL-M, seven wives were diagnosed with PTSD while others reported high PCL scores. Total PCL-M scores did not differ significantly between veterans and wives: there was, instead, a significantly positive correlation between these two groups (r = 0.563; P = 0.036). Veterans with PTSD reported significantly poorer sleep quality compared to their wives on the PSQI (P < 0.05), however, not in the actigraphy. Veterans’ PSQI and actigraphy sleep indices differed significantly (P < 0.01). Subjective sleep latency (41.79 ± 29.65) was significantly higher than objective (11.38 ± 28.64) among wives (P < 0.01). A significant positive correlation was observed between the two groups’ subjective sleep efficiency (r = 0.569; P = 0.03) and between PTSD severity and PSQI total scores (r = 0.53; P < 0.01). Conclusions: The wives of persons with PTSD indicated some degree of PTSD. Veterans with PTSD reported poorer sleep quality than their wives. PTSD can negatively influence sleep quality.

Although psychological trauma affects millions of Americans, few studies have examined treatment of posttraumatic stress disorder (PTSD) in real-world service environments. This study explored pharmacological treatment of PTSD among privately insured individuals. Data were from the MarketScan database, which compiles claims from private health insurance plans nationwide. Descriptive statistics and multivariate logistic regression were used to identify predictors of any use of a psychotropic medication and use of three medication classes: antidepressants, anxiolytics or sedative-hypnotics, and antipsychotics. Of 860,090 adult mental health care users in 2005, only 10,636 (1.2%) had a diagnosis of PTSD. Sixty percent of PTSD patients received any psychotropic medication: 74.3% of those received antidepressants, 73.7% received anxiolytics or sedative-hypnotics, and 21.3% received antipsychotics. Greater likelihood of any medication use was associated with greater use of mental health services and with several comorbid psychiatric disorders. Having a comorbid diagnosis of an indicated disorder was the most robust predictor of use of each of the three medication classes: major depressive disorder and dysthymia were most strongly associated with antidepressant use, schizophrenia and bipolar disorder were associated with antipsychotic use, and anxiety disorders were associated with use of anxiolytics or sedative-hypnotics. Psychotropic medications were frequently used in the treatment of PTSD among privately insured clients. Although use targeted specifically to PTSD and to comorbid disorders was common, substantial use appeared to be unrelated to diagnosis and may be targeted at specific symptoms rather than diagnosed illnesses. Further research is needed to determine symptom-specific responses to medications across diagnoses.

Poor sleep quality, often resulting from poor sleep hygiene, is common among medical students. Educational interventions aimed at improving sleep knowledge are beneficial for sleep quality in healthy populations. However, sleep education is often given minimal attention in medical school curriculums. The aim of the study was to explore whether a short educational intervention could improve sleep knowledge, and consequently sleep quality, among medical students. We recruited preclinical- and clinical-stage medical students during the 2017-2018 academic year. Students completed a demographic survey, the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), and the Assessment of Sleep Knowledge in Medical Education (ASKME) questionnaire. Students then attended a lecture on the physiology and importance of sleep. To assess the efficacy of the intervention, questionnaires were repeated 4 months thereafter. A total of 87 students (31 preclinical) with a mean age of 25.86 years (standard deviation [SD], 3.33), 51 of whom were women, participated in the study. At baseline, students had poor sleep quality with a PSQI mean score of 5.9 (SD, 2.37), without significant sleepiness, and a mean ESS score of 8.86 (SD, 4.32). The mean ASKME scores were consistent with poor sleep knowledge at 11.87 (SD, 4.32). After the intervention, the mean ASKME results improved to 14.15 (SD, 4.5; P < .001), whereas sleep quality did not. The effect was similar in preclinical and clinical medical students. Sleep knowledge was inadequate among medical students, who also experienced poor sleep quality. A short educational intervention improved sleep knowledge but was insufficient at improving sleep quality. Further studies are needed to determine which interventions may provide benefit in both sleep knowledge and sleep quality.

Military personnel and frontline emergency workers may be exposed to events that have the potential to precipitate negative mental health outcomes such as depression, symptoms of post-traumatic stress and even post-traumatic stress disorder (PTSD). Programmes have been designed to build psychological resilience before staff are deployed into the field. This review presents a synthesis of the literature on these "pre-deployment resilience-building programmes".The objective of this review was to assess the effectiveness of programmes that seek to build resilience to potentially traumatic events among military and frontline emergency service personnel prior to their deployment. These resilience programmes were compared to other interventions, treatment as usual or no intervention.Studies were identified through searches of electronic databases including Ovid MEDLINE, Embase, PsycINFO, Web of Science and Google Scholar. The initial search took place in January 2019, with an updated search completed at the end of September 2020.Only studies that used a randomised controlled trial (RCT)/cluster-RCT methodology were included. The programmes being evaluated must have sought to build resilience prior to exposure to trauma. Study participants must have been 18 years or older and be military personnel or frontline emergency workers.Studies that met the inclusion criteria were assembled. Data extracted included methods, participants' details, intervention details, comparator details, and information on outcomes. The primary outcomes of interest were resilience, symptoms of post-traumatic stress and PTSD. Secondary outcomes of interest included acute stress disorder, depression, social support, coping skills, emotional flexibility, self-efficacy, social functioning, subjective levels of aggression, quality of sleep, quality of life and stress. Assessment of risk of bias was also completed. A total of 28 studies were included in a narrative synthesis of results.All 28 included studies compared an experimental resilience building intervention versus a control or no intervention. There was a wide range of therapeutic modalities used, including cognitive behavioural therapy (CBT) informed programmes, biofeedback based programmes, stress-management programmes, mindfulness and relaxation programmes, neuropsychological-based programmes, and psychoeducational-informed programmes. The main outcomes are specified here, secondary outcomes such as depression, social support, coping skills, self-efficacy, subjective levels of aggression and stress are reported in text. No studies reported on the following pre-specified outcomes; acute stress disorder, emotional flexibility, social functioning, quality of sleep and quality of life. Resilience Eight studies reported resilience as an outcome. We narratively synthesised the data from these studies and our findings show that five of these interventions had success in building resilience in their respective samples. Two of the studies that reported significant results utilised a CBT approach to build resilience, while the other three successful programmes were mindfulness-based interventions. Symptoms of post-traumatic stress Our narrative synthesis of results included eight studies. Two of the eight studies produced significant reductions in symptoms of post traumatic stress compared to controls. These interventions used neuropsychological and biofeedback intervention models respectively. PTSD caseness Four studies reported PTSD caseness as an outcome. Our narrative synthesis of results suggests that evidence is mixed as to the effectiveness of these interventions in reducing clinical diagnosis of PTSD. One study of a neuropsychology-orientated Attention Bias Modification Training (AMBT) programme had success in reducing both symptoms of post-traumatic stress and numbers of participants receiving a diagnosis of PTSD. A stress-management programme reported that, when baseline differences in rates of pre-deployment mental health issues were controlled for, participants in the control condition were at 6.9 times the risk of a diagnosis of PTSD when compared to the intervention group. Given the diversity of intervention designs and theoretical orientations used (which included stress-management, neuropsychological and psychoeducational programmes), a definitive statement on the efficacy of pre-deployment programmes at reducing symptoms of post-traumatic stress and PTSD cannot be confidently offered.While a number of evaluations of relevant programmes have been published, the quality of these evaluations limits our ability to determine if resilience-building programmes 'work' in terms of preventing negative outcomes such as depression, symptoms of post-traumatic stress and diagnoses of PTSD. Based on our findings we recommend that future research should: a) report pre-/post-means and standard deviation scores for scales used within respective studies, b) take the form of large, RCTs with protocols published in advance, and c) seek to measure defined psychological facets such as resilience, PTSD and stress, and measure these concepts using established psychometric tools. This will provide more certainty in future assessments of the evidence base. From a clinical implications point of view, overall there is mixed evidence that the interventions included in this review are effective at safe guarding military personnel or frontline emergency workers from experiencing negative mental health outcomes, including PTSD, following exposure to potentially traumatic events. Based on this, practitioners seeking to build resilience in their personnel need to be aware of the limitations of the evidence base. Practitioners should have modest expectations in relation to the efficacy of resilience-building programmes as a prophylactic approach to employment-related critical incident traumas.

Sleep disturbances are well documented in relation to trauma exposure and posttraumatic stress disorder (PTSD), but correlates of such disturbances remain understudied in veteran populations. We conducted a preliminary study of sleep disturbances in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (n = 133; mean [standard deviation] age = 29.8 [4.7] y). Veterans were assigned to one of three groups based on responses to the Clinician Administered PTSD Scale: control (no trauma-exposure [TE] or PTSD), TE, and PTSD. Sleep disturbance was assessed using the Pittsburgh Sleep Quality Index (PSQI). Measures of resilience, trauma load, personality, coping, alcohol use, and mild traumatic brain injury were also assessed via self-report. The PTSD group had significantly more disturbed sleep (PSQI global score mean = 8.94, standard deviation = 3.12) than control (mean = 5.27, standard deviation = 3.23) and TE (mean = 5.34, standard deviation = 3.17) groups, but there were no differences between TE and control. The same pattern emerged across most PSQI subscales. Results of linear regression analyses indicated that current smoking, Army (versus other military branches), neuroticism, and using substances to cope were all significant correlates of higher sleep disturbance, whereas post-deployment social support was associated with less sleep disturbance. However, when combined together into a model with PTSD status, only neuroticism and substance use coping remained significant as predictors of more disturbed sleep. These initial findings suggest that TE itself may not be an independent risk factor for disturbed sleep in veterans, and that neurotic personality and a tendency to cope by using substances may partially explain sleep disturbance, above and beyond a diagnosis of PTSD.