Psychiatry - July 2008 - (Page 44)

TABLE 2. Complex PTSD Repeated and prolonged exposure to trauma in childhood leads to pervasive and chronic symptoms that may be better described by the concept of complex PTSD as set forth by Herman.57 Symptoms include all of those associated with the DSM-IV-TR definition of PTSD but also more pronounced problems with emotional regulation, self-image, preoccupation with the relationship to the perpetrator (e.g., preoccupied with revenge fantasies), and interpersonal and occupational relationships, including repeated search for a rescuer. Both cognitive processing therapy and Prolonged Exposure therapy can be equally effective for patients with complex PTSD.58 cognitive-behavioral therapy (CBT) and eye movement desensitization and reprocessing, as well as play therapy..5,6 The sleep disturbances associated with PTSD are some of the most disabling and difficult-totreat aspects of the disorder. In addition to the insomnia and nightmares that are part of the criteria for diagnosis, patients can develop anxiety over going to sleep or fear of going back to sleep after waking.7 Such individuals may condition themselves to stay awake as a way to avoid the anxiety induced by their trauma-related nightmares.8 According to Wittmann,9 about 50 percent of PTSD dreams are replications of traumatic events, and thus they do not necessarily have stereotypical content. Singareddy and Balon note that REM-related abnormalities of various sorts are often found on polysomnographic studies of patients with PTSD, but the findings are not consistent across the studies they reviewed.10 Spoormaker and Montgomery note that the sleep disturbances themselves are a core feature of PTSD and in fact predispose one to PTSD.11 They also cite the relatively high correlation of periodic limb movements and/or sleep disordered breathing in patients with PTSD as evidence for disturbed sleep requiring specific attention. They note that “with disturbed sleep any (critical) event will be more 44 Psychiatry 2008 [ J U L Y ] difficult to process and more likely to result in emotional complaints, and an extremely critical event will therefore be more likely to result in PTSD…” They also note that polysomnographic studies of PTSD patients are prone to be misleading as patients tend to view the sleep lab as a “safe” place and therefore are less likely to have nightmares there. A recent meta-analysis of polysomnographic studies showed that patients with PTSD had more stage 1 sleep, less slow wave sleep, and greater REM density than those without PTSD.12 TREATING PTSD THAT INCLUDES ASSOCIATED SLEEP PROBLEMS Building trust. All forms of treatment share a common element of building a trusting relationship between patient and physician. This is especially important for the patient with PTSD because his or her worldview has been disrupted by trauma(s). This may be further complicated in military populations exposed to combat related traumas. Surveys of soldiers in the field and returning home have found a reluctance to use behavioral health resources. This hesitation is often related to how seeking help would be viewed by commanders and peers. Some of these views may stay with the individual even after separating from the military.14,15 “Sleep hygiene” advice can be a place to start with trust-building. Patients who have been traumatized have such a sense of having lost control in their lives, having a sleep hygiene program they can take control of may have additional psychological benefits aside from the sleep quality issues, which may in and of themselves make a tremendous difference. A book we have found to be a useful resource for our patients is by Breus,16 who reviews the importance of getting regular exercise, avoiding alcohol, nicotine, and caffeine in the evening, and having a quiet, darkened room in which to sleep; he also discusses the television controversy, which is whether or not to have a television in the bedroom. It includes a sleep diary, a four-week “sleep boot camp” self-help exercise, and additional resources for patients. Case 1. Mrs. C was a 40-year-old wife of a retired Air Force major who had an extensive history of physical, sexual, and emotional abuse as a child. She also had a number of medical problems stemming from her history of abuse and was never able to get a good night’s sleep secondary to nightmares and chronic pain. She reported lying awake for hours at night, unable to get to sleep and becoming very frustrated and angry. Mrs. C was willing to participate in a sleep study after several sessions of rapport-building with her psychiatrist. She had a number of trepidations about the study initially, but during the course of the study it was discovered that she had moderate to severe sleep apnea and was fitted with a constant positive airway pressure (CPAP) device. She reported nonadherence with the device after several more weeks, stating “I feel like I’m suffocating.” After ensuring there was no technical issue with the machine, 12 sessions of desensitization therapy were completed, and Mrs. C was ultimately able to use it on a regular basis, resulting in a decrease of her pain symptoms as well as reduction of depression and anxiety. Case 2. Miss A was a 28-year-old college sophomore at a local university. She presented to the college mental health service with complaints of depression and

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Psychiatry - July 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Reliability of Diagnoses: Do Psychiatrists Use Structured Interviews In Real Clinical Settings? Trend Watch: Use of Atypical Antipsychotics in the Elderly Review: The Struggle for Mental Healthcare in New Orleans-One Case at a Time Psychotherapy Rounds: Psychotherapeutic and Adjuntive Pharmacologic Approaches to Treating Posttraumatic Stress Disorder Original Research: Baseline Dissociation and Prospective Success in Special Forces Assessment and Selection Commentary: Performance-Enhancing Drugs: Where Should the Line Be Drawn and By Whom? Commentary: Psychiatric Diagnosis and the Pathlogist's View of Schizophrenia Journal Watch Classified Advertising Information for Authors

Psychiatry - July 2008

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