Psychiatry - July 2008 - (Page 45)

anxiety. A thorough evaluation reveals a long history of PTSD stemming from severe physical, emotional, and sexual abuse by her stepfather from the ages of 4 to 15, at which point she ran away from home and has been on her own ever since. Symptoms included initial insomnia, taking at least two hours to get to sleep, and with multiple awakenings during sleep. She does not recall the content of her dreams, but reports difficulty getting back to sleep after awakening from a nightmare. Miss A was tried on a number of pharmacotherapeutic options for her insomnia and PTSD, including several selective serotonin reuptake inhibitors (SSRIs), two tricyclics, three benzodiazpines, two nonbenzodiazepine hypnotics, and several atypical antipsychotics at various times over the course of her two years in treatment, to no avail, developing side effects that limited her ability to tolerate medications soon after initiating them. Although agreeing to psychotherapeutic approaches at various times, she remained resistant to all forms of therapy, demonstrated by failing to attend sessions consistently for psychodynamic approaches and not adhering with homework for CBTbased approaches. Upon exploration of her difficulties in getting well, it was revealed that she did not at her core believe she would ever be able to get well. It was only after thoroughly exploring this belief that she began to adhere with homework assignments and give up her overreliance on medications to address her symptoms. Psychotherapy. Psychotherapy is the mainstay of treatment for PTSD, although insomnia is still a frequent complaint after successful treatment of other symptoms.38 Two psychotherapy approaches designed to specifically address the nightmares associated with PTSD are imagery rehearsal therapy and lucid dreaming therapy. Imagery rehearsal therapy (IRT). Developed by Krakow and colleagues,39 IRT is a brief (three 45 session) manualized treatment specifically for nightmares, and may have a positive effect on daytime symptoms of PTSD as well. In this form of therapy, nightmares are seen as a learned habit, and patients are taught positive imagery techniques, and attempt to “re-write” and practice the nightmares using the new “script.” IRT has reportedly been used successfully to treat nightmares associated with both sexual assault trauma40 and combat trauma.41 The study cited on sexual assault40 trauma involved 168 women in New Mexico; 88 were randomized to receive treatment over three sessions and 80 were assigned to a control situation. Using an intent-totreat analysis, the investigators found that there were significant improvements in the sleep function in the treatment group, with additional benefits for daytime symptoms as well. Krakow and Moore wrote a case series of 11 Army soldiers deployed to Iraq with therapy provided over four sessions by Moore while in Iraq. Seven of the 11 showed marked improvements, which were sustained or continued to improve at nine-month follow-up. Case 6. Mr. G is a 49-year-old sales executive who developed PTSD after being mugged. He suffered frequent recurrent nightmares of the incident, often with even worse outcomes than the incident itself. He underwent imagery rehearsal training in which he rewrote his nightmares with more positive endings and rehearsed them frequently during the day. Eventually, he no longer experienced the original nightmare, although he still remained somewhat symptomatic during the day. Lucid dreaming therapy (LDT). This is a technique that involves training the patient to realize he or she is dreaming when a nightmare occurs, and possibly even alter the nightmare itself to result in lessened anxiety overall.42 Randomized, controlled trials are necessary to fully evaluate lucid dreaming as a therapeutic technique.43 A study by Spoormaker and van den Bout44 of 23 nightmare sufferers, eight randomized to a single two-hour LDT individual session, eight randomized to a single two-hour group LDT session, and seven wait-list controls revealed no difference in the individual versus group approaches in terms of efficacy in reducing nightmares, and both were more effective than wait list.44 Patients did not show significant changes in sleep quality or PTSD symptom severity at 12-week follow-up. In the Spoormaker and van den Bout study,44 the single session of LDT consisted of exposure, mastery, and lucidity exercises, although they note the lucidity exercises per se did not seem to be necessary for reduction in nightmares.44 One may thus conclude that the success of treatment had more to do with the exposure and mastery components; however, further research is needed. Case 3. Mr. F is a 48-year-old local business man who suffered PTSD after a motor vehicle accident. He underwent training in LDT. He rehearsed alternative endings to his recurrent dream of the accident, and was ultimately able to implement them during his dreams. Differential diagnosis. Sleep disturbances can potentially arise from many underlying disorders, and a consideration of the differential is crucial in developing an effective treatment plan with one’s patient. Eiser presents a thoughtful discussion of the subject in his recent review.13 Considerations include nightmare disorder, which may persist through adulthood, sleep terrors, somnambulism, nocturnal seizures, which may manifest as stereotyped recurrent nightmares arising from a temporal lobe focus, REM sleep behavior disorder, obstructive sleep apnea, and hypnogogic/hypnopompic hallucinations associated with narcolepsy. Eiser mentions that these may all have different pathophysiologic manifestations of nightmares, with those nightmares occurring in association with PTSD occurring both within and outside of the context of REM sleep (especially [JULY] Psychiatry 2008 45

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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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