Insomnia and Anxiety (Series in Anxiety and Related Disorders) (11 page)

Posttraumatic Stress Disorder (PTSD) is a serious and unfortunately all too com-

mon disorder that arises in individuals exposed to unexpected and traumatic life

events. PTSD may be precipitated by personal exposure to an event that involves

serious injury to self or others, a threat of death to oneself, serious injury or death

of others, or threats to the physical integrity and safety of oneself or others. This

condition may also arise from “learning about unexpected or violent death, serious

harm, or threat of death or injury experienced by a family member of close associ-

ate” (American Psychiatric Association, 1997). Events most commonly leading to

PTSD include experiences such as the holocaust, military combat, personal assault

(e.g., rape, physical attack), being taken hostage, torture, terrorist attacks, severe

automobile or other accidents, man-made or natural disasters, or being diagnosed

with a serious illness. Witnessing others exposed to such events as well as seeing

dead bodies or body parts may also lead to this condition. Those who develop

PTSD respond to such events with intense fear, horror, and/or helplessness and

subsequently continue to reexperience the event through intrusive memories, night-

mares, or even dissociative “flashbacks” during which the trauma event is relived.

Additionally, the PTSD sufferer shows a persistent avoidance of all reminders of

the traumatic event and manifests generalized “numbing” of responsiveness and

chronic symptoms of heightened arousal.

Current evidence suggests that PTSD is both a relatively prevalent and often

debilitating form of mental disorder. Lifetime prevalence estimates for PTSD sug-

gest this condition may affect as many as 1–9% of the general population and

6–45% of all trauma victims (Hoge et al., 2004; Kessler et al., 2001; Pillar, Harder,

& Malhotra, 2006; Stein & Mellman, 2005). Factors related to the risk for develop-

ing PTSD include genetics, the nature/severity of the trauma, family/developmental

history, preexisting mental disorders, and the nature of the recovery environment

(American Psychiatric Association, 1997; Pillar et al., 2006). Those who develop

PTSD experience considerable morbidity in that they are at greater risk for academic

and vocational underachievement, marital instability, unemployment, substance

abuse, the development of comorbid mental disorders, and poor physical health

(Kessler et al., 2001). They are also up to six times more likely to attempt suicide

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3 Anxiety Disorders and Accompanying Insomnia

than are age-matched controls without PTSD symptoms (Kessler et al., 2001). They

also incur greater healthcare costs since they use more outpatient medical and men-

tal health services than do age-matched controls (Calhoun, Bosworth, Grambow,

Dudley, & Beckham, 2002). To put these costs into perspective, it is estimated that

the economic burden of PTSD in the US may be comparable to that of major

depression (Walker et al., 2003). Although as many as one half of all PTSD suffer-

ers show remission within 3 months of their trauma exposure, a substantial propor-

tion suffer from PTSD symptoms for decades after the onset of their condition.

For many, if not most, PTSD sufferers, sleep disturbance plays a prominent role

in the onset and maintenance of their symptoms. Unlike several of the other anxiety

disorders discussed herein, PTSD is characterized by sleep-specific complaints.

Indeed, the DSM-IV-TR diagnostic criteria include such complaints as difficulty

falling or staying asleep as well as recurrent distressing dreams of the precipitating

traumatic event (American Psychiatric Association, 1997). Although such com-

plaints are not mandatory for assigning a PTSD diagnosis, survey studies have

demonstrated that insomnia complaints and reports of distressing, sleep-disruptive

nightmares are present in the majority of those with this condition (Kuch & Cox,

1992; Neylan et al., 1998). Furthermore, such individuals appear more likely to

report excessive body movements and night terrors (i.e., screaming or shaking) dur-

ing their sleep than do matched controls without PTSD symptoms (Mellman,

Kulick-Bell, Ashlock, & Nolan, 1995). Interestingly, one study showed that the

presence of subjective sleep complaints one month after experiencing their trauma

was predictive of the eventual development of PTSD in a large group of traffic

accident victims (Thase et al., 2002).

In contrast to these studies, results of objective, polysomnographic sleep moni-

toring have provided somewhat equivocal evidence for the presence of sleep pathol-

ogy in PTSD sufferers. Despite the chronic insomnia complaints common among

PTSD patients, PSG studies have been inconsistent in showing marked sleep con-

tinuity differences between age and gender matched groups with and without this

condition (Dow, Kelsoe, & Gillin, 1996; Fisk et al., 1994; Hurwitz, Mahowald,

Kuskowski, & Engdahl, 1998; Mellman, Kulick-Bell et al., 1995; Mellman, Nolan,

Hebding, & Kulick-Bell, 1997; Woodward, Friedman, & Bliwise, 1996). Collectively

considered, these studies indicate that sleep is slightly, albeit often not significantly,

more disturbed than the sleep of matched controls by objective measures. In a more

recent large study (Breslau et al., 2004) of a large representative community sam-

ple, no polysomnographic sleep differences were noted between those with and

without PTSD, other than increased REM-related arousals in the PTSD group.

Findings such as these contrast markedly with the subjective complaints of most

PTSD sufferers. This apparent subjective/objective discrepancy has led to the

notion that PTSD patients may have a form of sleep state misperception, leading

them to over-report their sleep difficulties (Hurwitz et al., 1998; Pillar et al., 2006).

However, other studies have shown such findings as greater REM density (i.e.,

more rapid eye movements during REM sleep), tonic and phasic REM activity, and

body/leg movements and EMG activity during sleep in PTSD sufferers among

normal sleepers (Lavie & Hertz, 1979; Ross, Ball, Sullivan, & Caroff, 1989).

Posttraumatic Stress Disorder: PTSD

39

Additionally, one study showed that PTSD sufferers evidenced greater levels of

arousal during sleep as measured by heart rate and sleep EEG spectral measures

than did matched controls (Woodward, Murburg, & Bliwise, 2000). There also has

been speculation that the arousal mechanism in PTSD leads to increased risk for

sleep-disordered breathing in patients with this condition (Krakow et al., 2000;

Pillar et al., 2006). Unfortunately, many of the PSG studies of PTSD have been

confounded by the inclusion of medicated patients, those with comorbid mental

conditions and patients at various stages (acute vs. chronic) of their conditions. It

should also be noted that the most recent and comprehensive meta-analysis of the

literature (Kobayashi, Boarts, & Delahanty, 2007) highlights limitations in this lit-

erature and convincingly documents objective sleep difficulties in those who suffer

from PTSD syndromes. Thus, PTSD sufferers do appear to suffer from the objec-

tive sleep problems of which they complain.

Given the prominence of sleep-related complaints in this group, there has been

significant interest in the role or meaning of sleep difficulties in the development

and maintenance of this condition. Data suggests that PTSD sufferers do not show

a normal drop in noradrenergic production during the nighttime (Mellman, Kuman,

Kulick-Bell, Kuman, & Nolan, 1995). This finding in turn supports the speculation

of the central role of “hyerarousal” in disruptive nighttime sleep and enhancing

daytime startle and hypervigilence in PTSD sufferers. In contrast, other studies

showing that PTSD sufferers have elevated awakening thresholds from sleep, sug-

gest that a pathological “sleep deepening” may occur as a compensatory mecha-

nism to suppress trauma related material that emerges during sleep (Dagan, Lavie,

& Bleich, 1991; Lavie, Katz, Pillar, & Zinger, 1998). It has also been speculated

that chronic hyperarousal leads to insomnia and partial sleep deprivation that gives

way to heightened arousal thresholds during recovery sleep (Pillar et al., 2006).

Others have focused on the aberrations of REM sleep and the presence of recurrent,

repetitive nightmares in PTSD and have postulated that an abnormal REM mecha-

nism is central to this disorder (Fisk et al., 1994). Whereas each of these theories

has some appeal, additional studies that carefully control the effects of comorbidi-

ties, concurrent medication use, and the specific nature of the trauma are needed to

determine which current theory, if any, is best supported by the data.

Current treatment strategies for PTSD include pharmacotherapy with various

compounds (e.g., selective serotonin re-uptake inhibitors, tricyclic antidepessants,

momamine oxidase inhibitors) and psychological treatments such as cognitive-

behavior therapy specifically tailored for this condition. However, as noted recently,

clinically significant residual insomnia may persist in almost one half of those

patients who achieve PTSD remission with treatment (Zayfert & DeViva, 2004). In

such cases with long-standing sleep complaints, insomnia may have developed

some independence over time and represent a separate and clinically significant

comorbid disorder. Hence, sleep targeted therapies such as the cognitive-behavior

insomnia therapy described in Chap. 3 may be particularly appropriate for PTSD

sufferers who present insomnia complaints in the context of their PTSD syndrome

and also as residual symptoms. Distressing and recurrent nightmares also are a

hallmark and often treatment-resistant symptom of this disorder and merit specific

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3 Anxiety Disorders and Accompanying Insomnia

treatment attention. As discussed in more detail in Chap. 7, imagery rehearsal

therapy (IRT) involving nightmare rescripting and subsequent imagery rehearsal of

the rescripted nightmare has proven particularly effective for management of

PTSD-related nightmares. Indeed, this treatment has shown efficacy in groups such

as combat veterans and female rape victims (Forbes, Phelps, & McHugh, 2001;

Krakow et al., 2001). In many cases, patterns of nighttime sleep avoidance to mini-

mize nightmare exposure and daytime compensatory napping develop as PTSD

coping strategies. Those who present with this pattern have a complicated insomnia

problem and may benefit from both CBT for insomnia and IRT to manage night-

mares. Along with these treatment targets, some may develop excessive and elabo-

rate safety behaviors such as checking door locks or the perimeter around their

homes that delay their bedtime, whereas others may self-medicate with alcohol to

aid their sleep. Such problem behaviors should be identified and addressed thera-

peutically to maximize sleep outcomes in PTSD sufferers. Finally, due to the high

rate of comorbid mental conditions and particularly depression, appropriate treat-

ment for such conditions is often needed to maximize sleep outcomes among those

who suffer from this condition.

Obsessive–Compulsive Disorder

Obsessive–compulsive disorder is a rather debilitating condition characterized by

spontaneous, recurring, and upsetting thoughts (obsessions) coupled with repetitive

or ritualistic behaviors or mental acts performed as a means of reducing or control-

ling the anxiety precipitated by the associated obsessions (American Psychiatric

Association, 1997). The content of obsessions may vary but often centers on

thoughts of germ exposure/contamination, unwelcome sexual urges, doubts about

having performed some necessary task (e.g., locking the doors before going to bed),

personal or religious failings, or loss of control of aggressive impulses. Compulsions

arising from and accompanying such obsessions may include hand washing, repeti-

tive counting or praying, repeated checking, or ritualistic arranging or ordering of

personal items. Typically, the person feels driven to engage in the compulsive act in

order to control the obsessional thought and/or to prevent some feared and undesired

event from occurring. For example, an individual with obsessional fears focused on

germ exposure and consequent illness may repeatedly engage in hand washing after

contact with what is perceived as a contaminated surface or item so as to reduce

chances of developing a serious illness. At some point during the course of this

disorder, the affected individual recognizes the obsessions and associated compul-

sions are irrational, but these symptoms persist over time despite this insight.

Compared to other anxiety disorders, obsessive–compulsive disorder is rela-

tively rare, albeit often very persistent and debilitating. Most epidemiological sur-