Potential impact of sleep disorder treatment in fibromyalgia patients.
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Cognitive Behavioral Therapy↗
Biomedical subjects
Barry Krakow
Publications and source records attributed to Barry Krakow.
Assessing war trauma in refugees: properties of the Comprehensive Trauma Inventory-104.
In this article, the authors describe the properties of the Comprehensive Trauma Inventory-104 (CTI-104), developed and designed empirically to improve assessment of traumatic war-related events. The mean number of events reported by 252 community dwelling Kurdish and Vietnamese refugees was 32 (SD=27) out of the 104 items. Internal and test-retest reliability was excellent, and the validity of the CTI-104 as a measure of war trauma was supported by its high correlation with standard measures of known outcomes of trauma. The CTI-104 is reliable and valid, and assesses a broader range of traumatic war-related events in a broader range of refugees than currently available instruments.
Adult↗
Nasal dilator strip therapy for chronic sleep-maintenance insomnia and symptoms of sleep-disordered breathing: a randomized controlled trial.
To test the impact of nasal dilator strips (NDSs) on insomnia severity, sleep-disordered breathing (SDB) symptoms, sleep quality, and quality of life. Randomized, controlled trial of 4 weeks' duration. Community sample of nonobese, adults with a primary sleep complaint of chronic sleep-maintenance insomnia and mild to moderate SDB symptoms (treatment, n=42; control, n=38). Primary outcomes were four validated scales: Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), Functional Outcomes of Sleep Questionnaire (FOSQ), and Quality of Life Enjoyment and Satisfaction Questionnaire (QLESQ). Secondary outcomes were sleep indices, nonrestorative sleep ratings, and SDB symptoms, assessed retrospectively and prospectively. Both groups received nonspecific education about sleep disorders. Treatment group also received a brief SDB education and nasal strip instructions. At 4 weeks' follow-up, the treatment group demonstrated significant (p=.0001), large improvements in ISI and PSQI (mean Cohen's d=1.18) and significant (p<.02), medium-sized improvements in FOSQ and QLESQ (mean d=0.51) compared to small, nonsignificant changes in control group (Cohen's d range=0.36-0.09). Treatment group change scores among all four primary variables were significantly correlated (mean r=0.50, p=0.01). Secondary prospective and retrospective outcomes showed medium to large improvements in treatment compared to controls for sleep indices (mean d=0.52 vs 0.28), nonrestorative sleep ratings (mean d=0.69 vs 0.11), and sleep breathing symptoms (mean d=0.47 vs 0.09). Significance was obtained for prospective sleep indices (p=0.01), retrospective, and prospective nonrestorative sleep ratings (p=0.003, <0.05), and retrospective sleep breathing symptoms (p=0.03). SDB education and NDSs demonstrated therapeutic efficacy in a select sample of insomnia patients with SDB symptoms. Replication of results requires placebo controls and objectively confirmed SDB cases.
Chronic Disease↗
Nightmare complaints in treatment-seeking patients in clinical sleep medicine settings: diagnostic and treatment implications.
STUDY OBJECTIVES: To develop clinical guideposts to identify patients with salient nightmare conditions. DESIGN: Prevalence data from a retrospective chart review on a consecutive series of sleep patients to assess how or whether those with nightmares (1) rank nightmare complaints compared to other sleep complaints, (2) link nightmares to disrupted sleep, (3) report worse sleep symptoms and health outcomes compared to other sleep patients, and (4) endorse criteria for a salient nightmare condition on the Disturbing Dream and Nightmare Severity Index. SETTING: Two community sleep facilities: private sleep medical center and a hospital-based sleep lab. PATIENTS: Seven hundred eighteen patients presenting at intake: sleep center (n = 620); sleep lab (n = 98). MEASUREMENTS AND RESULTS: Standard sleep parameters and various health outcomes were assessed with self-report measures. Of 718 sleep patients, 186 ranked a nightmare complaint among their sleep problems, of whom 117 linked their bad dreams to disrupted sleep, suggesting a potential salient nightmare condition. Compared to all other sleep patients, these 117 cases demonstrated consistent significant patterns of worse or more prevalent problems with self-reported sleep indexes, insomnia, sleep quality, sleep-fragmentation factors, sleep-related daytime impairment, psychiatric history, medical comorbidity, and parasomnias. The Disturbing Dream and Nightmare Severity Index identified those with salient nightmare complaints and correlated with worse sleep and health outcomes. CONCLUSIONS: At 2 sleep medical facilities, 16% of patients presented with an apparent salient nightmare condition, and these patients were identified with simple clinical guideposts, which could be incorporated at intake in various sleep medicine settings.
Adolescent↗
Signs and symptoms of sleep-disordered breathing in trauma survivors: a matched comparison with classic sleep apnea patients.
Chronic posttraumatic sleep disturbance may include sleep-disordered breathing (SDB), but this disorder of sleep respiration is usually not suspected in trauma survivors. Sleep breathing signs and symptoms were studied in 178 adults-all with SDB-including typical sleep clinic patients (N = 89) reporting classic snoring and sleepiness and crime victims (N = 89) with insomnia and posttraumatic stress. Significant differences (p < 0.0001) were common between groups. Sleep breathing complaints, loud snoring, marked obesity, and obstructive sleep apnea were prevalent in sleep clinic patients; crime victims reported more insomnia, nightmares, poor sleep quality, leg jerks, cognitive-affective symptoms, psychotropic medication usage, and less snoring but more upper airway resistance syndrome. Both groups reported high rates of fatigue or sleepiness, nocturia, morning dry mouth, and morning headaches. Awareness of these clinical features might enhance detection of SDB among trauma survivors.
Adult↗
Clinical management of chronic nightmares: imagery rehearsal therapy.
Problems with nightmares are reported by a sizable proportion of individuals with a history of trauma and by approximately 5% to 8% of the general population. Chronic nightmares may represent a primary sleep disorder rather than a symptom of a psychiatric disorder, and direct targeting of nightmares is a feasible clinical approach to the problem. Of the treatments proposed, imagery rehearsal therapy (IRT) has received the most empirical support. An up-to-date account of this cognitive-imagery approach shows how to treat nightmares during 4 roughly 2-hr sessions. The main points covered in each therapy session and their underlying rationale are presented. Dismantling protocols are suggested to discern active ingredients of IRT and to develop flexible applications based on patients' needs.
Cognitive Behavioral Therapy↗
A brief sleep scale for Posttraumatic Stress Disorder: Pittsburgh Sleep Quality Index Addendum for PTSD.
Sleep disturbances reflect a core dysfunction underlying Posttraumatic Stress Disorder (PTSD). Specifically, disruptive nocturnal behaviors (DNB) may represent PTSD-specific sleep disturbances. The Pittsburgh Sleep Quality Index Addendum for PTSD (PSQI-A) is self-report instrument designed to assess the frequency of seven DNB. The goal of this study was to examine the psychometric properties of the PSQI-A to characterize DNB in a group of participants with and without PTSD. Results indicate that the PSQI-A has satisfactory internal consistency and good convergent validity with two standard PTSD measures even when excluding their sleep-related items. A global PSQI score of 4 yielded a sensitivity of 94%, a specificity of 82%, and a positive predictive value of 93% for discriminating participants with PTSD from those without PTSD. The PSQI-A is a valid instrument for PTSD applicable to both clinical and research settings.
Female↗
Suicidality and sleep disturbances.
STUDY OBJECTIVES: A growing body of research indicates that sleep disturbances may be specifically linked to suicidal behaviors. It remains unclear, however, whether this link is largely explained by depressive symptoms. The present study investigated the relationship between suicidality, depression, and sleep complaints in a clinical outpatient setting. DESIGN AND SETTING: Upon admission, 176 outpatients completed measures on sleep disturbances, suicidal symptoms, and depression. Several sleep disturbances were evaluated with regard to suicidal ideation, including insomnia, nightmares, and sleep-related breathing symptoms. MEASUREMENTS AND RESULTS: Regression analyses revealed that insomnia and nightmare symptoms were associated with both depressive symptoms and suicidality. Sleep-related breathing symptoms were associated with depressive symptoms, but did not show an association with suicidal ideation. After controlling for depressive symptoms, only nightmares demonstrated an association with suicidal ideation. This relationship emerged as a nonsignificant trend (P = .06). Nightmares were particularly associated with suicidality among women compared with men. Posthoc analyses revealed that, after controlling for sex and depressive symptoms, nightmare symptoms were significantly associated with suicidality (P = .04). CONCLUSIONS: Although insomnia and nightmares were significantly associated with depressive and suicidal symptoms, after controlling for additional variables, such as depression and sex, only nightmares remained associated with suicidality. This association was slightly stronger among women compared with men.
Adolescent↗
Refractory insomnia and sleep-disordered breathing: a pilot study.
OBJECTIVE: To assess an uncontrolled, open-label trial of sleep-disordered breathing (SDB) treatment on two different samples of chronic insomnia patients. METHOD: In Study 1 (Retrospective), data from one diagnostic and one continuous positive airway pressure (CPAP) titration polysomnogram were compiled from 19 chronic insomnia patients with SDB. Objective polysomnogram indicators of sleep and arousal activity and self-reported sleep quality were measured. In Study 2 (Prospective), clinical outcomes were assessed after sequential cognitive-behavioral therapy (CBT) and SDB therapy (CPAP, oral appliances, or bilateral turbinectomy) were provided to 17 chronic insomnia patients with SDB. Repeat measures included the Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, Pittsburgh Sleep Quality Index, and self-reported insomnia indices and CPAP use. RESULTS: In Study 1, seven objective measures of sleep and arousal demonstrated or approached significant improvement during one night of CPAP titration. Sixteen of 19 patients reported improvement in sleep quality. In Study 2, Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, and Pittsburgh Sleep Quality Index improved markedly with CBT followed by SDB treatment and achieved an average outcome equivalent to curative status. Improvements were large for each treatment phase; however, of 17 patients, only 8 attained a nonclinical level of insomnia after CBT compared with 15 patients after SDB therapy was added. Self-reported insomnia indices also improved markedly, and self-reported SDB therapy compliance was high. CONCLUSIONS: In one small sample of chronic insomnia patients with SDB, objective measures of insomnia, arousal, and sleep improved during one night of CPAP titration. In a second small sample, validated measures of insomnia, sleep quality, and sleep impairment demonstrated clinical cures or near-cures after combined CBT and SDB therapies. These pilot results suggest a potential value in researching the pathophysiological relationships between SDB and chronic insomnia, which may be particularly relevant to patients with refractory insomnia.
Chronic Disease↗
Nasal dilator strip therapy for chronic sleep maintenance insomnia: a case series.
Sleep-disordered breathing (SDB) is a salient factor in chronic sleep maintenance insomnia. However, many insomnia patients with comorbid SDB may not be interested initially in receiving treatment with continuous positive airway pressure or oral appliance therapy. As an interim pathway, we used Breathe Right nasal dilator strip (NDS) therapy to introduce these patients to the relationship between insomnia and SDB. We hypothesized that NDS-associated improvements might motivate patients to pursue comprehensive SDB therapies. In this open label trial, three men with chronic sleep maintenance insomnia were treated with an educational session about SDB coupled with nightly NDS therapy. At 4-week follow-up, global insomnia severity, difficulty staying asleep, difficulty falling back asleep when awakened, total number of awakenings, and wake time after sleep onset systematically improved. Following NDS therapy, all three insomnia patients elected to pursue comprehensive SDB treatment at local sleep centers.
Case-Control Studies↗
An emerging interdisciplinary sleep medicine perspective on the high prevalence of co-morbid sleep-disordered breathing and insomnia.
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Cognitive Behavioral Therapy↗
Nightmares, insomnia, and sleep-disordered breathing in fire evacuees seeking treatment for posttraumatic sleep disturbance.
Eight months after the Cerro Grande Fire, 78 evacuees seeking treatment for posttraumatic sleep disturbances were assessed for chronic nightmares, psychophysiological insomnia, and sleep-disordered breathing symptoms. Within this sample, 50% of participants were tested objectively for sleep-disordered breathing; 95% of those tested screened positive for sleep-disordered breathing. Multiple regression analyses demonstrated that these three sleep disorders accounted for 37% of the variance in posttraumatic stress symptoms, and each sleep disorder was significantly and independently associated with posttraumatic stress symptoms severity. The only systematic variable associated with posttraumatic stress symptoms of avoidance was sleep-disordered breathing. The findings suggest that three common sleep disorders relate to posttraumatic stress symptoms in a more complex manner than explained by the prevailing psychiatric paradigm, which conceptualizes sleep disturbances in PTSD merely as secondary symptoms of psychiatric distress.
Adult↗
Integrating psychosocial and biomedical CPAP adherence models. A commentary on: "Improving CPAP use by patients with the sleep apnea/hypopnea syndrome (SAHS)" (HM Engleman & MR Wild).
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Humans↗
Measuring trauma and health status in refugees: a critical review.
CONTEXT: Refugees experience multiple traumatic events and have significant associated health problems, but data about refugee trauma and health status are often conflicting and difficult to interpret. OBJECTIVES: To assess the characteristics of the literature on refugee trauma and health, to identify and evaluate instruments used to measure refugee trauma and health status, and to recommend improvements. DATA SOURCES: MEDLINE, PsychInfo, Health and PsychoSocial Instruments, CINAHL, and Cochrane Systematic Reviews (searched through OVID from the inception of each database to October 2001), and the New Mexico Refugee Project database. STUDY SELECTION: Key terms and combination operators were applied to identify English-language publications evaluating measurement of refugee trauma and/or health status. DATA EXTRACTION: Information extracted for each article included author; year of publication; primary focus; type (empirical, review, or descriptive); and type/name and properties of instrument(s) included. Articles were excluded from further analyses if they were review or descriptive, were not primarily about refugee health status or trauma, or were only about infectious diseases. Instruments were then evaluated according to 5 criteria (purpose, construct definition, design, developmental process, reliability and validity) as described in the published literature. DATA SYNTHESIS: Of 394 publications identified, 183 were included for further analyses of their characteristics; 91 (49.7%) included quantitative data but did not evaluate measurement properties of instruments used in refugee research, 78 (42.6%) reported on statistical relationships between measures (presuming validity), and 14 (7.7%) were only about statistical properties of instruments. In these 183 publications, 125 different instruments were used; of these, 12 were developed in refugee research. None of these instruments fully met all 5 evaluation criteria, 3 met 4 criteria, and 5 met only 1 of the criteria. Another 8 standard instruments were designed and developed in nonrefugee populations but adapted for use in refugee research; of these, 2 met all 5 criteria and 6 met 4 criteria. CONCLUSIONS: The majority of articles about refugee trauma or health are either descriptive or include quantitative data from instruments that have limited or untested validity and reliability in refugees. Primary limitations to accurate measurement in refugee research are the lack of theoretical bases to instruments and inattention to using and reporting sound measurement principles.
Health Status↗
To breathe, perchance to sleep: sleep-disordered breathing and chronic insomnia among trauma survivors.
Standard psychiatric classification (DSM-IV-TR) traditionally attributes post-traumatic sleep disturbance to a secondary or symptomatic feature of a primary psychiatric disorder. The DSM-IV-TR paradigm, however, has not been validated with objective sleep assessment technology, incorporated nosological constructs from the field of sleep disorders medicine, or adequately addressed the potential for post-traumatic stress disorder (PTSD) sleep problems to manifest as primary, physical disorders, requiring independent medical assessments and therapies. This paradigm may limit understanding of sleep problems in PTSD by promulgating such terms as "insomnia related to another mental disorder," a.k.a. "psychiatric insomnia." Emerging evidence invites a broader comorbidity perspective, based on recent findings that post-traumatic sleep disturbance frequently manifests with the combination of insomnia and a higher-than-expected prevalence of sleep-disordered breathing (SDB). In this model of complex sleep disturbance, the underlying sleep pathophysiology interacts with PTSD and related psychiatric distress; and this relationship appears very important as demonstrated by improvement in insomnia, nightmares, and post-traumatic stress with successful SDB treatment, independent of psychiatric interventions. Continuous positive airway pressure treatment in PTSD patients with SDB reduced electroencephalographic arousals and sleep fragmentation, which are usually attributed to central nervous system or psychophysiological processes. Related findings and clinical experience suggest that other types of chronic insomnia may also be related to SDB. We hypothesize that an arousal-based mechanism, perhaps initiated by post-traumatic stress and/or chronic insomnia, may promote the development of SDB in a trauma survivor and perhaps other patients with chronic insomnia. We discuss potential neurohormonal pathways and neuroanatomatical sites that may be involved in this proposed interaction between insomnia and SDB.
Adult↗
Nightmare frequency in sexual assault survivors with PTSD.
Sexual assault survivors with post-traumatic stress disorder (PTSD) were assessed for frequency of nightmares, measured retrospectively on the Nightmare Frequency Questionnaire (NFQ) and prospectively on nightmare dream logs (NLOG). Retrospective frequency was extremely high, averaging occurrences every other night and an estimated number of nightmares greater than five per week. Test-retest reliability data on the NFQ yielded weighted kappa coefficients of .85 (95% CI, .74-.95) for nights and .90 (95% CI, .83-.97) for nightmares. Correlations between retrospective and prospective nightmare frequencies ranged between .53 (P = .001) for nights and .63 (P = .001) for nightmares. Correlations between frequency and distress measures (anxiety, depression, post-traumatic stress) yielded coefficients ranging from (r = .28-.53). Compared with intrusive, cumbersome and time-consuming prospective measurements, the NFQ appears reliable, convenient, and equally useful in assessing nightmare frequency in a group of sexual assault survivors. Nightmare frequency, prevalence, distress and impairment are discussed.
Adult↗
Sleep-disordered breathing, psychiatric distress, and quality of life impairment in sexual assault survivors.
Using American Academy of Sleep Medicine research criteria, sleep-disordered breathing (SDB) was assessed in a pilot study of 187 sexual assault survivors with posttraumatic stress symptoms. Nightmares, sleep quality, distress, and quality of life were also assessed along with historical accounts of prior treatments for sleep complaints. Presumptive SDB diagnoses were established for 168 patients. Twenty-one of 168 underwent sleep testing, and all met objective SDB diagnostic criteria. There were no clinically meaningful differences in age, body-mass index, sleep quality, distress, or quality of life measures between 21 confirmed SDB cases and 147 suspected cases not tested. Compared with 19 women without SDB, 168 women with diagnosed or suspected SDB reported significantly worse nightmares, sleep quality, anxiety, depression, posttraumatic stress, and impaired quality of life. Despite suffering from sleep problems for an average of 20 years, which had not responded to repeated use of psychotropic medications or psychotherapy, few of these women had been referred to sleep specialists. SDB appears widespread among sexual assault survivors seeking help for nightmares. Research is needed to clarify the associations among SDB, distress, and physical and mental health impairment in trauma patients.
Adaptation, Psychological↗
Development of an inventory for measuring war-related events in refugees.
Knowledge about the range of war-related events experienced by refugees is lacking. This initial report of the New Mexico Refugee Project (NMRP) details the development of the Comprehensive Trauma Inventory (CTI), the first empirically developed instrument that measures war-related events in community-dwelling refugees. Both expert and participant methods using quantitative and qualitative approaches were used to broaden knowledge about the range of war-related experiences in refugees. The CTI-164, developed by expert rational methods, was administered to 36 Kurdish and 31 Vietnamese refugees along with an in-depth interview (IDI) and five other quantitative instruments measuring symptoms, impairment, and social support. Focus groups (FGs) were also conducted. Text and descriptive analyses, t tests, and correlations were used to analyze data. Refugees reported an average of 150 war-related events on the CTI-164, more than in other studies. IDIs and FGs revealed 123 war-related events and event types that were not on the CTI-164 or other measures currently used. Refugees reported multiple chronic symptoms and significant impairment in daily functioning. The CTI-164 was modestly correlated with symptoms and impairment. The definable number and type of war-related events endured by refugees is greater than in previously published research. Expert rational methods are not adequate to develop an instrument to define war-related events and measure their association with health outcomes. Participatory and qualitative methods reveal events and event types that have not been previously defined. The CTI warrants further testing after revision to incorporate items and event types determined by qualitative methods.
Adult↗