A pilot randomised control study to investigate the effect of the South African Adolescence Group Sleep Intervention (SAASI) on adolescent sleep and PTSD.

Background: Trauma exposure prevalence and consequent post-traumatic stress disorder among South African adolescents are significant. Sleep disturbances are among the most frequently reported difficulties faced by those dealing with PTSD. The current study examined the feasibility and preliminary efficacy of the South African Adolescence Group Sleep Intervention on PTSD symptom severity and sleep disturbance.Method: Sixty-one adolescents with PTSD diagnoses and sleep disturbance were randomly assigned (1:1) to one individual and four group sessions of a sleep intervention (SAASI) or a control group. Participants completed the Child PTSD symptom scale for DSM5 (CPSS-5) and the Pittsburgh Sleep Quality Index (PSQI) among other sleep and psychiatric measures. The trial was registered on the Pan African Trial Registry (PACTR202208559723690).Results: There was a significant but similar decrease in PSQI scores in both groups over time indicating no overall intervention effect (Wald test = -2.18, p = .029), mean slope = -0.2 (95% CI: -0.37 to -0.02) (p = .583). On the CPSS-5, interaction between groups was also not significant (p = .291). Despite this overall finding, the mean difference in CPSS-SR-5 scores increased over time, with the difference between groups post-treatment -9.10 (95%CI: -18.00 to -0.21), p = .045 and the 1-month follow-up contrast - 11.22 (95%CI: -22.43 to -0.03), p = .049 suggesting that PTSD symptom severity decreased more in the intervention group than the control group. The dropout rate was higher than expected for both the intervention (n = 10; 32%) and control (n = 8; 26.7%) groups. Dropout were mostly school commitments or travel related.Conclusions: Early findings suggest a trend towards dual improvement in sleep quality and PTSD symptom severity in adolescents with a sleep disturbance and PTSD receiving a group sleep intervention (SAASI). Further investigation in a properly powered RCT with detailed retention planning is indicated.

A four-week group sleep intervention seems feasible in adolescents with PTSD and sleep disturbances in a low-resource South African setting.Utilising less specialised mental health resources such as nurses and counsellors in intervention delivery was feasible and effective.Preliminary results are promising and support further research to establish the efficacy of the intervention.

A Transdiagnostic group therapy for sleep and anxiety among adults with substance use disorders: Protocol and pilot investigation.

Introduction: Treatment of substance use disorders (SUDs) is challenging with high rates of treatment dropout and relapse, particularly among individuals with comorbid psychiatric conditions. Anxiety and insomnia are prevalent among those with SUD and exacerbate poor treatment outcomes. Interventions that concurrently target anxiety and insomnia during the early stages of SUD treatment are lacking. To this end, we investigated the feasibility and preliminary effectiveness in a single-arm pilot trial of an empirically informed group transdiagnostic intervention, Transdiagnostic SUD Therapy, to concurrently reduce anxiety and improve sleep among adults receiving treatment for SUD. Specifically, we hypothesized that participants would evidence declines in anxiety and insomnia and improvements in sleep health, a holistic, multidimensional pattern of sleep-wakefulness that promotes wellbeing. A secondary aim was to describe the protocol for Transdiagnostic SUD Therapy and how it may be implemented into a real-world addiction treatment setting. Method: Participants were 163 adults (Mage = 43.23; 95.1% White; 39.93% female) participating in an intensive outpatient program for SUD who attended at least three of four Transdiagnostic SUD Therapy sessions. Participants had diverse SUDs (58.3% alcohol use disorder, 19.0% opioid use disorder) and nearly a third of the sample met criteria for two SUDs and comorbid mental health diagnoses (28.9% anxiety disorder, 24.6% major depressive disorder). Results: As anticipated, anxiety and insomnia reduced significantly across the 4-week intervention period from clinical to subclinical severity, and sleep health significantly improved (ps < 0.001). These statistically significant improvements following Transdiagnostic SUD Therapy demonstrated medium to large effects (ds > 0.5). Conclusion: Transdiagnostic SUD Therapy is designed to be flexibly administered in "real-world" clinical settings and, preliminarily, appears to be effective in improving emotional and behavioral factors that increase risk for return to substance use and poor SUD treatment outcomes. Additional work is needed to replicate these findings, determine the feasibility of widespread uptake of Transdiagnostic SUD Therapy, and examine whether the treatment effects translate to improvement in substance use outcomes.

Developing and Testing a Web-Based Provider Training for Cognitive Behavioral Therapy of Insomnia.

INTRODUCTION: Chronic insomnia is a common and debilitating disease that increases risk for significant morbidity and workplace difficulties. Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment, but there is a critical lack of behavioral health providers trained in CBT-I because, in part, of a bottleneck in training availability and costs. The current project developed and evaluated a web-based provider training course for CBT-I: CBTIweb.org. MATERIALS AND METHODS: Subject matter experts developed the content for CBTIweb.org. Then, trainees completed alpha testing (n = 24) and focus groups, and the site was improved. Next, licensed behavioral health providers and trainees completed beta testing (n = 41) and the site underwent another round of modifications. Finally, to compare CBTIweb.org to an in-person workshop, licensed behavioral health providers were randomly assigned to CBTIweb.org (n = 21) or an in-person workshop (n = 23). All participants were CBT-I naïve and completed the following assessments: Computer System Usability Questionnaire, Website Usability Satisfaction Questionnaire, Website Content Satisfaction Questionnaire, and Continuing Education knowledge acquisition questionnaires. RESULTS: Alpha and beta testers of CBTIweb.org reported high levels of usability and satisfaction with the site and showed significant within-group knowledge acquisition. In the pilot comparison study, linear fixed-effects modeling on the pre-/postquestionnaires revealed a significant main effect for time, indicating a significant increase in knowledge acquisition from 69% correct at baseline to 92% correct at posttraining collapsed across in-person and CBTIweb.org groups. The interaction effect of Time by Condition was nonsignificant, indicating equivalence in knowledge gains across both groups. CONCLUSION: CBTIweb.org appears to be an engaging, interactive, and concise provider training that can be easily navigated by its users and produce significant knowledge gains that are equivalent to traditional in-person workshops. CBTIweb.org will allow for worldwide dissemination of CBT-I to any English-speaking behavioral health providers. Future research will work on translating this training to other languages and extending this web-based platform to the treatment of other sleep disorders (e.g., nightmares) and populations (e.g., pediatric populations with insomnia).

Sleep, a Governor of Morbidity in PTSD: A Systematic Review of Biological Markers in PTSD-Related Sleep Disturbances.

BACKGROUND: Sleep disturbances (SD) are the most impactful and commonly reported symptoms in post-traumatic stress disorder (PTSD). Yet, they are often resistant to primary PTSD therapies. Research has identified two distinct SDs highly prevalent in PTSD; insomnia and nightmares. Those who report SDs prior to a traumatic event are at greater risk for developing PTSD; highlighting that sleep potentially plays a role in PTSD's pathology. To further understand the pathobiological mechanisms that lead to the development of PTSD, it is first imperative to understand the interplay which exists between sleep and PTSD on a biological level. The aim of this systematic review is to determine if biological or physiological markers are related to SD in PTSD. METHODS: A systematic literature search was conducted on the electronic databases; Medline, Embase, AMED and PsycINFO, using Medical Subject Headings and associated keywords. RESULTS: Sixteen studies were included in the final analyses. Physiological makers of autonomic function, and biochemical markers of HPA-axis activity; inflammatory processes; and trophic factor regulation were related to the severity of SDs in PTSD. CONCLUSION: These findings add to the growing literature base supporting a central focus on sleep in research aiming to define the pathophysiological processes which result in PTSD, as well as emphasising the importance of specifically targeting sleep as part of a successful PTSD intervention strategy. Resolving SDs will not only reduce PTSD symptom severity and improve quality of life but will also reduce all-cause mortality, hospital admissions and lifetime healthcare costs for those with PTSD. Limitations of the current literature are discussed, and key recommendations future research must adhere to are made within.

Traumatic Event Exposure, Posttraumatic Stress Disorder, and Sleep Disturbances in a National Sample of U.S. Adults.

Posttraumatic stress disorder (PTSD) is a highly prevalent, debilitating disorder found to develop after exposure to a potentially traumatic event (PTE). Individuals with PTSD often report sleep disturbances, specifically nightmares and insomnia, which are listed within the criteria for PTSD. This research examined prevalence of insomnia and nightmares within a national sample of 2,647 adults (data weighted by age and sex to correct for differences in sample distribution) who had been exposed to one or more PTEs. Prevalence of self-reported sleep disturbance, sleep disturbances by PTE type, and gender differences were examined. All participants completed a self-administered, structured online interview that assessed exposure to stressful events and PTSD symptoms. Among individuals who met DSM-5 criteria for PTSD, a large majority (more than 92%) reported at least one sleep disturbance. Insomnia was relatively more prevalent than PTE-related nightmares among individuals with PTSD and among all PTE-exposed individuals. A higher number of PTEs experienced significantly increased the likelihood of both trauma-related nightmares and insomnia, McFadden's pseudo R2 = .07, p < .001. Women exposed to PTEs were more likely to endorse experience of insomnia, χ2 (1, N = 2,647) = 99.13, p < .001, φ = .194, and nightmares compared to men, χ2 (1, N = 2,648) = 82.98, p < .001, φ = .177, but this gender difference was not significant among individuals with PTSD, ps = .130 and .050, respectively. Differences in sleep disturbance prevalence by PTE type were also examined. Implications for treatment and intervention and future directions are discussed.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Exposición a eventos traumáticos, trastorno de estrés postraumático y trastornos del sueño en una muestra nacional de adultos EXPOSICION AL TRAUMA, TEPT Y SUEÑO El trastorno de estrés postraumático (TEPT) es un trastorno altamente prevalente y debilitante que se desarrolla después de la exposición a un evento potencialmente traumático (EPT). Los individuos con TEPT a menudo reportan alteraciones del sueño, específicamente pesadillas e insomnio, que se enumeran dentro de los criterios para el TEPT. Esta investigación examinó la prevalencia de insomnio y pesadillas en una muestra nacional de 2647 adultos (datos ponderados por edad y sexo para corregir las diferencias en la distribución de la muestra) quienes habían sido expuestos a uno o más EPTs. Se examinó la prevalencia de trastornos del sueño autoinformados, los trastornos del sueño por tipo de EPT y las diferencias de género. Todos los participantes completaron una entrevista estructurada auto-administrada online, que evaluó la exposición a eventos estresantes y los síntomas de TEPT. Entre las personas que cumplieron con los criterios del DSM-5 para el TEPT, una gran mayoría (más de 92%) reportó al menos una alteración del sueño. El insomnio fue relativamente más prevalente que las pesadillas relacionadas con EPT entre individuos con TEPT y entre todos los individuos expuestos a EPT. Un mayor número de los que experimentaron EPT aumentó significativamente la probabilidad de ambos, pesadillas relacionadas a trauma e insomnio, pseudo R2 de McFadden = .07, p <.001. Las mujeres expuestas a los EPT fueron más propensas a respaldar la experiencia de insomnio, χ2 (1, N = 2647) = 99.13, p <.001, φ = .194, y pesadillas en comparación con los hombres, χ2 (1, N = 2648) = 82.98, p <.001, φ = .177, pero esta diferencia de género no fue significativa entre los individuos con TEPT, ps = .130 y .050, respectivamente. También se examinaron las diferencias en la prevalencia de trastornos del sueño por tipo de EPT. Se discuten las implicaciones para el tratamiento y la intervención y las direcciones futuras.

PTSD symptoms and overt attention to contextualized emotional faces: Evidence from eye tracking.

Abnormal patterns of attention to emotional faces and images are proposed by theories of posttraumatic stress disorder (PTSD), and this has been demonstrated empirically. However, few studies have examined how PTSD symptoms are associated with attention to emotional faces in the context of emotional background images. Eye tracking data were collected from seventy-eight undergraduates with a history of experiencing at least one traumatic event as they completed the Contextual Recognition of Affective Faces Task (CRAFT; Milanak and Berenbaum, 2014), which requires subjects to identify the emotion depicted by faces superimposed on an emotional background image. Greater PTSD symptom severity was associated with more time spent looking at background contexts and less time looking at target faces. This is consistent with greater susceptibility to distraction by task-irrelevant emotional stimuli. The duration of each gaze fixation upon fear faces was shorter for those with greater PTSD symptoms, and this pattern was marginally significant for disgust faces. These findings suggest that PTSD symptoms may relate to greater attention toward non-facial background scenes and less attention toward facial stimuli, especially when conveying a fear or disgust expression.

The association between PTSD and facial affect recognition.

The major aims of this study were to examine how, if at all, having higher levels of PTSD would be associated with performance on a facial affect recognition task in which facial expressions of emotion are superimposed on emotionally valenced, non-face images. College students with trauma histories (N = 90) completed a facial affect recognition task as well as measures of exposure to traumatic events, and PTSD symptoms. When the face and context matched, participants with higher levels of PTSD were significantly more accurate. When the face and context were mismatched, participants with lower levels of PTSD were more accurate than were those with higher levels of PTSD. These findings suggest that PTSD is associated with how people process affective information. Furthermore, these results suggest that the enhanced attention of people with higher levels of PTSD to affective information can be either beneficial or detrimental to their ability to accurately identify facial expressions of emotion. Limitations, future directions and clinical implications are discussed.

An examination of sleep quality in veterans with a dual diagnosis of PTSD and severe mental illness.

Poor sleep quality is one of the most frequently reported symptoms by veterans with Posttraumatic Stress Disorder (PTSD) and by veterans with severe mental illness (SMI; i.e., schizophrenia spectrum disorders, bipolar disorder, major depression with or without psychotic features). However, little is known about the compounding effects of co-occurring PTSD/SMI on sleep quality in this population. Given the high rates of comorbidity and poor functional outcomes associated with sleep dysfunction, there is a need to better understand patterns of poor sleep quality in this population. The present study provides a description of sleep quality in veterans with a dual diagnosis of PTSD/SMI relative to veterans with PTSD only. Results indicated that, despite similar reports of PTSD symptom severity between the groups, veterans with PTSD/SMI reported higher levels of poor sleep quality than veterans only diagnosed with PTSD. Specifically, veterans with PTSD/SMI reported significantly greater difficulties with sleep onset and overall more sleep disturbance than their non-SMI counterparts. Implications of the findings are discussed within the context of an existing model of insomnia and suggest that more comprehensive sleep assessment and the provision of targeted sleep interventions may be helpful for those with a dual diagnosis of PTSD/SMI.

National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria.

Prevalence of posttraumatic stress disorder (PTSD) defined according to the American Psychiatric Association's Diagnostic and Statistical Manual fifth edition (DSM-5; 2013) and fourth edition (DSM-IV; 1994) was compared in a national sample of U.S. adults (N = 2,953) recruited from an online panel. Exposure to traumatic events, PTSD symptoms, and functional impairment were assessed online using a highly structured, self-administered survey. Traumatic event exposure using DSM-5 criteria was high (89.7%), and exposure to multiple traumatic event types was the norm. PTSD caseness was determined using Same Event (i.e., all symptom criteria met to the same event type) and Composite Event (i.e., symptom criteria met to a combination of event types) definitions. Lifetime, past-12-month, and past 6-month PTSD prevalence using the Same Event definition for DSM-5 was 8.3%, 4.7%, and 3.8% respectively. All 6 DSM-5 prevalence estimates were slightly lower than their DSM-IV counterparts, although only 2 of these differences were statistically significant. DSM-5 PTSD prevalence was higher among women than among men, and prevalence increased with greater traumatic event exposure. Major reasons individuals met DSM-IV criteria, but not DSM-5 criteria were the exclusion of nonaccidental, nonviolent deaths from Criterion A, and the new requirement of at least 1 active avoidance symptom.

Prevalence and features of generalized anxiety disorder in Department of Veteran Affairs primary care settings.

Generalized anxiety disorder (GAD) is a highly prevalent distressing condition for individuals in both community and community primary care settings. However, despite the high prevalence of GAD identified in epidemiological studies, little is known about GAD and its related symptoms and impairments in veteran populations. The present study investigated the prevalence, comorbidity, physical and mental health impairment, and healthcare utilization of veteran participants with GAD, as well as comparing symptoms of GAD and posttraumatic stress disorder (PTSD). Veterans (N=884) participated in a cross-sectional investigation in primary care clinics in four Veteran Affairs Medical Centers (VAMCs) and completed diagnostic interviews and self-report questionnaires; a chart review was conducted to assess their VAMC healthcare utilization. A large number of participants (12%) met diagnostic criteria for GAD, reporting significantly worse emotional health, pain, and general health, in addition to increased mental healthcare utilization and antidepressant medications. In addition, GAD was found in 40% of participants with PTSD, resulting in more severe symptoms and impairment than in patients with GAD alone. These findings provide evidence of high prevalence and severe impairment associated with GAD in veterans and highlight the need for improved recognition, assessment, and treatments for GAD.

Frequency and severity of comorbid mood and anxiety disorders in prescription opioid dependence.

BACKGROUND AND OBJECTIVES: Comorbid substance use disorders and mood and anxiety disorders are associated with more severe psychiatric symptoms, social and occupational impairment, and economic burden. To date, the majority of research has focused on comorbidity in illicit drug users, rather than prescription drug users. To address this gap in the literature, the present cross-sectional study investigated the clinical profiles of individuals with prescription opioid dependence with or without comorbid mood and anxiety disorders. METHODS: Ninety individuals with prescription opioid use were recruited to participate in the study procedures. All participants completed a structured clinical interview and series of self-report measures. RESULTS AND CONCLUSIONS: Of the 85 individuals with prescription opioid dependence, 47.1% (n = 40) were diagnosed with a comorbid mood or anxiety disorder. The findings showed that individuals with prescription opioid dependence and comorbid mood and anxiety disorders demonstrated significantly more severe alcohol use, psychiatric symptoms, and sleep impairment than individuals without comorbidity. SCIENTIFIC SIGNIFICANCE: The findings highlight the frequency and severity of co-occurring mood and anxiety disorders in individuals with prescription opioid dependence and suggest that integrated interventions are needed to address these growing problems.

CONVERGENCE OF DEPRESSION AND ANXIETY SYMPTOMS IN FRIENDSHIP DYADS.

Despite psychometric rationale to include multiple informants, psychological assessment typically involves data collected from the patient (target) only, particularly with regard to depressive and anxious symptomatology. This study addressed this gap in the literature by assessing convergence between targets and their close friends (informants) in an ethnically diverse sample of young adults. One hundred and thirty-nine friendship dyads completed a packet of questionnaires including different versions administered to the targets and informants, with targets completing the standard questionnaire battery focused on their own symptoms and informants completing questionnaires on their view of the target participants' symptoms, rather than their own characteristics. Measures were included to assess a wide range of symptomatology, including behavioral, cognitive, and physiological symptoms of anxiety and depression. The target-informant correlations were largely significant and of small-to-medium magnitude. In addition, target-informant agreement was higher in more visible symptoms (e.g., behavioral) than in less visible symptoms (e.g., physiological) of anxiety and depression. Interestingly, level of closeness in the relationship did not influence the magnitude of correlations. Implications for future research and integration into clinical assessment practices are discussed.

Behavioral activation and therapeutic exposure: an investigation of relative symptom changes in PTSD and depression during the course of integrated behavioral activation, situational exposure, and imaginal exposure techniques.

Effectiveness of exposure therapy for posttraumatic stress disorder (PTSD) may be adversely influenced by comorbid disorders. The present study investigated behavioral activation and therapeutic exposure (BA-TE), a new integrated treatment designed specifically for comorbid symptoms of PTSD and depression. Combat veterans with PTSD (N = 117) completed eight sessions of BA-TE that included two phases of treatment: (a) behavioral activation (BA) in which some activities involved situational exposures and (b) BA and situational exposures with imaginal exposures. Findings supported improvements in symptoms of PTSD, and overlapping symptoms of PTSD and depression, but not in nonoverlapping symptoms of depression. The findings also demonstrated a relatively consistent rate of change in PTSD and depression symptoms during BA-TE, despite the addition of imaginal exposures midway through the treatment. Together, these findings provide preliminary support for BA-TE as a treatment for PTSD and depression, and highlight the utility of transdiagnostic treatments in addressing comorbidity and symptom overlap.

The relationship between PTSD symptom factors and emotion.

The relationship between posttraumatic stress disorder (PTSD) symptom factors and two facets of emotion were examined. Emotional congruence effects were examined using an affective priming word pronunciation (naming) task, and negative affect was measured using self-report. Current PTSD symptoms were assessed using the Clinician-Administered PTSD Scale in 95 adults with trauma histories. Two alternative PTSD symptom factor structures were examined, one of which included an emotional numbing factor, and one of which included a dysphoria factor. Emotional congruence effects were significantly associated with an emotional numbing factor, but not with any other PTSD factors. Negative affect was significantly associated with a dysphoria factor, but not with any other PTSD factors.

Mood influences on acute smoking responses are independent of nicotine intake and dose expectancy.

Acute responses to smoking are influenced by nicotine and by nonpharmacological factors such as nicotine dose expectancy and sensory effects of smoke inhalation. Because negative mood increases smoking reinforcement, the authors examined whether these effects may be altered by mood context. Smokers (n=200) participated in 2 sessions, negative or positive mood induction, and were randomized to 1 of 5 groups. Four groups comprised the 2x2 balanced placebo design, varying actual (0.6 mg vs. 0.05 mg yield) and expected nicotine dose (expected nicotine vs. denicotinized [denic]) of cigarettes. A fifth group was a no-smoking control. Smoking, versus not smoking, attenuated negative affect, as well as withdrawal and craving. Negative mood increased smoking reinforcement. However, neither actual nor expected nicotine dose had much influence on these responses; even those smokers receiving and expecting a denic cigarette reported attenuated negative affect. A follow-up comparison suggested that the sensory effects of smoke inhalation, but not the simple motor effects of smoking behavior, were responsible. Thus, sensory effects of smoke inhalation had a greater influence on relieving negative affect than actual or expected nicotine intake.

Emotional numbing in relation to stressful civilian experiences among college students.

Investigators have shown that hyperarousal is the best predictor of emotional numbing (EN), as compared with avoidance and reexperiencing. The aim of the present study was to extend this finding to the context of stressful civilian experiences among college students. Participants (N = 1,292) completed self-report checklists of stressful civilian experiences and PTSD symptoms. The results of multiple regression analyses in two subsamples consistently indicated that both hyperarousal and avoidance were good predictors of EN. These findings suggest that avoidance may play a more important role in the relationship between hyperarousal and EN in college students.

Magical beliefs and rituals in young children.

Thirty-one children were administered a structured interview that assessed their beliefs about magic, tricks and wishes. Children were also presented with demonstrations of magic tricks/illusions, and asked to offer explanations as to how they worked. Parents completed the Childhood Routines Inventory (CRI), a 19-item parent report measure that assesses children's rituals, habits and sensory-perceptual experiences that we have termed "compulsive-like" behavior. Results indicated that children's rituals and compulsions were positively related to their magical beliefs, and inversely related to their uses of concrete, physical explanations to describe various phenomena. In particular, children's beliefs about the effects of wishing were most consistently correlated with their compulsive-like rituals and routines. The findings extended the work on magical beliefs and obsessive-compulsive phenomena to the normative manifestation of compulsive behaviors found in typical development.