Aetiology and treatment of nightmare disorder: State of the art and future perspectives.

This consensus paper provides an overview of the state of the art in research on the aetiology and treatment of nightmare disorder and outlines further perspectives on these issues. It presents a definition of nightmares and nightmare disorder followed by epidemiological findings, and then explains existing models of nightmare aetiology in traumatized and non-traumatized individuals. Chronic nightmares develop through the interaction of elevated hyperarousal and impaired fear extinction. This interplay is assumed to be facilitated by trait affect distress elicited by traumatic experiences, early childhood adversity and trait susceptibility, as well as by elevated thought suppression and potentially sleep-disordered breathing. Accordingly, different treatment options for nightmares focus on their meaning, on the chronic repetition of the nightmare or on maladaptive beliefs. Clinically, knowledge of healthcare providers about nightmare disorder and the delivery of evidence-based interventions in the healthcare system is discussed. Based on these findings, we highlight some future perspectives and potential further developments of nightmare treatments and research into nightmare aetiology.

Virtual Trauma Interventions for the Treatment of Post-traumatic Stress Disorders: A Scoping Review.

Some post-traumatic stress disorder (PTSD) patients do not benefit from imaginal exposure therapy. One possible approach to reach such patients are virtual trauma interventions. Herein, a qualitative scoping review was conducted. Different types of virtual trauma exposure interventions were identified. For each type of virtual trauma exposure interventions it was examined in detail: (1) which in sensu trauma exposure approach serves as therapeutic framework, how it was transferred into virtual reality, and if it was manualized; (2) which hardware and software were used; (3) whether the influence of spatial and social presence on the efficacy of virtual trauma interventions have been measured, and (4) whether the efficacy of virtual trauma interventions for PTSD patients having imagination difficulties was evaluated. These research questions were analyzed qualitatively. Accordingly, an extensive literature search was conducted using the databases Web of Science, PsycINFO, LIVIVO, PTSDpubs, and PubMed for scientific articles published between January 2013 and July 2020. Only studies aimed to reduce PTSD symptoms using virtual trauma interventions were included. The literature search was not limited to a specific study design, treatment/intervention method, or a minimum sample size. Eighteen studies were identified, which reported three different virtual trauma intervention approaches, namely, virtual reality exposure therapy (VRET), multi-modular motion-assisted memory desensitization and reconsolidation (3MDR), and action-centered exposure therapy (ACET). Seven randomized controlled trials (RCTs), two pilot studies, and one case study were focused on VRET; while two RCTs, one pilot study, and three case studies focused on 3MDR, and two case studies on ACET. Regarding the first research question (1), the results show that VRET is based on prolonged exposure, aiming for a virtual re-creation of the patient's traumatic recounting. Several treatment protocols exist for VRET. 3MDR is based on eye movement desensitization and reprocessing, aiming to reduce the patient's avoidance behavior. In 3MDR patients walk toward individualized trauma-related symbolic images in a cave automatic virtual environment (CAVE). One treatment protocol exists for 3MDR. ACET is based on the inhibitory learning theory, aiming for active interactions with a virtual trauma-associated environment to alter the anxiety structure through new secondary inhibitory learning. One treatment protocol exists for ACET. For the second research question (2), the results indicate that all VRET studies used head-mounted displays (HMDs) with a virtual version of the Iraq/Afghanistan or the World Trade Center attacks, while 3MDR studies utilized two different versions of a CAVE with personalized trauma-related images, and the ACET studies used HMDs with virtual street scenarios. For the third research question (3), the results demonstrate that the influence of spatial or social presence on the efficacy of virtual trauma interventions was not examined in any of the included studies. Similarly, for the fourth research question (4), the results show that empirical evidence for the efficacy of virtual trauma interventions on PTSD patients having imagination difficulties was lacking. Therefore, such empirical studies are needed to fill these research gaps.

Changes in sleep architecture in German Armed Forces personnel with posttraumatic stress disorder compared with depressed and healthy control subjects.

BACKGROUND: This study compares the sleep architecture of patients with posttraumatic stress disorder (PTSD) with that of both patients with depression and subjects with no mental disorder. METHOD: 45 German armed forces personnel with PTSD, 72 German armed forces personnel with depression and 24 healthy control subjects underwent 24-hour polysomnography. The effects of group membership, medication and the statistical interaction of group and medication were analysed for the following variables: sleep onset latency, REM sleep latency, slow-wave sleep and REM sleep percentages. RESULTS: Sleep onset latency was significantly prolonged in both the PTSD and the depression group. Moreover, psychotropic medication was associated with significantly prolonged REM sleep latency. CONCLUSION: The impact on sleep onset latency is of special clinical relevance in that according to preliminary studies, it is of major importance for subjective sleep quality. In contrast to the other parameters, an increase in sleep onset latency results in a subjective reduction in sleep quality which can lead to hyperarousal and increased preoccupation with sleep, which in turn may lead to dysfunctional sleep patterns.

Psychometric evaluation of the Hamburg Nightmare Questionnaire (HNQ).

Background: Nightmares are a widespread phenomenon. In comparison to the general population, they occur in mentally ill and especially in traumatized individuals with an increased frequency. Despite the high prevalence, there is no short questionnaire in the German language that is able to characterize nightmares, to differentiate between different nightmare types and to assess their impact on daytime functioning. Objective: The Hamburg Nightmare Questionnaire (HNQ) has been developed as a short self-rating instrument to fill this gap. Method: Psychometric characteristics of the HNQ were evaluated in a sample of 707 German soldiers passing through the standard diagnostics of the Center for Mental Health at the German Armed Forces Hospital Hamburg. Results: The results of this study show satisfactory psychometric characteristics as a sound factorial structure and adequate internal consistency for the HNQ as well as initial indications of the construct validity of its subscales. Conclusions: The HNQ is a reliable and economic tool for the assessment of posttraumatic nightmares in clinical as well as research settings.

Antecedentes: Las pesadillas son un fenómeno ampliamente generalizado. En comparación con la población general, las pesadillas ocurren con una mayor frecuencia en personas con enfermedad mental y, especialmente, en personas traumatizadas. A pesar de su alta prevalencia, no existe ningún cuestionario breve en idioma alemán que sea capaz de caracterizar las pesadillas, diferenciarlas en tipos, y evaluar su impacto sobre la funcionalidad durante el periodo de vigilia.Objetivo: Se desarrolló el Cuestionario de Pesadillas de Hamburgo (HNQ, por sus siglas en inglés) como un instrumento de valoración breve auto-aplicado para subsanar esta brecha.Método: Se evaluaron las características psicométricas del HNQ a partir de una muestra de 707 soldados alemanes que eran sometidos a los diagnósticos estándar del Centro para la Salud Mental del Hospital de Hamburgo de las Fuerzas Armadas Alemanas.Resultados: Los resultados de este estudio mostraron características psicométricas satisfactorias, tales como una firme estructura factorial y una adecuada consistencia interna para el HNQ, así como indicadores iniciales de la validez del constructo de sus subescalas.Conclusiones: El HNQ es una herramienta confiable y económica para la evaluación de pesadillas postraumáticas tanto en el ámbito clínico como en el de investigación.

Multifeature Mismatch Negativity in Patients With Posttraumatic Stress Disorder.

OBJECTIVE: The mismatch negativity (MMN) component of the event-related brain potential has been used to examine auditory monitoring in various mental disorders. Previous research with posttraumatic stress disorder (PTSD) patients has revealed contradictory results. Enhanced as well as diminished MMNs have been obtained. METHOD: The multifeature protocol was employed to investigate the pattern of MMN in 17 military deployment-related PTSD patients and a group of healthy university student controls. RESULTS: Our results suggest no general effect of PTSD on the MMN involving the majority of acoustic features. There were slightly reduced MMNs in patients relative to controls for 2 of the features (duration, location). On the other hand, the N1 component was reduced in patients compared with controls. CONCLUSIONS: Choice of the stimulus protocol might be an important factor to explain inconsistent results in previous research. Differences in the auditory context between stimulus protocols and deficits in the formation of larger (auditory) contexts in PTSD might account for the results. SIGNIFICANCE: This study adds to the small number of studies on PTSD and MMN and revealed valuable information to guide future, related studies.

Association of posttraumatic nightmares and psychopathology in a military sample.

OBJECTIVE: Nightmares are among the most frequent and disturbing symptoms of posttraumatic stress disorder (PTSD). However, basic research questions regarding key associations between certain nightmare characteristics, especially replicativeness, and posttraumatic psychopathology need further empirical elaboration. METHOD: Sixty-two German soldiers (mean age 33.8 years, 17.7% females) admitted to a hospital-based treatment program for veterans completed extensive assessments consisting of clinical interviews and self-rating measures with respect to sociodemographic characteristics and psychopathology as well as dream-related variables. RESULTS: Although nightmare distress, frequency, and replicativeness were all linked to PTSD symptomatology, only the latter proved to be a significant predictor of PTSD diagnosis. Moreover, none of these nightmare characteristics predicted a depression diagnosis. CONCLUSIONS: The replicativeness of nightmares appears to be a key variable for understanding the relationship between posttraumatic nightmares and PTSD, whereas nightmare frequency and distress appear to be more aptly defined as generic markers of mental health. (PsycINFO Database Record