Cognitive Behavioural Therapy for Nightmares for Patients with Persecutory Delusions (Nites): An Assessor-Blind, Pilot Randomized Controlled Trial.

OBJECTIVE: Nightmares are relatively common in patients experiencing psychosis but rarely assessed or treated. Nightmares may maintain persecutory delusions by portraying fears in sensory-rich detail. We tested the potential benefits of imagery-focused cognitive behavioural therapy (CBT) for nightmares on nightmare severity and persecutory delusions. METHOD: This assessor-blind parallel-group pilot trial randomized 24 participants with nightmares and persecutory delusions to receive CBT for nightmares delivered over 4 weeks in addition to treatment as usual (TAU) or TAU alone. Assessments were at 0, 4 (end of treatment), and 8 weeks (follow-up). Feasibility outcomes assessed therapy uptake, techniques used, satisfaction, and attrition. The primary efficacy outcome assessed nightmare severity at week 4. Analyses were intention to treat, estimating treatment effect with 95% confidence intervals (CIs). RESULTS: All participants offered CBT completed therapy (mean [SD], 4.8 [0.6] sessions) with high satisfaction, and 20 (83%) participants completed all assessments. Compared with TAU, CBT led to large improvements in nightmares (adjusted mean difference = -7.0; 95% CI, -12.6 to -1.3; d = -1.1) and insomnia (6.3; 95% CI, 2.6 to 10.0; d = 1.4) at week 4. Gains were maintained at follow-up. Suicidal ideation was not exacerbated by CBT but remained stable to follow-up, compared with TAU, which reduced at follow-up (6.8; 95% CI, 0.3 to 3.3; d = 0.7). CBT led to reductions in paranoia (-20.8; 95% CI, -43.2 to 1.7; d = -0.6), although CIs were wide. Three serious adverse events were deemed unrelated to participation (CBT = 2, TAU = 1). CONCLUSIONS: CBT for nightmares is feasible and may be efficacious for treating nightmares and comorbid insomnia for patients with persecutory delusions. It shows promise on paranoia but potentially not on suicidal ideation.

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.

A hybrid type I trial to increase Veterans' access to insomnia care: study protocol for a randomized controlled trial.

BACKGROUND: Chronic insomnia is among the most reported complaints of Veterans and military personnel referred for mental health services. It is highly comorbid with medical and psychiatric disorders, and is associated with significantly increased healthcare utilization and costs. Evidence-based psychotherapy, namely Cognitive Behavioral Therapy for Insomnia (CBTI), is an effective treatment and recommended over prescription sleep medications. While CBTI is part of a nationwide rollout in the Veterans Health Administration to train hundreds of providers, access to treatment is still limited for many Veterans due to limited treatment availability, low patient and provider knowledge about treatment options, and Veteran barriers such as distance and travel, work schedules, and childcare. Uptake of a briefer, more primary-care-friendly treatment into routine clinical care in Veterans Affairs (VA) primary care settings, where insomnia is typically first recognized and diagnosed, may effectively and efficiently increase access to effective insomnia interventions and help decrease the risks and burdens related to chronic insomnia. METHODS: This hybrid type I trial is composed of two aims. The first preliminarily tests the clinical non-inferiority of Brief Behavioral Treatment for Insomnia (BBTI) versus the current "gold standard" treatment, CBTI. The second is a qualitative needs assessment, guided by the Consolidated Framework for Implementation Research (CFIR), to identify potential factors that may affect successful implementation and integration of behavioral treatments for insomnia in the primary care setting. To identify potential implementation factors, individual interviews are conducted with the Veterans who participate in the clinical trial, as well as VA primary care providers and nursing staff. DISCUSSION: It is increasingly important to better understand barriers to, and facilitators of, implementing insomnia interventions in order to ensure that Veterans have the best access to care. Furthermore, it is important to evaluate the potential for new avenues of treatment delivery, like BBTI in the primary care setting, which can benefit Veterans who may not have adequate access to specialty mental health providers trained in CBTI. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02724800 . Registered on 31 March 2016.

Veterans Affairs Primary Care Provider Perceptions of Insomnia Treatment.

STUDY OBJECTIVES: Insomnia is a widespread issue among United States adults and rates of insomnia among veterans are even higher than the general population. Prior research examining primary care provider (PCP) perspectives on insomnia treatment found that: sleep hygiene and pharmacotherapy are the primary treatments offered; PCPs tend to focus on perceived causes of insomnia rather than the insomnia itself; and neither patients nor providers are satisfied with insomnia treatment options. Although insomnia complaints are typically first reported to primary care providers, little research has focused on perspectives regarding insomnia treatment among PCPs working in the largest integrated health care system in the United States-the Veterans Affairs (VA) health care system. This study was conducted to examine VA PCP perceptions of the availability of insomnia treatments, identify specific strategies offered by PCPs, and examine perceptions regarding the importance of treating insomnia and the role of comorbid conditions. METHODS: A survey was conducted within the VA health care system. Primary care providers completed surveys electronically. RESULTS: A high percentage of veterans (modal response = 20% to 39%) seen in VA primary care settings report an insomnia complaint to their provider. Almost half of respondents do not consistently document insomnia in the medical record (46% endorsed "sometimes," "rarely," or "never"). PCPs routinely advise sleep hygiene recommendations for insomnia (ie, avoid stimulants before bedtime [84.3%], and keep the bedroom environment quiet and dark and comfortable [68.6%]) and many are uncertain if cognitive behavioral therapy for insomnia is available at their facility (43.1%). CONCLUSIONS: Findings point to the need for systems-level changes within health care systems, including the adoption of evidence-based clinical practice standards for insomnia and PCP education about the processes that maintain insomnia. COMMENTARY: A commentary on this article appears in this issue on page 937.

Pharmacological and non-pharmacological treatments for nightmare disorder.

Interest in the treatment of nightmares has greatly increased over the last several years as research has demonstrated the clinical significance of nightmare disorder. This paper provides an overview of nightmare disorder, its clinical relevance, and the leading treatments that are available. In particular, the paper defines nightmare disorder and then summarize the recent literature examining the clinical relevance of nightmare disorder, including its relation to post-traumatic stress disorder and other psychiatric conditions. The relation between nightmares and suicidality is also discussed. Recent findings on the treatment of nightmare with imagery rehearsal therapy and prazosin are then summarized. Lastly, the paper comments on potential future uses of nightmare treatment including using imagery rehearsal therapy or prazosin as a first-line intervention for post-traumatic stress disorder and using these treatments as an adjunctive therapy to reduce suicide risk in those at risk of suicide with nightmares.

Deployment-related insomnia in military personnel and veterans.

Insomnia is a prevalent disorder that greatly impacts military personnel, especially those deployed in support of combat efforts. Deployment-related stressors like combat exposure, mild traumatic brain injury (mTBI) irregular sleep-wake schedules, and adjustment to the return home all contribute to insomnia. However, insomnia can also exacerbate the deployment experience and is a risk factor for traumatic stress reactions such as PTSD, depression, and suicide. Military personnel with mTBI are significantly impacted by insomnia; the majority experience sleep disruption and this can impede recovery and rehabilitation. As more service members return home from deployment, treatment is vital to reduce the impact of insomnia. Preliminary outcome data, showing positive results for reduction of sleep disruption, has been found with treatments such as combined cognitive behavioral treatment of insomnia (CBTI) and imagery rehearsal therapy (IRT), preference-based interventions, as well as efforts to broadly disseminate CBTI. The recent literature on the impact and treatment of deployment-related insomnia is reviewed.

Post-traumatic stress symptoms correlate with smaller subgenual cingulate, caudate, and insula volumes in unmedicated combat veterans.

Prior studies have examined differences in brain volume between patients with post-traumatic stress disorder (PTSD) and control subjects. Convergent findings include smaller hippocampus and medial prefrontal cortex volumes in PTSD. However, post-traumatic stress symptoms (PTSS) exist on a spectrum, and neural changes may occur beyond the diagnostic threshold of PTSD. We examined the relationship between PTSS and gray matter among combat-exposed U.S. military veterans. Structural brain magnetic resonance imaging (MRI) was obtained on 28 combat veterans from Operations Enduring and Iraqi Freedom. PTSS were assessed using the Clinician-Administered PTSD Scale (CAPS). Thirteen subjects met criteria for PTSD. Subjects were unmedicated, and free of major comorbid psychiatric disorders. Images were analyzed using voxel-based morphometry, and regressed against the total CAPS score and trauma load. Images were subsequently analyzed by diagnosis of PTSD vs. non-PTSD. CAPS scores were inversely correlated with volumes of the subgenual cingulate (sgACC), caudate, hypothalamus, insula, and left middle temporal gyrus (MTG). Group contrast revealed smaller sgACC, caudate, hypothalamus, left insula, left MTG, and right MFG in the PTSD group. PTSS are associated with abnormalities in limbic structures that may underlie the pathophysiology of PTSD. These abnormalities exist on a continuum with PTSS, beyond a diagnosis of PTSD.

K-complexes are not preferentially evoked to combat sounds in combat-exposed Vietnam veterans with and without post-traumatic stress disorder.

The primary objective was to compare the evoked K-complex response to salient versus non-salient auditory stimuli in combat-exposed Vietnam veterans with and without post-traumatic stress disorder (PTSD). Three categories of auditory stimuli (standard 1000Hz tones, trauma-related combat sounds, and affectively neutral environmental sounds) were presented during stage 2 sleep utilizing an oddball paradigm with probabilities of occurrence of 60%, 20% and 20% respectively. Twenty-four combat-exposed Vietnam veterans, 14 with PTSD and 10 without PTSD were studied in a sleep laboratory at the National Center for PTSD in Menlo Park, CA. While significantly fewer K-complexes overall were elicited in patients, there were no differences in the proportion of K-complexes elicited by tones and combat stimuli within either group. Patients produced significantly more K-complexes to neutral stimuli than to tone or combat stimuli. Examination of the N550 component of the evoked K-complex revealed significantly longer latencies in the patient group. Across the entire sample, N550 latencies were longer for combat stimuli relative to tone neutral stimuli. There were no group or stimulus category differences for N550 amplitude. The results suggest that salient information, as defined by trauma-related combat sounds, did not preferentially elicit K-complexes in either the PTSD group or the control group, suggesting that K-complexes function to protect sleep more than to endogenously process meaningful stimuli.

Neurobiology of non-REM sleep in depression: further evidence for hypofrontality and thalamic dysregulation.

OBJECTIVE: Sleep disturbances characterize depression and may reflect the abnormal persistence of brain activity from wakefulness into non-REM sleep. The goal of this study was to investigate the functional neuroanatomical correlates of non-REM sleep relative to presleep wakefulness in depressed patients and healthy subjects. METHOD: Twelve medication-free depressed patients and 13 healthy subjects underwent polysomnography and [(18)F]fluorodeoxyglucose positron emission tomography scans during presleep wakefulness and non-REM sleep. Statistical parametric mapping contrasts were performed to detect differences in relative regional cerebral glucose metabolism between presleep wakefulness and non-REM sleep in each group as well as interactions across states and between groups. RESULTS: Relative to healthy subjects, depressed patients showed less of a decrease in relative regional cerebral glucose metabolism from presleep wakefulness to non-REM sleep in the left and right laterodorsal frontal gyri, right medial prefrontal cortex, right superior and middle temporal gyri, insula, right posterior cingulate cortex, lingual gyrus, striate cortex, cerebellar vermis, and left thalamus. CONCLUSIONS: Patterns of relative regional cerebral glucose metabolism changes from presleep wakefulness to non-REM sleep differ in healthy subjects and depressed patients. Specifically, the transition from wakefulness to non-REM sleep was characterized by the relative persistence of elevated metabolic activity in frontoparietal regions and thalamus in depressed patients compared with healthy subjects. These findings suggest that abnormal thalamocortical network function may underlie sleep anomalies and complaints of nonrestorative sleep in depressed patients.

Impact of imagery rehearsal treatment on distressing dreams, psychological distress, and sleep parameters in nightmare patients.

We investigated the impact of imagery rehearsal treatment (IRT) on nightmare frequency, psychological distress, and sleep quality using polysomnography (PSG). 12 chronic nightmare patients completed prospective dream logs, measures of psychological distress, and underwent PSG prior to and 8.5 weeks following a single IRT session. Post-treatment, significant reductions were observed in retrospective nightmare frequency (d = 1.06, p = .007), prospective bad dream frequency (d = 0.53, p = .03), and anxiety scores (d = 1.01, p = .004). Minimal sleep alterations were found post-IRT, and varied as a function of nightmare etiology. The results independently replicate the efficacy of IRT for alleviating disturbing dreams and psychological distress. Sleep improvement may occur later in the recovery process.