Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares.

STUDY OBJECTIVES: This study's objective was to evaluate the effect of nightmares (NMs) on attrition and symptom change following cognitive behavioral therapy for insomnia (CBT-I) treatment using data from a successful CBT-I randomized controlled trial delivered to participants with recent interpersonal violence exposure. METHODS: The study randomized 110 participants (107 women; mean age: 35.5 years) to CBT-I or to an attention-control group. Participants were assessed at 3 time periods: baseline, post-CBT-I (or attention control), and at time 3 (T3) post-cognitive processing therapy received by all participants. NM reports were extracted from the Fear of Sleep Inventory. Participants with weekly NMs were compared with those with fewer than weekly NMs on outcomes including attrition, insomnia, posttraumatic stress disorder, and depression. Change in NM frequency was examined. RESULTS: Participants with weekly NMs (55%) were significantly more likely to be lost to follow-up post-CBT-I (37%) compared with participants with infrequent NMs (15.6%) and were less likely to complete T3 (43%) than patients with less frequent NMs (62.5%). NMs were unrelated to differential treatment response in insomnia, depression, or posttraumatic stress disorder. Treatment with CBT-I was not associated with reduced NM frequency; however, change in sleep-onset latency from post-CBT-I to T3 predicted fewer NMs at T3. CONCLUSIONS: Weekly NMs were associated with attrition but not a reduced change in insomnia symptoms following CBT-I. NM symptoms did not change as a function of CBT-I, but change in sleep-onset latency predicted lower NM frequency. CBT-I trials should screen for NMs and consider augmenting CBT-I to specifically address NMs. CITATION: Hamilton NA, Russell JA, Youngren WA, et al. Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares. J Clin Sleep Med. 2023;19(11):1913-1921.

Testing the nightmare cognitive arousal processing model.

OBJECTIVE: Posttrauma nightmares are recurring nightmares that begin after a traumatic experience. Research has only recently begun to identify variables that predict posttrauma nightmare occurrences. Research has identified presleep arousal-cognitive (PSA-C) and presleep arousal physiological (PSA-PHYS), sleep onset latency (SOL), and sleep-disordered breathing (SDB) as potential predictors of posttrauma nightmares. However, previous research includes methodological limitations, such as a lack of physiological measures and a homogeneous sample. To replicate previous findings and increase generalizability, the current study investigated predictors of nightmare occurrences in a sample of male inpatient veterans with mixed-trauma history. METHOD: Participants (n = 15) completed an initial assessment battery and seven consecutive days of pre and postsleep diaries, including measures of posttrauma nightmare triggers and posttrauma nightmare occurrences. Portable objective measurements of sleep and presleep states were used to examine sleep quality and physical arousal. RESULTS: Analyses revealed that PSA-C and SOL both predicted posttrauma nightmare occurrences and that PSA-PHYS was significantly higher on nights when nightmares occurred. CONCLUSION: Results replicate earlier research which posits that PSA and SOL play a role in triggering the occurrence of posttrauma nightmares. It should be noted that the sample was relatively small, warranting cautious interpretation of results. However, when taken together with the findings of the replicated study, results could suggest the plausibility of therapies targeting presleep cognitions, SOL, and presleep arousal in the treatment of posttrauma nightmares. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Influence of Service Era: Comparing Personality Assessment Inventory (PAI) Scale Scores Within a Posttraumatic Stress Disorder Treatment Clinic (PCT).

Research is mixed on the role of service era in symptom endorsement among Veterans, with differences emerging depending on the instrument evaluated. This study compares Personality Assessment Inventory (PAI) scale scores of VA test-takers who served during the Vietnam, Desert Storm, or Post-9/11 service eras. The sample was collected at a VA Posttraumatic Stress Disorder Clinical Team. Associations between gender and combat exposure were also examined as covariates. Results suggest that Veterans' self-report on the PAI is influenced by service era, even after accounting for gender and combat exposure during deployment. The largest differences were between Vietnam or Post-9/11 Veterans and those from the Gulf War era. Symptom differences typically varied across scales commonly associated with symptoms of trauma exposure/posttraumatic stress disorder. Implications for the clinical use of, and research with, the PAI and other broadband personality assessments within the VA healthcare system and trauma treatment settings are discussed.

Depression and substance use: The CES-D's utility in predicting treatment outcomes in a longitudinal multi-site study of residential treatment centers.

This investigation utilized a large sample of individuals undergoing substance use treatment to examine the CES-D's structural validity and establish its predictive utility relative to treatment discharge. The sample included 5750 individuals who were receiving substance abuse treatment at 19 different residential treatment facilities. The CES-D was administered to participants over the course of their time in a residential inpatient substance use treatment program. The present study used a split sample method to conduct both exploratory (EFA) and confirmatory (CFA) factor analyses. Results of both the EFA and CFA indicated that the CES-D contains three first order factors measuring negative mood, positive affect, and interpersonal interactions as well as a second-order high score factor which can be used to guide interpretation and symptom monitoring. Individuals receiving residential treatment fell into one of three distinct groups based on their CES-D scores, and that their scores (and subsequent trajectories of scores over time) were differentially related to discharge status. Implications for practice and the utility of the CES-D within substance use populations are discussed.

Assessing Triggers of Posttrauma Nightmares.

Posttrauma nightmares are recurring nightmares that begin after a traumatic experience and can occur as often as multiple times per week, often in a seemingly random pattern. Although these nightmares are prevalent in trauma survivors, little is known about the mechanisms underlying their sporadic occurrence. The present study aimed to investigate predictors of posttrauma nightmares. The sample included 146 observations nested within 27 female college students who reported frequent nightmares related to sexual trauma. Participants were recruited from an undergraduate student subject pool (n = 71) or were clinical referrals (n = 75). Participants completed an initial assessment battery and six consecutive days of pre- and postsleep diaries, which included measures of potential posttrauma nightmare triggers and measures intended to assess sleep quality and posttrauma nightmare occurrence. Descriptive statistics, mean comparisons, and multilevel modeling were used to examine the data. The results showed that both presleep cognitive arousal, γ10 SLij = 0.58, p = .006, z(1, N = 146) = -2.61; and sleep latency (SL), γ20 PCAij = 0.76, p < .001, z(1, N = 146) = -2.69, predicted posttrauma nightmare occurrence. Further investigation suggested that presleep cognitive arousal moderated the relation between SL and posttrauma nightmare occurrence, γ30 PCA x SLij = 0.67, p = .048 z(1, N = 146) = 1.98. The present results are the first to show that the co-occurrence of presleep arousal and delayed sleep onset latency may influence posttrauma nightmare occurrence, suggesting that the time immediately before sleep is crucial to the production of the posttrauma nightmares.

An Assessment of Medical Practitioners' Knowledge of, Experience with, and Treatment Attitudes Towards Sleep Disorders and Nightmares.

Sleep disorders are frequently under assessed and not well understood by medical practitioners. This study investigated medical practitioners' knowledge of, experience with, and treatment considerations for sleep disorders, with a particular emphasis on nightmares. Eighty-eight individuals practicing medicine in the United States completed a survey eliciting information in three domains: (a) professional experience with nightmares, (b) knowledge of nightmares, and (c) attitudes about treatment of sleep disturbances. Seventy percent of participants reported a lack of professional experience with nightmares, 78% endorsed inaccurate definitions of a nightmares, and 82% considered sleep disorders to be a secondary problem, with 75% considering nightmares a secondary problem. Seventy-two percent of participants reported they would be likely to consider psychological treatment for nightmares. Results suggest that medical practitioners may not be receiving updated and/or adequate education about sleep disorders, including nightmares. This lack of information may contribute to sleep disorders being under assessed and untreated.