Treatment and management of seven children with fractured femurs experiencing night terrors in hospital: a case study.

This article reports on seven cases of night terror disorder in children with no previous history of parasomnias, or night time disturbance. All children were admitted to a metropolitan children's hospital with a traumatic fracture of the femur and treated with Thomas' traction splint, a phenomenon not previously reported in the literature. The characteristic presentation of a night terror is described and a strategy for immediate nursing management of a night terror is suggested. Various forms of projective play therapy as a safe short-term treatment are described to assist children with night terror disorder.

Self-efficacy as a Mechanism of Action of Imagery Rehearsal Therapy's Effectiveness: An Exploratory Mediation Analysis.

Imagery rehearsal therapy (IRT) is an empirically validated therapy targeting recurring nightmares, for which the mechanisms of action remain poorly understood. The objective of this study was to investigate how an exploratory measure of self-efficacy could mediate IRT's effectiveness. Thirty-five victims of sexual assault with recurring nightmares were randomly assigned to either IRT or a control condition. Participants completed questionnaires about self-efficacy and nocturnal symptoms at pre- and posttreatment. Regression analyses showed that IRT predicted greater self-efficacy about dreams (ß = .578) and that self-efficacy about dreams predicted improvement in insomnia (ß = -.378). IRT also predicted greater self-efficacy about nightmares (ß = .366), which in turn predicts sleep quality (ß = -.412). However, self-efficacy was not a significant mediator of IRT's effectiveness on insomnia and sleep quality. Although IRT did increase patients' self-efficacy over dreams and nightmares, self-efficacy may not be a primary mechanism of action explaining IRT's effectiveness.

It's Not a Nightmare: Understanding Sleep Terrors.

Sleep terrors, one of the non-rapid eye movement parasomnias, are interesting nighttime phenomena that can be distressing for parents. For most children, this behavior is temporary and does not cause significant problems. However, some psychiatric conditions may have a higher prevalence of parasomnias, including sleep terrors. Although sleep terrors may be a benign and common event in children, a basic mental health examination should include a sleep-related screening to possibly identify underlying issues. Nurses must be knowledgeable about sleep terrors and able to provide education and support when parents share their concerns. [Journal of Psychosocial Nursing and Mental Health Services, 56(8), 11-14.].

Depression and the relationship between sleep disturbances, nightmares, and suicidal ideation in treatment-seeking Canadian Armed Forces members and veterans.

BACKGROUND: Research on the relationship between insomnia and nightmares, and suicidal ideation (SI) has produced variable findings, especially with regard to military samples. This study investigates whether depression mediated the relationship between: 1) sleep disturbances and SI, and 2) trauma-related nightmares and SI, in a sample of treatment-seeking Canadian Armed Forces (CAF) personnel and veterans (N = 663). METHOD: Regression analyses were used to investigate associations between sleep disturbances or trauma-related nightmares and SI while controlling for depressive symptom severity, posttraumatic stress disorder (PTSD) symptom severity, anxiety symptom severity, and alcohol use severity. Bootstrapped resampling analyses were used to investigate the mediating effect of depression. RESULTS: Approximately two-thirds of the sample (68%; N = 400) endorsed sleep disturbances and 88% (N = 516) reported experiencing trauma-related nightmares. Although sleep disturbances and trauma-related nightmares were both significantly associated with SI on their own, these relationships were no longer significant when other psychiatric conditions were included in the models. Instead, depressive symptom severity emerged as the only variable significantly associated with SI in both equations. Bootstrap resampling analyses confirmed a significant mediating role of depression for sleep disturbances. CONCLUSIONS: The findings suggest that sleep disturbances and trauma-related nightmares are associated with SI as a function of depressive symptoms in treatment-seeking CAF personnel and veterans. Treating depression in patients who present with sleep difficulties may subsequently help mitigate suicide risk.

Trauma characteristics and sleep impairment among trauma-exposed children.

Trauma-related sleep difficulties are quite common and their functional and clinical importance are increasingly recognized. High rates of sleep problems have been documented among trauma-exposed adults, particularly those diagnosed with posttraumatic stress disorder (PTSD); however, research with trauma-exposed children is relatively limited. Research specifically with child samples is critical due to the numerous developmental and functional implications that may result from sleep impairment. Characteristics of the traumatic event may play a key role in understanding sleep difficulties, yet, these associations are not well understood among trauma-exposed children. The current study therefore investigated whether aspects of the traumatic event (i.e., type, nature, chronicity, age of onset, removal from home, and complex trauma) were related to higher levels of sleep disturbances among 276 treatment-seeking children ages 6-18 years (M = 10.88, SD = 3.39; 63.4% female; 62.7% Black). Sleep problems were common in this sample. Domestic and community violence exposure were associated with higher levels of select sleep difficulties, as were interpersonal trauma, chronic trauma, a trauma that began early in life, and complex trauma. Nonetheless, type of trauma and characteristics of the traumatic event were largely unrelated to sleep problems on either caregiver's or children's reports. Removal from the home was not linked with sleep impairment. Although findings signify the relevance of sleep disturbances among trauma-exposed children, trauma characteristics may have limited influence on sleep problems.

Nightmares and nonsuicidal self-injury: The mediating role of emotional dysregulation.

INTRODUCTION: Nonsuicidal self-injury (NSSI) is a transdiagnostic behavior associated with significant psychopathology. Research has shown a positive association between sleep disturbances, (e.g., nightmares and insomnia), and suicidal behavior, however, the relation between NSSI and sleep disturbances has yet to be examined. Sleep disturbances have been found to have a causal role in problems with emotional dysfunction. Specifically, sleep disturbances inhibit the emotion processing function of sleep. Importantly, a majority of individuals engage in NSSI to regulate intense emotions, and it is possible that sleep disturbances increase propensity for NSSI by contributing to dysregulated emotions. METHODS: In two cross-sectional studies, the present research examined whether insomnia symptoms and nightmares were related to NSSI in a clinical sample (Study 1, N = 313) and in a university sample (Study 2, N = 152). Furthermore, the hypothesis that emotional dysregulation would atemporally mediate the relationship between sleep disturbances and NSSI was tested in Study 2. RESULTS: Findings showed that nightmares, but not insomnia symptoms, were associated with NSSI while controlling for depressive symptoms. This pattern of findings was consistent across both clinical and university samples, which underscores the robustness of the finding. Further, the relationship between nightmares and NSSI was fully mediated by emotional dysregulation. CONCLUSION: The present research provides initial evidence that nightmares are atemporally associated with an increased propensity for NSSI by contributing to emotional dysregulation, and provides support for the emotion regulation function of dreams.

Sexsomnia: A Specialized Non-REM Parasomnia?

Introduction: To describe patients with sexsomnia and to contrast their clinical and sleep measures with those of healthy controls and sleepwalkers. Aims and Methods: Subjects referred for sexsomnia and for sleepwalking/night terror were interviewed, completed the Paris Arousal Disorder Severity Scale (PADSS), and were monitored 1-2 nights with video-polysomnography. Results: Seventeen patients (70.6% male, aged 17-76 years) had sexsomnia, with amnestic fondling of the bed partner (n = 11), complete sexual intercourse (n = 8), masturbation (n = 8), and spontaneous orgasm (n = 1). The sexual behaviors were more direct during sleep than during wakefulness (n = 12), leading to 6 sexual assaults, including intra-conjugal rape (n = 3), assault of a family member (n = 2), rape of a friend (n = 1), and forensic consequences (n = 2). In 47% of sexsomnia patients, there was a history or current occurrences of sleepwalking/night terrors. Patients with sexsomnia had more N3 awakenings than healthy matched controls and the same amount as regular sleepwalkers. Half of them presented evidence of cortico-cortical dissociation, including concomitant slow (mostly frontal) and rapid (mostly temporal and occipital) electroencephalography (EEG) rhythms, with concomitant N3 penile erection in 1 case. Of 89 sleepwalkers, 10% had previous episodes of amnestic sexual behaviors, with a higher PADSS-A score and a trend of a higher total PADSS score than the 80 sleepwalkers without sexsomnia. Conclusion: In this single-center series, we confirmed the male predominance of sexsomnias and its potential for severe clinical and forensic consequences. The results suggest a continuum of regular sleepwalking, sleepwalking with occasional sexsomnia, and quasi-exclusive sexsomnia.

[Forensic Implications of Sleep-Associated Behavior Disorders]. / Strafrechtliche Implikationen schlafassoziierter Verhaltensstörungen.

Parasomnias represent a category of disorders that involve complex behaviors or emotional experiences, arising from or occurring during sleep, which might be also associated with (incomplete) awakening. These phenomena are classified as REM- or Non-REM-parasomnias. In particular the latter, including confusional arousal, sleepwalking and sleep terrors but also REM-sleep behavior disorder might result in criminal consequences. Using polysomnography, the pathophysiological mechanisms of these disorders have been investigated thoroughly. Nevertheless, in German literature, forensic implications of complex behaviors arising from sleep disorders have only been described insufficiently. Here we describe the most relevant parasomnias and also how to proceed in the context of forensic assessments.

Increased Reward-Related Behaviors during Sleep and Wakefulness in Sleepwalking and Idiopathic Nightmares.

BACKGROUND: We previously suggested that abnormal sleep behaviors, i.e., as found in parasomnias, may often be the expression of increased activity of the reward system during sleep. Because nightmares and sleepwalking predominate during REM and NREM sleep respectively, we tested here whether exploratory excitability, a waking personality trait reflecting high activity within the mesolimbic dopaminergic (ML-DA) system, may be associated with specific changes in REM and NREM sleep patterns in these two sleep disorders. METHODS: Twenty-four unmedicated patients with parasomnia (12 with chronic sleepwalking and 12 with idiopathic nightmares) and no psychiatric comorbidities were studied. Each patient spent one night of sleep monitored by polysomnography. The Temperament and Character Inventory (TCI) was administered to all patients and healthy controls from the Geneva population (n = 293). RESULTS: Sleepwalkers were more anxious than patients with idiopathic nightmares (Spielberger Trait anxiety/STAI-T), but the patient groups did not differ on any personality dimension as estimated by the TCI. Compared to controls, parasomnia patients (sleepwalkers together with patients with idiopathic nightmares) scored higher on the Novelty Seeking (NS) TCI scale and in particular on the exploratory excitability/curiosity (NS1) subscale, and lower on the Self-directedness (SD) TCI scale, suggesting a general increase in reward sensitivity and impulsivity. Furthermore, parasomnia patients tended to worry about social separation persistently, as indicated by greater anticipatory worry (HA1) and dependence on social attachment (RD3). Moreover, exploratory excitability (NS1) correlated positively with the severity of parasomnia (i.e., the frequency of self-reported occurrences of nightmares and sleepwalking), and with time spent in REM sleep in patients with nightmares. CONCLUSIONS: These results suggest that patients with parasomnia might share common waking personality traits associated to reward-related brain functions. They also provide further support to the notion that reward-seeking networks are active during human sleep.

Treating nighttime fears in young children with bibliotherapy: evaluating anxiety symptoms and monitoring behavior change.

OBJECTIVE: Children's nighttime fears are a normal part of child development and are transient for most children, but result in considerable distress for others. The present study evaluated a 4-week bibliotherapy intervention designed to treat young children with persistent and interfering nighttime fears utilizing a multiple baseline design. METHOD: Nine children between 5 and 7 years of age with specific phobia diagnoses were randomized into one of three baseline control conditions (1, 2, or 3 weeks). The treatment protocol involved parents reading Uncle Lightfoot, Flip that Switch: Overcoming Fear of the Dark, Academic Version (Coffman, 2012) with their children over 4 weeks while engaging in activities prescribed in the book. Assessments took place at baseline, post treatment, and 1 month following treatment. Daily and weekly tracking of nighttime behaviors was also obtained. RESULTS: Pre-post group analyses revealed that eight of the nine children demonstrated clinically significant change in anxiety severity. In addition, decreases in child-reported nighttime fears were observed, as were parent-reported decreases in separation anxiety and increases in the number of nights children slept in their own bed. CONCLUSIONS: The present study provides initial support for the use of bibliotherapy in the treatment of nighttime fears. Further replication and evaluation are needed to determine appropriate length of treatment and long-term effects. Implications of the findings are discussed.

Is sleep-related verbal memory consolidation impaired in sleepwalkers?

In order to evaluate verbal memory consolidation during sleep in subjects experiencing sleepwalking or sleep terror, 19 patients experiencing sleepwalking/sleep terror and 19 controls performed two verbal memory tasks (16-word list from the Free and Cued Selective Reminding Test, and a 220- and 263-word modified story recall test) in the evening, followed by nocturnal video polysomnography (n = 29) and morning recall (night-time consolidation after 14 h, n = 38). The following morning, they were given a daytime learning task using the modified story recall test in reverse order, followed by an evening recall test after 9 h of wakefulness (daytime consolidation, n = 38). The patients experiencing sleepwalking/sleep terror exhibited more frequent awakenings during slow-wave sleep and longer wakefulness after sleep onset than the controls. Despite this reduction in sleep quality among sleepwalking/sleep terror patients, they improved their scores on the verbal tests the morning after sleep compared with the previous evening (+16 ± 33%) equally well as the controls (+2 ± 13%). The performance of both groups worsened during the daytime in the absence of sleep (-16 ± 15% for the sleepwalking/sleep terror group and -14 ± 11% for the control group). There was no significant correlation between the rate of memory consolidation and any of the sleep measures. Seven patients experiencing sleepwalking also sleep-talked during slow-wave sleep, but their sentences were unrelated to the tests or the list of words learned during the evening. In conclusion, the alteration of slow-wave sleep during sleepwalking/sleep terror does not noticeably impact on sleep-related verbal memory consolidation.

Sleep-related violence and sexual behavior in sleep: a systematic review of medical-legal case reports.

OBJECTIVE: To review systematically medical-legal cases of sleep-related violence (SRV) and sexual behavior in sleep (SBS). SEARCH METHODS: We searched Pubmed and PsychINFO (from 1980 to 2012) with pre-specified terms. We also searched reference lists of relevant articles. SELECTION CRITERIA: Case reports in which a sleep disorder was purported as the defense during a criminal trial and in which information about the forensic evaluation of the defendant was provided. DATA EXTRACTION AND ANALYSIS: Information about legal issues, defendant and victim characteristics, circumstantial factors, and forensic evaluation was extracted from each case. A qualitative-comparative assessment of cases was performed. RESULTS: Eighteen cases (9 SRV and 9 SBS) were included. The charge was murder or attempted murder in all SRV cases, while in SBS cases the charge ranged from sexual touching to rape. The defense was based on sleepwalking in 11 of 18 cases. The trial outcome was in favor of the defendant in 14 of 18 cases. Defendants were relatively young males in all cases. Victims were usually adult relatives of the defendants in SRV cases and unrelated young girls or adolescents in SBS cases. In most cases the criminal events occurred 1-2 hours after the defendant's sleep onset, and both proximity and other potential triggering factors were reported. The forensic evaluations widely differed from case to case. CONCLUSION: SRV and SBS medical-legal cases did not show apparent differences, except for the severity of the charges and the victim characteristics. An international multidisciplinary consensus for the forensic evaluation of SRV and SBS should be developed as an urgent priority.

Impact of frequency of nightmares comorbid with insomnia on depression in Japanese rural community residents: a cross-sectional study.

OBJECTIVE: Nightmares and insomnia are known to be associated with the development and aggravation of depression. Our community-based study was conducted to clarify the relation between the impacts of nightmares and insomnia on depression. METHODS: A cross-sectional questionnaire-based survey was administered to residents of a rural community in Japan. In all, 2822 participants responded to questions assessing personal characteristics, the Pittsburgh Sleep Quality Index (PSQI) for assessing insomnia, and a 12-item version of the Center for Epidemiological Studies Depression scale (CES-D) for evaluating depression. Nightmare frequency was assessed using an item for nightmares on the PSQI. RESULTS: Nightmares more frequently occurred in participants with insomnia than those without (P < .01). Multiple regression analysis revealed that the scores of both nightmares and insomnia were significantly associated with the increase in depression score (nightmares (ß = 0.09, P < .01); insomnia (ß = 0.39, P < .01)). Participants with coexisting nightmares and insomnia showed higher depression scores than participants with insomnia alone or those with nightmares who did not have insomnia (P < .01). CONCLUSIONS: Insomnia and nightmares independently and additively impact the aggravation of depression.

A scale for assessing the severity of arousal disorders.

BACKGROUND: Arousal disorders may have serious health consequences. OBJECTIVE: To develop a scale assessing the severity of arousal disorders (Paris Arousal Disorders Severity Scale, PADSS). SETTING: University hospital. DESIGN: Controlled study. PARTICIPANTS: Consecutive patients (older than 15 y), with sleepwalking (SW) and/or sleep terrors (ST), subjects with previous SW/ST, normal controls and patients with rapid eye movement sleep behavior disorder. INTERVENTION: The self-rated scale listed 17 parasomniac behaviors (PADSS-A), assessed their frequency from never to twice or more per night (PADSS-B) and evaluated the consequences (PADSS-C: disturbed sleep, injuries, fatigue, and psychological consequences). The clinimetric properties and face validity of the scale were tested. RESULTS: Half of the 73 patients with SW/ST (more men than women) had injured themselves or others, whereas 15% had concomitant sexsomnia and 23% had amnestic eating behaviors. The total PADSS score (range: 0-50) was 19.4 ± 6.3 (range: 8-36) in this group, 11.7 ± 5.9 in 26 subjects with previous SW/ST, 8.8 ± 3.2 in 26 patients with RBD, and 2.0 ± 3.5 in 53 normal controls (P < 0.05). The PADSS demonstrated high sensitivity (83.6%), specificity (87.8%), internal consistency, and test-retest reliability (0.79). The best cutoff for the total score was at 13/14. Exploratory factor analysis revealed two components: wandering and violence/handling. The complexity of behaviors emerging from N3 sleep (scored on videopolysomnography) positively correlated with scores for the PADSS-total, PADSS-A, PADSS-C, and the "violence/handling" factor. CONCLUSION: This scale had reasonable psychometric properties and could be used for screening and stratifying patients and for evaluating the effects of treatments.

Análisis psicométrico de la Escala de Soledad de UCLA (Versión 3) en una muestra de guardias civiles / No disponible

La soledad es un constructo psicológico complejo que influye en nuestra salud a través del estrés y el cortisol. En este estudio se analizó psicométricamente la traducción española de la UCLA Loneliness Scale (Versión 3) en una muestra de miembros de la Guardia Civil. Los resultados señalaron una fiabilidad adecuada (alfa de Cronbach 0,954) para fines de investigación y de evaluación de individuos concretos. Se calculó el índice KMO (0,969), la prueba de la esfericidad de Bartlett (χ2 (190)=14.406,221, ρ<0,000) y el determinante de la matriz de correlaciones (0,0000018), para estudiar la conveniencia de realizar un análisis factorial. Para dicho análisis se utilizó la matriz de correlaciones policóricas (explica el 81,49% de la varianza total), extrayendo dos componentes a través el método de Componentes Principales y la rotación Varimax (10.184 y 1.080). No parece necesario eliminar ni revisar ninguno de los ítems (correlación ítem-total 0,486-0,804). En consecuencia, se concluye que esta escala podría ser válida para estudiar cómo influye esta variable en el estado de salud de los miembros de este cuerpo de policía militarizado

Loneliness is a complex psychological construct that influences our health through stress and cortisol. In this study we examined psychometrically the Spanish translation of the UCLA Loneliness Scale (Version 3) in a sample of members of the Guardia Civil. The results showed adequate reliability (Cronbach’s alpha .954) for research and evaluation of specific individuals. KMO index was calculated (.969), the Bartlett’s test of sphericity (χ2 (190)=14406.221, ρ<.000) and the determinant of the correlation matrix (.0000018), to examine the appropriateness of analysis factorial. For this analysis we used the polychoric correlation matrix (explains 81.49 % of the total variance), extracting two components through the principal components analysis (PCA) and varimax rotation (10,184 and 1,080). On the other hand, does not seem necessary to delete or revise any items (item-total correlation .486-.804). Consequently, it is concluded that this scale might be valid to study how this variable influences the health of the members of this militarized police force

Fight or flight? Dream content during sleepwalking/sleep terrors vs. rapid eye movement sleep behavior disorder.

OBJECTIVE: Dreams enacted during sleepwalking or sleep terrors (SW/ST) may differ from those enacted during rapid eye movement sleep behavior disorder (RBD). METHODS: Subjects completed aggression, depression, and anxiety questionnaires. The mentations associated with SW/ST and RBD behaviors were collected over their lifetime and on the morning after video polysomnography (PSG). The reports were analyzed for complexity, length, content, setting, bizarreness, and threat. RESULTS: Ninety-one percent of 32 subjects with SW/ST and 87.5% of 24 subjects with RBD remembered an enacted dream (121 dreams in a lifetime and 41 dreams recalled on the morning). These dreams were more complex and less bizarre, with a higher level of aggression in the RBD than in SW/ST subjects. In contrast, we found low aggression, anxiety, and depression scores during the daytime in both groups. As many as 70% of enacted dreams in SW/ST and 60% in RBD involved a threat, but there were more misfortunes and disasters in the SW/ST dreams and more human and animal aggressions in the RBD dreams. The response to these threats differed, as the sleepwalkers mostly fled from a disaster (and 25% fought back when attacked), while 75% of RBD subjects counterattacked when assaulted. The dreams setting included their bedrooms in 42% SW/ST dreams, though this finding was exceptional in the RBD dreams. CONCLUSION: Different threat simulations and modes of defense seem to play a role during dream-enacted behaviors (e.g., fleeing a disaster during SW/ST, counterattacking a human or animal assault during RBD), paralleling and exacerbating the differences observed between normal dreaming in nonrapid eye movement (NREM) vs rapid eye movement (REM) sleep.