Cognitive Behavioral Treatments for Post-traumatic Stress Disorder (PTSD) Sleep Disturbance

Study Overview
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Brief Summary
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The purpose of this study is to compare the effectiveness of two cognitive behavioral group psychotherapy interventions in controlling the subjective sleep disturbance in veterans with Post-traumatic Stress Disorder.

Detailed Description
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Repetitive, stereotypical nightmares and insomnia commonly characterize post-traumatic stress disorder (PTSD). Identifying the pathophysiological mechanisms of disrupted sleep in PTSD has therefore assumed considerable clinical importance. We previously reported an increase in rapid eye movement activity (REM activity) during REM sleep (REMS) in Vietnam War combat veterans with PTSD, and this finding can be seen as consistent with the view that most, although not all, dreaming occurs during REMS and the repeated observation that REM activity correlates with the intensity of dream mentation. There is a growing body of evidence that post-traumatic nightmares can respond to psychological treatment interventions. Namely, a cognitive-behavioral technique entitled imagery rehearsal (IR) has been reported to be effective in the treatment of such nightmares in victims of crime and in women who have been sexually assaulted. In a small pilot study, it has also been reported to be effective in the treatment of Vietnam veterans with combat-related PTSD. The two objectives of this proposal are: 1. To compare, in a study with random assignment and a parallel group design, the effectiveness in controlling the subjective sleep disturbance in veterans with PTSD of IR and Sleep and Nightmare Management (SN), a psychological treatment that targets life stressors and problems with sleep hygiene that may exacerbate insomnia and nightmares. 2. In a subset of these subjects, to compare the effectiveness in reducing REM activity of IR and SN.

Official Title
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7857 Cognitive - Behavioral Treatments for PTSD Sleep Disturbance

Conditions
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Post-traumatic Stress Disorder

Intervention / Treatment
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* Behavioral: Imagery Rehearsal
* Behavioral: Sleep and Nightmare Management


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Male Vietnam Combat Veteran Diagnosis of combat-related PTSD Stable psychotropic regimen for a minimum of three months Experiences recurrent nightmares Exclusion Criteria: Bipolar disorder, delirium, dementia, amnestic and other cognitive disorders Schizophrenia and other psychotic disorders Substance abuse or dependence within the last six months Untreated medical disorders known to impact sleep
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Arm 1<br>Imagery Rehearsal Therapy | Behavioral: Imagery Rehearsal<br>* IR is a manual-based CBT predicated on the idea that waking mental activity influences nighttime dreams. Veterans examine the content of a recurrent nightmare, use imagery to alter disturbing aspects of the nightmare to promote mastery and control, and rehearse the new dream nightly, before bedtime.<br>|
| Active Comparator: Arm 2<br>Sleep and Nightmare Management | Behavioral: Sleep and Nightmare Management<br>* This comparison condition involved psychoeducation about PTSD, sleep and nightmares, progressive muscle relaxation and standard CBT for insomnia. This latter part included education about sleep hygiene (e.g., avoidance of caffeine and alcohol close to bedtime, benefit of regular bed time routines), stimulus control and sleep restriction (i.e., reestablishing a conditioned association between the bed/bedroom and sleep by reducing time spent tossing and turning in bed). Therapists worked with patients to identify problem areas in their sleep habits and to problem-solve about possible treatment targets<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Weekly Number of Nightmares |  | Baseline and 1, 3, and 6 months post-treatment | 
| Weekly Nights With a Nightmare |  | Baseline and 1, 3, and 6 months post-treatment | 
| Pittsburgh Sleep Quality Index | Total scores range from 0 to 21, with higher values indicating poorer sleep quality. A score greater than 5 distinguishes between poor and good sleepers. | Baseline and 1, 3, and 6 months post-treatment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pittsburgh Sleep Quality Index - Addendum | The PSQI-A is a measure of PTSD-related sleep and dream disturbances. Scores can range from 0 to 21, with higher scores reflecting greater sleep problems. | Baseline and 1, 3, and 6 months post-treatment | 
| Nightmare Effects Survey | This self-report questionnaire assesses psychosocial impairment attributed to nightmares. Eleven self-report questions are rated on a scale of zero to four. The individual scores are summed to produce a total score ranging from 0 to 44 (reported in the Table). Higher scores reflect greater impairment. | Baseline and 1, 3, and 6 months post-treatment | 
| PTSD Military Checklist | Seventeen items indicating the 17 DSM-IV criteria for PTSD are rated on a 5-point scale, from 1 to 5. Scores range from 17 to 85, with a higher score indicating greater symptom severity. | Baseline and 1, 3, and 6 months post-treatment | 
| Beck Depression Inventory | Twenty-one items are rated on a 4-point scale. Total scores range from zero to 63, with higher scores indicating more severe depression. | Baseline and 1, 3, and 6 months post-treatment | 
| SF-36 Physical Component | The Health Assessment Questionnaire Short Form 36 (SF-36) determines participants' overall quality of life by assessing 1) limitations in physical functioning due to health problems; 2) limitations in usual role because of physical health problems; 3) bodily pain; 4) general health perceptions; 5) vitality; 6) limitations in social functioning because of physical or emotional problems; 7) limitations in usual role due to emotional problems; and 8) general mental health. Scales 1-4 primarily contribute to the physical component summary score (PCS) of the SF-36. Scores on each scale are summed and averaged (range = 0 worst-100 best). | Baseline and 1, 3, and 6 months post-treatment | 
| SF-36 Mental Component | The Health Assessment Questionnaire Short Form 36 (SF-36) determines participants' overall quality of life by assessing 1) limitations in physical functioning due to health problems; 2) limitations in usual role because of physical health problems; 3) bodily pain; 4) general health perceptions; 5) vitality; 6) limitations in social functioning because of physical or emotional problems; 7) limitations in usual role due to emotional problems; and 8) general mental health. Scales 5-8 primarily contribute to the mental component summary score (PCS) of the SF-36. Scores on each scale are summed and averaged (range = 0 worst-100 best). | Baseline and 1, 3, and 6 months post-treatment | 
| Clinician-Administered PTSD Scale (CAPS) | Seventeen questions assess the frequency and intensity of PTSD symptoms. Scores range from zero to 136, with a higher score indicating more severe symptoms. | Baseline and 1 month post-treatment | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Imagery, Nightmares, Post-Traumatic Stress Disorder, Psychotherapy