DenDowhy

Sleep and Anxiety: Focus on PTSD and Generalized Anxiety Disorder: Posttraumatic Stress Disorder Authors and Disclosures Print This Email this Introduction Posttraumatic Stress Disorder Generalized Anxiety Disorder Conclusions [*] References Posttraumatic Stress Disorder Sleep disturbance is a core feature of PTSD, as reflected in its inclusion in 2 of the 3 major symptom clusters in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR®): difficulty falling asleep as a hyperarousal symptom and nightmares as a reexperiencing symptom.[7] Sleep disturbance is highly prevalent among patients with PTSD; 70% to 91% of individuals with civilian- or combat-related PTSD experience some sleep disruption.[8-11] For example, 91% of 116 Vietnam veterans with PTSD seen in a Veterans Administration clinic reported sleep disturbance (distinct from nightmares), with 73% experiencing recurrent dreams and nightmares and 39% avoiding sleep because of anticipation of troubling thoughts or nightmares.[11] The development of sleep disturbance following trauma exposure appears to be a marker and a potential risk factor for the subsequent development of PTSD.[12] In one study, PTSD developed by 6-month follow-up in almost three fourths of individuals (72%) reporting sleep disturbance in the month following trauma exposure.[13] Disturbed sleep among individuals with PTSD is associated with a number of measures of poorer clinical status, including depression and suicidality,[14] poorer overall quality of life and functioning,[15] poorer health functioning and somatic symptoms,[16,17] and increased rates of alcohol and substance use.[18,19] Sleep disturbances appear to both worsen and prolong the PTSD syndrome,[20] which is consistent with preclinical data demonstrating that sleep deprivation leads to impaired extinction learning in fear-conditioned rats.[21] Although a number of agents and psychosocial interventions have been tested and used for the treatment of PTSD, there is relatively little systematic controlled data specifically addressing the treatment of associated sleep disturbance. Treatment with selective serotonin reuptake inhibitors (SSRIs) has been associated with small but significant overall improvement in sleep disturbance in large randomized, controlled trials of patients with PTSD[22,23]; however, sleep disturbance is also noted after the administration of these agents.[24,25] These medications can have a number of adverse effects on sleep, including increased arousals and decreased rapid eye movement (REM) sleep and total sleep time.[26,27] Other sedating antidepressants, such as amitriptyline or mirtazapine, show weak results for the treatment of PTSD symptoms, and studies that suggested benefit were small and had methodologic limitations, including significant dropout rates.[28,29] Although a consensus treatment guideline[30] and survey data[31] suggest that trazodone may be beneficial for patients with PTSD, there is no controlled study of its application in affected individuals. Benzodiazepines are commonly administered to patients with PTSD,[32] although there are relatively few systematic data addressing their use in this patient population. However, in a small randomized, controlled trial, alprazolam did not have substantial benefit for PTSD or for nightmares, although it did improve anxiety.[33] In a small single-blind, placebo-controlled crossover study, clonazepam did not demonstrate significant benefit in any sleep parameters, including nightmares, although there were some modest, nonsignificant improvements in sleep latency and maintenance.[34] Further, although the findings need to be understood in the context of the small number of patients examined, data from 2 studies[35,36] suggest that although benzodiazepines administered to individuals who have been recently traumatized may have a salutary acute effect on reducing anxiety and insomnia, their use is associated with an increased risk for PTSD at up to a 6-month follow-up. The use of benzodiazepines is also constrained by their potential for abuse and dependence and because they may worsen depression, which is of particular relevance given the high comorbidity rate of substance abuse and depression in individuals with PTSD. Further, patients with combat-related PTSD have experienced severe withdrawal symptoms, including disinhibition and rage with even gradual withdrawal of alprazolam.[37] Prazosin, an alpha-1 adrenergic antagonist antihypertensive, has demonstrated efficacy in double-blind, randomized, controlled trials in civilian- and combat-related PTSD for nightmares, sleep disturbance, and overall PTSD symptomatology.[38,39] Although this agent was generally well tolerated in those trials, it can be associated with orthostatic hypotension, particularly early in treatment. Atypical antipsychotic medications are being used as adjunctive therapy and, occasionally, as monotherapy for PTSD and other mood and anxiety disorders. For instance, in a double-blind, placebo-controlled study of olanzapine augmentation of SSRI in patients with persistent symptomatology despite antidepressant treatment alone, there was significant improvement in sleep disturbance as well as in other symptoms of PTSD in combat veterans.[40] Of note, however, the average weight gain for olanzapine-treated patients in this study was more than 13 pounds. Quetiapine also demonstrated benefit for sleep-related symptoms in patients with PTSD in a 6-week open-label adjunctive study.[41] The potential salutary effects on sleep and PTSD associated with the use of atypical antipsychotic drugs, however, need to be weighed against their potential to cause significant weight gain, diabetes, and other manifestations of metabolic syndrome, as well as extrapyramidal effects. Although cyproheptadine, a 5HT2 and H1 receptor antagonist used to treat symptomatic allergies, showed benefit for the treatment of nightmares in individuals with PTSD in a number of open reports,[42,43] it was ineffective for nightmares or PTSD in a double-blind, randomized, controlled trial, and in fact appeared to exacerbate sleep disturbance and other PTSD symptoms.[44] A retrospective report suggested that the anticonvulsant gabapentin was effective in enhancing sleep duration and decreasing nightmares when used adjunctively with antidepressants for individuals with PTSD,[45] although there has been no subsequent systematic study of this issue. The hypnotic zolpidem reduced sleep disturbance, including nightmares, in an open series of patients with combat-related PTSD, although effects on other PTSD symptoms were not reported.[46] Eszopiclone was recently reported to improve both PTSD symptomatology and sleep disturbance when administered as monotherapy or augmentation therapy for PTSD in a double-blind, randomized, controlled crossover study.[47] Exposure-based cognitive behavioral therapy (CBT) has been demonstrated effective in numerous studies for the treatment of PTSD.[29] A specific form of CBT called imagery rehearsal therapy, which targets chronic nightmares, has demonstrated efficacy in a randomized controlled study for reducing nightmares, insomnia, and overall PTSD symptoms in affected individuals.[48] Although CBT is clearly effective, its use can be limited by patients' willingness and ability to participate in the necessary interventions, as well as by problems with the broad dissemination of these treatments.

From Medscape Medical News Symptoms of PTSD Linked to Increased Prevalence of Asthma News Author: Laurie Barclay, MD CME Author: Penny Murata, MD Authors and Disclosures CME Released: 11/29/2007; Valid for credit through 11/29/2008 Print This Email this November 29, 2007 — Symptoms of posttraumatic stress disorder (PTSD) are linked to increased prevalence of asthma even after careful adjustment for familial or genetic factors and other potential confounders, according to an analysis of data from the Vietnam Era Twin Registry reported in the November 15 issue of the American Journal of Respiratory & Critical Care Medicine. "Studies have suggested heightened anxiety among adults with asthma; the mechanism of this association is not known," write Renee D. Goodwin, PhD, MPH, from Columbia University in New York, NY, and colleagues. "Evidence to date suggests that panic disorder and post–traumatic stress disorder (PTSD) are the anxiety disorders most strongly associated with asthma in clinical samples. . . . The goals of the current study are as follows: (1) to determine the strength of the relationship between PTSD symptoms and asthma and (2) to examine if the association is due to familial or genetic confounding factors." The Vietnam Era Twin Registry includes male veteran twin pairs born between 1939 and 1956 who served from 1965 to 1975 during the Vietnam era. Variables included a symptom scale for PTSD, history of clinician-diagnosed asthma, and sociodemographic and health confounding factors. Mixed-effects logistic regression was used to account for the paired structure of the twin data and to evaluate the association between PTSD symptoms and asthma in all twins. Separate analyses were conducted within twin pairs and were based on zygosity. Even after adjustment for confounding factors, such as smoking and body mass index, PTSD symptoms were associated with a significantly increased likelihood of asthma (P for trend < .001). Compared with twins in the lowest quartile of PTSD symptoms, those in the highest quartile were 2.3 times as likely (95% confidence interval [CI], 1.4 - 3.7) to have asthma. Results were similar when evaluated within twin pairs and after stratification by zygosity. Limitations of the study include lack of data concerning some risk factors for asthma, such as exposure to cockroach allergen and environmental tobacco smoke during childhood; lack of information on timing or severity of asthma; measurement of PTSD symptoms not contemporaneous with the measurement of a lifetime history of asthma; lack of data on other types of anxiety; sample limited to men; possible bias if individuals with more PTSD symptoms seek out medical care more often vs those with fewer symptoms; possible overreporting of physical illnesses in patients with PTSD; and cross-sectional analysis. "Symptoms of PTSD were associated with an elevated prevalence of asthma," the study authors write. "Even after careful adjustment for familial/genetic factors and other potential confounding factors, an association between PTSD symptoms and asthma remains. Efforts to understand this comorbidity may be useful in identifying modifiable environmental risk factors contributing to this pattern and therefore in developing more effective prevention and intervention strategies." The US Department of Veterans Affairs has provided financial support for the development and maintenance of the Vietnam Era Twin Registry. The study authors have disclosed no relevant financial relationships. Am J Respir Crit Care Med. 2007;176:983-987. Clinical Context Asthma has been linked to mental disorders. According to a study by Kean and colleagues in the January 2006 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, PTSD was associated with severity of asthma in adolescents. In the July 2002 issue of Psychiatric Services, Weisberg and colleagues noted an association between PTSD and asthma in adults. However, the role of risk factors, including genetic factors, has not been determined. This study of male veteran twin pairs evaluates whether PTSD symptoms are associated with the likelihood of asthma and the role of familial or genetic factors in the association between PTSD and asthma. Study Highlights 7375 male twin pairs born between 1939 and 1957 who had active duty during the Vietnam era were enrolled in the Vietnam Era Twin Registry.Data on twins who responded to the 1987 survey that assessed zygosity and PTSD symptoms and the 1991 survey that assessed asthma were analyzed.Zygosity was based on a survey similarity algorithm and blood group typing.PTSD was based on 15 questions about frequency of symptoms in the previous 6 months; the questions came from criteria of the Diagnostic and Statistical Manual of Mental Disorders (Third Edition).Prevalence of asthma, based on self-report of clinician-diagnosed asthma, was 6% (346/5804).Twins with asthma were younger vs twins without asthma (38 vs 38.4 years; P < .05) and were more likely to report clinician-diagnosed depression (12% [40/346] vs 7% [358/5458]; P < .001).Twins with asthma vs those without asthma did not differ in zygosity, mean body mass index, educational level, cigarette smoking history, or combat exposure.Twin correlations for asthma were greater in the monozygotic vs the dizygotic pairs.Twin correlations for the PTSD symptom scale were greater in the monozygotic vs the dizygotic pairs.PTSD was associated with increased prevalence of asthma ( P for trend < .001), even after adjustment for educational level, combat exposure, cigarette smoking, age, body mass index, and depression.Twins in the higher quartile of PTSD symptoms had higher prevalence of asthma vs twins in the lowest quartile (odds ratio [OR], 2.3; 95% CI, 1.4 - 3.7), even after adjustment for familial and genetic factors within twin pairs (OR, 2.0; 95% CI, 1.1 - 3.6).PTSD association with asthma was significant within dizygotic pairs ( P for trend, =.04) and less significant within monozygotic pairs ( P for trend, =.08).Twins in the higher quartile of PTSD symptoms had higher prevalence of asthma vs twins in the lowest quartile both within monozygotic (OR, 1.8; 95% CI, 0.7 - 4.9) and dizygotic pairs (OR, 2.0; 95% CI, 0.9 - 4.4).Limitations of the study included lack of data on timing and severity of asthma and inability to generalize results to women.