Abstract Index
Conference Index
ASD 2000 Conference 17 Abstracts
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Millennial Dreaming:
Washington, D.C.
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ABSTRACT
Treatment of Sleep Disorders and Subsequent Impact
on Chronic Nightmares
Barry Krakow, M.D.
Recent research has demonstrated that a high proportion of sexual
assault survivors and other crime victims with PTSD suffer from
intrinsic sleep disorders, notably sleep-disordered breathing (SDB).
While this may prove to be a coincidental finding, anecdotal treatment
studies suggest that a successful therapeutic intervention for SDB will
result in reductions in nightmares and PTSD symptoms. In one case report
series (n=22) all the patients suffered from chronic nightmares and 14
suffered from PTSD. Of the total of 22 patients, 14 elected to use CPAP
(continuous positive airway pressure) for SDB and 8 chose not to receive
treatment. Approximately 80% or more of the treated group improved their
nightmares, and for the 8 people in this group with PTSD, 6 showed
improvement in stress symptoms. In the group of 8 who did not pursue
treatment, of which 6 had PTSD, there was no change or a worsening of
nightmares and PTSD.
One of the fascinating aspects of these reports and a similar single
case report on a PTSD combat veteran is that few of the patients
received any sort of psychiatric intervention concurrently with their
sleep disorders treatment. Thus, there is at least the implication that
sleep-disordered breathing is in some way associated with nightmares and
PTSD.
One theory to explain this association is through the simple effects of
chronic sleep deprivation caused by SDB. As with many intrinsic sleep
disorders, SDB fragments sleep quality, leading to reduced total sleep
regardless of the patient's perceptions of actual sleep time. The result
is a state of chronic sleep deprivation, which, in numerous studies, has
been associated with a variety of mood and behavioral changes in both
normals and psychiatric patients. Thus, through a state of chronic
exhaustion and low energy, it is conceivable that the PTSD patients'
symptoms are exacerbated, and when SDB is successfully treated, their
energy reserves improve to the point of improving other stress symptoms.
Another theory which might explain this process is that SDB has been
shown to produce physical damage to the airway. Histological changes
have been reported in SDB and have been described as an injury and
inflammation pattern of certain airway tissues. In this model, it is
hypothesized that physical damage to the airway not only further worsens
SDB, but may also produce altered breathing patterns during wakefulness.
Overall, such patients might experience subtle difficulties in breathing
while awake or asleep, which may promote anxiety given the fundamental
importance of breathing in sustaining life. Such anxiety may translate
into nightmares, and it would be expected that some disturbing dreams
might even contain elements of choking or other images of suffocation.
Therapeutically, alleviation of the airway problem through appropriate
sleep disorders treatment could result in normalized breathing after
which anxiety might decrease. In turn, nightmares might abate as well.
While these theories are highly speculative, the anecdotal findings of
nightmare and PTSD reductions following SDB treatment are of such a
dramatic nature that they warrant further intensive investigation. Both
nightmares and PTSD appear to be useful outcome measures to assess for
the impact of treatment on SDB.
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