[Sleep disturbances in post-traumatic stress disorder. An overview of the literature]. / Slaapafwijkingen bij posttraumatische stressstoornis. Overzicht van onderzoeksbevindingen.

BACKGROUND: Nightmares and insomnia are experienced by 70% of patients suffering from post-traumatic stress disorder (PTSD). These sleep problems are often resistant to treatment and exert a strong negative influence on the quality of life. In the last few decades several studies have reported on the characteristics of sleep disturbances in PTSD. AIM: To provide an overview of objective features of sleep disturbances - as opposed to self-report methods - in patients with PTSD. METHOD: Articles on this topic, published in peer-reviewed journals between 1980 and the present, were retrieved from Medline and Embase, using the search terms 'PTSD', 'sleep', 'nightmares', 'insomnia', 'polysomnography'. RESULTS: Studies reported on changes in sleep efficiency, arousal regulation, motor activity during sleep, rem characteristics and delta sleep activity during sleep. Also, correlations were found between nightmares and sleep apnoea in ptsd. In some studies on sleep disturbance no objective sleep disturbances were found in PTSD patients. However, most studies on PTSD related sleep disturbances were conducted in small, heterogeneous groups, and results were therefore inconsistent. Even the results of larger and more homogeneous studies were sometimes contradictory. CONCLUSION: There is a discrepancy between the clinical importance of sleep problems in PTSD and unambiguous objective sleep disorders. Future research should try to establish objective criteria for identifying the altered sleep patterns in PTSD. These criteria should help us to understand the neurobiological mechanisms of sleep disturbances in PTSD and develop new treatment strategies.

A cross-national study of posttraumatic stress disorder in Dutch-Australian immigrants.

OBJECTIVE: Studying the rates of posttraumatic stress disorder (PTSD) in people who experienced World War II, but who have subsequently lived in different environments is a way of looking at the impact of recovery environment on PTSD. Immigrants had less support in terms of the social cohesion in their home country, but were not subjected to the same triggers of war-related intrusions. METHOD: Posttraumatic stress disorder was investigated in citizens from the Netherlands who emigrated to Australia in the post-World War II years (n = 251). Immigrants born between 1920 and 1930 (n = 171) were compared with a same-aged group living in Holland (n = 1461) for stressful war experiences and the extent of PTSD. RESULTS: Those who had been exposed to the most severe war stress were overrepresented in the immigrant group. Immigrants with current PTSD more often stated that motives for migration were threat of a third world war, disappointment with Dutch society and personal problems. We were unable to demonstrate specific effects of emigration on the prevalence of current PTSD. CONCLUSIONS: This study suggests that exposure to severe war stress promoted the need to emigrate. The comparable PTSD scores of the groups of war victims living in Australia and the Netherlands support the notion that extreme war stress may be considered the primary determining factor in the development of PTSD, and that actual post-war living circumstances are, in the long term, of subordinate importance.

Reported physical health in resistance veterans from World War II.

Male Dutch Resistance veterans from World War II who reported on chronic diseases were compared with subjects from a population survey. Resistance veterans in general reported significantly more disease. Veterans with symptoms of posttraumatic stress disorder reported more disease than those who had none. Furthermore, 13 specific disease categories were more prevalent in the Resistance veterans than in the general population. In the Resistance veterans total number of reported diseases was significantly correlated with anxiety, depression, and posttraumatic stress disorder. In Resistance veterans weekly tobacco use was comparable to that of the control subjects, but alcohol consumption was significantly less.

Prevalence and course of posttraumatic stress disorder in Dutch veterans of the civilian resistance during World War II: an overview.

This study concerns the prevalence of current and lifetime Posttraumatic Stress Disorder (PTSD) in various groups of officially recognized Veterans of the Dutch civilian Resistance against the Nazi occupation during World War II. In total, 1046 Resistance veterans living in The Netherlands and 52 who immigrated to the United States after the war were examined. Between four and five decades after the end of WW II, between 25 and 50% were suffering from current PTSD. The life-time prevalence is estimated to be substantially higher. The course of PTSD proved highly variable. There had often been a delay of several decades between the end of the war and reoccurrence or first onset of posttraumatic symptoms. The prevalence of PTSD in Resistance veterans who emigrated to the United States was hardly different from that of the veterans still living in The Netherlands.

Status epilepticus during vigabatrin treatment: a report of three cases.

Vigabatrin (gamma-vinyl-GABA or GVG) is an irreversible inhibitor of gamma-aminobutyric acid transaminase (GABA-T), which is an enzyme responsible for gamma-aminobutyric acid (GABA) catabolism. Inhibition of GABA catabolism increases brain concentration of GABA, a neural inhibitor. GVG has been found to be a potent new anti-epileptic drug, especially in the treatment of refractory epilepsy, in particular of complex partial seizures. Three patients who developed a severe status epilepitus while on GVG treatment are reported. A possible proconvulsive effect of GVG is hypothesized, which might result from disinhibition in the nigro-collicular pathway due to increased GABA-levels.

Posttraumatic stress disorder in male and female Dutch Resistance veterans of World War II in relation to trait anxiety and depression.

In this study, 680 male and 144 female Dutch Resistance veterans of World War II were evaluated on Posttraumatic Stress Disorder, trait anxiety, and depression. Approximately 27% of these men and 20% of these women showed current Posttraumatic Stress Disorder. Resistance veterans, as a group, appeared comparable to the controls from Dutch validation studies on trait anxiety and depression. Gender differences were not observed. Veterans with current PTSD symptoms scored higher on trait anxiety and depression than the remaining veterans and were comparable on trait anxiety and depression to psychiatric patients. Correlational analyses showed that there was a strong association between trait anxiety and depression. Posttraumatic Stress Disorder correlated highly with trait anxiety and depression.

A self-rating scale for the assessment of posttraumatic stress disorder in Dutch Resistance veterans of World War II.

The present study reports on the development of a Dutch PTSD scale based on the DSM-III criteria for PTSD. Test-retest reliability was .91. The scale showed an internal consistency with a coefficient alpha of .88. Factor analysis on a large sample of Resistance veterans (N = 967) yielded six factors, which represent intrusive thoughts, physiological reactions, detachment, rage, active confrontation, and guilt.

Snoring and anxiety dreams.

In a group of elderly males who had been exposed to excessive stress during World War II, 56% of whom suffered from current post-traumatic stress disorder, a significant association was found between snoring and the occurrence of anxiety dreams, independent of the use of sedatives, antidepressants, smoking and alcohol and coffee consumption. Anxiety dream incidence was highest when snoring was accompanied by respiratory pauses. The underlying pathophysiologic mechanisms are thought to be hypercapnia and autonomic-vegetative arousal, resulting from obstructive sleep apneic episodes in heavy snoring. Polysomnographic sleep studies are needed to confirm this hypothesis.

Fluvoxamine treatment for chronic PTSD: a pilot study.

A group of 24 Dutch World War II Resistance veterans with a documented traumatic war history and a (partially) positive diagnosis of current posttraumatic stress disorder (PTSD) was studied. This special group of war victims is characterised by chronicity, suffering from intractable posttraumatic complaints for decades. They were treated with fluvoxamine (Fevarin), a selective serotonin reuptake inhibitor with antidepressive and anxiolytic properties. The study was designed as an open-ended, outpatient pilot study, with a treatment period of 12 weeks. Results of clinical examination, and questionnaires investigating PTSD, depression, sleeping problems, anxiety, and vital exhaustion indicate that a significant number of the subjects improved with respect to their PTSD symptomatology, and their symptoms of anxiety and vital exhaustion. However, at the end of the study, quantitative improvement was modest. The results indicate that treatment with fluvoxamine may offer alleviation of chronic PTSD symptoms, in particular insomnia, nightmares, anxiety, intrusive recollections, guilt feelings and tiredness.

Current posttraumatic stress disorder and cardiovascular disease risk factors in Dutch Resistance veterans from World War II.

The extraordinary trauma experienced by Resistance veterans from World War II (WW II) and other veterans may be associated with an increased incidence of posttraumatic stress disorder (PTSD) and somatic morbidity, including cardiovascular disease (CVD). This study explored some relationships between current PTSD and CVD risk factors in 147 male Dutch WW II Resistance veterans. They were compared to 65 same-aged male patients with a recent myocardial infarction and 79 surgical patients. Of these subjects, WW II Resistance veterans scored highest on CVD risk factors (i.e., angina pectoris, type A behavior, life stressors, and vital exhaustion), except smoking. Fifty-six percent of these veterans were currently suffering from PTSD. They reported CVD risk factors, in particular type A behavior and vital exhaustion, more often than veterans without PTSD; they also reported more premorbid adverse living conditions. These data suggest that early sensitization to environmental stressors may be associated with a high prevalence of current PTSD and excess CVD risk factors in subjects exposed to extraordinary war-time trauma and that this may lead to vital exhaustion.

Anxiety, depression and anger in Dutch Resistance veterans from World War II.

In this study, 147 Dutch Resistance veterans from WW II are evaluated on psychometric instruments for anxiety, depression and anger. Resistance veterans appeared to be more anxious, depressive and angry on these instruments compared to controls from the validation studies of the respective instruments. Veterans currently suffering from PTSD (56%) were significantly more anxious, depressed, and angry than veterans without PTSD. With respect to staying in Nazi concentration camps, which is an extremely severe stressor, and in which half of the veterans were imprisoned, no difference on the three instruments was found. Anxiety, depression and anger were observed to be highly interrelated in PTSD. The close interrelationship between anxiety and depression, anxiety and danger, and depression and anger mediated by way of anxiety is, however, not unique for traumatized subjects. It is argued that for Resistance veterans only the intrusive reminiscences of the stressful events discriminate this constellation of symptoms from subjects with an anxious-depressive symptomatology.

[Snoring as a symptom of severe respiratory obstruction during sleep: causes and results]. / Snurken als uiting van ernstige ademhalingsbelemmering tijdens de slaap: oorzaken en gevolgen.

Snoring is an epiphenomenon of obstructive respiration during sleep, which may be caused by higher airway abnormalities and may result in impaired quality of nocturnal sleep, complaints of fatigue and daytime sleepiness, decreased performance level, psychic complaints and cardiovascular problems. The test results of seven patients complaining of excessive snoring and daytime sleepiness are discussed. The importance of multidisciplinary management of the underlying pathology is stressed.

Ambulatory sleep-wake polygraphy in narcolepsy.

We have presented an ambulatory monitoring and off-line data analysis system for sleep-wake polygraphy and have illustrated its use for the diagnosis of narcolepsy. The advantages over conventional polysomnography have been discussed.

Influence of diffuse brain stimulation (DBS) on human sleep. I. Sleep pattern changes.

A 20 min period of diffuse brain stimulation (DBS), administered just before sleep onset in 16 human subjects, appeared to alter significantly the first sleep cycle of the succeeding sleep. The length of the first sleep cycle and the amount of REM sleep increased, whereas a shift from deep to more superficial NREM sleep occurred. This effect of DBS on sleep is discussed with respect to data from the literature on the effect of narcotic DBS and on that of local brain stimulation in animals.

Influence of diffuse brain stimulation (DBS) on human sleep. II. Sleep-induced periodic breathing with apnoea.

The influence of diffuse brain stimulation (DBS), administered just before sleep onset, on the number of apnoeas and of sleep stage changes during the first part of the succeeding night sleep to the end of the first sleep cycle has been studied in 7 patients with sleep-induced periodic breathing with apnorea. When compared with the corresponding period of the baseline night, both phenomena are increased significantly. These results indicate that DBS influences slow periodic sleep phenomena. It is suggested that the target area for this influence might be mesencephalo-pontine reticular structures, which play a role in the generation of these slow periodic phenomena.

Periodic nocturnal myoclonus in a patient with hyperexplexia (startle disease).

The periodic nocturnal myoclonus of a patient with hyperexplexia has been studied. Evidence has been given that the jerks are spontaneous arousal reactions. The temporal characteristics of the jerks have been analysed. The jerks appear to be correlated with the respiratory rhythm and the data suggest a correlation of the jerks with circulatory and respiratory higher order waves. The results are discussed with relation to the literature concerning spontaneous sleep jerks.