Thomas D. Hurwitz

REM sleep behaviour disorder: an update on a series of 96 patients and a review of the world literature

SUMMARY  REM sleep behaviour disorder (RBD) is an injurious clinical disorder of attempted dream‐enactment (‘oneirism’) in humans which has a corresponding experimental animal model involving dorsolateral pontine tegmental lesions in cats. To date, our sleep disorders centre has collected data on 96 chronic RBD cases which can be compared with pooled data on 70 chronic RBD cases from other centres contained in 26 reports published in the world literature since 1985, when our initial cases were first reported. The data from our centre and from other centres demonstrate a male predominance in RBD (87.5% vs 63.5%); indicate a similar mean age of RBD onset (52.4 y vs 55.9y); contain substantial numbers of diverse central nervous system disorders causally associated with RBD (47.9%vs 60.0%); and identify clonazepam treatment as being very effective in controlling both the (violent) dream and sleep behavioural disturbances of RBD. Our centres data additionally reveal an 80% prevalence of elevated stage 3/4 (slow‐wave) sleep% for age in RBD, and reveal a frequent presence of periodic and aperiodic limb movements during NREM sleep. Thus, RBD in humans is a complex syndrome in which there is generalized REM and NREM sleep motor dyscontrol, as was originally observed in the animal RBD model by Jouvet and Delorme in 1965.

Polysomnographic sleep is not clinically impaired in vietnam combat veterans with chronic posttraumatic stress disorder

BACKGROUND Because sleep is typically disturbed in posttraumatic stress disorder (PTSD), this study was undertaken to evaluate a group of Vietnam combat veterans with the disorder using clinical polysomnographic techniques. METHODS Eighteen Vietnam combat veterans with PTSD and 10 healthy non-combat-exposed Vietnam era veterans participated in 2 nights of polysomnographic study and a multiple sleep latency test. RESULTS No significant differences between subjects and controls were noted except for greater sleep onset latency to stage 2 (p < .03), and lower arousals/hour from stages 3 & 4 (p < .04) on night 2, and lower subjectively estimated total sleep time on night 1 (p < .005) in the case of PTSD subjects. Otherwise, results from the second night served to replicate those from the first, and no significant differences appeared on 2 successive nights for any polysomnographic variable. No daytime hypersomnolence was detected. CONCLUSIONS Polysomnographically recorded sleep was notably better than expected in the presence of clinically significant PTSD with typical histories of disrupted sleep. In these subjects, there is no clinically significant sleep disorder or typical pattern of sleep disturbance detectable by standard polysomnography.

Sleep in a community sample of elderly war veterans with and without posttraumatic stress disorder

BACKGROUND Although sleep disturbances are commonly reported by individuals with posttraumatic stress disorder (PTSD), objective findings have been inconsistent, due in part to small sample sizes, comorbid psychiatric disorders, variations in the recentness of trauma exposure, and the use of PTSD subjects involved in psychiatric treatment. METHODS A community sample of elderly males (n = 59) exposed to war trauma 28-50 years ago and free from sleep-affecting medications and disorders other than PTSD completed 3 nights of polysomnography. Of these participants, 30 met criteria for current PTSD; three were receiving supportive outpatient psychotherapy. RESULTS Two statistically significant differences were observed: Those with PTSD had a higher percentage of rapid eye movement (REM) sleep and fewer arousals from non-REM sleep. The perceptions of sleep quality among the participants with PTSD were lower than the perceptions of non-PTSD participants. Although participants with untreated obstructive sleep apnea and sleep movement disorders were not included in the sample, many cases were detected on initial screening. Treatment resulted in improved sleep and increased feelings of well being. CONCLUSIONS Alterations in REM and arousals characterized PTSD in this sample. When comorbid sleep disorders were ruled out, sleep was clinically similar across the groups. Trauma-related sleep disturbances that subjects reported as arising early in the course of the disorder appear to have declined over time.

Sleep violence--forensic science implications: polygraphic and video documentation

During the past century, infrequent, anecdotal reports of sleep-related violence with forensic science implications have appeared. Recent rapid developments in the field of sleep-disorders medicine have resulted in greater understanding of a variety of sleep-related behaviors, and formal sleep-behavior monitoring techniques have permitted their documentation and classification. Sleep-related violence can be associated with a number of diagnosable and treatable sleep disorders, including (1) night terrors/sleepwalking, (2) nocturnal seizures, (3) rapid eye movement (REM) sleep-behavior disorder, (4) sleep drunkenness, and (5) psychogenic dissociative states occurring during the sleep period. Potentially violent automatized behavior, without consciousness, can and does occur during sleep. The violence resulting from these disorders may be misinterpreted as purposeful suicide, assault, or even homicide. Sleep-related violence must be added to the list of automatisms. A classification system of both waking and sleep-related automatic behavior is proposed, with recommendations for assessment of such behavior.

A Retrospective Outcome Study and Review of Hypnosis as Treatment of Adults with Sleepwalking and Sleep Terror

Hypnosis has been described anecdotally to be effective in the treatment of sleepwalking and sleep terror, potentially dangerous parasomnias. The authors report the use of hypnosis in the treatment of 27 adult patients with these disorders. A total of 74% of these individuals reported much or very much improvement when followed over substantial periods after instruction in self-hypnotic exercises that were practiced in the home. Hypnosis, often preferred over pharmacotherapy by patients, required one to six office visits (mean=1.6). This represents a very cost-effective and noninvasive means of treatment, especially when constrasted with lengthy psychotherapy and pharmacotherapy.

Correlates of daytime sleepiness in patients with posttraumatic stress disorder and sleep disturbance.

OBJECTIVE To assess the correlates of daytime sleepiness in patients with a lifetime diagnosis of posttraumatic stress disorder (PTSD) and ongoing sleep disturbance not due to sleep apnea or other diagnosed sleep disorders. METHOD The sample consisted of 26 veterans receiving mental health care at the Minneapolis VA Medical Center, Minneapolis, Minnesota. The Epworth Sleepiness Scale was the primary outcome measure. Other sleep-related instruments consisted of the Pittsburgh Sleep Quality Scale, a daily sleep log, and daily sleep actigraphy. In addition, data included 3 symptom ratings (Posttraumatic Stress Disorder Checklist, Clinician Administered PTSD Scale [CAPS], and Beck Depression Inventory). Data were collected from 2003 to 2005. Current and lifetime PTSD diagnoses were based on DSM-IV criteria and were obtained by experienced psychiatrists using the CAPS interview. RESULTS Univariate analyses showed that daytime sleepiness on the Epworth Sleepiness Scale was associated with daytime dysfunction on the Pittsburgh Sleep Quality Index (P < .001), less use of sleeping medication (P = .02), and more self-rated posttraumatic symptoms (P = .05). Within posttraumatic symptom categories, hypervigilance symptoms were more correlated with daytime sleepiness (P = .03) than were reexperiencing and avoidance symptoms (P = .09 for both). CONCLUSION In this selected sample, daytime sleepiness was most strongly and independently associated with daytime dysfunction.

Effect of sleep skills education on sleep quality in patients attending a psychiatry partial hospitalization program

OBJECTIVE To evaluate the effectiveness of cognitive-behavioral therapy for insomnia (CBT-I)-informed sleep skills education on sleep quality and initial sleep latency in patients attending a psychiatry partial hospitalization program. METHOD This retrospective chart review was conducted in a psychiatry partial hospitalization program of a teaching Veterans Affairs medical center located in Minneapolis, Minnesota. Patients typically attend the program for 1 month. Data were collected from a continuous improvement project from November 2007 to March 2009. The Pittsburgh Sleep Quality Index (PSQI) was administered to the patients at the time of entry into the program and at their discharge. Patients who completed both PSQI assessments were included in the study. RESULTS A total of 183 patients completed both PSQI assessments. Of those, 106 patients attended CBT-I-informed sleep skills education and 77 did not (all patients completed the psychiatry partial hospitalization program). For all patients, the mean ± SD baseline PSQI score was 12.5 ± 4.8. PSQI scores improved by a mean of 3.14 points (95% CI, 2.5-3.8; P < .001) in all patients who completed the psychiatry partial hospitalization program. For all patients, there were significant reductions in sleep latency (17.6 minutes) (t 183 = 6.58, P < .001) and significant increases in overall sleep time, from 6.1 to 6.7 hours (t 183 = 4.72, P < .001). There was no statistically significant difference in PSQI scores of patients who attended CBT-I-informed sleep skills education and those who did not during their stay in the partial hospitalization program. CONCLUSIONS The quality of sleep and initial sleep latency improved in patients who completed the psychiatry partial hospitalization program regardless of whether they attended CBT-I-informed sleep skills education or not. In this study, a structured psychiatry partial hospitalization program improved perceived sleep quality and initial sleep latency. Additional randomized controlled trials with a higher intensity of CBT-I-informed sleep skills education are needed.

Obstructive Sleep Apnea and Depression: A Review

Obstructive sleep apnea is a common sleep disorder associated with several medical conditions, increased risk of motor vehicle accidents, and overall healthcare expenditure. There is higher prevalence of depression in people with obstructive sleep apnea in both clinical and community samples. Many symptoms of depression and obstructive sleep apnea overlap causing under-diagnosis of obstructive sleep apnea in depressed patients. Sleep problems, including obstructive sleep apnea, are rarely assessed on a regular basis in patients with depressive disorders, but they may be responsible for antidepressant treatment failure. The mechanism of the relationship between obstructive sleep apnea and depression is complex and remains unclear. Though some studies suggest a mutual relationship, the relationship remains unclear. Several possible pathophysiological mechanisms could explain how obstructive sleep apnea can cause or worsen depression. Increased knowledge of the relationship between obstructive sleep apnea and depression might significantly improve diagnostic accuracy as well as treatment outcomes for both obstructive sleep apnea and depression.

Sleep-related abnormal sexual behaviors (sexsomnia) successfully treated with a mandibular advancement device: A case report

ABSTRACT Sleep-related abnormal sexual behaviors (sexsomnia) are classified as a subtype of non-rapid eye movement sleep parasomnias. There are reported cases of control of sexsomnia with treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure. We present a case of sexsomnia controlled with the treatment of OSA with a mandibular advancement device.

Actigraphy and PTSD

Insomnia and nightmares are common symptoms of posttraumatic stress disorder (PTSD) in addition to wakeful symptoms of reexperiencing traumatic events and avoidance of stimuli associated with the trauma. Sleep disturbance is frequently, though not often, the principal focus of therapy in PTSD. Emergence of insomnia following trauma may predict subsequent development of PTSD.