RESUMEN
OBJECTIVE: Sleep disturbances are a core and salient feature of posttraumatic stress disorder (PTSD). Pilot studies have indicated that combined cognitive-behavioral therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT) for nightmares improves sleep as well as PTSD symptoms. METHOD: The present study randomized 40 combat veterans (mean age 37.7 years; 90% male and 60% African American) who served in Afghanistan and/or Iraq (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]) to 4 sessions of CBT-I with adjunctive IRT or a waitlist control group. Two thirds of participants had nightmares at least once per week and received the optional IRT module. RESULTS: At posttreatment, veterans who participated in CBT-I/IRT reported improved subjectively and objectively measured sleep, a reduction in PTSD symptom severity and PTSD-related nighttime symptoms, and a reduction in depression and distressed mood compared to the waitlist control group. CONCLUSION: The findings from this first controlled study with OEF/OIF veterans suggest that CBT-I combined with adjunctive IRT may hold promise for reducing both insomnia and PTSD symptoms. Given the fact that only half of the patients with nightmares fully implemented the brief IRT protocol, future studies should determine if this supplement adds differential efficacy to CBT-I alone.
Asunto(s)
Terapia Cognitivo-Conductual/métodos , Imágenes en Psicoterapia/métodos , Trastornos del Inicio y del Mantenimiento del Sueño/terapia , Sueño/fisiología , Trastornos por Estrés Postraumático/terapia , Veteranos/psicología , Adulto , Campaña Afgana 2001- , Depresión/epidemiología , Depresión/terapia , Sueños/psicología , Femenino , Humanos , Guerra de Irak 2003-2011 , Masculino , Persona de Mediana Edad , Trastornos del Inicio y del Mantenimiento del Sueño/epidemiología , Trastornos por Estrés Postraumático/epidemiología , Estrés Psicológico/epidemiología , Estrés Psicológico/terapia , Resultado del Tratamiento , Estados Unidos , Adulto JovenRESUMEN
STUDY OBJECTIVES: Sleep disturbances in cirrhosis are assumed to be due to hepatic encephalopathy (HE). The interaction between cirrhosis, prior HE, and obstructive sleep apnea (OSA) has not been evaluated. We aimed to evaluate the additional effect of cirrhosis with and without prior HE on the sleep architecture and perceived sleep disturbances of OSA patients. METHODS: A case-control review of OSA patients who underwent polysomnography (PSG) in a liver-transplant center was performed. OSA patients with cirrhosis (with/without prior HE) were age-matched 1:1 with OSA patients without cirrhosis. Sleep quality, daytime sleepiness, sleep quality, and sleep architecture was compared between groups. RESULTS: Forty-nine OSA cirrhotic patients (age 57.4 ± 8.3 years, model for end-stage liver disease (MELD) 8.3 ± 5.4, 51% HCV, 20% prior HE) were age-matched 1:1 to OSA patients without cirrhosis. Apnea-hypopnea index, arousal index, sleep efficiency, daytime sleepiness, and effect of sleepiness on daily activities were similar between OSA patients with/ without cirrhosis. Sleep architecture, including %slow wave sleep (SWS), was also not different between the groups. MELD was positively correlated with time in early (N1) stage (r = 0.4, p = 0.03). All prior HE patients (n = 10) had a shift of the architecture towards early, non-restorative sleep (higher % [N2] stage [66 vs 52%, p = 0.005], lower % SWS [0 vs 29%, p = 0.02], lower REM latency [95 vs 151 minutes, p = 0.04]) compared to the rest. Alcoholic etiology was associated with higher latency to N1/N2 sleep, but no other effect on sleep architecture was seen. CONCLUSIONS: OSA can contribute to sleep disturbance in cirrhosis and should be considered in the differential of sleep disturbances in cirrhosis. Prior HE may synergize with OSA in worsening the sleep architecture.
Asunto(s)
Encefalopatía Hepática/complicaciones , Cirrosis Hepática/complicaciones , Apnea Obstructiva del Sueño/complicaciones , Fases del Sueño/fisiología , Estudios de Casos y Controles , Enfermedad Hepática en Estado Terminal/complicaciones , Enfermedad Hepática en Estado Terminal/fisiopatología , Femenino , Encefalopatía Hepática/fisiopatología , Humanos , Cirrosis Hepática/fisiopatología , Masculino , Polisomnografía , Estudios Retrospectivos , Apnea Obstructiva del Sueño/fisiopatología , Sueño REM/fisiologíaRESUMEN
Five new antiepileptic drugs (AEDs) have been approved in the last five years and several new formulations and new dose strengths for both the classical and newer agents exist. Patients arriving for neurodiagnostic studies are often on complex regimens with medications being weaned and new agents being added. All technologists need a working knowledge of the known mechanisms and indications for these drugs in addition to an understanding of their potential adverse effects. Fortunately the latter problems are limited in this recent generation of drugs and their broad spectrum of action is leading to improved seizure control and better quality of life for our patients.