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Forensic Updates

Long Term Treatment for PTSD; Traumatic Brain Injury Link to Circadian Rhythm Sleep Disorder

Dr. Sam Goldstein

NLBC LEGAL UPDATE: October, 2007 – Issue #26

Sam Goldstein, Ph.D., Editor
Complimentary Service of the Neurology, Learning and Behavior Center

In this issue I review Post Traumatic Stress Disorder specifically focusing on the chronic nature of this condition and whether long term treatment can cure PTSD.  I also briefly review a recent article raising important questions about frequently reported sleep problems in patients following traumatic brain injury. 

Long Term Treatment for PTSD

Post Traumatic Stress Disorder (PTSD) is an anxiety disorder that typically occurs after severe psychological stress.  PTSD occurs frequently but not always in stressful situations.  In a past Forensic Updates (Issue #4 and #6) I discussed the variables currently being researched in an effort to better predict risk for and course of PTSD in specific individuals.  PTSD results when a stressor induces intense fear or helplessness.  Single and multiple episodes of stress can induce PTSD.  It has yet to be demonstrated whether these two phenomena lead to different types of PTSD.  The most common single episode inducement typically involves a fear of death to self or severe bodily harm during the course of accidents, many of which typically result in litigation.

The Fourth Edition of the Text Revision of the Diagnostic and Statistical Manual of the American Psychiatric Association defines three symptom clusters present in PTSD: (1) re-experiencing the traumatic event; (2) avoidance of reminders of the event; and (3) psychological numbing and hyper-arousal symptoms.

  1. Re-experiencing symptoms can include intrusive memories of the trauma,  nightmares, suddenly acting or feeling as if the trauma were re-occurring and psychological or physiological reactivity on exposure to reminders of the trauma.

  2. Avoidance symptoms can include avoidance of people, places or situations that remind the individual of the traumatic event, psychological numbing, feelings of detachment from others and a foreshortened sense of the future.

  3. Hyper-arousal symptoms can include irritability, insomnia, difficulty concentrating, exaggerated startle responses and hyper-vigilance.

At least some symptoms in each category must be demonstrated for at least a month period following the trauma to meet the diagnostic criteria for PTSD.  When symptoms present but remit in a shorter duration, these are considered to reflect a different diagnostic condition known as Acute Stress Disorder.

Chronic un-remitting PTSD appears to lead to significant disability, often major depression and generalized anxiety leading to impairments in all walks of life including social and occupational functions.  According to National Comorbidity Surveys completed in 1995 and recently in 2006, the estimated lifetime prevalence of PTSD is between 7% to 8% in the United States.

The standard of care and treatment of PTSD involves a combination of psychosocial interventions (e.g., counseling) along with psychiatric medications.  Psychotherapy utilizing a cognitive model as well as Eye Movement Desensitization Therapy, a form of mild hypnosis, have both been reported as beneficial in relieving symptoms of PTSD.  Two anti-depressant medications have been approved for the treatment PTSD.  However, most physicians use a wide range of anti-anxiety and anti-depressant medications to treat their patients.

In studies lasting over twelve weeks, the early initiation of treatment following the traumatic exposure appears to be the best predictor of reducing the risk of the condition becoming chronic as well as for relapse.  A number of studies have found that early intervention with cognitive therapy and/or EMDR may mitigate the long term negative effects of the trauma.  In fact, a study completed this year found that EMDR was more effective than an anti-depressant medication in adult onset trauma victims suffering from PTSD at a six month follow-up.

The longest follow-up study for PTSD published to date examined a group of individuals three to four years post-twelve week of treatment with anti-depressant medication.  Nine of the ten individuals reported that the medication was effective and wanted to continue taking it.  The majority of these individuals, however, continued to demonstrate some PTSD symptoms with seven of ten reporting that they were much improved, two minimally improved and one worse compared to baseline assessment.

Long term studies, in particularly those combining anti-depressant medications with various forms of psychotherapy, show promise in successfully treating patients with chronic PTSD.  However, at this time it is clear that more studies are needed and that even at the conclusion of the published studies, many individuals still report significant symptoms.

Traumatic Brain Injury Link to Circadian Rhythm Sleep Disorder

Among the most common post traumatic brain injury complaints is a change in sleep patterns.  Some patients report they have difficulty falling asleep, others staying asleep while many report not feeling rested in the morning.  A recent study published in Neurology (Volume 68, 1136-1140), completed at the University of California, San Diego suggests that a mild head injury can boost the odds of developing a Circadian Rhythm Sleep Disorder (CRSD).  In this study, 36% of patients with mild traumatic brain injury complaining of insomnia were suffering from CRSD.

CRSD is characterized by complaints of inability to fall asleep and wake up at appropriate times leading to fatigue and sleepiness.  CRSD results from a misalignment between the timing of sleep and the twenty-four hour social and physical environment. Additionally, CRSD’s are often associated with cognitive and psychological problems suggesting that appropriate treatment might lead to improvement in other TBI symptoms.  Of note is the fact that the typical agents used to facilitate sleep (e.g., Ambien, Lunesta, etc.) may not help and in fact may make the CRSD worse. 

In this study, forty-two people were evaluated at the Institute for Fatigue and Sleep Medicine and the Trauma Clinic at the Sheba Medical Center in Tel-Hashmore, Israel complaining of insomnia following mild TBI.  The 36% incidence of CRSD in  this group is significantly greater than the 7% to 10% incidence reported in most sleep clinics.

The diagnosis of CRSD is completed in the seven to fourteen day period in which sleep logs and actograph data is collected during sleep. CRSD’s are more appropriately treated with melatonin and bright lights which aim to synchronize the sleep wake cycle with the environmental dark light cycle.  

It appears that sleep disorders that involve changes in the timing of sleep may be relatively frequent among TBI patients and should be considered when these patients report problems.

The Neurology, Learning and Behavior Center provides clinical and forensic assessment, case management, trial consultation and treatment services for children and adults with brain injury and dysfunction, Attention-Deficit Hyperactivity Disorder, language disorders, learning disability, developmental delay, emotional disorders, Autism and adjustment problems. The Center is dedicated to the provision of treatment services.

References

Davis, L.L., Frazier, E.C., Willford, R.B., & Newell, J.M. (2006).  Long-term ph.armacotherapy for post Traumatic stress disorder.  CNS Drugs, 20, 465-476.

Hamner, M.B., Robert, S., Frueh, B.C. (2004).  Treatment resistant post traumatic stress disorder:  Strategies for intervention.  CNS Spectrum, 10, 740-752.

Hertzberg, M.A., Feldman, M.A., Beckman, J.C., et al. (2002).  Three to four year follow-up with an open trial of Nefazodone in combat related post traumatic stress disorder.  Archives of General Psychiatry, 14, 215-221. 

Kessler, R.C., Sonnega, A., Bromet, E., et al. (1995).  Post Traumatic Stress Disorder in the National Comorbidity Survey.  Archives of General Psychiatry, 42, 1048-160.

Kessler, R.C., Chiu, W.T., Demier, O., et al. (2006).  Prevalence, severity and comorbidity of 12-month DSM-IV symptoms in the National Comorbidity Survey Replication.  Archives of General Psychiatry, 62, 629-640.

Rothbaum, B.O., Cahill, S.P., Foa, E.B., et al. (2006).  Trials of Sertraline with prolonged exposure to post traumatic stress disorder.  Journal of Trauma and Stress, 19, 625-638.

Van der Kolk, B.A., Spinazzola, J., Blostein, M.E., et al. (2007).  Randomized clinical trial of EMDR, Fluoxetine and pill placebo in the treatment of post traumatic stress disorder: Treatment effects and long-term maintenance.  Journal of Clinical Psychiatry, 68, 37-46.