addition to imagery rehearsal therapy for nightmares. Sleep Dynamic Therapy consists of six two-hour sessions given weekly in a group format with an emphasis on psychoeducation and sleep-directed cognitive behavioral therapy (CBT). Sleep-directed cognitive behavioral therapy involves identifying stimuli that either interfere with or help with sleep, together with identification and abandonment of maladaptive habits that interfere with sleep. The psychoeducation includes identification of" "symptoms of sleep problems, including lack of restorative sleep, daytime sleepiness, and frequent awakenings, etc., which are often ignored because of the other obvious symptoms of PTSD. In addition, proper bedtime habits (good sleep hygiene) are taught.

INCREASING UNDERSTANDING

While the importance of nightmares and insomnia as symptoms of PTSD has long been appreciated, it is increasingly becoming apparent that this may be only the tip of the iceberg. Other types of sleep abnormalities such as sleep-disordered breathing and periodic limb movements in sleep are apparently common and may play a role in insomnia or nightmares. Importantly, not only are sleep disturbances major sources of distress for patients with PTSD, but they may play key roles in causing or perpetuating the disorder. They may also contribute to substance abuse, particularly of alcohol. While alcohol may help patients fall sleep, there is a rebound awakening. Furthermore, sleep worsens during withdrawal. These factors lead to increasing amounts of alcohol consumption. Fortunately, there are an increasing number of treatments available for sleep disturbances (e.g., imagery rehearsal therapy, Sleep Dynamic Therapy, pharmacotherapy, and, in

some cases, continuous positive airway pressure). Yet in order for these treatments to be effective, the sleep problems must be noted. While it is hoped that clinicians are becoming more aware of the prevalence and importance of sleep disturbances, it behooves the

patient to bring them forward if the clinician does not focus on the issue.

Patients’ descriptions of sleep disturbances are the gold standard for their identification. While polysomnography (EEG, eye movement, and muscle activity measurements obtained during sleep) may be helpful in identifying

and/or confirming some cases of sleep disturbances, there are many"

“Not only are sleep disturbances major sources of distress for patients with PTSD, but they may play key roles in causing or perpetuating the disorder. Fortunately, there are an increasing number of treatments available for sleep disturbances, such as, imagery rehearsal therapy, Sleep Dynamic Therapy, pharmacotherapy, and, in some cases, continuous positive airway pressure.”

"false negatives. This is because sleep laboratories, and even home monitoring, induce feelings of safety in many patients with PTSD. The partner may

supply invaluable information regarding sleep-disturbance symptoms.

DETERMINING A PERSON'S OPTIONS

Further studies are required to determine how to optimally use the great variety of treatments now available for sleep disturbances, including nightmares, associated with PTSD. Among the questions requiring answers is this one: Is there one "best" treatment or, as is more likely, are different clinical patterns associated with different responses to a given treatment? Medications may improve sleep and decrease nightmares while psychotherapy may help with the reprocessing of traumatic thoughts. Since at least some good quality sleep is required for optimal reprocessing, the two techniques are likely complementary. In view of this, should medications and psychological therapies then be used at the same time or in sequence? These and many other questions need to be answered.

Since it is likely that different treat ments and/or their combinations may be required for a given patient, patience and persistence will be required while sequential trials are performed. But it is fair to say that this should be done with a spirit of optimism and conviction that an effective treatment regimen will be found. Not only may such treatments alleviate a decreased quality of life for individuals due to sleep disturbances, but they may also improve other PTSD symptoms. •"

ABOUT THE AUTHOR:

James Halper, MD, is Clinical Associate Professor of Psychiatry at New York University School of Medicine, working with the Brain Research Laboratories of NYU's Langone Medical Center, and Attending Psychiatrist at Lenox Hill Hospital. He has a private practice in New York City. He is board-certified in psychiatry and medicine.