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EFFICACY OF A COGNITIVE-BEHAVIORAL TREATMENT FOR INSOMNIA AMONG AFGHANISTAN AND IRAQ (OEF/OIF) VETERANS WITH PTSD

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Virginia Commonwealth University VCU Scholars Compass Theses and Dissertations Graduate School 2011 EFFICACY OF A COGNITIVE-BEHAVIORAL TREATMENT FOR INSOMNIA AMONG AFGHANISTAN AND IRAQ (OEF/OIF) VETERANS
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Virginia Commonwealth University VCU Scholars Compass Theses and Dissertations Graduate School 2011 EFFICACY OF A COGNITIVE-BEHAVIORAL TREATMENT FOR INSOMNIA AMONG AFGHANISTAN AND IRAQ (OEF/OIF) VETERANS WITH PTSD Margolies Skye Ochsner Virginia Commonwealth University Follow this and additional works at: Part of the Clinical Psychology Commons The Author Downloaded from This Dissertation is brought to you for free and open access by the Graduate School at VCU Scholars Compass. It has been accepted for inclusion in Theses and Dissertations by an authorized administrator of VCU Scholars Compass. For more information, please contact Skye Ochsner Margolies, 2011 All Rights Reserved ii EFFICACY OF A COGNITIVE-BEHAVIORAL TREATMENT FOR INSOMNIA AMONG AFGHANISTAN AND IRAQ (OEF/OIF) VETERANS WITH PTSD A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University By: Skye Ochsner Margolies M.A., University of Richmond, 2005 B.S., Georgetown University, 1995 Director: Scott Vrana, Ph.D. Professor of Psychology Department of Psychology Virginia Commonwealth University Richmond, Virginia December, 2011 ii Acknowledgements I would like to thank a number of people for making this dissertation possible. First I would like to acknowledge the Department of Veterans Affairs for the funding to conduct and complete this research. Secondly, I am indebted to the veterans who participated in this study and for the sacrifices they have made. I hope you benefited from being a part of this project. My graduate studies began with Beth Crawford, at the University of Richmond. Her enthusiasm and passion for research was infectious. Furthermore, her belief in me as a fellow researcher was empowering and allowed me the courage to further pursue my PhD at VCU. She is a true mentor and friend. I am similarly grateful for the guidance and support of my advisor, Scott Vrana. He has provided unwavering support as I jumped between research topics and it was through our initial conversations and work together that I came to be interested in the study and clinical treatment of PTSD. His critical (yet non-judgmental) eye for solid reasoning, not to mention grammar, has made me a better researcher and writer. Bruce Rybarczyk introduced me to the world of sleep research for which I am greatly indebted. He has been accessible and supportive at every step of the process and I feel fortunate that I was able to work under his guidance and mentorship. John Lynch at the McGuire VA Medical Center was an invaluable partner, mentor and advocate. This research would not have been possible without his support. Leticia Flores provided me with the first opportunity to work with veterans in a clinical setting. Her clinical acumen, approachable nature, and friendship have been a model to which I aspire. Rachel Gow was a true friend and instrumental in my conducting this research without unraveling emotionally. I would iii also like to thank Drs. Michael Southam-Gerow and David Leszczyszyn for their suggestions and advice during the completion of this dissertation. I cannot write these acknowledgments without mentioning Martee and Charles Johnson who put a roof over my head throughout my VCU years. No amount of honey could match their sweetness and generosity. My family has supported me along the way. I am grateful for the love I have received from Sylvia and Larry Margolies. Allison Margolies has been an amazing friend and confidante. She would do well in this field. My sister Virginia has never ceased to take an interest in my studies and research. She has lovingly supported and celebrated me along the way. I am particularly grateful to my mother, Rise Ochsner. Her love and encouragement gave me the strength to make the leap from journalism to pursuing my doctorate and have sustained me along the way. The courage she has demonstrated in her life has inspired me in mine. This dissertation is dedicated to my children and husband. My daughter Lark s sense of humor and passion are a constant source of joy. Her patience and independence have made conducting this research feasible. My newborn twins, Aura and Birch, light up a room with their sweet smiles. Although they continue to keep me on a schedule of sleep restriction, they have made my life fuller than I could have imagined. Finally, I would like to thank my husband Dan for his infinite love and wisdom. His conviction in my ability to accomplish anything I set my mind to, combined with his passion for life and for pursuing his dreams (from Mongolia to West Virginia) are inspirational. I love you and thank you for sharing this journey with me. iv Table of Contents Page Acknowledgements ii List of Tables....ix List of Figures...xi Abstract xii Introduction Review of the Literature....4 Posttraumatic Stress Disorder (PTSD)..4 Sleep Disturbance and PTSD.4 Chronic Nightmares in PTSD 8 The Effect of Insomnia and Chronic Nightmares on Functioning with PTSD 10 Insomnia and Chronic Nightmares..11 Insomnia Insomnia Intervention..12 CBT for Insomnia (CBT-I) Nuts and Bolts...17 Sleep Scheduling..18 Sleep Hygiene..19 Cognitive Restructuring...19 Chronic Nightmares...19 Three-Factor Model of Post-Traumatic Nightmare Development and Maintenance...19 Treatment of Chronic Nightmares...20 v Insomnia and Nightmare Intervention for PTSD...21 IRT for Trauma Related Nightmares...22 Combination of CBT-I and IRT for Trauma Related Insomnia and Nightmares...23 Insomnia and Nightmare Intervention for Combat-Related PTSD..23 IRT for Combat-Related Posttraumatic Insomnia and Nightmares.23 CBT-I for Combat-Related Posttraumatic Insomnia and Nightmares.24 Combination of CBT-I and IRT for Combat- Related Insomnia and Nightmares...25 PTSD and Operation Enduring Freedom/Operation Iraqi Freedom Military Personnel..29 Statement of The Problem...29 Aims and Hypotheses Methods Objectives of Proposed Study..32 Study Site...33 Experimental Overview...33 Participants..34 Inclusion Criteria.34 Exclusion Criteria 35 Study Procedures...35 Baseline Assessment Measures at Baseline 36 vi Sleep Diary...36 Actigraphy 36 PTSD Symptom Scale- Self Report.37 Pittsburgh Sleep Quality Index (PSQI) Pittsburgh Sleep Quality Index Addendum for PTSD (PSQI-A)...38 Insomnia Severity Index (ISI) Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS)...38 Insomnia Treatment Evaluation Questionnaire (ITEQ)...39 Patient Health Questionnaire (PHQ) 39 The Profile of Mood States (POMS)...40 Intervention Cognitive Behavioral Therapy for Insomnia with Imagery Rehearsal Therapy Waitlist Control Group...43 Follow-up assessments.43 Two-week follow-up 43 Six to Nine Month Follow-Up.43 Dependent Measures 43 Data Analysis Hypothesis # Hypothesis #2..46 Hypothesis # Results..47 vii Demographics..46 Data Screening and Manipulation Checks...48 Outliers and Tests of Normality...48 Success of Randomization...48 Attrition 51 Treatment Plausibility..52 Hypothesis # Sleep Diary Variables..53 Sleep Questionnaires Hypothesis # PTSD Severity...60 Mood Symptoms and Daytime Functioning 64 Hypothesis # Follow-up Analyses...68 Sleep Diary Variables.. 69 Sleep Questionnaires 71 PTSD Severity...72 Mood Symptoms and Daytime Functioning Discussion 73 Effects of CBT-I and IRT on Subjective Measures of Sleep...74 Effects of CBT-I and IRT on PTSD Symptoms..77 PTSD Symptom Severity...77 PTSD-Specific Sleep Disturbances...78 viii Effect of CBT-I on Mood Symptoms..82 Depression 82 Overall Distress, Mood, and Daytime Functioning...83 Effects of CBT-I and IRT on Objective Measures of Sleep Comparison of Objective and Subjective Measures of Sleep within Treatment Condition. 84 Directions for Future Research 85 Study Implications and Clinical Applications...87 Conclusion...88 Footnotes...90 List of References...91 Appendices Appendix A 103 Appendix B Appendix C 106 Appendix D 107 Appendix E Appendix F 110 Appendix G 115 Appendix H 116 Appendix I. 117 Appendix J. 120 Vita ix List of Tables Page Table 1. Articles assessing behavioral treatments (CBT-I and IRT) for posttraumatic insomnia and nightmares.27 Table 2. Participant Characteristics: Treatment Condition (n =20) and Waitlist Control (n =20) Table 3. Baseline Comparisons: Treatment Condition (n = 18) and Waitlist Condition (n = 16) 49 Table 4. Mean (and standard deviation) of CBT-I on Sleep Diary Variables: Treatment Condition (n=16) and Waitlist Condition (n = 14).. 56 Table 5. Mean (and standard deviation) of Subjective Measures of Sleep: Treatment Condition (n=15) and Waitlist Condition (n = 12).. 60 Table 6. Mean (and standard deviation) of CBT-I and PTSD Treatment on PTSD Severity).62 Table 7. Frequency of nightmares reported on Question 1C, PSQI-A from baseline to posttreatment...64 Table 8. Mean (and standard deviation) of CBT-I on PTSD Severity: Treatment Condition (n =15), Waitlist Condition (n = 12) 64 Table 9. Mean (and standard deviation) of CBT-I on Mood Symptoms: Treatment Condition (n = 14), Waitlist Condition (n = 12)...67 Table 10. Means (and standard deviations) of Cognitive Behavioral Treatment of Insomnia (CBT-I) on Objective Sleep Measures: Treatment Condition (n =9).. 70 Table 11. Means (and standard deviations) of CBT-I on Sleep Diary Variables 71 Table 12. Means (and standard deviations) of CBT-I on Subjective Measures of Sleep 71 Table 13. Means (and standard deviations) of CBT-I on PTSD Symptom Severity...72 Table 14. Means (and standard deviations) of CBT-I on Mood Symptoms and Daytime Functioning..72 Table 15. Repeated-Measures Multivariate Analysis of Variance: Effects of Cognitive Behavioral Treatment of Insomnia (Condition X Time) on Sleep Diary..120 x Table 16. Repeated-Measures Analysis of Variance for Effects of Cognitive Behavioral Treatment of Insomnia (Condition X Time) on Sleep Diary Variables.120 Table 17. Repeated-Measures Analysis of Variance for Effects of CBT-I over time on Sleep Diary Variables Within Each Group..120 Table 18. Repeated-Measures Analysis of Variance for Effects of CBT-I (Condition X Time) on Insomnia Severity and Overall Sleep Quality..121 Table 19. Repeated-Measures Analysis of Variance for Effects of CBT-I over time for Insomnia Severity and Overall Sleep Quality 121 Table 20. Repeated-Measures Analysis of Variance for Effects of Cognitive Behavioral Treatment of Insomnia (Condition X Time) on PTSD Symptom Severity and PTSD Related Nighttime Disturbances Table 21. Repeated-Measures Analysis of Variance for Effects of CBT-I over time for PTSD Symptom Severity and PTSD Related Nighttime Disturbances Table 22. Repeated-Measures Analysis of Variance for Effects of Cognitive Behavioral Treatment of Insomnia (Condition X Time) on Mood Symptoms and Daytime Functioning 122 Table 23. Repeated-Measures Analysis of Variance for Effects of CBT-I over time for Mood Symptoms and Daytime Functioning (POMS and PHQ)..123 Table 24. Repeated-Measures Analysis of Variance: Effects of CBT-I on Objective Measures of Sleep (Actigraphy) over time (Treatment Group)...125 xi List of Figures Page Figure 1. Flow chart of participants through study..51 Figure 2. Sleep efficiency at pretreatment and posttreatment for the two conditions (treatment condition [CBT-I] compared with waitlist control condition).54 Figure 3. Sleep onset latency at pretreatment and posttreatment for the two conditions (treatment condition [CBT-I] compared with waitlist control condition)...54 Figure 4. Wake after sleep onset at pretreatment and posttreatment for the two conditions (treatment condition [CBT-I] compared with waitlist control condition)...55 Figure 5. Insomnia severity (ISI) at pretreatment and posttreatment for the two conditions (treatment condition [CBT-I] compared with waitlist control condition) Figure 6. Overall sleep quality (PSQI) at pretreatment and posttreatment for the two conditions (treatment condition [CBT-I] compared with waitlist control condition)..58 Figure 7. Beliefs about sleep (DBAS-16) at pretreatment and posttreatment for the two conditions (treatment condition [CBT-I] compared with waitlist control condition...59 Figure 8. PTSD Symptom Severity at pretreatment and posttreatment for the two conditions (treatment condition [CBT-I] compared with waitlist control condition)...61 Figure 9. PTSD related nighttime disturbances pretreatment and posttreatment for the two conditions (treatment condition [CBT-I] compared with waitlist control condition)..63 Figure 10. Overall distress pretreatment and posttreatment for the two conditions (treatment condition [CBT-I] compared with waitlist control condition).65 Figure 11. Depression ratings (PHQ) at pretreatment and posttreatment for the two conditions (treatment condition [CBT-I] compared with waitlist control condition)...67 Abstract EFFICACY OF A COGNITIVE-BEHAVIORAL TREATMENT FOR INSOMNIA AMONG AFGHANISTAN AND IRAQ (OEF/OIF) VETERANS WITH PTSD By Skye Ochsner Margolies, M.A. A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University. Virginia Commonwealth University, Major Director: Scott Vrana, Ph.D. Professor Department of Psychology Sleep disturbances are a core and salient feature of PTSD and can maintain or exacerbate associated symptoms. Recent research demonstrates that cognitive-behavioral sleep-focused interventions improve sleep disturbances as well as PTSD symptoms. The present study is a randomized controlled trial comparing Cognitive Behavioral Therapy for Insomnia (CBT-I) to a waitlist control group. Conducted at a Veterans Affairs Medical Center, the study: 1) compared subjective outcome measures of sleep amongst veterans assigned to either a treatment group (CBT-I) or a waitlist control group; (2) examined the influence of the intervention on measures of PTSD, general mood and daytime functioning, comparing veterans in a treatment group to those in a waitlist control group and (3) examined the effect of the CBT-I intervention using objective measures of sleep for veterans included in the treatment arm of the study. Study participants were (n = 40) combat veterans who served in Afghanistan and/or Iraq (OEF/OIF). Participants were randomized to either a CBT-I treatment group or a waitlist control group. Those in the treatment condition participated in four CBT-I sessions over six weeks. CBT-I included sleep restriction, stimulus control, cognitive restructuring, sleep education, sleep hygiene and imagery rehearsal therapy. All participants completed subjective and objective measures at baseline and post-treatment. At six weeks post treatment, veterans who participated in CBT-I reported improved sleep, a reduction in PTSD symptom severity and PTSD-related nightmares, as well as a reduction in depression and distressed mood compared to veterans in the waitlist control group. When controlling for current participation in evidence-based PTSD treatment, veterans in the CBT-I group reported a reduction in PTSD symptom severity while their waitlist counterparts demonstrated an increase in these PTSD symptoms. Veterans in the treatment group also reported improved objectively measured sleep quality between baseline and posttreatment. These data suggest that CBT-I is an effective treatment for insomnia, nightmares and PTSD symptoms in OEF/OIF veterans with combat related PTSD and should be used as an adjunctive therapy to standard PTSD treatment. Efficacy of a Cognitive-Behavioral Treatment for Insomnia among Afghanistan and Iraq (OEF/OIF) Veterans with PTSD The current conflicts in Iraq and Afghanistan have resulted in thousands of military personnel returning home psychologically damaged and wounded. Estimates indicate that approximately 20% of these military personnel will develop Posttraumatic Stress Disorder (PTSD) post deployment (Seal, Metzler, Gina, Bertenthal, Maguen & Marmar, 2009; Hoge, McGurk, Thomas, Cox, Engel, & Castro, 2008). Sleep disturbances are a core feature of PTSD and yet they rarely garner non-pharmacologic therapeutic attention (Harvey, Jones & Schmidt, 2003). Furthermore, insomnia and chronic nightmares are often resistant to standard pharmaceutical and psychological treatments of PTSD (Zayfert & DeViva, 2004; Galovsi, Monson, Bruce, & Resick, 2009). Such sleep disturbances have a significant impact on overall PTSD and can maintain and/or exacerbate PTSD severity (Spoormaker & Montgomery, 2008; Belleville, Guay, & Marchand, 2009). Recent research has shown that sleep-focused interventions can improve both sleep disturbances and PTSD symptoms (DeViva, Zayfert, Pigeon, & Mellman, 2005; Germain, Shear & Buysse, 2007; Ulmer, Edinger & Calhoun, 2011). The purpose of the present study is to examine the effects of a brief cognitivebehavioral intervention (four sessions) for PTSD-related insomnia in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans. To date, there have been very few investigations of such treatment with OEF/OIF veterans. The goals of the proposed intervention are to create significant improvements in sleep as well as decrease the severity of PTSD symptoms from which these veterans suffer. If proven to be effective, this treatment approach can be implemented as a time- and cost-effective adjunct to the standard PTSD 1 treatment and in turn provide a more comprehensive and high quality approach to services for veterans diagnosed with PTSD. The present study begins with a review of the literature on posttraumatic stress disorder and the co-occurrence of PTSD with insomnia and chronic nightmares. Theories behind the co-occurrence of PTSD and sleep disturbances as well as physical and psychological implications are reviewed. Finally a review of cognitive behavioral therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT) as therapeutic interventions for insomnia and chronic nightmares, respectively, are discussed and examined within the context of current research looking at the implications for these interventions for treating PTSD and more specifically, combat-related PTSD. As stated above, this study will evaluate the implementation of a brief cognitivebehavioral intervention for insomnia amongst OEF/OIF veterans using a randomized controlled trial. Veterans diagnosed with PTSD will be assigned to either a Cognitive Behavioral Therapy for Insomnia treatment (CBT-I) group or to a waitlist control group. Given the impact of poor sleep on PTSD maintenance, this study aims to determine whether insomnia focused treatment will result in both better sleep and decreased PTSD symptom severity. Subjective measures of sleep, PTSD symptom presentation and overall mood and daytime functioning will be collected at baseline and two weeks posttreatment for participants in both groups. It is hypothesized that after four sessions of CBT-I, veterans in the treatment group will report improved sleep, decreased PTSD symptom severity and an overall improvement in mood and daytime functioning compared to their waitlist counterparts. Objective outcome measures of sleep will also be collected for veterans in the 2 treatment group at baseline and posttreatment. If the treatment is effective, veterans should show improvements on these objective measures of sleep at a two-week follow-up. 3 Review of the Literature Posttraumatic Stress Disorder (PTSD) Posttraumatic stress disorder (PTSD) is a clinical syndrome that is characterized by reexperiencing of a traumatic event, avoidance of reminders of the event, and physiological hyperarousal symptoms that occur for more than one month after exposure to a traumatic event (APA, 2000). A traumatic event can include a violent crime, natural disasters or combat exposure, and must be associated with a threat to the integrity of the self and/or others. While exposure to such trauma is not rare it is estimated that about 60% of the population will be witness to a traumatic event - it has been found that only 8-14% of the population
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