A poster describing the necessity for adequate sleep history.

1. AIMS
‘To Sleep: Perchance to Dream!’ – Detailed Sleep History -
An Essential Tool In Post-Traumatic Stress Disorder Evaluation & Management
Frank W Meissner, MD, RDMS, RDCS1,Cynthia Garza, JD, MD2, M. Brown, MD, MPH3, D. Dallam, MD3
1TTUHSC Paul L. Foster School of Medicine, PGY-4 Child & Adolescent Psychiatry Fellow, El Paso TX
2TTUHSC Paul L. Foster School of Medicine, PGY-5 Child & Adolescent Psychiatry Fellow, El Paso TX
3El Paso VA Health Care System - Department of Psychiatry, El Paso TX
No Conflicts Of Interest
To highlight by the presentation of illustrative cases the essential
nature of a detailed sleep history in the evaluation of Post-
Traumatic Stress Disorder.
Methods
Case presentation and focused literature review. Exposition and
explanation of the necessity for formal phenomenological analysis of
a detailed sleep history obtained from the patient with PTSD.
Results
Night terrors are parasomnias, characterised by sudden arousals
from deep (polysomnographic stage 4) sleep during which the
individual may present with a constricted awareness of his/her
surroundings. Night terrors are distinct from nightmares (which occur
in rapid eye movement (REM) sleep when muscle tone is greatly
reduced), but they bear some clinical resemblances to other, more
recently recognized REM onset parasomnias, such as that seen in
our second case, REM Behavior Sleep Disorder (RBD). Night terrors
are seen in no more than 1-3% of the adult population, and in the
setting of trauma related onset imply the possibility of dissociative
psychological phenomena as seen in our case.1
The late development of PTSD in combat veterans (principally
Vietnam Veterans, but occasionally seen in surviving Korean War &
WW II veterans) is a clinical marker for an underlying dementing
process.2,3
In Dallam et al2, Lewy Body Dementia was much more positively
associated with late occurrence PTSD than Dementia of the
Alizhemer’s Type, Vascular Dementia, Mixed Dementia’s or
Parkinson’s Dementia subtypes. Furthermore, as is more and more
apparent from the work of the Mayo Clinic group, REM Sleep
Behavior Disorder is increasingly appreciated to be associated with
Dementia with Lewy bodies, even in the absence of a history of
Parkinsonism or Visual Hallucinations.4
Thus we see illustrated by these two clinical cases that a detailed
exploration of the phenomenological nature of the PTSD - associated
‘nightmare’ rather than a simple characterization of the presence or
absence of nightmares as a diagnostic criteria is fundamental to in
making an accurate and complete clinical formulation of the case.
Conclusions
1. Elucidation of ‘nightmares’ as a diagnostic criteria for PTSD is inadequate for the purposes of
understanding the totality of the PTSD patients clinical presentation.
2. Detailed phenomenological exploration of the ‘nightmare’ is a necessity and leads to a fuller
understanding of the patient’s psychological milieu but also has the potential to lead to further
psychiatric diagnosis’s and divergent therapeutic approaches based on the more complete history.
The patient was a 36 y/o Hispanic male who served in the USA from
Y2005 until Y2012. Prior to entry in the USA he had no psychological
morbidity and there is no family history of psychiatric illness. He had
no substance use issues pre-military, intra-military, or post-military
service. During his military service he was a parts supply & logistics
clerk for motorized vehicles. He left the USA with an honorable
discharge at the conclusion of his enlistment obligation with the rank
of E-5 and never had any non-judicial punishment during his service.
However, during his combat deployments to Iraq, 1st for 6 months
(January - June) Y2006 and then from late Y2007 - middle of Y2009,
he was involved in Convoy Duties where his duties included recovery
of vehicles damaged or destroyed by enemy actions. During these
activities he came under small arms direct and indirect mortar fire, as
well as IED (Improvised Explosive Demolition) attacks. He left USA
service without requiring psychiatric treatment or evaluation.
Shortly after discharge from the USA, he began to experience intense
and nearly uniformly nightly parasomnia’s, consisting of intense ‘night
terrors.’ The nature of these episodes were generally several
episodes of ‘night terrors’ per night, with extreme agitation, waking
screaming and physical lashing out, on at least one occasion he
attempted to strangle his wife, with the result that he now sleeps in a
separate room, in a separate bed from his wife.
Unlike the classical night terror, but characteristically for the PTSD
associated night terror, he had full memory of the events comprising
his night terrors. Additionally, unlike the usual PTSD patient, he has
no acknowledged symptoms of PTSD within the course of his daily
life. Specifically, no intrusive thoughts, no ‘flashbacks’, no anticipatory
anxiety states, no panic attacks. The dream material was related to
memories of combat.
However, he endorsed marked dissociative phenomena, specifically,
he notes that he often has large blocks of time when he is without
direct access to the memories of his day. He has been keeping a
notebook where he logs memories or events that had happened to
him that day, that he wishes to keep available and recall. He
estimates about 1/3 of any given day belongs in a 'black hole' where
he can't recall what happened even with reference to his notes.
Additionally, he related that he will find unusual text messages on his
phone that come from numbers and/or people he doesn't recognize
nor with whom he has no recollection of any interactions with them.
He says he doesn't recall ever responding to any text messages from
anybody he doesn't recognize, however, he has found text responses
on his phone that he can’t recall composing or sending.
Additionally, he has found clothing in his closet that he can’t recall
ever purchasing. He has had several occasions when he has been
approached by others he did not independently recognize but who
talked to and responded to him as if they recognized him, even
though he couldn’t recall any circumstances when he had any
memory of that person.
He seems to spend much of any time or day, without direct access to
all memories of the events experienced by him in that day. For
example, he recalls taking his three children on a Sunday in October
to Disney on Ice while they were performing in El Paso. He says that
he has no independent recallable memory of what happened at that
event.
In his own words, he describes a state of profound depersonalization
or focal memory deficit so complete that he has no access to
memories of these events. He says this is his experience of reality on
most days and he has taken to keeping a reminder file of dates and
events.
Of note, review of his chart demonstrates many, many missed
appointments. He maintains these are not for lack of wishing to make
the appointments, but rather simply completely failing to recall or
track the appointments.
Also, when 'angry' and acting out, he maintains, that this is a situation
in which he completely cannot recall the events of his rage attack, but
additionally can't recall the trigger, or any parts of his experiences
during the anger event(s).
He has been treated with several different SSRI’s and a SNRI without
improvement in his night terrors and with no effect on his daily
depersonalization events.
Of particular importance, he had been seen by another practitioner for
several years prior to my initial evaluation of the patient. He was noted
to have PTSD associated nightmares, but the phenomenological
characteristics of the nightmare were not elaborated or explored.
Given the contentious association between parasomnias and
dissociative states, an exploration for existing dissociative phenomena
was undertaken with the resultant outpouring of clear-cut dissociative
states being reported by the patient.
Since the VA Health System has championed manualized
psychotherapy interventions for PTSD, it is vital that evidence of
underlying psychopathological processes not conforming to the
‘standard PTSD’ case; such as in this case, the presence of prominent
daytime depersonalization states need to be elaborated so that an
individual psychotherapeutic approach can augment the more
standard cognitive behavioral therapy for his unusual PTSD
manifestations.
Case #1
The patient was a 71 y/o Caucasian male, Vietnam era combat
veteran with a 10 year long history of PTSD symptoms, i.e.,
delayed onset of PTSD symptoms, who denied systematic
hypervigilance, free-floating anxiety, anticipatory anxiety,
flashbacks, or intrusive memories.
However, according to his wife, he was experiencing at least 3
episodes of severe nightmares, in which the patient generally
attempts to run in his bed and for which he reports amnesia for
the events. He often shouts at the beginning of the ‘nightmare’
state. There is no report from the wife consistent with increased
sympathetic tone, or inconsolability occurring during or after the
nightmare. She has taken to sleeping in a different bed and
room than her husband due to presence of these disturbing
nightmares. Her description of the nightmares was most
consistent with REM Sleep Behavior Disorder. Both the patient
and his wife denied the presence of visual hallucinations.
At his inital evaluation, she also complained as did the patient
of progressive memory issues, specifically, difficulties with word
choice or word search, e.g., struggling to recall the word ‘bus’,
an episode in which the patient repetitively asking her (4-5
times during the course of an evening) if ‘the dishes had
finished cleaning in the dishwater.’ The patient had voluntarily
(against his character) sacrificed his control of the family
checkbook. He still was driving and had not yet become
disoriented or lost while driving. Concurrent with his memory
problems he has begun to demonstrate increased emotional
lability, so extreme that recently while in a restaurant the patient
became so unreasonably upset at a ‘green chilli’ sauce being
too tepid, that the wait staff after being verbally abused by the
patient, had restaurant security escort the patient from the
restaurant, humiliating the wife.
There was a history of ‘PTSD’ associated hospitalizations over
the past 10 years, always precipitated by domestic arguments,
where the patient left his home, and drove to Arizona or San
Antonio Texas, presenting to VA hospitals with inpatient
psychiatric wards, for short periods of hospitalization. His
substance history is remarkable for long term tobacco
dependence but no dysfunctional alcohol use or history of
illegal drug use. A recent CNS MRI was normal for age. There
is no family history of dementia. A AAA-stent was placed
several years previously thus representing a substrate for
vascular dementia, but as noted previously no findings on CNS
MRI consistent with old CVA’s.
His mental status examination was notable for impaired
registration (2/7 digits forward, and 1/4 digits reverse), serial 7’s
accurate to 65, 3/3 objects recalled immediately, 1/3 objects at
5 minutes in spite of cue’s, thought was found to be concrete
for similes and proverbs, his clock construction displays marked
defects in executive function and is reproduced in the figure
seen below.
Case #2
1. D Hartman, A H Crisp, P Sedgwick, S Borrow. Is there a dissociative process in
sleepwalking and night terrors? Postgrad Med J 2001;77:244–249.
2. Dallam DL, Mellman TA, et al. Trauma Reenactments in Aging Veterans with
Dementia. J Am Geriatr Soc. 2011 Apr; 59(4): 766–768.
3. Ruzich MJ, Looi JC, Robertson MD. Delayed onset of posttraumatic stress disorder
among male combat veterans: A Case Series. Am J Geriatr
Psychiatry. 2005;13:424–427.
4. Ferman TJ, Boeve BF, et al. Dementia with Lewy bodies may present as dementia
and REM sleep behavior disorder without parkinsonism or hallucinations. J Int
Neuropsychol Soc. 2002 Nov;8(7):907-14.
5. Avidan AY, Kaplish N. The Parasomnias: Epidemiology, Clinical Features, and
Diagnostic Approach. Clin Chest Med 31 (2010) 353–370.
Select References
A Humanistic Model of Medicine
.
Patient #2 - Clock Construction
Parasomnias
Non-REM Sleep
Night Terrors
Sleep Walking
Confusional Arousals
Bruxism
Enuresis
Sleep Starts
Sleep Talking
Head Banging
REM Sleep
REM Sleep Behavior
Sleep Paralysis
Nightmares
From Avidan AY & Kaplish N 5