Graduation Year

2016

Document Type

Dissertation

Degree

Ph.D.

Degree Name

Doctor of Philosophy (Ph.D.)

Degree Granting Department

Nursing

Major Professor

Kevin Kip, Ph.D.

Committee Member

Kristen Salomon, Ph.D.

Committee Member

Constance Visovsky, Ph.D.

Committee Member

Cecile A. Lengacher, Ph.D.

Committee Member

Janice Zgibor, Ph.D

Keywords

Sleep Disturbance, PTSD, Nightmares, Accelerated Resolution Therapy (ART)

Abstract

Posttraumatic Stress Disorder (PTSD) is a prevalent anxiety disorder that is debilitating to both veterans and civilians following one or more traumatic events. Sleep disturbances are hallmark features of PTSD. Sleep disturbances and PTSD remain two significant PTSD-related issues that continue to plague veterans returning from active duty, thereby preventing full reintegration into society. The same problem exists for civilians. This research was conducted as a previously collected pilot study data and a secondary data analysis. The purpose of the study consisted of: 1) examining the impact of treatment with Accelerated Resolution Therapy (ART) on symptoms of PTSD and sleep disturbances; 2) examining the relationships and treatment response among both subjective and objective measures of sleep function; and 3) comparing the relationship between PTSD and sleep disturbances among military versus civilians, including the effects of treatment with ART.

The study represents one of only a few studies consisting of subjective measures of PTSD (PCL checklist) and sleep quality (Pittsburgh Quality Sleep Index (PSQI)), and objective measurement of sleep function by use of electroencephalography (EEG) testing and based on a 30-minute nap protocol. The aims of this study were to: 1) investigate the effects of ART on comorbid PTSD and sleep disturbances in U.S. veterans measured both subjectively (self-report) and objectively (sleep EEG data) from previously collected pilot study data; 2) assess the relationships between objective and subjective measures of sleep disturbances before and after treatment with ART for symptoms of PTSD in U.S. veterans from previously collected pilot study data; and 3) compare self-report PTSD and sleep disturbances symptoms between civilians and veterans before and after treatment with ART using a secondary analysis from two previously conducted studies.

For Specific Aims 1 and 2, the methods consisted of previously collected pilot study data of 8 veterans who were treated with ART at the University of South Florida, College of Nursing. For Specific Aim 3, data were pooled from two completed studies of ART directed by Dr. Kevin Kip that included civilians (n=75) and veterans (n=50) who were treated for PTSD. Data analysis for Aim 1 included the use of paired t tests to compare PSQI score and each stage of sleep measured from qEEG (Delta, Theta, Alpha, Beta, Gamma) before and after treatment with ART. For Aim 2, Pearson correlation was used to assess the relationship between objective measurement of sleep disturbances and subjective sleep quality before and after ART. For Aim 3, multiple linear regression models were fit with PSQI (sleep) score as the dependent variable, PCL (PTSD) score as the primary independent variable, along with a main effect term for military status (civilian versus military) and an interaction term (military status * PCL score).

Results for aims 1 and 2 showed the mean age of the sample to be 37.6 years, 87.5% male, 87.5% White (non-Hispanic), 87.5% had experienced prior combat, 50% had experienced 5 or more traumatic memories that impacted their lives, and 87.5% had previous treatment for PTSD. Sample mean scores were above established screening criteria for PTSD (PCL-M = 63.7), sleep disturbance (PSQI = 14.5), and Center for Epidemiologic Studies Depression Scale (CES-D = 28.9). For Aim 1, after treatment with ART, the mean score on the PSQI dropped 4.88 points, mean score on the PCL-M dropped -30.13 points, thereby indicating significant reductions in sleep dysfunction and symptoms of PTSD. Mean Delta 1.5-3.5 Hz waves increased pre/post by 299.89 (p=.032), and Theta 4-6.5 Hz waves increased pre/post mean by 83.07 (p<0.001), both indicative of improved sleep quality. Results for Aim 2 showed statistically significant strong inverse correlations between PSQI and Theta 1.5-3.5 Hz waves (r=-0.79) and PSQI and Alpha 8-11 Hz waves (r=-0.89) at baseline. Post-ART, non-significant trends were observed for higher PSQI scores and higher Beta (conscious, alert) waves. For Aim 3, mean age of military participants (n=50) was 41.9 years versus 40.4 years among civilians (n=75, p=.439). For the military cohort, 18% were female compared to 80% among civilians (p<0.001), with lower Hispanic ethnicity among military compared to civilian participants (12% vs. 27%, p=0.04). In multiple regression analysis, change in PCL score was a strong predictor of change in PSQI score, regardless of military status PCL.

In summary, within the setting of PTSD, military participants tend to present with different traumatic exposures and worse sleep quality compared to civilian counterparts. In spite of these differences, the treatment protocol with ART demonstrated similar level of benefit (reduction in symptoms of PTSD and sleep disturbance) for both military and civilian personnel. Thus, nurses caring for individuals with PTSD, whether military or civilian, need to routinely assess sleep disturbances and initiate an open dialogue regarding these conditions. In return, nurses will be able to provide patients with resources to help them better understand and address these concerns, including after experiencing restless nights of sleep. Lastly, nurses should recognize the bi-directional temporal relationship between PTSD and sleep disturbances places. This places a premium on assessing these conditions collectively, rather than as discrete, independent clinical conditions.

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