Correspondence

Post-Traumatic Stress Disorder and Sleep

N Engl J Med 2002; 346:1334-1335April 25, 2002

Article

To the Editor:

Lavie (Dec. 20 issue)1 has shown that objective, sleep-laboratory measures do not consistently support the subjective reports of insomnia given by Western survivors of traumatic events. However, Lavie does not provide an explanation for this inconsistency.

We believe that beliefs about illness, which vary among cultures,2 may play a part. Elevated rates of subjective reporting of insomnia after trauma are not necessarily found outside of the Western or industrialized world. In a population-based study comparing 526 Bhutanese refugees in Nepal who had been tortured with 526 who had not been tortured, those who had been tortured were more likely to report 16 of the 17 symptoms of post-traumatic stress disorder (PTSD) (P<0.05); the exception was insomnia (chi-square statistic=1.3, P=0.25).3 The frequency of reports of nightmares, however, was elevated among the refugees who had been tortured. This observation is consistent with Lavie's review, which does not provide any strong or objective evidence that nightmares are overreported by survivors of traumatic events.

We expect that future investigations will confirm that insomnia is not specific to PTSD but that trauma-related nightmares are a core symptom of the disorder. In contrast to Lavie's recommendation regarding sleep disturbances, trauma-related nightmares should therefore be treated as a symptom of PTSD rather than as an independent clinical entity. Effective therapies for PTSD are available.4,5 Moreover, evidence-based explanations of the reasons behind the overestimation of insomnia by Western survivors of trauma will improve understanding of their overall experience of trauma.

Mark Van Ommeren, Ph.D.
Joop T.V.M. de Jong, M.D., Ph.D.
Ivan Komproe, Ph.D.
Transcultural Psychosocial Organization, 1016 EE Amsterdam, the Netherlands
mvo2@wanadoo.fr

5 References

1. 1

   Lavie P. Sleep disturbances in the wake of traumatic events. N Engl J Med 2001;345:1825-1832
   Full Text | Web of Science | Medline

2. 2

   Helman C. Culture, health and illness: an introduction for health professionals. 3rd ed. Oxford, England: Butterworth–Heinemann, 1994.
   

3. 3

   Shrestha NM, Sharma B, Van Ommeren M, et al. Impact of torture on refugees displaced within the developing world: symptomatology among Bhutanese refugees in Nepal. JAMA 1998;280:443-448
   CrossRef | Web of Science | Medline

4. 4

   Foa EB, Keane TM, Friedman MJ, eds. Effective treatments for PTSD. New York: Guilford, 2000.
   

5. 5

   Krakow B, Hollifield M, Johnston L, et al. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA 2001;286:537-545
   CrossRef | Web of Science | Medline

To the Editor:

A press release from the American Society for Technion–Israel Institute of Technology1 expanding on the article by Dr. Lavie states that he “questions the traditional treatment for traumatized patients, which is based on reliving the trauma.” According to the press release, “Dr. Lavie's studies with Holocaust survivors suggest that learning to leave traumatic memories behind may be more effective for a good night's sleep.” We adamantly disagree with Dr. Lavie's conclusions regarding the treatment of traumatized persons with chronic psychiatric disturbances such as PTSD.

PTSD is characterized by symptoms of reexperiencing the trauma, avoidance of reminders of the trauma, and increased arousal, including sleep disturbances. The treatment that has been found to be extremely effective in ameliorating PTSD in numerous studies is “prolonged exposure.”2 This approach involves having the patient repeatedly recount the traumatic memory in a therapeutic manner3 until the memory ceases to evoke strong anxiety. The goal of prolonged exposure is to help the survivor process the traumatic memory in such a way that he or she will be able to remember it without disruptive distress.

Dr. Lavie's assertions that survivors of trauma should “learn to leave traumatic memories behind” can be interpreted as encouraging survivors to avoid this type of processing of the traumatic event. Dissemination of Dr. Lavie's assertions is damaging and harmful, because such avoidance is known to prolong and exacerbate the symptoms of PTSD rather than ameliorate them. Research has demonstrated that survivors of trauma must emotionally process their traumatic experiences to be able to return to normal functioning and that systematic avoidance of the painful memories actually perpetuates PTSD.4 Survivors must face the memories to get past them. Advising them to “leave traumatic memories behind” is counterproductive, and physicians should not recommend such avoidance to their patients.

Barbara O. Rothbaum, Ph.D.
Emory University School of Medicine, Atlanta, GA 30322
brothba@emory.edu

Edna B. Foa, Ph.D.
University of Pennsylvania School of Medicine, Philadelphia, PA 19104

4 References

1. 1

   Trauma survivors losing less sleep than they think. New York: American Society for Technion–Israel Institute of Technology, December 2001. (Accessed April 5, 2002, at http://www.ats.org/v2/News/2001_News/2001_news.html.)
   

2. 2

   Rothbaum BO, Meadows EA, Resick P, Foy DW. Cognitive-behavioral treatment position paper summary for the ISTSS Treatment Guidelines Committee. J Trauma Stress 2000;13:558-563
   

3. 3

   Foa EB, Rothbaum BO. Treating the trauma of rape: a cognitive-behavioral therapy for PTSD. New York: Guilford, 1998.
   

4. 4

   Rothbaum BO, Mellman TA. Dreams and exposure therapy in PTSD. J Trauma Stress 2001;14:481-490
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Lavie replies:

To the Editor: Rothbaum and Foa's warning against advising patients to leave traumatic memories behind them is a surprise. The conviction and vehemence with which they attack this idea stand in sharp contrast to the scientific rigor that has been used in the evaluation of treatments for PTSD. As Foa and coworkers concluded in their guidelines for treatment of PTSD,1 “the study of treatment efficacy for PTSD is still in its initial stage relative to other mental disorders.” They were right. None of the references that Rothbaum and Foa cite in their letter provide a shred of evidence that prolonged exposure is effective in severely traumatized patients such as Holocaust survivors or survivors of catastrophic traumatic experiences.

Moreover, in the same journal issue in which the guidelines of Foa et al. appear, Krakow et al.2 present evidence that the use of the imagery rehearsal technique alleviates the symptoms of PTSD in rape victims; they explain that this “treatment discourages discussion of traumatic experiences and traumatic content of nightmares, and instructs patients to avoid rehearsing old nightmares.” Krakow et al. go on to note that “many of [their] participants reported that they were previously offered (or they had previously attempted) desensitization procedures to help them with their PTSD-related symptoms. Of those who attempted such therapy, essentially all reported no improvement or worsening.”

Finally, a review of the effectiveness of brief psychological debriefing in patients with PTSD,3 a method that is conceptually similar to prolonged exposure (albeit of shorter duration), concluded that “there is no current evidence that psychological debriefing is a useful treatment for the prevention of PTSD after traumatic incidents. Compulsory debriefing of victims should cease.”

Peretz Lavie, Ph.D.
Technion–Israel Institute of Technology, 32000 Haifa, Israel
plavie@tx.technion.ac.il

3 References

1. 1

   Guidelines for treatment of PTSD. J Trauma Stress 2000;13:539-588
   CrossRef | Web of Science | Medline

2. 2

   Krakow B, Hollifield M, Schrader R, et al. A controlled study of imagery rehearsal for chronic nightmares in sexual assault survivors with PTSD: a preliminary report. J Trauma Stress 2000;13:589-609
   CrossRef | Web of Science | Medline

3. 3

   Suzanna R, Johnathan B, Simon W. Psychological debriefing for preventing post traumatic stress disorder (PTSD) (Cochrane review). Cochrane Database Syst Rev 2001;3:CD000560-CD000560
   Medline

Citing Articles (3)

Citing Articles

1. 1

   Marieke Soeter, Merel Kindt. (2011) Noradrenergic enhancement of associative fear memory in humans. Neurobiology of Learning and Memory 96:2, 263-271
   CrossRef

2. 2

   Mohammed R. Milad, Roger K. Pitman, Cameron B. Ellis, Andrea L. Gold, Lisa M. Shin, Natasha B. Lasko, Mohamed A. Zeidan, Kathryn Handwerger, Scott P. Orr, Scott L. Rauch. (2009) Neurobiological Basis of Failure to Recall Extinction Memory in Posttraumatic Stress Disorder. Biological Psychiatry 66:12, 1075-1082
   CrossRef

3. 3

   Jeiran Farrahi, Nouzar Nakhaee, Vahid Sheibani, Behshid Garrusi, Ahmad Amirkafi. (2009) Psychometric properties of the Persian version of the Pittsburgh Sleep Quality Index addendum for PTSD (PSQI-A). Sleep and Breathing 13:3, 259-262
   CrossRef