Anxiety Disorders: Woodward SH

Sheikh JI, Woodward SH, Leskin GA. · Veterans Affairs Palo Alto Healthcare System (116A-MP), Menlo Park, California 94025, USA. · Depress Anxiety. · Pubmed #14661188 No free full text.

Abstract: Disturbed sleep is a common clinical problem in anxiety disorders, particularly in patients with post-traumatic stress disorder (PTSD) and panic disorder (PD). Several studies have attempted to validate the subjective sleep complaints of these disorders using laboratory polysomnography. These attempts, typically focusing on PTSD or PD independently, have demonstrated inconsistent results. To our knowledge, no such studies have attempted to directly compare and contrast sleep disturbances in PTSD and PD together. Our review of the studies of subjective sleep disturbances, sleep architecture, and sleep-related biologic phenomena suggests that a comparative characterization of sleep disturbances in these two disorders is timely. Such an inference is based on our identification of several areas of convergence and divergence between PTSD and PD found in the published literature, as well as our own preliminary investigations. Specifically, PTSD and PD seem to converge on several sleep-related parameters, namely, sleep quality, presence of episodic parasomnias, and movement time. They also appear to diverge in other important sleep-related areas such as respiratory disturbances and the particular phenomenological nature of episodic parasomnias, namely nightmares or nocturnal panic attacks. Investigations focusing on such overlapping phenomena may provide groundwork for further elucidation of central fear systems underlying these two disorders. Additionally, such sleep studies have the potential to provide important insights into ongoing efforts to develop a cohesive conceptual framework into the patho-physiologies of these disorders.

Woodward SH, Murburg MM, Bliwise DL. · National Center for PTSD, Clinical Laboratory and Education Division, VA Palo Alto Health Care System, Palo Alto, CA 94304, USA. · Physiol Behav. · Pubmed #10978496 No free full text.

Abstract: Posttraumatic stress disorder is widely understood to include "persistent symptoms of increased arousal." This presumption has rarely been tested under conditions in which effects of anticipatory anxiety could be ruled out. In this study, heart rate and electroencephalogram spectral power were assessed during sleep, a state free of most sources of artifact contaminating indices of tonic arousal. Fifty-six unmedicated nonapneic Vietnam combat-related inpatients with posttraumatic stress disorder (PTSD) and 14 controls spent 3 or more nights in the sleep laboratory during which their electrocardiograms and electroencephalograms were continuously recorded. Heart rate and electroencephalogram spectral power were quantified continuously off-line and averaged by sleep stage over all postadaptational nights. Sleep heart rate exhibited no group differences and no covariation with the severity of subjective hyperarousal reported by PTSD patients. PTSD patients exhibited a trend toward reduced low-frequency electroencephalogram spectral power during nonrapid-eye-movement (NREM) sleep. This reduction was significant during slow-wave sleep in those subjects producing scoreable slow-wave sleep. The relationship of rapid-eye-movement (REM) beta-band power to NREM beta-band power was different in PTSD patients and controls, with the patients exhibiting more beta in REM versus NREM sleep than controls. In patients, NREM sleep sigma-band electroencephalogram spectral power exhibited a positive correlation with subjective hyperarousal. Finally, a novel and surprisingly strong inverse correlation between REM-NREM sleep heart rate difference and REM percent of sleep was observed in PTSD patients only. In summary, peripheral and central measures of tonic arousal during sleep demonstrated contrastive relations to PTSD diagnostic and symptom status. The data suggest that more consideration should be directed to mechanisms of central arousal in PTSD.

Woodward SH, Kaloupek DG, Streeter CC, Kimble MO, Reiss AL, Eliez S, Wald LL, Renshaw PF, Frederick BB, Lane B, Sheikh JI, Stegman WK, Kutter CJ, Stewart LP, Prestel RS, Arsenault NJ. · National Center for PTSD, Clinical Laboratory and Education Division and Psychology Service, VA Palo Alto Healthcare System, Palo Alto, CA 94025, USA. · J Trauma Stress. · Pubmed #17955544 No free full text.

Abstract: Children and adolescents with maltreatment-related posttraumatic stress disorder (PTSD) exhibit smaller intracranial tissue volume than controls. Linear relationships have also been observed between intracranial tissue volume and the age of maltreatment onset. The authors explored associations among adult PTSD, early trauma, and cerebral volumes in 99 combat veterans. A bone-based estimate of cranial volume was developed to adjust for variation in body size. Posttraumatic stress disorder was not associated with smaller cerebral tissue volume, but rather with smaller cerebrospinal fluid (CSF) and cranial volumes. These findings co-occurred with expected effects of alcoholism and aging on cerebral tissue and CSF volumes. The results point to early developmental divergences between groups with and without PTSD following adult trauma.

Woodward SH, Stegman WK, Pavao JR, Arsenault NJ, Hartl TL, Drescher KD, Weaver C. · National Center for PTSD, Clinical Laboratory and Education Division, VA Palo Alto HCS, Menlo Park Division, Menlo Park, CA 94025, USA. · J Trauma Stress. · Pubmed #17721964 No free full text.

Abstract: Psychobiological studies of posttraumatic stress disorder (PTSD) often challenge participants to assess the dynamics of systems evolved to organize responses to extreme events. Informed consent insures that volunteers have every opportunity to preevaluate the conditions of the research experience and decline if made uncomfortable by them. Notwithstanding their necessity, these protections set the stage for self-selection phenomena that may bias study outcomes. This study compared prospectively obtained psychometric data from 196 participants and 1229 nonparticipants in sleep and psychophysiological studies of PTSD. Lower subjective nightmare severity was endorsed by persons who later agreed to participate in a study of baseline sleep, an observation consistent with the low nightmare frequencies observed in most laboratories studies of sleep in PTSD.

Woodward SH, Kaloupek DG, Streeter CC, Kimble MO, Reiss AL, Eliez S, Wald LL, Renshaw PF, Frederick BB, Lane B, Sheikh JI, Stegman WK, Kutter CJ, Stewart LP, Prestel RS, Arsenault NJ. · National Center for PTSD, Clinical Laboratory and Education Division, Mail Code 334 PTSD, VA Palo Alto HCS, 3801 Miranda Ave., Palo Alto, CA 94304, USA. · Am J Psychiatry. · Pubmed #16585443 links to  free full text

Abstract: Studies imposing rigorous control over lifetime alcohol intake have usually not found smaller hippocampal volumes in persons with posttraumatic stress disorder. Because the majority of negative studies have used adolescent samples, it has been suggested that chronicity is a necessary condition for such findings. To test the hypothesis that a smaller hippocampus in PTSD is unrelated to comorbid alcoholism or to chronicity, this study estimated hippocampal volume in a relatively large group (N=99) of combat veterans in which PTSD, lifetime alcohol abuse/dependence, and Vietnam versus Gulf War service were crossed. In subjects with histories of alcoholism, unadjusted hippocampal volume was 9% smaller in persons with PTSD than in those without PTSD. In nonalcoholic subjects, the PTSD-related difference in hippocampal volume was 3%. The failure to observe a strong association between PTSD and hippocampal volume in nonalcoholic subjects was not ascribable to younger age, reduced PTSD chronicity, or lower PTSD symptom severity. The possibility that smaller hippocampal volume is limited to groups in which PTSD is compounded by comorbid alcoholism is not necessarily incompatible with results suggesting a smaller hippocampus is predispositional to PTSD. Further examination of the role of alcoholism and other comorbid conditions in studies of brain structure and function in PTSD appears warranted.

Woodward SH, Kaloupek DG, Streeter CC, Martinez C, Schaer M, Eliez S. · Clinical Laboratory and Education Division and Psychology Service, National Center for PTSD, VA Palo Alto Healthcare System, Palo Alto, California 94034, USA. · Biol Psychiatry. · Pubmed #16165099 No free full text.

Abstract: BACKGROUND: Neuroanatomical data point to functional relationships between the anterior cingulate cortex (ACC) and subcortical centers regulating fear, in particular, the amygdala. Functional brain imaging has disclosed divergent patterns of ACC activation in persons with posttraumatic stress disorder (PTSD). In addition, two preliminary structural imaging studies have found evidence of smaller ACC volume in PTSD. We explored associations between PTSD and ACC volume in a relatively large sample of adult combat veterans in which PTSD, lifetime alcohol abuse/dependence, and Vietnam versus Gulf War service were crossed. METHODS: Subjects were US military combat veterans of the Vietnam and Gulf Wars recruited from two metropolitan areas served by allied Department of Veterans Affairs PTSD treatment/research centers. Anterior cingulate cortex volume was analyzed as a function of grouping factors with and without adjustment for body size. RESULTS: Posttraumatic stress disorder was associated with smaller anterior cingulate cortex volume. This effect persisted in subjects without histories of alcoholism, did not interact with cohort effects, and was not modified by adjustment for body size. CONCLUSIONS: Anterior cingulate cortex volume is substantially smaller in association with combat-related PTSD, a finding broadly consistent with cingulate hypofunctionality in that disorder.

Woodward SH, Leskin GA, Sheikh JI. · National Center for PTSD, Clinical Laboratory and Education Division, Veterans' Administration Palo Alto Health Care System, California, USA. · Depress Anxiety. · Pubmed #14661189 No free full text.

Abstract: Posttraumatic stress disorder (PTSD) patients with comorbid panic disorder (PD) may express additive symptoms of central fear system disturbance. They endorse elevated levels of sleep and nightmare disturbance [Leskin GA, et al., J Psychiatr Res 2002;36:449-452], and demonstrate movement suppression during laboratory sleep [Woodward SH, et al., Sleep 2002;25:681-688]. We estimated respiratory rate and rate variability separately for rapid-eye movement (REM) and non-rapid-eye movement (NREM) sleep. Subjects were 49 Vietnam combat-related PTSD inpatients (11 with comorbid PD and 38 without) and 15 controls. Computer-based estimates of respiratory rate and variability were derived from 10 to 18 hr of baseline sleep collected over two or three nights. Neither rate nor rate variability distinguished PTSD patients with comorbid PD from those without, or PTSD patients from controls; however, PTSD patients failed to exhibit the expected differences between REM and NREM respiratory rates. Moreover, the difference between REM and NREM respiratory rate was inversely related to a continuous measure of PTSD severity. PTSD patients with trauma-related nightmare complaint exhibited higher sleep respiration rates over both REM and NREM sleep. Conversely, in addition to slowed respiration, nightmare-free patients exhibited reduced respiratory rate variability in REM relative to NREM sleep, which was a reversal of the normal pattern. These finding are discussed in light of known telencephalic regulatory influences upon respiration rate.

Leskin GA, Woodward SH, Young HE, Sheikh JI. · VA Palo Alto Health Care System (116A-MP), 795 Willow Road, Menlo Park, CA 94025, USA. · J Psychiatr Res. · Pubmed #12393315 No free full text.

Abstract: OBJECTIVE: Patients with post-traumatic stress disorder (PTSD) are frequently diagnosed with other psychiatric comorbid conditions. This study tested the hypothesis that PTSD patients suffer a greater proportion of sleep problems according to comorbid diagnoses. METHOD: National Comorbidity Survey (NCS) data from 591 individuals diagnosed with PTSD were analyzed. Revised versions of the Diagnostic Interview Schedule and Composite International Diagnostic Interview were administered to a representative sample of males and females. Groups consisted of patients diagnosed with lifetime PTSD and with current comorbid panic disorder, major depressive disorder, generalized anxiety disorder, and alcohol dependence. RESULTS: Patients diagnosed with PTSD/panic disorder reported a significantly greater proportion of nightmare complaints (96%) and insomnia (100%) compared with the other comorbid groups. CONCLUSIONS: A greater proportion of PTSD patients with comorbid panic disorder complain of sleep-related problems than other comorbid groups. This effect appears unique to panic, rather than other general anxiety disorder or depression. Prospective sleep studies are needed to differentiate the role of sleep in PTSD and PD, as well as to examine the role of psychiatric comorbidity in worsening sleep in PTSD patients.

Woodward SH, Leskin GA, Sheikh JI. · National Center for PTSD, Clinical Laboratory and Education Division, VA Palo Alto Health Care System, Palo Alto, CA, USA. · Sleep. · Pubmed #12224848 No free full text.

Abstract: STUDY OBJECTIVES: To corroborate findings from the National Comorbidy study with objective sleep data. DESIGN: Retrospective data review. SETTING: Sleep Laboratory, National Center for Posttraumatic Stress Disorder PARTICIPANTS: Male Vietnam combat veteran. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: We reanalyzed laboratory sleep data obtained from subjects undergoing inpatient treatment for posttraumatic stress disorder. Comorbid panic disorder was not associated with a significant worsening of objective sleep in this sample. Posttraumatic stress disorder, comorbid panic disorder, and trauma-related nightmare complaint were all associated with significant and systematic reductions of sleep movement time. Analyses of potential "rescoring" artifacts provided further support for this effect. CONCLUSIONS: A curvilinear function may describe the relationship between anxiety symptom severity and sleep-movement time in both posttraumatic stress disorder and panic disorder. Evidence for movement suppression in association with pathologic levels of human anxiety is consistent with the suppression of movement ("freezing") exhibited by animals under conditions of perceived threat.

Woodward SH, Arsenault NJ, Murray C, Bliwise DL. · National Center for PTSD, Clinical Laboratory and Education Division, Veterans Administration Palo Alto Health Care System, Palo Alto, California, USA. · Biol Psychiatry. · Pubmed #11094141 No free full text.

Abstract: BACKGROUND: Nightmares are rare in the sleep laboratory, even in patients with posttraumatic stress disorder for whom nightmare complaints are diagnostic. Nevertheless, it is possible that laboratory conditions do not preclude the observation of telltales-nightmare-related modifications of tonic sleep-given sufficiently large samples. METHODS: Sixty-three unmedicated, nonapneic Vietnam combat veterans undergoing inpatient treatment for posttraumatic stress disorder underwent polysomnographic testing and assessment of nightmare complaint. RESULTS: Trauma-related nightmare complaint, but not non-trauma-related complaint, was associated with increased wake-after-sleep-onset in the sleep laboratory. No relationships between nightmare complaint and rapid eye movement sleep architecture were observed. CONCLUSIONS: Increased wake-after-sleep-onset was specifically associated with trauma-related nightmare complaint, confirming data from other quarters suggesting they are both phenomenologically and functionally distinct from normal dreaming.

Woodward SH, Neylan TC, Mellman TA, Ross RJ. · No affiliation provided · Arch Gen Psychiatry. · Pubmed #16894072 No free full text.

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