efficacy of a cognitive-behavioral treatment for insomnia among afghanistan and iraq

141 Pages·2017·0.88 MB·English

VViirrggiinniiaa CCoommmmoonnwweeaalltthh UUnniivveerrssiittyy
VVCCUU SScchhoollaarrss CCoommppaassss
Theses and Dissertations Graduate School
2011
EEFFFFIICCAACCYY OOFF AA CCOOGGNNIITTIIVVEE--BBEEHHAAVVIIOORRAALL TTRREEAATTMMEENNTT FFOORR
IINNSSOOMMNNIIAA AAMMOONNGG AAFFGGHHAANNIISSTTAANN AANNDD IIRRAAQQ ((OOEEFF//OOIIFF))
VVEETTEERRAANNSS WWIITTHH PPTTSSDD
Margolies Skye Ochsner
Virginia Commonwealth University
Follow this and additional works at: https://scholarscompass.vcu.edu/etd
Part of the Clinical Psychology Commons

© The Author
DDoowwnnllooaaddeedd ffrroomm
https://scholarscompass.vcu.edu/etd/2608
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 [email protected].
© 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.……………………………………………………………………………...……1

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…………………………………………………………...…………11
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………………………………………………...……………...31
Methods……………………………………………………………………………….……...32
Objectives of Proposed Study………………………………………………………..32
Study Site……………………………………………………………………….........33
Experimental Overview……………………………………………………………...33
Participants…………………………………………………………………………..34
Inclusion Criteria…………………………………………………………….34
Exclusion Criteria……………………………………………………………35
Study Procedures……………………………………………………………….........35
Baseline Assessment………………………………………………….……...35
Measures at Baseline…………………………………………………………36
vi
Sleep Diary…………………………………………………………...36
Actigraphy……………………………………………………………36
PTSD Symptom Scale- Self Report………………………………….37
Pittsburgh Sleep Quality Index (PSQI)………………………..……..37
Pittsburgh Sleep Quality Index Addendum for PTSD (PSQI-A)…....38
Insomnia Severity Index (ISI)…….……………………………...…..38
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…………………………………………………………………...……...40
Cognitive Behavioral Therapy for Insomnia with Imagery Rehearsal
Therapy………………………………………………………………….…...40
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……………………………………………………………………...…44
Hypothesis #1……………………………………………………………..…45
Hypothesis #2………………………………………………………………..46
Hypothesis #3………………………………………………………………...46
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 #1………………………………………………………………………...52
Sleep Diary Variables………………………………………………………..53
Sleep Questionnaires…………………………………………………...…….56
Hypothesis #2……………………………………………………………………..…60
PTSD Severity………………………………………………………….........60
Mood Symptoms and Daytime Functioning…………………………………64
Hypothesis # 3………………………………………………………………………..68
Follow-up Analyses…………………………………………………………….........68
Sleep Diary Variables……………………………………………………..…69
Sleep Questionnaires…………………………………………………………71
PTSD Severity………………………………………………………….........72
Mood Symptoms and Daytime Functioning…………………………..……..72
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……………..…………..83
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……………………………………………………………………………….....103
Appendix A…………………………………………………………………………103
Appendix B………………………………………………………………………....105
Appendix C…………………………………………………………………………106
Appendix D…………………………………………………………………………107
Appendix E………………………………………………………………………....109
Appendix F…………………………………………………………………………110
Appendix G…………………………………………………………………………115
Appendix H…………………………………………………………………………116
Appendix I….………………………………………………………………………117
Appendix J….………………………………………………………………………120
Vita……………..…………………………………………………………………………..126