Validation of the Fear of Sleep Inventory (FOSI) in an urban young adult African American sample

Unlocking Population-Specific Treatments to Render Equitable Approaches and Management in Cardiovascular Disease: Development of a Situation-Specific Theory for African American Emerging Adults

BACKGROUND

Emerging adulthood (18-25 years old) is a distinct developmental period in which multiple life transitions pose barriers to engaging in healthy lifestyle behaviors that reduce cardiovascular disease risk. There is limited theory-based research on African American emerging adults.

OBJECTIVE

This article introduces a synthesized empirically testable situation-specific theory for cardiovascular disease prevention in African American emerging adults.

METHODOLOGY

Im and Meleis' integrative approach was used to develop the situation-specific theory.

RESULTS

Unlocking Population-Specific Treatments to Render Equitable Approach and Management in Cardiovascular Disease is a situation-specific theory developed based on theoretical and empirical evidence and theorists' research and clinical practice experiences.

DISCUSSION

African American emerging adults have multifaceted factors that influence health behaviors and healthcare needs. Unlocking Population-Specific Treatments to Render Equitable Approaches and Management in Cardiovascular Disease has the potential to inform theory-guided clinical practice and nursing research. Recommendations for integration in nursing practice, research, and policy advocacy are presented. Further critique and testing of the theory are required.

A pilot randomised control study to investigate the effect of the South African Adolescence Group Sleep Intervention (SAASI) on adolescent sleep and PTSD

Background: Trauma exposure prevalence and consequent post-traumatic stress disorder among South African adolescents are significant. Sleep disturbances are among the most frequently reported difficulties faced by those dealing with PTSD. The current study examined the feasibility and preliminary efficacy of the South African Adolescence Group Sleep Intervention on PTSD symptom severity and sleep disturbance.Method: Sixty-one adolescents with PTSD diagnoses and sleep disturbance were randomly assigned (1:1) to one individual and four group sessions of a sleep intervention (SAASI) or a control group. Participants completed the Child PTSD symptom scale for DSM5 (CPSS-5) and the Pittsburgh Sleep Quality Index (PSQI) among other sleep and psychiatric measures. The trial was registered on the Pan African Trial Registry (PACTR202208559723690).Results: There was a significant but similar decrease in PSQI scores in both groups over time indicating no overall intervention effect (Wald test = -2.18, p = .029), mean slope = -0.2 (95% CI: -0.37 to -0.02) (p = .583). On the CPSS-5, interaction between groups was also not significant (p = .291). Despite this overall finding, the mean difference in CPSS-SR-5 scores increased over time, with the difference between groups post-treatment -9.10 (95%CI: -18.00 to -0.21), p = .045 and the 1-month follow-up contrast - 11.22 (95%CI: -22.43 to -0.03), p = .049 suggesting that PTSD symptom severity decreased more in the intervention group than the control group. The dropout rate was higher than expected for both the intervention (n = 10; 32%) and control (n = 8; 26.7%) groups. Dropout were mostly school commitments or travel related.Conclusions: Early findings suggest a trend towards dual improvement in sleep quality and PTSD symptom severity in adolescents with a sleep disturbance and PTSD receiving a group sleep intervention (SAASI). Further investigation in a properly powered RCT with detailed retention planning is indicated.

Associations between fears related to safety during sleep and self-reported sleep in men and women living in a low-socioeconomic status setting

South Africans living in low socioeconomic areas have self-reported unusually long sleep durations (approximately 9-10 h). One hypothesis is that these long durations may be a compensatory response to poor sleep quality as a result of stressful environments. This study aimed to investigate whether fear of not being safe during sleep is associated with markers of sleep quality or duration in men and women. South Africans (n = 411, 25-50 y, 57% women) of African-origin living in an urban township, characterised by high crime and poverty rates, participated in this study. Participants are part of a larger longitudinal cohort study: Modelling the Epidemiologic Transition Study (METS)-Microbiome. Customised questions were used to assess the presence or absence of fears related to feeling safe during sleep, and the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index were used to assess daytime sleepiness, sleep quality and insomnia symptom severity respectively. Adjusted logistic regression models indicated that participants who reported fears related to safety during sleep were more likely to report poor sleep quality (PSQI > 5) compared to participants not reporting such fears and that this relationship was stronger among men than women. This is one of the first studies outside American or European populations to suggest that poor quality sleep is associated with fear of personal safety in low-SES South African adults.

Fear of sleep in people with epilepsy

More than one third of people with epilepsy (PWE) report experiencing insomnia. This is highly concerning given that sleep loss both triggers and exacerbates seizures. It is therefore paramount that we understand the underlying mechanisms of insomnia in PWE. Nevertheless, research in this area remains limited, with little understanding of the emerging or maintaining factors of insomnia in PWE. Therefore, the current study sought to explore fear of sleep as a novel explanation for the increased rate of insomnia in PWE, and whether fear of sleep was related to post-seizure trauma. We recruited 184 PWE and 197 healthy controls via social media and collected data using a series of online questionnaires. We found that fear of sleep did not significantly differ between the epilepsy and control group. In the epilepsy group, fear of sleep seemed to be largely driven by trauma, especially post-seizure trauma but also non-seizure related trauma, along with anxiety and higher seizure frequency. Fear of sleep in the control group was also largely driven by trauma, but also anxiety and depression. Finally, we found more severe and prevalent insomnia in PWE relative to controls, and in both groups, fear of sleep was the most significant contributor to insomnia. Our novel findings carry important clinical implications. First, they point to the central role of trauma in fear of sleep not only in PWE but also in the general population. Our findings also indicate that fear of sleep is an important maintaining factor of insomnia. Ultimately, these results suggest that all individuals with insomnia may benefit from insomnia interventions targeted at trauma, depression, anxiety, and fear of sleep. PWE are likely to benefit from additional treatment components for seizure-related trauma and seizure management. To better understand the reliability and generalisability of our novel findings, future research should further assess fear of sleep and its role in maintaining insomnia in the epilepsy population.

Fear of sleep and sleep quality mediate the relationship between trauma exposure and suicide attempt in adolescents

Prior work has established bivariate associations between suicidal thoughts and behaviors, trauma exposure and sleep disturbance broadly. Specifically, this study tested whether fear of sleep and sleep quality mediated the association between trauma exposure and suicide attempt. Participants (N = 100) were adolescents admitted to an inpatient psychiatric program for suicidality. Trauma exposure history was retrieved from admission notes and participants completed self-report surveys assessing sleep quality, fear of sleep and number of suicide attempts within the previous month. Structural equation modelling was used to investigate the relationships between childhood trauma, fear of sleep, sleep quality, and suicide attempt. Path analysis was used to investigate the indirect effects from trauma exposure to suicide attempt through fear of sleep, and sleep quality. Path analysis revealed a significant indirect effect from trauma exposure to suicide attempt through fear of sleep and sleep quality. Our findings suggest that a significant portion of the association between trauma exposure and suicide attempts in adolescence may be explained by the negative impact of trauma exposure on sleep. Fear of sleep may increase the risk of a suicide attempt by negatively impacting sleep quality. Future studies should investigate whether interventions targeting sleep and fear of sleep reduce the association between trauma and suicide attempt.

Interaction of Insomnia and Somatization with Post-Traumatic Stress Disorder in Pregnant Women During the COVID-19 Pandemic

INTRODUCTION

Post-traumatic stress disorder (PTSD) has an adverse impact on the emotional health of prenatal maternal women and their offspring. During the Coronavirus Disease 2019 (COVID-19) pandemic, pregnant women are vulnerable to traumatic events and are prone to PTSD symptoms. The aim of the study was to explore the predictive effects of insomnia and somatization on PTSD in pregnant women by utilizing generalized additive model (GAM).

MATERIALS AND METHODS

A total of 1638 pregnant women from three local cities in China underwent online survey on sleep quality, somatization, and PTSD symptoms tested by the Insomnia Severity Index (ISI), the subscale somatization of Symptom Checklist-90 (SCL-90-S) and the Checklist for DSM-5 (PCL-5), respectively.

RESULTS

Insomnia was positively correlated with PTSD symptoms in pregnant women (p = 1.79×10^-5). Interestingly, insomnia and somatization showed a complex non-primary linear interaction in predicting PTSD (p = 2.00×10^-16).

CONCLUSION

Our results suggest that insomnia is a prominent predictor of PTSD symptoms in pregnant women in the context of public emergencies. In addition, the effects of insomnia and somatization on PTSD symptoms are characterized by complex non-primary linear relationships.

Fear of sleep and trauma-induced insomnia: A review and conceptual model

Trauma-induced insomnia is a symptom of posttraumatic stress disorder (PTSD), and is reported to be particularly distressing and often persists even after remission of the core symptoms of PTSD. Recently, it has been suggested that fear of sleep plays an important role in the development and maintenance of trauma-induced insomnia. The aim of this review is to propose a conceptual model of fear of sleep as a maintaining factor of trauma-induced insomnia. After a brief overview of the role of sleep in PTSD, the concept of fear of sleep is introduced. Theoretical considerations and empirical findings on the role of fear of sleep for trauma-induced insomnia in the context of PTSD are summarized and integrated. Specifically, links between PTSD symptoms and fear of sleep are presented, as well as possible consequences of fear of sleep leading to trauma-induced insomnia. Finally, we highlight methodological issues, identify areas for future research, and discuss potential clinical implications.

Pre-Sleep Arousal and Fear of Sleep in Trauma-Related Sleep Disturbances: A Cluster-Analytic Approach

Background

Trauma-related sleep disturbances constitute critical symptoms of posttraumatic stress disorder (PTSD), but sleep symptoms often reside even after successful trauma-focused psychotherapy. Therefore, currently unattended factors - like fear of sleep (FoS) - might play a crucial role in the development and maintenance of residual sleep disturbances. However, it is unclear whether trauma-exposed individuals exhibit different symptomatic profiles of sleep disturbances that could inform individualized therapeutic approaches and eventually enhance treatment efficacy.

Method

In a large online study, a two-step cluster analysis and a hierarchical cluster analysis using Ward's method were performed to explore subgroups among trauma-exposed individuals (N = 471) in terms of FoS, different aspects of trauma-related sleep disturbances (e.g., insomnia symptoms, nightmares, arousal), and PTSD symptoms. These variables were compared between resulting clusters using ANOVAs and Scheffé's post-hoc tests.

Results

The hierarchical cluster analysis supported 3- and 4-cluster solutions. The 3-cluster solution consisted of one "healthy" (n = 199), one "subclinical" (n = 223), and one "clinical" (n = 49) cluster, with overall low, medium, and high symptomatology on all used variables. In the 4-cluster solution, the clinical cluster was further divided into two subgroups (n = 38, n = 11), where one cluster was specifically characterized by elevated somatic pre-sleep arousal and high levels of FoS.

Conclusions

A subgroup of trauma-exposed individuals with PTSD and sleep disturbances suffers from increased pre-sleep arousal and FoS, which has been suggested as one possible explanation for residual sleep disturbances. In these patients, FoS might be a relevant treatment target.

Adolescent Nocturnal Fears: a psychometric evaluation of the fear of sleep inventory (FoSI)

Objective: Nocturnal fears are associated with trauma-related sleep disturbance in adults, yet research is limited addressing this relationship in adolescents. This study evaluated the validity of the Fear of Sleep Inventory (FoSI) as a measure of nocturnal fears broadly and in relation to trauma exposure in adolescents. Participants: Students ages 14-18 from two urban school-based health centers were the participants. Methods: De-identified clinical data were utilized from a mental health screening battery. Two exploratory factor analyses (EFA) were conducted using the full 23-item FoSI and the 13-item short form. Cronbach's α and Pearson correlation coefficients were employed to examine the convergent and divergent validity of the total scores and the factors derived from the EFA with Insomnia Severity, probable PTSD, and parental monitoring respectively. Results: The 23-item FoSI showed high internal consistency (α = .84); however, EFA yielded an unclear factor structure. Further analysis indicated that an 11-item FoSI yielded a clear 2-factor structure with subscales conceptualized as (a) Fear of Sleep and (b) Vigilant Behavior. Conclusions: The FoSI-11 demonstrates promise as a measure of nocturnal fears in adolescents and can help reveal distinctions between trauma-related nocturnal fears and nocturnal fears associated with psychological or environmental factors. It can be utilized as a screener to highlight adolescent nocturnal fears in large group settings, while also identifying individuals in need of further assessment of trauma exposure. Future studies should include the FoSI-11 to provide a more thorough examination of the role of adolescent nocturnal fears in the relationship between trauma and sleep disturbance.

Neighborhood stress and autonomic nervous system activity during sleep

Study Objectives

Stressful neighborhood environments are known to adversely affect health and contribute to health disparities but underlying mechanisms are not well understood. Healthy sleep can provide a respite from sustained sympathetic nervous system (SNS) activity. Our objective was to evaluate relationships between neighborhood stress and nocturnal and daytime SNS and parasympathetic nervous system (PNS) activity.

Methods

Eighty-five urban-residing African Americans (56.5% female; mean age of 23.0) participated. Evaluation included surveys of neighborhood stress and sleep-related vigilance, and continuous electrocardiogram (ECG) and actigraphic recording in participants' homes from which heart rate variability (HRV) analysis for low frequency/high frequency (LF/HF) ratio and normalized high frequency (nHF), as indicators of SNS and PNS activity, respectively, and total sleep time (TST), and wake after sleep onset were derived.

Results

All significant relationships with HRV measures were from the sleep period. Neighborhood disorder correlated negatively with nHF (r = -.24, p = .035). There were also significant correlations of HRV indices with sleep duration and sleep fears. Among females, LF/HF correlated with exposure to violence, r = .39, p = .008, and nHF with census tract rates for violent crime (r = -.35, p = .035). In a stepwise regression, TST accounted for the variance contributed by violent crime to nHF in the female participants.

Conclusions

Further investigation of relationships between neighborhood environments and SNS/PNS balance during sleep and their consequences, and strategies for mitigating such effects would have implications for health disparities.

Cognitive Behavioral Therapy for Insomnia Reduces Fear of Sleep in Individuals With Posttraumatic Stress Disorder

STUDY OBJECTIVES

Our study aims were to examine (1) the association between fear of sleep and posttraumatic stress disorder (PTSD) symptoms, (2) the association between fear of sleep and subjective and objective insomnia symptoms and disruptive behaviors during sleep, and (3) whether fear of sleep decreases following cognitive behavioral therapy for insomnia (CBT-I).

METHODS

Forty-five adults with PTSD and insomnia participated in the study. Fear of sleep was assessed using the Fear of Sleep Inventory; PTSD symptoms were assessed using the Clinician Administered PTSD Scale; and sleep disturbance symptoms were assessed using the Insomnia Severity Index, polysomnography, sleep diaries, and the Pittsburgh Sleep Quality Index Addendum for PTSD. Participants were randomly assigned to 8 weeks of CBT-I (n = 29) or a waitlist control condition (n = 16).

RESULTS

Greater fear of sleep was associated with greater PTSD symptom severity, greater nightmare frequency, and greater hypervigilance intensity. Greater fear of sleep was associated with decreased wake after sleep onset (WASO), reduced total sleep time, and greater disruptive nocturnal behaviors. Following CBT-I, there was a significant reduction in fear of sleep compared to the waitlist condition. These improvements persisted 6 months later.

CONCLUSIONS

Fear of sleep was related to sleep disturbances specific to trauma rather than "classic" insomnia symptoms. Unexpectedly, greater fear of sleep was associated with reduced WASO. These results may be related to having a truncated sleep period and thus more consolidated sleep. Fear of sleep deceased following CBT-I despite not being a permissible target for this research protocol and not being related to insomnia symptoms.

CLINICAL TRIAL REGISTRATION

Registry: CinicalTrials.gov; Name: Treating People with Post-traumatic Stress Disorder with Cognitive Behavioral Therapy for Insomnia; Identifier: NCT00881647; URL: https://clinicaltrials.gov/ct2/show/NCT00881647.

Why did adolescents have sleep problems after earthquakes? Understanding the role of traumatic exposure, fear, and PTSD

To examine the relationships between trauma exposure, fear, post-traumatic stress disorder, and sleep problems in adolescents, 746 adolescent survivors of the 2008 Wenchuan earthquake in China were assessed at 1 year (T1) and 1.5 years (T2) after the earthquake using a trauma exposure questionnaire, a fear questionnaire, a child posttraumatic stress disorder symptom scale, and a subscale on child sleep problems. The results showed that T1 trauma exposure were not directly associated with sleep problems at T1 and T2, but played a positive role in sleep problems at both T1 and T2 indirectly through T1 posttraumatic stress disorder and T1 fear. T1 trauma exposure was also positively and indirectly associated with T2 sleep problems through T1 posttraumatic stress disorder via T1 sleep problems, or through T1 fear via the path from T1 posttraumatic stress disorder to T1 sleep problems. These findings indicated that fear and posttraumatic stress disorder 1 year after the earthquake played a mediating role in the relationship between trauma exposure at 1 year after the earthquake, and sleep problems at both 1 year and 1.5 years after the earthquake, respectively. In particular, posttraumatic stress disorder also had a multiple mediating effect in the path from trauma exposure to sleep problems via fear. Furthermore, the findings indicated that sleep problems were relatively stable between 1 and 1.5 years after an earthquake.

Insomnia and PTSD one month after wildfires: evidence for an independent role of the "fear of imminent death"

OBJECTIVE

The relationship of insomnia with Post-Traumatic Stress Disorder (PTSD) one month after wildfires and more specifically with the experience of 'fear of imminent death' were investigated.

METHODS

Ninety-two randomly chosen victims of wildfires in the Greek province of Ilia, were assessed through a specifically designed semi-structured psychiatric interview comprising of questionnaires and scales to measure psychopathology, as well as psychosocial and environmental parameters. PTSD was set according to ICD-10 research diagnostic criteria, while insomnia was assessed with the Athens Insomnia Scale (AIS).

RESULTS

The presence of insomnia was identified in 63.0% of the victims. 46.7% of the participants were diagnosed with PTSD in the first post-disaster month, while 51.1% of the total sample experienced 'fear of imminent death'. The majority of sleep complaints were significantly more frequent in subjects with PTSD. Female gender, PTSD, older age, and 'fear of imminent death' were independently associated with insomnia.

CONCLUSIONS

The findings of the present study indicate that the diagnosis of insomnia, as well as, certain specific insomnia complaints were more frequent in female victims of wildfires who have experienced 'fear of imminent death' and have developed PTSD.

The impact of posttraumatic stress disorder versus resilience on nocturnal autonomic nervous system activity as functions of sleep stage and time of sleep

Posttraumatic stress disorder (PTSD) has been associated with sleep disturbances including alterations in sleep stages and recently, elevated nocturnal autonomic nervous system (ANS) arousal (i.e., dominance of the sympathetic nervous system over the parasympathetic nervous system). Data suggest that sleep contributes to the regulation of ANS activity. In our previous ambulatory heart rate variability (HRV) monitoring study, strong relationships between sleep and nocturnal ANS activity in resilient participants (i.e., individuals who had never had PTSD despite exposure to high-impact trauma) were not seen with PTSD. In this study, we examined the impact of PTSD vs. resilience on ANS activity as a function of sleep stage and time of sleep. Participants (age 18-35) with current PTSD (n=38) and resilience (n=33) completed two overnight polysomnography recordings in a lab setting. The second night electrocardiogram was analyzed for frequency domain HRV parameters and heart rate within rapid-eye-movement (REM) and non-REM (NREM) sleep periods. Results indicated that ANS arousal indexed by HRV was greater during REM compared with NREM sleep and that the REM-NREM difference was greater in the PTSD than in the resilient participants. This effect of PTSD was reduced to non-significance when analyses controlled for REM sleep percentage, which was lower with PTSD. Exploratory analyses revealed that the REM-NREM difference in HRV was correlated with REM sleep percentage in resilient participants, but not with PTSD. In contrast with our data from home settings, the present study did not find increased overall nocturnal ANS arousal with PTSD. Analyses did reveal higher heart rate during initial NREM sleep with more rapid decline over the course of NREM sleep with PTSD compared with resilience. Findings suggest that elevated ANS arousal indexed by heart rate with PTSD is specific to the early part of sleep and possible impairment in regulating ANS activity with PTSD related to REM sleep.

Period 3 gene polymorphism and sleep adaptation to stressful urban environments

This study's objective was to investigate the relationship between a variable-number tandem-repeat (VNTR) Period 3 gene (PER3) polymorphism and sleep adaptation to stressful urban environments. Seventy-five (49 female) African American participants (ages 18-35 years) living in neighbourhoods with high rates of violent crime were selected for the study based on converging criteria for good or poor sleep. Categorization of sleep quality was based on the Insomnia Severity Index (ISI), estimates of typical sleep duration and sleep efficiency. Other assessments included the Fear of Sleep Index (FOSI) and City Stress Inventory (CSI). Whole blood DNA was analysed for the 4 and 5 VNTR alleles using polymerase chain reaction (PCR) and restrictive enzyme digestion. Fifty-seven per cent of those who were homo- or heterozygous for the 4-repeat allele were poor sleepers versus 25% of those homozygous for the 5-repeat allele; χ²  = 4.17, P = 0.041. In a logistic regression model with all the variables with significant bivariate relationships to sleep quality group, FOSI was the only significant predictor (χ²  = 5.68, P = 0.017). FOSI scores were higher among those with the 4-repeat allele (t = 2.66, P = 0.013). The PER3 4 and 5 VNTR polymorphisms appear to influence sensitivity to the effects of stressful urban environments on sleep. While FOSI was the only variable associated independently with sleep quality category, the candidate vulnerability allele was also associated with greater 'fear of sleep'.

The Role of Trauma Type in the Risk for Insomnia

OBJECTIVE

Insomnia is common following exposure to trauma and can occur independently or as a feature of posttraumatic stress disorder (PTSD). However, there is limited research identifying risk factors associated with the development of insomnia following exposure to a traumatic event. The goal of this study was to evaluate the role of specific trauma types in the risk for insomnia in a community sample of urban African Americans young adults.

METHODS

A sample of 554 nonclinical, urban, young adult African Americans was recruited for a larger study from which 465 participants were utilized for this study based on their completion of all study self-report measures. Participants were initially screened by phone to determine whether they provisionally met study criteria. Once selected, participants underwent informed consent and then completed a battery of self-report measures that included the Life Events Checklist, the PTSD Checklist, the Insomnia Severity Index, and the Fear of Sleep Index.

RESULTS

Of the seven trauma categories that were endorsed by at least 20% of the sample, results from logistic regression models indicated that sexual trauma, physical assault, accidents, natural disasters, and sudden violent death predicted insomnia independent of sex. However, PTSD symptom severity and nocturnal fears differentially influenced the relationship between trauma type and risk for insomnia.

CONCLUSIONS

Exposure to specific types of trauma increases the odds of insomnia twofold to threefold. Additionally, PTSD symptom severity and nocturnal fears contribute differentially to the relationship between trauma exposure and insomnia suggesting the possibility of multiple underlying pathways.

Longitudinal relationships between posttraumatic stress symptoms and sleep problems in adolescent survivors following the Wenchuan earthquake in China

Purpose

To examine the longitudinal relationships between Posttraumatic Stress Disorder (PTSD) and sleep problems among adolescent survivors in the Wenchuan earthquake, China.

Methods

350 adolescent survivors were randomly selected from several primary and secondary schools in the counties of Wenchuan and Maoxian, the two areas most severely affected by the Wenchuan earthquake. Participants completed Revised Child PTSD Symptom Scale and Sleep Problems Subscale of Self-generated Child Behavior Problems Questionnaire at one year (T1), one-and-a-half years (T2), two years (T3) after the earthquake, respectively.

Results

There was a bidirectional relationship between intrusive symptom clusters of PTSD and sleep problems from T1 to T2, and this relationship became non-significant from T2 to T3. There was a one-way predictive relationship of avoidance symptom clusters of PTSD onto sleep problems from T1 to T3. The hyperarousal symptom clusters of PTSD had effects on sleep problems from T1 to T2 but not from T2 to T3, while sleep problems have no significant effect on hyperarousal symptom clusters of PTSD from T1 to T3. In addition, the relationships between three symptom clusters of PTSD and sleep problems weakened with time change.

Conclusions

From 1 year to 1.5 years after the earthquake, all the three symptom clusters of PTSD could be important predictive factors for the development and maintenance of sleep problems, while sleep problems could only be risk factors for the intrusive symptom clusters of PTSD. From 1.5 years to 2 years, only the avoidance symptom clusters of PTSD were risk factors for sleep problems, and sleep problems had no significant effects on any symptom clusters of PTSD. Overall, the relationship between PTSD and sleep problems weakened with time change.