Sleep Disturbance in Posttraumatic Stress Disorder: Epiphenomenon or Causal Factor?

Pharmacotherapy for sleep disturbances in post-traumatic stress disorder (PTSD): A network meta-analysis

BACKGROUND

Sleep disturbances are an important symptom dimension of post-traumatic-stress-disorder (PTSD). There is no meta-analytic evidence examining the effects of all types of pharmacotherapy on sleep outcomes among patients with PTSD.

METHODS

Medline/Embase/PsychInfo/CENTRAL/clinicaltrials.gov/ICTRP, reference lists of published reviews and all included studies were searched for Randomised Controlled Trials (RCTs) examining any pharmacotherapy vs. placebo or any other drug among patients with PTSD.

PRIMARY OUTCOMES

total sleep time, nightmares, sleep quality.

SECONDARY OUTCOMES

sleep onset latency, number of nocturnal awakenings, time spent awake following sleep onset, dropouts due to sleep-related adverse-effects, insomnia/somnolence/vivid-dreams as adverse-effects. Pairwise and network meta-analyses were performed.

RESULTS

99 RCTs with 10,481 participants were included. Prazosin may be the most effective treatment for insomnia (SMD = -0.88, 95%CI = [-1.22;-0.54], nightmares (SMD = -0.44, 95%CI = [-0.84;-0.04]) and poor sleep quality (SMD = -0.55, 95%CI = [-1.01;-0.10]). Evidence is scarce and indicates lack of efficacy for SSRIs, Mirtazapine, z-drugs and benzodiazepines, which are widely used in daily practice. Risperidone and Quetiapine carry a high risk of causing somnolence without having a clear therapeutic benefit. Hydroxyzine, Trazodone, Nabilone, Paroxetine and MDMA-assisted psychotherapy may be promising options, but more research is needed.

CONCLUSIONS

Underpowered individual comparisons and very-low to moderate confidence in effect estimates hinder the generalisability of the results. More RCTs, specifically reporting on sleep-related outcomes, are urgently needed.

The mediating effect of sleep quality on exposure to community violence and posttraumatic stress symptoms in the United States

Objectives

The role of sleep quality is not yet fully understood in the context of posttraumatic stress disorder (PTSD) following exposure to community violence. Thus, the primary aim of this study is to examine the mediating effect of sleep quality in the relationship between community violence exposure and posttraumatic stress symptoms.

Methods

Utilizing a cross-sectional survey administered to an online opt-in panel of adults in the United States in 2023 (age ≥ 18 years) (N = 342), respondents reported on their exposure to community violence, sleep quality, and posttraumatic stress symptoms. Covariate-adjusted regressions were used to test these relationships.

Results

Directly experiencing community violence was associated with poorer sleep quality (β = 0.11, 95 % CI [0.02, 0.20], p = 0.022) and posttraumatic stress symptoms (β = 0.33, 95 % CI [0.17, 0.48], p = < 0.001), and poorer sleep quality predicted greater posttraumatic stress symptoms (β = 0.74, 95 % CI [0.58, 0.91], p = 0<.001). Further, sleep quality was a partial mediator (β = 0.24, 95 % CI [0.04, 0.50], p = 0.028), accounting for 24 % of the relationship.

Conclusions

Findings from this study help deepen understanding of the processes that contribute to the development of PTSD and provide insights into possible interventions, including treatment for sleep problems in the aftermath of violence exposure as a means for lessening the mental health burdens of community violence.

Longitudinal Association Between Posttraumatic Stress Symptoms and Depression Symptoms Among Chinese Adolescents During COVID-19: Evidence from Network Perspective

Although there are an increasing number of studies that have explored the mental health consequences of COVID-19 focusing on revealing risk factors, the longitudinal research examining the potential mechanism of the co-occurrence of posttraumatic stress symptoms (PTSS) and depression symptoms among adolescents were scarce. The present study identified the important comorbidity symptoms and explored longitudinal relationship of PTSS and depression symptoms from the network perspective. A two-wave investigation (4 months interval; T1 and T2) was conducted with a sample of 1225 Chinese adolescents. Cross-sectional network and cross-lagged panel network (CLPN) analyses were adopted. Results showed that comorbidity symptoms consisted of both overlapping and non-overlapping symptoms, including "Future foreshortening" at T1 and T2 from PTSS, and "Hard to get started" at T1 and "Not sleep well" at T2 from depression symptoms. Strong longitudinal pathways appeared from all PTSS to depression symptoms, among which the pathway from "Difficulty concentrating" to "Hard to get started" was the strongest. These findings suggest that the possible comorbidity between PTSS and depression symptoms is caused by their independent and related structures, and their longitudinal association. Clinical intervention for these symptoms may alleviate adolescents' psychological problems in the aftermath of traumatic events.

The sleep response to stress: how sleep reactivity can help us prevent insomnia and promote resilience to trauma

Sleep reactivity is a predisposition to sleep disturbance during environmental perturbations, pharmacological challenges, or stressful life events. Consequently, individuals with highly reactive sleep systems are prone to insomnia disorder after a stressor, engendering risk of psychopathology and potentially impeding recovery from traumatic stress. Thus, there is tremendous value in ameliorating sleep reactivity to foster a sleep system that is robust to stress exposure, ultimately preventing insomnia and its downstream consequences. We reviewed prospective evidence for sleep reactivity as a predisposition to insomnia since our last review on the topic in 2017. We also reviewed studies investigating pre-trauma sleep reactivity as a predictor of adverse post-traumatic sequelae, and clinical trials that reported the effect of behavioural treatments for insomnia on mitigating sleep reactivity. Most studies measured sleep reactivity via self-report using the Ford Insomnia Response to Stress Test (FIRST), demonstrating high scores on this scale reliably indicate a sleep system with a lower capacity to tolerate stress. Nascent evidence suggests elevated sleep reactivity prior to trauma increases the risk of negative posttraumatic outcomes, namely acute stress disorder, depression, and post-traumatic stress disorder. Lastly, sleep reactivity appears most responsive to behavioural insomnia interventions when delivered early during the acute phase of insomnia. Overall, the literature strongly supports sleep reactivity as a premorbid vulnerability to incident acute insomnia disorder when faced with an array of biopsychosocial stressors. The FIRST identifies individuals at risk of insomnia a priori, thereby guiding early interventions toward this vulnerable population to prevent insomnia and promote resilience to adversity.

From childhood adversity to latent stress vulnerability in adulthood: the mediating roles of sleep disturbances and HPA axis dysfunction

Childhood adversity is a prominent predisposing risk factor for latent stress vulnerability, expressed as an elevated likelihood of developing stress-related psychopathology upon subsequent exposure to trauma in adulthood. Sleep disturbances have emerged as one of the most pronounced maladaptive behavioral outcomes of childhood adversity and are also a highly prevalent core feature of stress-related psychopathology, including post-traumatic stress disorder (PTSD). After reviewing the extensive literature supporting these claims, the current review addresses the notion that childhood adversity-induced sleep disturbances may play a causal role in elevating individuals' stress vulnerability in adulthood. Corroborating this, sleep disturbances that predate adult trauma exposure have been associated with an increased likelihood of developing stress-related psychopathology post-exposure. Furthermore, novel empirical evidence suggests that sleep disturbances, including irregularity of the sleep-wake cycle, mediate the link between childhood adversity and stress vulnerability in adulthood. We also discuss cognitive and behavioral mechanisms through which such a cascade may evolve, highlighting the putative role of impaired memory consolidation and fear extinction. Next, we present evidence to support the contribution of the hypothalamic-pituitary-adrenal (HPA) axis to these associations, stemming from its critical role in stress and sleep regulatory pathways. Childhood adversity may yield bi-directional effects within the HPA stress and sleep axes in which sleep disturbances and HPA axis dysfunction reinforce each other, leading to elevated stress vulnerability. To conclude, we postulate a conceptual path model from childhood adversity to latent stress vulnerability in adulthood and discuss the potential clinical implications of these notions, while highlighting directions for future research.

Posttraumatic stress disorder and depression after the 2018 Strasbourg Christmas Market terrorist attack: a comparison of exposed and non-exposed police personnel

Background: Police personnel are among the first responders exposed to terrorist attacks, raising in number in the late decades. Due to their profession, they are also exposed to repetitive violence, increasing their vulnerability to PTSD and depression.Objective: Our study aims at comparing the prevalence of PTSD and depression, and the risk factors associated with these conditions among directly and indirectly exposed versus non-exposed police personnel during the Strasbourg Christmas Market terrorist attack.Method: Three months after the attack, participants completed a survey assessing their sociodemographic characteristics, occupational data, degree of exposure, sleep debt around the event, event centrality (CES), and three mental health conditions: PTSD (PCL-5), depression (PHQ-9), and suicide risk (yes/no questions).Results: A total of 475 police personnel responded to the questionnaire: 263 were exposed to the attack (182 of them directly) and 212 were non-exposed. Among directly exposed participants, the prevalences of partial and complete PTSD were 12.6 and 6.6%, and the prevalence of moderate-to-severe depression was 11.5%. Multivariate analysis revealed that direct exposure was associated with a higher risk of PTSD (OR = 2.98 [1.10-8.12], p = .03). Direct exposure was not associated with a higher risk of depression (OR = 0.40 [0.10-1.10], p = .08). A significant sleep debt after the event was not associated with a higher risk of later PTSD (OR = 2.18 [0.81-5.91], p = .13) but was associated with depression (OR = 7.92 [2.40-26.5], p < .001). A higher event centrality was associated with both PTSD and depression (p < .001).Conclusions: Police personnel directly exposed to the Strasbourg Christmas Market terrorist attack were at higher risk of PTSD but not depression. Efforts to prevent and treat PTSD should focus on directly exposed police personnel. However, general mental health should be monitored for every personnel member.

Longitudinal associations between PTSD and sleep disturbances among World Trade Center responders

OBJECTIVE/BACKGROUND

Post-traumatic stress disorder (PTSD) is characterized by substantial disruptions in sleep quality, continuity, and depth. Sleep problems also may exacerbate PTSD symptom severity. Understanding how PTSD and sleep may reinforce one another is critical for informing effective treatments.

PATIENTS/METHODS

In a sample of 452 World Trade Center 9/11 responders (mean age = 55.22, 89.4% male, 66.1% current or former police), we examined concurrent and cross-lagged associations between PTSD symptom severity, insomnia symptoms, nightmares, and sleep quality at 3 time points ∼1 year apart. Data were analyzed using random intercept cross-lagged panel models.

RESULTS

PTSD symptom severity and sleep variables were relatively stable across time (intraclass correlation coefficients: 0.63 to 0.84). Individuals with more insomnia symptoms, more nightmares, and poorer sleep quality had greater PTSD symptom severity, on average. Within-person results revealed that greater insomnia symptoms and nightmares at Time 1 were concurrently associated with greater PTSD symptoms at Time 1. Insomnia symptoms were also concurrently associated with PTSD symptoms at Times 2 and 3, respectively. Cross-lagged and autoregressive results revealed that PTSD symptoms and nightmares predicted nightmares at the next timepoint.

CONCLUSIONS

Overall, results suggest PTSD and sleep problems may be linked at the same point in time but may not always influence each other longitudinally. Further, individuals who experience more sleep disturbances on average may suffer from more debilitating PTSD. Evidence-based treatments for PTSD may consider incorporating treatment of underlying sleep disturbances and nightmares.

Association between the experience of sexual violence and insomnia in a national sample of French adults

PURPOSEL

The experience of sexual violence has been associated with sleeping disorders; however, few studies have examined this association using a large sample of the general population. This study investigates whether lifetime experience of sexual violence and childhood experience of sexual violence are associated with insomnia.

METHODS

Our study is based on data from the 2017 French Health Barometer, a general population phone cross-sectional survey, which included 25 319 adults aged 18-75 years in 2017. Questions regarding sleep quality were asked to 12 560 participants, and insomnia was defined according to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). We conducted adjusted Log-binomial regressions to examine the association between the experience of sexual violence and insomnia by calculating adjusted Prevalence Ratios (PRa; 95% CI).

RESULTS

The weighted prevalence of insomnia was 13.5%, with women more affected than men (17.9% vs 9.6%). The prevalence of lifetime experience of sexual violence was around 3 times higher among those who suffer from insomnia (12.3%) compared to those who do not (4.5%). The adjusted associations between lifetime experience of sexual violence and insomnia, as well as between childhood experience of sexual violence and insomnia were both statistically significant (PRa = 1.79; 95% CI: 1.59-2.02; and PRa = 1.42; 95% CI: 1.23-1.64 respectively).

CONCLUSIONS

Sexual violence could explain the substantial sex-difference in insomnia. Our findings reiterate the importance of systematically screening for sexual violence among patients suffering from sleep disorders to propose adequate trauma-informed interventions.

Sleep disturbance during COVID-19: Correlates and predictive ability for mental health symptomatology in a Canadian online sample

BACKGROUND

Sleep disturbance is associated with mental health symptomatology, but this impact is understudied during COVID-19. The aims of this study are to: 1) examine correlates of sleep disturbance, and 2) examine the longitudinal relationship between sleep disturbance and mental health symptoms 6 months later, during the pandemic.

METHODS

Data were analyzed from COVID-19 Survey Canada conducted between May 2020 (T1) and November 2021 (T2) (n = 489). We examined COVID-related baseline correlates of sleep disturbance at T1, and used multivariable regressions to examine the relationship between T1 sleep disturbance and T2 post-traumatic stress (PTS), health anxiety, generalized anxiety, and depressive symptoms, controlling for baseline mental health symptoms and sociodemographics.

RESULTS

Females, ages 30-49, and those with an annual household income <$50,000, showed a higher prevalence of clinically significant sleep disturbance. After adjustment, compared to those without sleep disturbance at baseline, those with sleep disturbance showed a significant increase in PTS symptoms at 6 months (b = 11.80, 95% CI = [8.21-15.38], p < 0.001).

LIMITATIONS

Results are not nationally representative. Data may be subject to response biases due to self-report methods and we are unable to determine causality.

CONCLUSION

Being able to predict adverse mental health implications of sleep disturbance will help clinicians be equipped to target future impacts of the COVID-19 pandemic as well as any future potential pandemics or traumas. This study emphasizes the importance of screening individuals for sleep disturbance.

Does sleep disturbance predicts posttraumatic stress disorder and depression among college students during COVID-19 lockdown? A longitudinal survey

Aim

To examine the cross-sectional and longitudinal associations between self-reported sleep disturbances, posttraumatic stress disorder (PTSD) and depression in a large cohort of Chinese adolescents experiencing the COVID-19 pandemic.

Methods

Participants were 67905 Chinese college students in the two-wave longitudinal web-based survey during early COVID-19 outbreak (Time1, T1: Feb 3rd to 10th, 2020) and initial remission period (Time2, T2: March 24th to April 3rd, 2020). The Youth Self Rating Insomnia Scale (YSIS), 6-Item Impact of Event Scale (IES-6), and 9-Item Patient Heath Questionnaire (PHQ-9) were used to assess adolescents' sleep, PTSD, and depressive symptoms, respectively, at T1 and T2.

Results

Self-reported PTSD and depression prevalence at T1 were 34.6% and 21.6% respectively. While depressive symptoms worsened as the lockdown time increased, while PTSD symptoms decreased. After adjusting for confounding factors, sleep disturbance and sleep deprivation at T1 were significantly associated with increased PTSD and depressive symptoms at T2. Furthermore, sleep disturbance and sleep deprivation also predicted the new onset and persistence of PTSD and depression.

Conclusion

Sleep disturbance predicts the development and persistence of PTSD and depression. Early assessment and treatment of sleep disturbance may be an important strategy for prevention and intervention of PTSD and depression in adolescents after experiencing the special public health emergency.

Acute sleep interventions as an avenue for treatment of trauma-associated disorders

Scientific evidence that acute, posttrauma sleep disturbances (eg, nightmares and insomnia) can contribute significantly to the pathogenesis of trauma-induced disorders is compelling. Sleep disturbances precipitating from trauma are uniquely predictive of daytime posttrauma symptom occurrence and severity, as well as subsequent onset of mental health disorders, including post-traumatic stress disorder. Conversely, adequate sleep during the acute posttrauma period is associated with reduced likelihood of adverse mental health outcomes. These findings, which are broadly consistent with what is known about the role of sleep in the regulation of emotion, suggest that the acute posttrauma period constitutes a "window of opportunity" during which treatment of sleep disturbances may be especially effective for preventing or mitigating progression of aberrant psychophysiological processes. At this point, the weight of the scientific evidence supporting this possibility warrants initiation of clinical trials to confirm the benefits of targeted prophylactic sleep enhancement, and to establish treatment guidelines as appropriate.

CITATION

Swift KM, Thomas CL, Balkin TJ, Lowery-Gionta EG, Matson LM. Acute sleep interventions as an avenue for treatment of trauma-associated disorders. J Clin Sleep Med. 2022;18(9):2291-2312.

Pre-pandemic sleep reactivity prospectively predicts distress during the COVID-19 pandemic: The protective effect of insomnia treatment

The COVID-19 pandemic is a rare stressor that has precipitated an accompanying mental health crisis. Prospective studies traversing the pandemic's onset can elucidate how pre-existing disease vulnerabilities augured risk for later stress-related morbidity. We examined how pre-pandemic sleep reactivity predicted maladaptive stress reactions and depressive symptoms in response to, and during, the pandemic. This study is a secondary analysis of a randomised controlled trial from 2016 to 2017 comparing digital cognitive behavioural therapy for insomnia (dCBT-I) against sleep education (N = 208). Thus, we also assessed whether dCBT-I moderated the association between pre-pandemic sleep reactivity and pandemic-related distress. Pre-pandemic sleep reactivity was measured at baseline using the Ford Insomnia Response to Stress Test. In April 2020, participants were recontacted to report pandemic-related distress (stress reactions and depression). Controlling for the treatment condition and the degree of COVID-19 impact, higher pre-pandemic sleep reactivity predicted more stress reactions (β = 0.13, ± 0.07 SE, p = 0.045) and depression (β = 0.22, ± 0.07 SE, p = 0.001) during the pandemic. Further, the odds of reporting clinically significant stress reactions and depression during the pandemic were over twice as high in those with high pre-pandemic sleep reactivity. Notably, receiving dCBT-I in 2016-2017 mitigated the relationship between pre-pandemic sleep reactivity and later stress reactions (but not depression). Pre-pandemic sleep reactivity predicted psychological distress 3-4 years later during the COVID-19 pandemic, and dCBT-I attenuated its association with stress reactions, specifically. Sleep reactivity may inform prevention and treatment efforts by identifying individuals at risk of impairment following stressful events.

Post-traumatic stress disorder prevalence and sleep quality in fire victims and rescue workers in southern Brazil: a cross-sectional study

OBJECTIVES

This survey was conducted to evaluate the prevalence of post-traumatic stress disorder (PTSD) and the sleep quality in victims and rescue team of the third deadliest nightclub fire in the world.

STUDY DESIGN

A cross-sectional study.

METHODS

Participants were victims and rescue workers exposed to a fire at a nightclub, which occurred in January 2013 in Southern Brazil. The Pittsburgh Sleep Quality Index (PSQI), composed of seven subjective sleep variables (including daytime dysfunction), and PTSD Checklist - Civilian version (PCL-C) were applied to all people who sought medical attention at the local reference center in the first year after the event. Comprehensive information was obtained concerning sociodemographic factors, health status, and sleep complaints.

RESULTS

A total of 370 individuals, 190 victims and 180 rescue workers, were included. Participants were 70% male, with an average age of 29 years. The prevalence of PTSD was 31.9%, ranging from 24.4% for rescue workers to 38.9% for victims. The prevalence of poor sleep quality was 65.9%, ranging from 56.1% for rescue workers to 75.3% for victims. Most of the participants with PTSD (91.5%) had PSQI scores >5 (poor sleepers), against 54.0% of the non-PTSD individuals. All seven PSQI subscores showed significant differences between PTSD and non-PTSD individuals, especially daytime dysfunction. Sex, shift work, previous psychiatric disease, and sleep quality remained associated with PTSD in adjusted models, with a prevalence ratio (95% CI) of 1.76 (1.28-2.43) in females, 1.73 (1.17-2.55) in shift workers, 1.36 (1.03-1.80) in individuals with psychiatric disease history, and 5.42 (2.55-11.52) in poor sleepers.

CONCLUSIONS

The presence of daytime dysfunction increased by at least tenfold the prevalence of PTSD in this sample. Considering that daytime dysfunction was shown to be strongly associated with PTSD, sleep-related issues should be addressed in the assessment of individuals exposed to traumatic events, both victims and rescuers. Factors like shift work and female sex were also associated with PTSD, especially among victims.

Prenatal insomnia and childbirth-related PTSD symptoms: A prospective population-based cohort study

BACKGROUND

Certain populations are at high risk of experiencing a traumatic event and developing post-traumatic stress disorder (PTSD). Yet, primary preventive interventions against PTSD are lacking. It is therefore crucial to identify pre-traumatic risk factors, which could be targeted with such interventions. Insomnia may be a good candidate, but studies on civilians are sparse. Furthermore, the mechanisms at stake in the relationship between pre-traumatic insomnia and PTSD symptoms are unclear.

METHODS

This prospective population-based cohort study (n = 1,610) examined the relationship between insomnia symptoms at 32 weeks of pregnancy and childbirth-related PTSD (CB-PTSD) symptoms at eight weeks postpartum. Postnatal insomnia symptoms, prenatal psychological symptoms (depression, anxiety, PTSD, fear of childbirth), subjective birth experience (SBE) and birth medical severity were included as covariates in the analyses, which were based on a Piecewise Structural Equation Modelling approach.

RESULTS

The relationship between prenatal insomnia and CB-PTSD symptoms was mediated by negative SBE and postnatal insomnia symptoms. All relationships involving insomnia symptoms had small or very small effect sizes.

LIMITATIONS

This study used self-report questionnaires. Postnatal insomnia and CB-PTSD symptoms were concurrently measured.

CONCLUSION

Prenatal insomnia symptoms may impair the ability to cope with a difficult birth experience and contribute to postnatal insomnia, a risk factor for CB-PTSD. Thus, prenatal insomnia symptoms may be a promising target for CB-PTSD primary preventive interventions, although other prenatal psychological symptoms could also be considered. Even beyond the perinatal context, future studies on pre-traumatic insomnia and PTSD should include post-traumatic insomnia as a covariate.

Insomnia Symptoms and Acute Coronary Syndrome-Induced Posttraumatic Stress Symptoms: A Comprehensive Analysis of Cross-sectional and Prospective Associations

BACKGROUND

Acute coronary syndrome (ACS) induces clinically significant posttraumatic stress symptoms (PTSS) in 12% of patients. Subjective sleep problems are a risk factor for the development of PTSS, but this is underexplored in patients with ACS.

PURPOSE

To examine the association of insomnia symptoms with ACS-induced PTSS.

METHODS

In this longitudinal study with 154 patients (all white, 84.4% male, mean age 58.7 years) with a verified ACS, insomnia symptoms were interviewer assessed at hospital admission and at 3 months, using the Jenkins Sleep Scale (JSS)-4. ACS-induced PTSS were assessed with the Clinician-Administered Posttraumatic Stress Disorder Scale 3 months after hospital admission. In multivariable linear models, insomnia symptoms were regressed on PTSS, adjusting for demographics, clinical variables, health behaviors, and psychological data, including cognitive depressive symptoms.

RESULTS

Greater insomnia symptoms at admission (β = .165, p = .034), greater increase in insomnia symptoms from admission to 3 months (β = .233, p = .008), and greater insomnia symptoms at 3 months (β = .239, p = .002) were independently associated with more severe total PTSS at 3 months. Concerning the individual PTSS clusters, both insomnia symptoms at admission (β = .214, p = .007) and at 3 months (β = .213, p = .012) were independently associated with reeexperiencing symptoms. Removing sleep items from PTSS scores and excluding patients on antidepressants in two sensitivity analyses did not substantially change the results.

CONCLUSIONS

Insomnia symptoms could play an important role in the development and severity of ACS-induced PTSS. This relationship seems not simply explained by the fact that sleeping difficulties are inherent to the phenotype of posttraumatic stress disorder.

CLINICAL TRIAL INFORMATION

NCT01781247.

A network analysis investigation of the comorbidity between sleep dysfunction and PTSD symptomatology among Filipino domestic workers in Macao (SAR) China

Posttraumatic stress disorder (PTSD) is highly comorbid with sleep dysfunction. This association was previously explained based on cognitive and emotional dysfunction. The current study extends this literature by investigating the symptom level comorbidity of sleep dysfunction and DSM-5 PTSD utilizing a network approach. Participants were trauma-exposed female Filipino domestic workers (N = 1241). Network analysis was applied to 23 items: 18 items from PCL-5 measuring PTSD (Community 1) and 5 items from PSQI assessing sleep dysfunction (Community 2). The results showed that the symptoms within each community had the strongest correlations. Bridge connections were identified between the sleep dysfunction and PTSD symptom communities. Symptoms with the highest bridge strength were concentration difficulties, recklessness, irritability, and sleep disturbance. This is among the first studies investigating the comorbidity between PTSD and sleep dysfunction from the network approach. Future interventions may be developed that emphasize the bridge symptoms to address comorbidity among trauma exposed migrants.

Mixed-method research protocol: Development and evaluation of a nursing intervention in patients discharged from the intensive care unit

AIM

(a) To understand patients' lived experience at intensive care unit (ICU) discharge and (b) to evaluate the impact of a nursing empowerment intervention (NEI) on patients' anxiety and depression levels at ICU discharge.

DESIGN

A mixed-methods approach will be applied.

METHODS

In the qualitative phase, the hermeneutic phenomenological method will be used. Participants will be patients from three university hospitals who will be selected by purposive sampling. Data will be gathered through in-depth interviews and analysed using content analysis. The qualitative data obtained will be employed to develop the nursing intervention. Subsequently, a multicenter, parallel-group, experimental pre-test/post-test design with a control group will be used to measure the effectiveness of the nursing empowerment intervention in the quantitative phase by means of the Hospital Anxiety and Depression Scale (HADS). Simple random probabilistic sampling will include 172 patients in this phase.

Investigating the link between subjective sleep quality, symptoms of PTSD and level of functioning in a sample of trauma-affected refugees

STUDY OBJECTIVES

To examine whether baseline sleep quality is associated with baseline symptoms of posttraumatic stress disorder (PTSD) and level of functioning, and whether baseline sleep quality and improvement of sleep quality are specific predictors of change in PTSD symptoms and level of functioning.

METHODS

Data were derived from a four-armed randomised controlled superiority trial (N=219 trauma-affected refugees). All four groups received treatment as usual consisting of a 10-12 months bio-psycho-social treatment program with an additional differential treatment component added to each arm. We performed bivariate correlation analyses, multiple linear regression analyses and mediation analyses to examine associations between baseline sleep quality, change in sleep quality and treatment response for PTSD symptoms and level of functioning.

RESULTS

Baseline sleep quality correlated with symptoms of PTSD (r = .33) and level of functioning (r=0.15). Baseline sleep quality, improvement of sleep quality and improvement of general well-being were predictors of treatment response for symptoms of PTSD and level of functioning when controlling for age, gender, and baseline symptoms of PTSD and depression.

CONCLUSIONS

We found that good sleep quality at baseline and improvement of sleep quality were predictors of PTSD treatment response. However, treatment response was more closely associated with improvement in general well-being. The results indicate that the effect of improved sleep quality was partly mediated by a more general mental state improvement. Further research is needed to differentiate if a selected subgroup of patients may profit from sleep enhancing treatment.

Cognitive Processing Therapy for Posttraumatic Stress Disorder Is Associated with Negligible Change in Subjective and Objective Sleep

Background: Patients receiving Cognitive Processing Therapy (CPT), an evidence based therapy for posttraumatic stress disorder (PTSD), report improved sleep quality. However, the majority of studies have examined residual sleep disturbance via self-report surveys or separate items on PTSD measures. This study examined whether CPT delivered to veterans in a VA setting improved sleep indices using state-of-the-art objective and subjective insomnia measures. Participants: Participants were war veterans with a current PTSD diagnosis scheduled to begin outpatient individual or group CPT at two Veteran's Affairs (VA) locations (n = 37). Methods: Sleep symptom severity was assessed using the recommended research consensus insomnia assessment, the consensus daily sleep diary and actigraphy. PTSD symptomatology pre- and post-treatment were assessed using the Clinician Administered PTSD Scale. Results: A small to moderate benefit was observed for the change in PTSD symptoms across treatment (ES_RMC = .43). Effect sizes for changes on daily sleep diary and actigraphy variables after CPT were found to be negligible (Range ES_RMC = - .16 to .17). Sleep indices remained at symptomatic clinical levels post-treatment. Discussion: These findings support previous research demonstrating a need for independent clinical attention to address insomnia either before, during, or after PTSD treatment.

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.

Impact of TBI, PTSD, and Hearing Loss on Tinnitus Progression in a US Marine Cohort

INTRODUCTION

Mild TBI (TBI) is associated with up to a 75.7% incidence of tinnitus, and 33.0% of tinnitus patients at the US Veterans Administration carry a diagnosis of post-traumatic stress syndrome (PTSD). Yet factors contributing to new onset or exacerbation of tinnitus remain unclear.

MATERIALS AND METHODS

Here we measure intermittent and constant tinnitus at two time points to ascertain whether pre-existing or co-occurring traumatic brain injury (TBI), hearing loss, or post-traumatic stress disorder (PTSD) predicts new onset, lack of recovery and/or worsening of tinnitus in 2,600 United States Marines who were assessed before and after a combat deployment.

RESULTS

Ordinal regression revealed that constant tinnitus before deployment was likely to continue after deployment (odds ratio [OR] = 28.62, 95% confidence interval [CI]: 9.84,83.26). Prior intermittent tinnitus increased risk of post-deployment constant tinnitus (OR = 4.95, CI: 2.97,8.27). Likelihood of tinnitus progression increased with partial PTSD (OR = 2.39, CI: 1.50,3.80) and TBI (OR = 1.59, CI: 1.13,2.23), particularly for blast TBI (OR = 2.01, CI: 1.27,3.12) and moderate to severe TBI (OR = 2.57, CI: 1.46,4.51). Tinnitus progression also increased with low frequency hearing loss (OR = 1.94, CI: 1.05,3.59), high frequency loss (OR = 3.01, CI: 1.91,4.76) and loss across both low and high frequency ranges (OR = 5.73, CI: 2.67,12.30).

CONCLUSIONS

Screening for pre-existing or individual symptoms of PTSD, TBI, and hearing loss may allow for more focused treatment programs of comorbid disorders. Identification of those personnel vulnerable to tinnitus or its progression may direct increased acoustic protection for those at risk.

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.

Post traumatic stress symptom variation associated with sleep characteristics

BACKGROUND

Post traumatic stress disorder (PTSD) and sleep problems are highly related. The relationship between nighttime sleep characteristics and next day post traumatic stress symptoms (PTSS) is not well known. This study examined the relationship between the previous night's sleep duration, number of awakenings, sleep quality, trouble falling asleep, and difficulty staying asleep and PTSS the following day.

METHODS

Using an ecological momentary assessment methodology, individuals with probable PTSD (N = 61) reported their nighttime sleep characteristics daily and PTSS four times per day for 15 days. Univariate and multivariate linear mixed models were used to examine the previous night's (within-subjects) and person's mean (between-subjects) associations between sleep characteristics and PTSS.

RESULTS

The previous night's sleep duration (p < .001), sleep quality (p < .001), trouble falling asleep (p < .001), and difficulty staying asleep (p < .001) significantly predicted the next day's PTSS. When examined in a multivariate model including all characteristics simultaneously, previous night's sleep duration (p = .024), trouble falling asleep (p = .019), and difficulty staying asleep (p < .001) continued to predict PTSS, but sleep quality (p = .667) did not. When considering a person's mean, trouble falling asleep (p = .006) and difficulty staying asleep (p = .001) predicted PTSS, but only difficulty staying asleep (p = .018) predicted PTSS in a multivariate model.

CONCLUSIONS

Among individuals with PTSD, the previous night's sleep duration, trouble falling asleep, and difficulty staying asleep predict next day PTSD symptoms. Interventions that facilitate falling and staying asleep and increase time slept may be important for treating PTSD.

Combat exposure, post-traumatic stress symptoms, and health-related behaviors: the role of sleep continuity and duration

STUDY OBJECTIVES

Aggression, substance misuse, and other health risk behaviors are common among combat veterans. We examined whether sleep quality and quantity predict the association between combat exposure, post-traumatic stress symptoms, and adverse health-related behaviors.

METHODS

Soldiers (N = 2420) from a brigade combat team completed surveys assessing combat experiences, and psychological and behavioral health factors, approximately 3 months following deployment to Afghanistan in 2011.

RESULTS

Respondents were 93.5% male; 73% were age 18-29 years old. The response rate was 80% (3076/3832); 94% (2876/3076) of the soldiers who attended the recruitment briefings consented to participate in this research. Complete data were available across the variables used in this study for up to 2420 soldiers. Sleep continuity disturbance accounted for the association of combat exposure with post-traumatic stress symptoms and aggression, alcohol use, and risky behavior. Moreover, for soldiers who reported sleep duration of <6 hr per day, the indirect association of combat exposure and post-traumatic stress on aggression, alcohol use, risky behavior, and opioid use was strongest.

CONCLUSIONS

This study is the first to model sleep problems as a predictor of the association between combat exposure and post-traumatic stress symptoms and frequently reported health-related behavior problems. Sleep disturbance is highly prevalent among Warfighters. While not fully preventable in operational contexts, these problems can be effectively mitigated postdeployment with appropriate policy and intervention resources. Improving the sleep characteristics of combat-exposed soldiers following deployment should reduce subsequent post-traumatic stress and related health compromising behavior, thereby enhancing force readiness.

Sleep, a Governor of Morbidity in PTSD: A Systematic Review of Biological Markers in PTSD-Related Sleep Disturbances

BACKGROUND

Sleep disturbances (SD) are the most impactful and commonly reported symptoms in post-traumatic stress disorder (PTSD). Yet, they are often resistant to primary PTSD therapies. Research has identified two distinct SDs highly prevalent in PTSD; insomnia and nightmares. Those who report SDs prior to a traumatic event are at greater risk for developing PTSD; highlighting that sleep potentially plays a role in PTSD's pathology. To further understand the pathobiological mechanisms that lead to the development of PTSD, it is first imperative to understand the interplay which exists between sleep and PTSD on a biological level. The aim of this systematic review is to determine if biological or physiological markers are related to SD in PTSD.

METHODS

A systematic literature search was conducted on the electronic databases; Medline, Embase, AMED and PsycINFO, using Medical Subject Headings and associated keywords.

RESULTS

Sixteen studies were included in the final analyses. Physiological makers of autonomic function, and biochemical markers of HPA-axis activity; inflammatory processes; and trophic factor regulation were related to the severity of SDs in PTSD.

CONCLUSION

These findings add to the growing literature base supporting a central focus on sleep in research aiming to define the pathophysiological processes which result in PTSD, as well as emphasising the importance of specifically targeting sleep as part of a successful PTSD intervention strategy. Resolving SDs will not only reduce PTSD symptom severity and improve quality of life but will also reduce all-cause mortality, hospital admissions and lifetime healthcare costs for those with PTSD. Limitations of the current literature are discussed, and key recommendations future research must adhere to are made within.

Pre-deployment insomnia is associated with post-deployment post-traumatic stress disorder and suicidal ideation in US Army soldiers

Study Objectives

Insomnia is prevalent among military personnel and may increase risk of mental disorders and suicidal ideation. This study examined associations of pre-deployment insomnia with post-deployment post-traumatic stress disorder (PTSD) and suicidal ideation among US Army soldiers.

Methods

Soldiers from three Brigade Combat Teams completed surveys 1-2 months before deploying to Afghanistan in 2012 (T0), on return from deployment (T1), 3 months later (T2), and 9 months later (T3). Logistic regression was performed to estimate associations of pre-deployment (T0) insomnia with post-deployment (T2 or T3) PTSD and suicidal ideation among respondents who completed surveys at all waves (n = 4645). A hierarchy of models incorporated, increasing controls for pre-deployment risk factors and deployment experiences.

Results

Pre-deployment insomnia was associated with increased risk of post-deployment PTSD (adjusted odds ratio [AOR] = 3.14, 95% confidence interval [CI] = 2.58% to 3.82%, p < .0005) and suicidal ideation (AOR = 2.78, 95% CI = 2.07% to 3.74%, p < .0005) in models adjusting for sociodemographic characteristics and prior deployment history. Adjustment for other pre-deployment risk factors and deployment experiences attenuated these associations; however, insomnia remained significantly associated with post-deployment PTSD (AOR = 1.50, 95% CI = 1.19% to 1.89%, p = .001) and suicidal ideation (AOR = 1.43, 95% CI = 1.04% to 1.95%, p = .027). Subgroup models showed that pre-deployment insomnia was associated with incident PTSD (AOR = 1.55, 95% CI = 1.17% to 2.07%, p = .003) and suicidal ideation (AOR = 1.67, 95% CI = 1.16% to 2.40%, p = .006) among soldiers with no pre-deployment history of these problems.

Conclusions

Pre-deployment insomnia contributed to prediction of post-deployment PTSD and suicidal ideation in Army soldiers, suggesting that detection of insomnia could facilitate targeting of risk mitigation programs. Future studies should investigate whether treatment of insomnia helps prevent PTSD and suicidal ideation among deployed service members.

Posttraumatic Stress Disorder Severity and Insomnia-Related Sleep Disturbances: Longitudinal Associations in a Large, Gender-Balanced Cohort of Combat-Exposed Veterans

Few studies have investigated the range and severity of insomnia-related sleep complaints among veterans with posttraumatic stress disorder (PTSD), and the temporal association between insomnia and PTSD severity has yet to be examined. To examine these associations, a large, gender-balanced cohort of veterans (N = 1,649) of the Iraq and Afghanistan conflicts participated in longitudinal assessments of PTSD and insomnia-related symptoms over a period of 2.5 years following enrollment (range: 2-4 years). Data were obtained from multiple sources, including interviews, self-report assessments, and electronic medical record data. Three-fourths (74.0%) of veterans with PTSD diagnoses at Time 1 (T1) reported insomnia-related sleep difficulties on at least half the nights during the past 30 days, and one-third of participants had received a prescription for a sedative-hypnotic drug in the past year. Veterans without PTSD had fewer sleep problems overall, although the prevalence of sleep problems was high among all study participants. In longitudinal, cross-lagged panel models, the frequency of sleep problems at T1 independently predicted increases in PTSD severity at Time 2 (T2), B = 0.27, p < .001, after controlling for gender and relevant comorbidities. Conversely, T1 PTSD severity was associated with increasing sleep complaints at T2 but to a lesser degree, B = 0.04, p < .001. Moderately high rates of sedative-hypnotic use were seen in veterans with PTSD, with more frequent use in women compared to men (40.4% vs. 35.0%). Sleep complaints were highly prevalent overall and highlight the need for increased clinical focus on this area.

Sleep in posttraumatic stress disorder: A systematic review and meta-analysis of polysomnographic findings

Polysomnographic studies have been performed to examine sleep abnormalities in posttraumatic stress disorder (PTSD), but clear associations between PTSD and sleep disturbances have not been established. A systematic review of the evidence examining the polysomnographic changes in PTSD patients compared with controls was conducted using MEDLINE, EMBASE, All EBM databases, PsycINFO, and CINAHL databases. Meta-analysis was undertaken where possible. The searches identified 34 studies, 31 of which were appropriate for meta-analysis. Pooled results indicated decreased total sleep time, slow wave sleep and sleep efficiency, and increased wake time after sleep onset in PTSD patients compared with healthy controls. PTSD severity was associated with decreased sleep efficiency and slow wave sleep percentage. Rapid eye movement (REM) sleep percentage was significantly decreased in PTSD patients compared with controls in studies including participants with mean age below 30 y, but not in studies with other mean age groups (30-40 y and >40 y). Our study shows that polysomnographic abnormalities are present in PTSD. Sex, age, PTSD severity, type of controls, medication status, adaptation night, polysomnographic scoring rules and study location are several of the demographic, clinical and methodological factors that contribute to heterogeneity between studies.

Comparison of Sleep Patterns in Vietnam Veterans With and Without Posttraumatic Stress Disorder Using Wrist Actigraphy

STUDY OBJECTIVES

Disturbed sleep is a hallmark feature of posttraumatic stress disorder (PTSD). However, few studies have examined sleep objectively in individuals with PTSD compared to trauma-exposed controls. This study used wrist actigraphy to measure and compare sleep patterns in trauma-exposed Australian Vietnam veterans (VV) with and without PTSD.

METHODS

Trauma-exposed Australian VV with and without PTSD were recruited from the PTSD Initiative. VV wore wrist accelerometers over 14 days and completed daily sleep diaries. Sleep parameters were compared between groups including sleep latency (SL), time in bed (TIB), total sleep time (TST), wake after sleep onset (WASO), and movement index (MI). Night-to-night and overall within-individual variability were assessed by root mean squared successive differences and comparison of individual standard deviations. Correlations between sleep diary (self-reported) and wrist actigraphy (objective) variables were also assessed.

RESULTS

A total of 40 male VV (20 with PTSD) participated in the study. We found no difference in sleep patterns determined by wrist actigraphy between groups with the exception of reduced SL in VV with PTSD (3.9 ± 0.9 versus 4.9 ± 1.4 minutes, P < .05). Overall within-individual variability was significantly greater in VV with PTSD for TIB, TST, WASO, and MI. Self-reported and objective TST and WASO were more strongly correlated in VV without PTSD than those with PTSD.

CONCLUSIONS

Although there were no significant differences in sleep parameters, VV with PTSD had increased within-individual overall sleep variability and reduced correlation between self-reported and objective sleep parameters compared to trauma-exposed controls. Further evaluation of extended sleep patterns by actigraphy in VV with PTSD is warranted.

The role of modifiable health-related behaviors in the association between PTSD and respiratory illness

BACKGROUND

Posttraumatic stress disorder (PTSD) increases risk of future respiratory illness. However, mechanisms that underpin the association between these common and debilitating conditions remain unknown. The aim of this study was to identify modifiable, health-related behaviors they may explain the link between PTSD and respiratory problems.

METHODS

World Trade Center responders (N = 452, 89% male, mean age = 55 years) completed baseline PTSD and sleep questionnaires, followed by 2-weeks of daily diaries, actigraphy and ambulatory spirometry to monitor lower respiratory symptoms, pulmonary function, activity levels, stressors, and sleep. Lipid levels were obtained from electronic medical records.

RESULTS

Cross-sectional mediation analyses revealed that the association between PTSD and self-reported respiratory symptoms was explained by poor sleep, low activity, and daily stressors. The association between PTSD symptoms and pulmonary function was explained by insomnia and low activity.

CONCLUSIONS

A range of health-related daily behaviors and experiences, especially sleep disturbances and inactivity, may explain excess respiratory illness morbidity in PTSD. The findings were generally consistent across daily self-report and spirometry measures of respiratory problems. Targeting these behaviors might enhance prevention of and intervention in respiratory problems in traumatized populations.

Dynamic Patterns of Threat-Associated Gene Expression in the Amygdala and Blood

Stress and trauma profoundly influence psychiatric biobehavioral outcomes. The identification of treatment and biomarker targets would be accelerated by a broad understanding of the biological responses to these events. The goal of this study was to determine genes responsive to auditory fear conditioning (FC), a well-characterized amygdala-dependent rodent model of threat-exposure, in the presence or absence of prior stress history, providing insight into the physiological processes underlying response to trauma. RNA-sequencing was performed in blood and amygdala from mice that underwent fear conditioning with (Immo+FC) and without (FC) prior immobilization stress, a paradigm that induces HPA axis, and behavioral stress sensitization. In the amygdala, 607 genes were regulated by FC vs. home-cage (HC) controls, and 516 genes differed in stress-sensitized mice (Immo+FC vs. FC). In the former, we observed an enhancement of specific biological processes involved in learning and synaptic transmission, and in the latter processes associated with cell proliferation and the cellular response to drugs. In the blood of stress-sensitized animals, 468 genes were dynamically regulated when compared to FC, and were enriched for the biological pathways of inflammation and cytokine signaling. This study identified genes and pathways that respond to threat in the amygdala and blood of mice with and without a prior stress history and reveals the impact of stress history on subsequent inflammation. Future studies will be needed to examine the role of these dynamically regulated genes may play in human clinical stress and trauma-related disorders.

Successful use of closed-loop allostatic neurotechnology for post-traumatic stress symptoms in military personnel: self-reported and autonomic improvements

BACKGROUND

Military-related post-traumatic stress (PTS) is associated with numerous symptom clusters and diminished autonomic cardiovascular regulation. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) is a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology that produces real-time translation of dominant brain frequencies into audible tones of variable pitch and timing to support the auto-calibration of neural oscillations. We report clinical, autonomic, and functional effects after the use of HIRREM® for symptoms of military-related PTS.

METHODS

Eighteen service members or recent veterans (15 active-duty, 3 veterans, most from special operations, 1 female), with a mean age of 40.9 (SD = 6.9) years and symptoms of PTS lasting from 1 to 25 years, undertook 19.5 (SD = 1.1) sessions over 12 days. Inventories for symptoms of PTS (Posttraumatic Stress Disorder Checklist - Military version, PCL-M), insomnia (Insomnia Severity Index, ISI), depression (Center for Epidemiologic Studies Depression Scale, CES-D), and anxiety (Generalized Anxiety Disorder 7-item scale, GAD-7) were collected before (Visit 1, V1), immediately after (Visit 2, V2), and at 1 month (Visit 3, V3), 3 (Visit 4, V4), and 6 (Visit 5, V5) months after intervention completion. Other measures only taken at V1 and V2 included blood pressure and heart rate recordings to analyze heart rate variability (HRV) and baroreflex sensitivity (BRS), functional performance (reaction and grip strength) testing, blood and saliva for biomarkers of stress and inflammation, and blood for epigenetic testing. Paired t-tests, Wilcoxon signed-rank tests, and a repeated-measures ANOVA were performed.

RESULTS

Clinically relevant, significant reductions in all symptom scores were observed at V2, with durability through V5. There were significant improvements in multiple measures of HRV and BRS [Standard deviation of the normal beat to normal beat interval (SDNN), root mean square of the successive differences (rMSSD), high frequency (HF), low frequency (LF), and total power, HF alpha, sequence all, and systolic, diastolic and mean arterial pressure] as well as reaction testing. Trends were seen for improved grip strength and a reduction in C-Reactive Protein (CRP), Angiotensin II to Angiotensin 1-7 ratio and Interleukin-10, with no change in DNA n-methylation. There were no dropouts or adverse events reported.

CONCLUSIONS

Service members or veterans showed reductions in symptomatology of PTS, insomnia, depressive mood, and anxiety that were durable through 6 months after the use of a closed-loop allostatic neurotechnology for the auto-calibration of neural oscillations. This study is the first to report increased HRV or BRS after the use of an intervention for service members or veterans with PTS. Ongoing investigations are strongly warranted.

TRIAL REGISTRATION

NCT03230890 , retrospectively registered July 25, 2017.

Sleep Disturbance Mediates the Association of Post-Traumatic Stress Disorder Symptoms and Pain in Patients With Cancer

BACKGROUND

Sleep disturbance is a common complaint of patients with cancer and is well established in both pain conditions and post-traumatic stress disorder (PTSD). An estimated one-third of patients with cancer develop symptoms of PTSD at some point in their treatment. However, few studies have evaluated the contributions of PTSD and sleep disturbance to pain processes in cancer populations. The current study used mediation models to test the hypothesis that sleep disturbance would mediate the relationships between PTSD symptoms and pain intensity and PTSD symptoms and pain interference in a sample of patients with cancer.

METHODS

A cross-sectional, retrospective chart review was conducted of the electronic medical records of 85 adult patients with cancer (89.4% female; 59% white; 42% metastatic) who sought individual psychosocial support services at our institution.

RESULTS

Post-traumatic stress disorder symptoms, sleep disturbance, pain intensity, and pain interference were all positively correlated ( P < .01). Clinical levels of PTSD symptoms were reported by 30% to 60% of the sample. Even after controlling for metastatic disease, race, and cancer type, sleep disturbance mediated the relationships between PTSD symptoms and pain intensity ( B = 0.27; 95% CI: 0.10-0.44) and PTSD symptoms and pain-related interference ( B = 0.58; 95% CI: 0.28-0.87).

CONCLUSIONS

The relationships among PTSD symptoms, pain intensity, and pain interference could be explained by co-occurring sleep disturbance. Given the high frequency of PTSD symptoms among patients with cancer and PTSD's known links to sleep problems and pain, clinicians should be attentive to the role that traumatogenic processes may play in eliciting sleep and pain-related complaints among patients with cancer.

Better Sleep in a Strange Bed? Sleep Quality in South African Women with Posttraumatic Stress Disorder

Although individuals diagnosed with posttraumatic stress disorder (PTSD) regularly report subjective sleep disruption, many studies using objective measures (e.g., polysomnography) report no PTSD-related sleep disruption. To account for these inconsistencies, some authors hypothesize that PTSD-diagnosed individuals have sleep-state misperception; that is, they self-report experiencing poor sleep quality, but objectively sleep relatively normally. We tested this sleep-state misperception hypothesis, collecting data on subjectively-reported sleep quality (in the home, and in the laboratory) and on objectively-measured, laboratory-based, sleep quality in PTSD-diagnosed participants from low socioeconomic status South African communities. Women with PTSD (n = 21), with trauma exposure but no PTSD (TE; n = 19), and healthy controls (HC; n = 20) completed questionnaires on their average sleep quality in the past 30 days, and on their sleep quality after a night (8 h) of polysomnographic-monitored sleep in the laboratory. PTSD-diagnosed individuals reported poorer everyday subjective sleep quality than TE and HC individuals. In the laboratory, however, there were no between-group differences in subjective sleep quality, and few between-group differences in objective sleep quality (PTSD-diagnosed individuals only had decreased sleep depth). Furthermore, whereas measures of laboratory-based objective and subjective sleep quality correlated significantly, especially in PTSD-diagnosed individuals, there were few significant associations between objective sleep measures and everyday subjective sleep quality. Taken together, these findings suggest that PTSD-diagnosed individuals likely experienced better sleep quality in the laboratory than at home. Descriptive observations corroborated this interpretation, with almost half the sample rating their laboratory sleep (which they described as “safe” and “quiet”) as better than their home sleep (which was experienced in an atmosphere marked by high levels of violence and nighttime noise). These findings disconfirm the sleep-state misperception hypothesis as related to PTSD, and suggest that the laboratory environment may influence sleep quality positively in these individuals. Many investigations of sleep in PTSD do not consider the influence of the laboratory environment. Our findings suggest that future studies in this field should consider that sleep-state misperception may be an artifact of the laboratory setting, especially when samples are drawn from communities where violence and crime are an everyday reality.