Sleep problems among persons with a lifetime history of posttraumatic stress disorder alone and in combination with a lifetime history of other psychiatric disorders: a replication and extension

Metabotropic glutamate receptor function and regulation of sleep-wake cycles

Metabotropic glutamate (mGlu) receptors are the most abundant family of G-protein coupled receptors and are widely expressed throughout the central nervous system (CNS). Alterations in glutamate homeostasis, including dysregulations in mGlu receptor function, have been indicated as key contributors to multiple CNS disorders. Fluctuations in mGlu receptor expression and function also occur across diurnal sleep-wake cycles. Sleep disturbances including insomnia are frequently comorbid with neuropsychiatric, neurodevelopmental, and neurodegenerative conditions. These often precede behavioral symptoms and/or correlate with symptom severity and relapse. Chronic sleep disturbances may also be a consequence of primary symptom progression and can exacerbate neurodegeneration in disorders including Alzheimer's disease (AD). Thus, there is a bidirectional relationship between sleep disturbances and CNS disorders; disrupted sleep may serve as both a cause and a consequence of the disorder. Importantly, comorbid sleep disturbances are rarely a direct target of primary pharmacological treatments for neuropsychiatric disorders even though improving sleep can positively impact other symptom clusters. This chapter details known roles of mGlu receptor subtypes in both sleep-wake regulation and CNS disorders focusing on schizophrenia, major depressive disorder, post-traumatic stress disorder, AD, and substance use disorder (cocaine and opioid). In this chapter, preclinical electrophysiological, genetic, and pharmacological studies are described, and, when possible, human genetic, imaging, and post-mortem studies are also discussed. In addition to reviewing the important relationships between sleep, mGlu receptors, and CNS disorders, this chapter highlights the development of selective mGlu receptor ligands that hold promise for improving both primary symptoms and sleep disturbances.

Psychiatric comorbidity predicts sleep disturbances among adolescent earthquake survivors: a 10-year cohort study

OBJECTIVE

To examine the prevalence of sleep disturbances 10 years after Wenchuan earthquake, and to explore whether comorbid post-traumatic stress disorder (PTSD) and depressive symptoms could predict sleep disturbances and whether such effects were modified by gender.

METHODS

Participants were 1357 adolescents in the Wenchuan Earthquake Adolescent Health Cohort Study (WEAHC). 799 of the participants completed the followed-up survey 10 years after the earthquake. At 12-month post-earthquake (T_12m), a battery of standardized measures were used to assess individual earthquake exposure, sleep disturbances (insomnia symptoms and poor sleep quality), PTSD, and depressive symptoms. At 10 years post-earthquake (T_10y), those survivors reported their sleep disturbances via an online survey. Data were analyzed using binary logistic regression.

RESULTS

The prevalence of insomnia (14.3%) and of poor sleep quality (19.8%) at T_10y decreased when compared with it at T_12m. After controlling for covariates, it is revealed that depression-only and comorbidity groups at T_12m predicted sleep disturbances at T_10y among the whole sample and males. As for females, who have depression-only and comorbidity were more likely to develop insomnia symptoms but not poor sleep quality.

CONCLUSIONS

Sleep disturbances remained highly prevalent among survivors even 10 years after the earthquake. Depression-only and comorbidity groups were related to higher risks of sleep disturbances, especially for males. Assessments and interventions targeting both depressive symptoms and comorbid PTSD to reduce sleep disturbances after a deadly disaster are warranted.

Preliminary evidence linking complex-PTSD to insomnia in a sample of Yazidi genocide survivors

Complex post-traumatic stress disorder (CPTSD) is a psychiatric diagnosis that includes three additional symptom clusters beyond those necessary for post-traumatic stress disorder (PTSD) diagnosis. CPTSD is typically associated with a prolonged trauma exposure in which a person's destiny is under the control of other people and escape is not an option. Insomnia prevalence in women suffering from CPTSD was compared to the prevalence of insomnia in those with no-PTSD and those with only PTSD. Yazidi women (N = 108, age = 24.41 ± 5.71) former captives of the Islamic State terrorist group were queried about captivity variables, psychological distress, resilience, PTSD, CPTSD, and insomnia. CPTSD prevalence was high (>50%) and was highly correlated with insomnia (95% of those with CPTSD had insomnia). A dichotomous insomnia variable was regressed on age and marital-status (Step 1), captivity-duration and number of fellow captives (Step 2), resilience and psychological distress (Step 3), and group (no-PTSD/PTSD/CPTSD) (Step 4). Insomnia was 18 times more likely in the CPTSD group than in the no-PTSD group. There were no differences in insomnia prevalence between the no-PTSD and PTSD groups. Insomnia levels among Yazidi women released from captivity support an understanding of CPTSD as a separate entity than PTSD. Potential factors linking CPTSD to insomnia, beyond those associated with PTSD are discussed.

Symptom Presentation and Prescription of Sleep Medications for Veterans With Posttraumatic Stress Disorder

This study tested whether sleep medications prescribed to veterans diagnosed with posttraumatic stress disorder (PTSD) are being targeted to patients who report more severe insomnia or nightmares. Secondary analysis of survey and pharmacy data was conducted in samples of veterans from two periods: from 2006 to 2008 and from 2009 to 2013. Logistic regression tested associations between self-reported insomnia and nightmare severity, and being prescribed trazodone, prazosin, zolpidem, and benzodiazepines, controlling for PTSD severity and other covariates. In both samples, insomnia severity independently predicted trazodone receipt, and nightmare severity independently predicted prazosin receipt. In the later study, insomnia severity predicted receipt of zolpidem. Veterans in the later sample were more likely to receive trazodone, prazosin, and non-benzodiazepine hypnotics, and less likely to receive benzodiazepines than those in the earlier sample. Further research is needed to evaluate and optimize pharmacological and psychosocial treatments for sleep problems among veterans with PTSD.

Relationships between Sleep Problems and Psychiatric Comorbidities among China's Wenchuan Earthquake Survivors Remaining in Temporary Housing Camps

Earthquake survivors are a diverse population. This study focused on a special group of earthquake survivors, who had still stayed in temporary housing camps for about 2 years after China's Wenchuan Earthquake rather than those who moved back to rebuild their lives or immigrated to large cities to seek new lives. The research goals were to (1) assess their sleep problems as well as their PTSD, depression and anxiety and (2) examine the relationship between different dimensions of sleep quality and PTSD, depression, and anxiety among these survivors. Three-hundred and eighty seven earthquake survivors who remained in temporary housing camps and had sleep problems were recruited 17-27 months after Wenchuan Earthquake. Four standardized instruments-The Pittsburgh Sleep Quality Index, PTSD Checklist-Civilian Version, Self-rating Depression Scale, Self-rating Anxiety Scale, and face-to-face one-on-one structured interviews were used to assess these survivors' sleep quality, PTSD, depression, and anxiety. It was found that (1) 83.20% of these survivors reported having sleep problems, and 79.33% of them considered insomnia as the most common sleep problem; (2) 12.14% suffered PTSD, 36.43% experienced depression, and 38.24% had anxiety; (3) sleep disturbance, sleep medication use, and subjective sleep quality were significantly related to PTSD; (4) habitual sleep efficiency, sleep disturbance, sleep medication use, and daytime dysfunction were significantly related to depression; and (5) sleep disturbance, sleep medication use, and daytime dysfunction were significantly related to anxiety. Clinic implications of the study are discussed.

Psychological effects following the Iran nuclear deal: Iranian nuclear threat salience moderates the relationship between PTSD symptoms and sleep problems

Following the July-14th, 2015 Iranian agreement, we examined if preoccupation with the threat of a nuclear Iran moderates the relationship between posttraumatic stress disorder (PTSD) symptoms and reported sleep problems in individuals exposed to the 2014 Israel-Gaza conflict. While sleep problems were evident in individuals suffering from PTSD symptoms, they were especially pronounced when PTSD symptoms were coupled with increased Iranian nuclear threat salience. Preoccupation with future national threats may increase PTSD-related sleep problems. Therefore, it may be useful if such threats are accounted for in interventions aiming to ameliorate trauma-related sleep problems arising in the context of security situation.

Trouble Sleeping Associated With Lower Work Performance and Greater Health Care Costs: Longitudinal Data From Kansas State Employee Wellness Program

OBJECTIVE

To examine the relationships between employees' trouble sleeping and absenteeism, work performance, and health care expenditures over a 2-year period.

METHODS

Utilizing the Kansas State employee wellness program (EWP) data set from 2008 to 2009, multinomial logistic regression analyses were conducted with trouble sleeping as the predictor and absenteeism, work performance, and health care costs as the outcomes.

RESULTS

EWP participants (N = 11,698 in 2008; 5636 followed up in 2009) who had higher levels of sleep disturbance were more likely to be absent from work (all P < 0.0005), have lower work performance ratings (all P < 0.0005), and have higher health care costs (P < 0.0005). Longitudinally, more trouble sleeping was significantly related to negative changes in all outcomes.

CONCLUSIONS

Employees' trouble sleeping, even at a subclinical level, negatively impacts on work attendance, work performance, and health care costs.

Development of the National Healthy Sleep Awareness Project Sleep Health Surveillance Questions

OBJECTIVES

For the first time ever, as emphasized by inclusion in the Healthy People 2020 goals, sleep health is an emphasis of national health aims. The National Healthy Sleep Awareness Project (NHSAP) was tasked to propose questions for inclusion in the next Behavioral Risk Factor Surveillance System (BRFSS), a survey that includes a number of questions that target behaviors thought to impact health, as a means to measure community sleep health. The total number of questions could not exceed five, and had to include an assessment of the risk for obstructive sleep apnea (OSA).

METHODS

An appointed workgroup met via teleconference and face-to-face venues to develop an inventory of published survey questions being used to identify sleep health, to develop a framework on which to analyze the strengths and weaknesses of current survey questions concerning sleep, and to develop recommendations for sleep health and disease surveillance questions going forward.

RESULTS

The recommendation was to focus on certain existing BRFSS questions pertaining to sleep duration, quality, satisfaction, daytime alertness, and to add to these other BRFSS existing questions to make a modified STOP-BANG questionnaire (minus the N for neck circumference) to assess for risk of OSA.

CONCLUSIONS

Sleep health is an important dimension of health that has previously received less attention in national health surveys. We believe that 5 questions recommended for the upcoming BRFSS question banks will assist as important measures of sleep health, and may help to evaluate the effectiveness of interventions to improve sleep health in our nation.

Association of Per3 length polymorphism with bipolar I disorder and schizophrenia

BACKGROUND

Sleep-wake disturbances have frequently been reported in bipolar disorder and schizophrenia, and are considered to be caused by an underlying circadian rhythm disorder. The study presented here was designed to investigate the existence of Per3 polymorphism in bipolar disorder type I (BD-I) and schizophrenic patients in South India.

METHODS

Blood samples were collected from 311 BD-I patients, 293 schizophrenia patients, and 346 age- and sex-matched normal controls. Per3 genotyping was performed on DNA by polymerase chain reaction using specific primers.

RESULTS

An increased prevalence of five repeat homozygotes was seen in BD-I patients as compared with healthy controls (odds ratio =1.72 [95% confidence interval: 1.08-2.76, P=0.02]). In BD-I patients, the frequency of the five repeat allele was higher (allele frequency =0.41), and that of the four repeat allele lower (allele frequency =0.36) (χ (2)=4.634; P<0.03) than in the control group. No significant association was observed in the allele frequencies of four and five repeat alleles in schizophrenia patients when compared with controls.

CONCLUSION

The occurrence of the five repeat allele of Per3 may be a risk factor for BD-I onset in this ethnic group.

A promoter polymorphism in the Per3 gene is associated with alcohol and stress response

The period homolog genes Per1, Per2 and Per3 are important components of the circadian clock system. In addition to their role in maintaining circadian rhythm, these genes have been linked to mood disorders, stress response and vulnerability to addiction and alcoholism. In this study, we combined high-resolution sequence analysis and quantitative trait locus (QTL) mapping of gene expression and behavioral traits to identify Per3 as a compelling candidate for the interaction between circadian rhythm, alcohol and stress response. In the BXD family of mouse strains, sequence variants in Per3 have marked effects on steady-state mRNA and protein levels. As a result, the transcript maps as a cis-acting expression QTL (eQTL). We found that an insertion/deletion (indel) variant in a putative stress response element in the promoter region of Per3 causes local control of transcript abundance. This indel results in differences in protein binding affinities between the two alleles through the Nrf2 transcriptional activator. Variation in Per3 is also associated with downstream differences in the expression of genes involved in circadian rhythm, alcohol, stress response and schizophrenia. We found that the Per3 locus is linked to stress/anxiety traits, and that the basal expression of Per3 is also correlated with several anxiety and addiction-related phenotypes. Treatment with alcohol results in increased expression of Per3 in the hippocampus, and this effect interacts with acute restraint stress. Our data provide strong evidence that variation in the Per3 transcript is causally associated with and also responsive to stress and alcohol.

Sleep disturbances and suicidality: a common association to look for in clinical practise and preventive care

Suicidality and suicide has been associated with many risk factors, while recent clinical and epidemiological studies increasingly point to a potential link between sleep loss or sleep disturbances and suicidality. This review on studies of sleep disturbances associated with suicidality, i.e., suicidal ideation, suicide attempt and completed suicide suggests a frequent association especially with insomnia and nightmares but also hypersomnia and sleep panic attacks. In suicidal insomniacs with comorbid psychiatric disorders, there is some evidence for an even independent predictive nature of sleep problems for suicidality. Considerations on the shared neurobiology, risk assessment and treatment options complement the overview. Thus, sleep disturbances may qualify as an individual treatable target of personalised medicine in the clinical routine as well as in suicide prevention programmes. A more detailed assessment of sleep problems and identification of specific risk domains in primary or secondary prevention of suicidality seem to be a future area of high importance.