Sleep in PTSD: Conceptual model and novel directions in brain-based research and interventions

Towards accurate screening and prevention for PTSD (2-ASAP): protocol of a longitudinal prospective cohort study

BACKGROUND

Effective preventive interventions for PTSD rely on early identification of individuals at risk for developing PTSD. To establish early post-trauma who are at risk, there is a need for accurate prognostic risk screening instruments for PTSD that can be widely implemented in recently trauma-exposed adults. Achieving such accuracy and generalizability requires external validation of machine learning classification models. The current 2-ASAP cohort study will perform external validation on both full and minimal feature sets of supervised machine learning classification models assessing individual risk to follow an adverse PTSD symptom trajectory over the course of 1 year. We will derive these models from the TraumaTIPS cohort, separately for men and women.

METHOD

The 2-ASAP longitudinal cohort will include N = 863 adults (N = 436 females, N = 427 males) who were recently exposed to acute civilian trauma. We will include civilian victims of accidents, crime and calamities at Victim Support Netherlands; and who were presented for medical evaluation of (suspected) traumatic injuries by emergency transportation to the emergency department. The baseline assessment within 2 months post-trauma will include self-report questionnaires on demographic, medical and traumatic event characteristics; potential risk and protective factors for PTSD; PTSD symptom severity and other adverse outcomes; and current best-practice PTSD screening instruments. Participants will be followed at 3, 6, 9, and 12 months post-trauma, assessing PTSD symptom severity and other adverse outcomes via self-report questionnaires.

DISCUSSION

The ultimate goal of our study is to improve accurate screening and prevention for PTSD in recently trauma-exposed civilians. To enable future large-scale implementation, we will use self-report data to inform the prognostic models; and we will derive a minimal feature set of the classification models. This can be transformed into a short online screening instrument that is user-friendly for recently trauma-exposed adults to fill in. The eventual short online screening instrument will classify early post-trauma which adults are at risk for developing PTSD. Those at risk can be targeted and may subsequently benefit from preventive interventions, aiming to reduce PTSD and relatedly improve psychological, functional and economic outcomes.

Distinguishing vulnerability and resilience to posttraumatic stress disorder evaluating traumatic experiences, genetic risk and electronic health records

What distinguishes vulnerability and resilience to posttraumatic stress disorder (PTSD) remains unclear. Levering traumatic experiences reporting, genetic data, and electronic health records (EHR), we investigated and predicted the clinical comorbidities (co-phenome) of PTSD vulnerability and resilience in the UK Biobank (UKB) and All of Us Research Program (AoU), respectively. In 60,354 trauma-exposed UKB participants, we defined PTSD vulnerability and resilience considering PTSD symptoms, trauma burden, and polygenic risk scores. EHR-based phenome-wide association studies (PheWAS) were conducted to dissect the co-phenomes of PTSD vulnerability and resilience. Significant diagnostic endpoints were applied as weights, yielding a phenotypic risk score (PheRS) to conduct PheWAS of PTSD vulnerability and resilience PheRS in up to 95,761 AoU participants. EHR-based PheWAS revealed three significant phenotypes positively associated with PTSD vulnerability (top association "Sleep disorders") and five outcomes inversely associated with PTSD resilience (top association "Irritable Bowel Syndrome"). In the AoU cohort, PheRS analysis showed a partial inverse relationship between vulnerability and resilience with distinct comorbid associations. While PheRSvulnerability associations were linked to multiple phenotypes, PheRSresilience showed inverse relationships with eye conditions. Our study unveils phenotypic differences in PTSD vulnerability and resilience, highlighting that these concepts are not simply the absence and presence of PTSD.

Sleep Spindles Favor Emotion Regulation Over Memory Consolidation of Stressors in Posttraumatic Stress Disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is a trauma-induced condition, characterized by intrusive memories and trauma-associated anxiety. Non-rapid eye movement (NREM) sleep spindles might play a crucial role in learning and consolidating declarative stressor information. However, sleep and possibly sleep spindles are also known to regulate anxiety, suggestive of a dual role for sleep spindles in the processing of stressors. Specifically, in individuals with high PTSD symptom burden, spindles might fail to regulate anxiety levels after exposure and instead might maladaptively consolidate stressor information.

METHODS

To disentangle the role of spindles in declarative memory versus anxiety regulation after stressor exposure and to examine the role of PTSD in these processes, we measured nap sleep after a cohort of 45 trauma-exposed participants were exposed to laboratory stress. Participants (high vs. low PTSD symptoms) completed 2 visits: a stress visit involving exposure to negatively valent images before nap and a control visit. In both visits, sleep was monitored via electroencephalography. A stressor recall session occurred after the nap in the stress visit.

RESULTS

Stage 2 NREM (NREM2) spindle rates were higher in stress versus control sleep, indicative of stress-induced changes in spindles. In participants with high PTSD symptoms, NREM2 spindle rates in stress sleep predicted poorer recall accuracy of stressor images relative to participants with low PTSD symptoms, while correlating with greater reduction in stressor-induced anxiety levels after sleep.

CONCLUSIONS

Contrary to our expectations, although spindles are known to play a role in declarative memory processes, our findings highlight an important role for spindles in sleep-dependent anxiety regulation in PTSD.

Translation, Cross-Cultural Adaptation and Preliminary Validation of a French Version of the Trauma-Related Nightmare Survey (TRNS-FR) in a PTSD Veteran Population

INTRODUCTION

In the military population, trauma-related nightmares (TRNs) are highly associated with deployments and combat-related events. Trauma-related nightmares are also correlated with severity, treatment resistance, and chronicity of Post-Traumatic Stress Disorder (PTSD). However, to date, no specific measure of TRNs has been validated for use in the French language. This study aimed to translate and culturally adapt the English version of the Trauma-Related Nightmare Survey into French and to evaluate the psychometric properties of the translation on veterans.

MATERIALS AND METHODS

After the translation and cultural adaptation process, we evaluated the reliability and validity of the French version of the questionnaire (TRNS-FR) in a population of veterans suffering from PTSD with nightmare complaints (n = 56 patients for test-retest and n = 60 for internal consistency), recruited from five French military hospitals.

RESULTS

Analyses demonstrated that TRNS-FR has good test-retest reliability (r = 0.59) and good internal consistency with PTSD symptoms, insomnia symptoms, and subjective sleep parameters assessed at home. This questionnaire provides a rapid and comprehensive assessment of sleep disturbance and a specific description of TRNs in the population of veterans with severe PTSD. Our results allowed us to propose a valid and reliable French adaptation of the questionnaire.

CONCLUSION

Because sleep disturbances and TRNs require specific therapeutic management, the psychometric qualities of TRNS-FR make it a tool of choice for assessing TRNs in future clinical research settings.

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 impairments in refugees diagnosed with post-traumatic stress disorder: a polysomnographic and self-report study

Background: Post-traumatic stress disorder (PTSD) is the clinical manifestation of traumatic events and is associated with sleep disturbances. Sleep disturbances, if left untreated, may perpetuate or even worsen symptoms of PTSD. Previous studies of other PTSD populations show a higher incidence of sleep impairments and sleep disorders compared to healthy controls (HCs); however, this has never been investigated in trauma-affected refugees diagnosed with PTSD.Objectives: To examine subjective sleep quality, measure sleep architecture, and identify latent sleep disorders in refugees diagnosed with PTSD compared to HCs.Method: This comparative study included 20 trauma-affected refugees diagnosed with PTSD and 20 HC matched on age, sex, and body mass index. All participants completed self-report questionnaires assessing sleep quality, insomnia severity, and disturbing nocturnal behaviour, and all took part in a one-night polysomnography (PSG) assessment.Results: Patients reported significantly poorer subjective sleep quality, sleep latency, sleep duration, and sleep efficiency compared to HCs. Subjective reports on hours spent in bed were not significantly different between patients and HCs. Patients reported significantly higher nightmare frequency and severity compared to HCs. PSG measures showed that patients had significantly reduced sleep efficiency, more awakenings, and longer REM sleep latency, and spent more time awake, whereas there was no significant differences regarding total time in bed, total sleep time, or sleep latency. The prevalence of sleep disorders was equal between groups.Conclusions: The study identified significant impairments in several sleep domains, with a preponderance of disturbed regulation of sleep resulting in awakenings. These results indicate a need for more focus on hyperarousal and nightmares as key elements of disturbed sleep in PTSD. Furthermore, the study identified a discrepancy between subjective and objective measures concerning total sleep time, raising questions regarding the causes of 'sleep state misperception'.Trial registration: ClinicalTrials.gov identifier: NCT03535636..Trial registration: Sleep Impairments in Refugees Diagnosed with PTSD (PSG-PTSD). URL: https://clinicaltrials.gov/ct2/show/NCT03535636. ClinicalTrials.gov NCT03535636. Date of registration: 24/05/2018.

The bi-directional relationship between post-traumatic stress disorder and obstructive sleep apnea and/or insomnia in a large U.S. military cohort

OBJECTIVES

Determine if a bi-directional relationship exists between the development of sleep disorders (obstructive sleep apnea [OSA] and/or insomnia) and existing post-traumatic stress disorder (PTSD), and vice versa; and examine military-related factors associated with these potential relationships.

DESIGN

Longitudinal analyses of a prospective representative U.S. military cohort.

PARTICIPANTS

Millennium Cohort Study responders in 2011-2013 (Time 1 [T1]) and 2014-2016 (Time 2 [T2]) without insomnia or OSA at T1 (N = 65,915) or without PTSD at T1 (N = 71,256).

MEASUREMENTS

Provider-diagnosed OSA, self-reported items for insomnia, provider-diagnosed PTSD, and current PTSD symptoms were assessed at T1 and T2. Adjusted multivariable models identified military-related factors associated with new-onset PTSD in those with OSA and/or insomnia, and vice versa.

RESULTS

Self-reported history of provider-diagnosed PTSD without current symptoms at T1 was associated with new-onset OSA only and comorbid OSA/insomnia at T2, while current PTSD symptoms and/or diagnosis was associated with new-onset insomnia only. OSA/insomnia at T1 was consistently associated with newly reported PTSD symptoms or diagnosis except that insomnia only was not associated with newly reported provider-diagnosed PTSD. Military-related risk factors significantly associated with the bi-directional relationship for new-onset PTSD or OSA/insomnia included prior deployment with higher combat exposure and recent separation from the military; being an officer was protective for both outcomes.

CONCLUSIONS

In this large military cohort, findings suggest that PTSD and OSA and/or insomnia are bi-directionally predictive for their development, which was sometimes revealed by health care utilization. Relevant military-related risk factors should be considered in efforts to prevent or treat PTSD and/or sleep disorders.

COVID-related stress and substance use: examining the role of sleep disturbance

The current investigation employed a cross-sectional design to evaluate the associations of COVID-19 stress, sleep disturbance, and substance use among a national sample of 143 adults (57.3% male, Mage = 38.5 years, SD = 11.28), surveyed at a single time-point using Amazon's MTurk platform. We hypothesized that COVID-19-related stress would be indirectly related to substance use outcomes (i.e. number of substance classes used daily, number of alcoholic drinks per occasion, substance use coping motives; but not substance use enhancement motives) through sleep disturbance severity. As expected, results indicated that the models examining indirect effects were statistically significant for number of substance classes used daily and substance use coping motives. However, there was no evidence that sleep disturbance explained the relation between COVID-19-related stress and number of alcoholic drinks per occasion or substance use enhancement motives. These findings underscore the importance of sleep disturbance in efforts to better understand how COVID-19-related stress is associated with certain types of substance use behavior.

The Association Between Sleep Disturbance and Health Outcomes in Chronic Whiplash-Associated Disorders: A Series of Mediation Analyses

OBJECTIVES

To investigate the association between sleep disturbance and clinical features of chronic whiplash-associated disorders. We also aimed to use a bootstrapped mediation analysis approach to systematically examine both direct and indirect pathways by which sleep disturbance may affect chronic pain and functional status.

METHODS

One hundred and sixty-five people (63% female) with chronic whiplash-associated disorders and not taking medications for sleep disturbance completed questionnaires evaluating sleep disturbance, pain intensity, pain interference, disability, physical and mental health quality of life, stress, anxiety, depression, pain catastrophizing, and posttraumatic stress severity.

RESULTS

Greater sleep disturbance was associated with increased duration of symptoms, higher levels of pain and disability, higher levels of emotional distress and pain catastrophizing, and functional impairment (reduced health-related quality of life). Mediation analyses demonstrated that sleep disturbance influenced chronic pain intensity and interference through both direct and indirect associations inclusive of stress, anxiety and pain catastrophizing. Similarly, sleep disturbance was associated with higher levels of disability and poor health-related quality of life, both directly and also through its negative association with pain intensity and interference.

DISCUSSION

Sleep disturbance in chronic WAD was associated with worse health outcomes and demonstrated both direct and indirect effects on both chronic pain and function.

Memory reconsolidation impairment using the β-adrenergic receptor blocker propranolol reduces nightmare severity in patients with post-traumatic stress disorder: a preliminary study

STUDY OBJECTIVES

Post-traumatic nightmares may exacerbate and perpetuate the daytime symptoms of post-traumatic stress disorder (PTSD) and might represent a therapeutic target. The therapeutic strategy of memory reconsolidation using the β-adrenergic receptor blocker propranolol associated with re-exposure psychotherapy is a promising treatment in PTSD patients. Previous studies have established this therapy is effective in reducing overall clinician-assessed PTSD symptoms but to date no previous study has specifically focused on posttraumatic nightmares in this therapy. This study provides a preliminary assessment of the evolution of nightmares severity during this therapy protocol, compared with the decrease of the other PTSD symptoms. It evaluates the incidence of side effects and examines the relative effects on posttraumatic nightmares.

METHODS

Patients were recruited as part of the Paris Mémoire Vive study. Data were collected using a prospective longitudinal design including one baseline visit, six therapeutic visits, and two follow-up visits. During the six therapeutic visits, propranolol was administered orally 60 to 75 minutes prior to the psychotherapeutic session.

RESULTS

On average, nightmare severity decreased from "severe" to "mild" during the protocol and remained stable two months after the last session. Whereas 85% of patients reported nightmares at baseline, only 50% still had them after the protocol. The protocol was generally well tolerated and, did not increase nightmare severity for any patient in the study.

CONCLUSIONS

Memory reconsolidation therapy with propranolol seems promising in reducing nightmare severity, up to and including remission. However, research using a randomized controlled design, and assessing maintenance of nightmare extinction, is warranted.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Using Reconsolidation Blockade to Treat Trauma Related Disorders After Paris Attacks: An Effectiveness Study (PARIS-MEM); Identifier: NCT02789982; URL: https://www.clinicaltrials.gov/ct2/show/NCT02789982.

Sleep Difficulties Among COVID-19 Frontline Healthcare Workers

OBJECTIVE

To identify COVID-19 work-related stressors and experiences associated with sleep difficulties in HCW, and to assess the role of depression and traumatic stress in this association.

METHODS

A cross-sectional study of HCW using self-report questionnaires, during the first peak of the pandemic in Israel (April 2020), conducted in a large tertiary medical center in Israel. Study population included 189 physicians and nurses working in designated COVID-19 wards and a comparison group of 643 HCW. Mean age of the total sample was 41.7 ± 11.1, 67% were female, 42.1% physicians, with overall mean number of years of professional experience 14.2 ± 20. The exposure was working in COVID-19 wards and related specific stressors and negative experiences. Primary outcome measurement was the Insomnia Severity Index (ISI). Secondary outcomes included the Primary Care-Post Traumatic Stress Disorder Screen (PC-PTSD-5); the Patient Health Questionnaire-9 (PHQ-9) for depression; the anxiety module of the Patient-Reported Outcomes Measurement Information System (PROMIS); Pandemic-Related Stress Factors (PRSF) and witnessing patient suffering and death.

RESULTS

Compared with non-COVID-19 HCW, COVID-19 HCW were more likely to be male (41.3% vs. 30.7%) and younger (36.91 ± 8.81 vs. 43.14 ± 11.35 years). COVID-19 HCW reported higher prevalence of sleep difficulties: 63% vs. 50.7% in the non-COVID group (OR 1.62, 95% CI 1.15-2.29, p = 0.006), mostly difficulty maintaining sleep: 26.5% vs. 18.5% (OR 1.65, 95% CI 1.11-2.44, p = 0.012). Negative COVID-19 work-related experiences, specifically witnessing patient physical suffering and death, partially explained the association. Although past psychological problems and current depression and PTSD were associated with difficulty maintaining sleep, the main association remained robust also after controlling for those conditions in the full model.

CONCLUSION AND RELEVANCE

COVID-19 frontline HCW were more likely to report sleep difficulties, mainly difficulty maintaining sleep, as compared with non-COVID-19 HCW working at the same hospital. Negative patient-care related experiences likely mediated the increased probability for those difficulties. Future research is needed to elucidate the long-term trajectories of sleep difficulties among HCW during large scale outbreaks, and to identify risk factors for their persistence.

Sleep and PTSD in the Military Forces: A Reciprocal Relationship and a Psychiatric Approach

Sleep disturbances are well-recognised symptoms of Post-Traumatic Stress Disorder (PTSD). This review updates knowledge regarding the relationship between sleep during deployment, combat-related trauma, and PTSD in military personnel, from which the importance of restorative sleep results. The description of the characteristics of sleep in military forces with the considerable roles of the operational and training contexts highlights the important consequences of degraded sleep. Indeed, a lot of data suggest a dynamic link between sleep and the onset and chronicity of PTSD. We propose a reciprocal relationship model with strategies strongly recommended or already adopted by the military to promote restorative sleep before and after combat exposure. Among the alterations in a variety of sleep architecture and sleep patterns described in PTSD, the physiological hypothesis of REM sleep fragmentation in the development of PTSD symptoms may be important because REM sleep is generally associated with emotional memory. Finally, we address clinical and research perspectives that could be used to detect or restore sleep continuity before and during military deployment to possibly alleviate nightmares and insomnia related to combat exposure and PTSD occurrence and improve our understanding of sleep in PTSD.

Moderating effects of sleep difficulties on relations between posttraumatic stress disorder symptoms and positive memory count

OBJECTIVES

Posttraumatic stress disorder (PTSD) severity relates to positive memory retrieval difficulties. One variable potentially influencing this relation is sleep difficulties. We examined moderating effects of sleep difficulties (duration and quality) on relations between PTSD severity and count of specific positive memories covarying for age, gender, and depression.

METHODS

Participants were an Amazon Mechanical Turk-recruited trauma-exposed community sample of 205 respondents (M age  = 35.44; 61.40% women).

RESULTS

Moderated regression analyses indicated significant interaction effects between sleep quality (b = 0.03; p = 0.036) and PTSD severity on specific positive memory count. Among individuals reporting better sleep quality, there were negative associations between PTSD severity and specific positive memory count (b = -0.04, SE = 0.02, p = 0.010). Similar results were obtained for PTSD's intrusion and arousal clusters.

CONCLUSION

Results support targeting sleep quality and PTSD severity to improve positive memory retrieval in PTSD and memory interventions, and the importance of considering sleep when examining links between PTSD and positive memory retrieval.

Posttraumatic stress disorder symptoms and neurocognitive functioning in fire fighters: The mediating role of sleep problems and resilience

BACKGROUND

Firefighters are often exposed to terrible and dangerous scenes due to their duties, and thus have a high risk of developing posttraumatic stress disorder(PTSD). The purpose of the study is to examine the relationship between PTSD symptoms, sleep problems, resilience and neurocognitive functioning of firefighters, and to identify the sequential mediating effects of sleep problems and resilience on the relationship between PTSD symptoms and neurocognitive functioning (especially psychomotor speed and processing speed).

METHODS

Data were collected from 325 firefighters in eight fire departments in four regions of Korea. Subjects performed neurocognitive function tests and completed the following questionnaires: Primary Care PTSD Screening, Pittsburgh Sleep Quality Index-K and Connor-Davidson Resilience Scale-2. The correlation and dual mediation effects were analysed using SPSS 22.0 program and PROCESS macro 3.4 program.

RESULTS

PTSD symptoms, neurocognitive functioning, sleep problems and resilience were significantly correlated with each other. In the sequential mediation model, the relationship between PTSD and psychomotor speed/processing speed was sequentially mediated by sleep problems and resilience after adjusting for demographic variables.

CONCLUSIONS

The PTSD symptoms of firefighters were related to a sequential link between sleep problems, low resilience and decreased neurocognitive function. These findings could serve as a basis for more effective and integrated interventional strategies for facilitating better neurocognitive functioning in firefighters.

Sleep Quality Improvements After MDMA-Assisted Psychotherapy for the Treatment of Posttraumatic Stress Disorder

Sleep disturbances (SDs) are among the most distressing and commonly reported symptoms in posttraumatic stress disorder (PTSD). Despite increased attention on sleep in clinical PTSD research, SDs remain difficult to treat. In Phase 2 trials, 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy has been shown to greatly improve PTSD symptoms. We hypothesized that MDMA-assisted psychotherapy would improve self-reported sleep quality (SQ) in individuals with PTSD and be associated with declining PTSD symptoms. Participants in four studies (n = 63) were randomized to receive 2-3 sessions of active MDMA (75-125 mg; n = 47) or placebo/control MDMA (0-40 mg, n = 16) during all-day psychotherapy sessions. The PSQI was used to assess change in SQ from baseline to the primary endpoint, 1-2 months after the blinded sessions. Additionally, PSQI scores were measured at treatment exit (TE) and 12-month follow-up. Symptoms of PTSD were measured using the CAPS-IV. At the primary endpoint, CAPS-IV total severity scores dropped more after active MDMA than after placebo/control (-34.0 vs. -12.4), p = .003. Participants in the active dose group showed more improvement in SQ compared to those in the control group (PSQI total score ΔM = -3.5 vs. 0.6), p = .003. Compared to baseline, SQ had improved at TE, p < .001, with further significant gains reported at 12-month follow-up (TE to 12-months ΔM = -1.0), p = .030. Data from these randomized controlled double-blind studies provide evidence for the beneficial effects of MDMA-assisted psychotherapy in treating SDs in individuals with PTSD.

Associations between prenatal sleep and psychological health: a systematic review

STUDY OBJECTIVES

This systematic review aimed to examine the: (1) strength of associations between prenatal sleep (ie, duration, quality, and insomnia) and psychological health (ie, depression, anxiety, and stress); and (2) moderating influence of sociodemographic characteristics (ie, maternal age, gestational age/trimester, parity, marital and socioeconomic status [SES]), body mass index (BMI), and meeting sleep recommendations.

METHODS

A systematic search was conducted using PubMed, PsycINFO, Web of Science, and CINHAL to identify studies with at least one sleep measure and a psychological health outcome. Effect sizes (ES) were calculated by associations between individual components of sleep and psychological health (eg, sleep quality-depression).

RESULTS

Reviewed studies (n = 32) included 14,648 participants and yielded 219 ES. ES for anxiety/stress were combined due to insufficient data to analyze individually. Average strengths of associations for sleep duration-depression (ES = .52) and sleep duration-anxiety/stress (ES = .48), sleep quality-depression (ES = .55) and sleep quality-anxiety/stress (ES = .58), and insomnia-depression (ES = .67) ranged from medium to large. Marital status, parity, BMI, and meeting sleep recommendations moderated sleep duration-depression and sleep duration-anxiety/stress. SES, gestational age/trimester, parity, and BMI moderated sleep quality-depression and sleep quality-anxiety/stress associations.

CONCLUSIONS

Poor sleep quality and depression are prevalent during pregnancy and may negatively impact maternal and fetal outcomes. Moderating effects suggest that pregnant women of different BMI status and gestational age differ in their sleep habits and depression and anxiety/stress levels. Findings highlight the need to better understand the impact of these associations on maternal-fetal outcomes to inform interventions to improve sleep and psychological health.

Posttraumatic Stress Disorder and Persistent Somatic Symptoms During the COVID-19 Pandemic: The Role of Sense of Threat

OBJECTIVE

Persistent somatic symptoms, such as pain and fatigue, have been referred to as somatization. Somatization is commonly associated with histories of trauma and posttraumatic stress disorder (PTSD). Although previous research has demonstrated that PTSD can predict somatic problems, there has been no examination of this at the level of PTSD symptom clusters and multidimensional assessment of somatic symptoms. We examined the association between the three International Classification of Disease (11th Edition) PTSD symptom clusters (reexperiencing in the here and now, avoidance, and sense of threat), measured in relation to the COVID-19 pandemic as the stressor, and somatic symptoms while statistically adjusting for confounding variables.

METHODS

Participants were a nationally representative sample of 1041 adults from the general population of the Republic of Ireland. Physical health problems across the domains of pain, gastrointestinal, cardiopulmonary, and fatigue were assessed by the Patient Health Questionnaire, and PTSD symptoms were assessed using the International Trauma Questionnaire.

RESULTS

Sense of threat was associated with the presence of pain (β = 0.254), fatigue (β = 0.332), gastrointestinal (β = 0.234), and cardiovascular symptoms (β = 0.239). Avoidance was associated with pain (β = 0.347). Reexperiencing was not associated with any physical health variable.

CONCLUSIONS

In the context of COVID-19, the sense of threat symptoms in PTSD is most strongly related to somatic problems. Findings suggest that interventions addressing sense of threat symptoms might provide relief from somatization.

Altered sleep behavior in a genetic mouse model of impaired fear extinction

Sleep disturbances are a common complaint of anxiety patients and constitute a hallmark feature of post-traumatic stress disorder (PTSD). Emerging evidence suggests that poor sleep is not only a secondary symptom of anxiety- and trauma-related disorders but represents a risk factor in their development, for example by interfering with emotional memory processing. Fear extinction is a critical mechanism for the attenuation of fearful and traumatic memories and multiple studies suggest that healthy sleep is crucial for the formation of extinction memories. However, fear extinction is often impaired in anxiety- and trauma-related disorders-an endophenotype that is perfectly modelled in the 129S1/SvImJ inbred mouse strain. To investigate whether these mice exhibit altered sleep at baseline that could predispose them towards maladaptive fear processing, we compared their circadian sleep/wake patterns to those of typically extinction-competent C57BL/6 mice. We found significant differences regarding diurnal distribution of sleep and wakefulness, but also sleep architecture, spectral features and sleep spindle events. With regard to sleep disturbances reported by anxiety- and PTSD patients, our findings strengthen the 129S1/SvImJ mouse models' face validity and highlight it as a platform to investigate novel, sleep-focused diagnostic and therapeutic strategies. Whether the identified alterations causally contribute to its pathological anxiety/PTSD-like phenotype will, however, have to be addressed in future studies.

Digital cognitive behavioral therapy for insomnia promotes later health resilience during the coronavirus disease 19 (COVID-19) pandemic

STUDY OBJECTIVES

Stressful life events contribute to insomnia, psychosocial functioning, and illness. Though individuals with a history of insomnia may be especially vulnerable during stressful life events, risk may be mitigated by prior intervention. This study evaluated the effect of prior digital cognitive-behavioral therapy for insomnia (dCBT-I) versus sleep education on health resilience during the COVID-19 pandemic.

METHODS

COVID impact, insomnia, general- and COVID-related stress, depression, and global health were assessed in April 2020 in adults with a history of insomnia who completed a randomized controlled trial of dCBT-I (n = 102) versus sleep education control (n = 106) in 2016-2017. Regression analyses were used to evaluate the effect of intervention conditions on subsequent stress and health during the pandemic.

RESULTS

Insomnia symptoms were significantly associated with COVID-19 related disruptions, and those who previously received dCBT-I reported less insomnia symptoms, less general stress and COVID-related cognitive intrusions, less depression, and better global health than those who received sleep education. Moreover, the odds for resurgent insomnia was 51% lower in the dCBT-I versus control condition. Similarly, odds of moderate to severe depression during COVID-19 was 57% lower in the dCBT-I condition.

CONCLUSIONS

Those who received dCBT-I had increased health resilience during the COVID-19 pandemic in adults with a history of insomnia and ongoing mild to moderate mental health symptoms. These data provide evidence that dCBT-I is a powerful tool to promote mental and physical health during stressors, including the COVID-19 pandemic.

CLINICAL TRIAL REGISTRATION

NCT02988375.

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.

Disturbed Sleep in PTSD: Thinking Beyond Nightmares

Sleep disturbances frequently co-occur with posttraumatic stress disorder (PTSD). Insomnia and nightmares are viewed as core symptoms of PTSD. Yet, relations between disturbed sleep and PTSD are far more complex: PTSD is linked to a broad range of sleep disorders and disturbed sleep markedly affects PTSD-outcome. This article provides a concise overview of the literature on prevalent comorbid sleep disorders, their reciprocal relation with PTSD and possible underlying neurophysiological mechanisms. Furthermore, diagnostic procedures, standard interventions-particularly first choice non-pharmacological therapies-and practical problems that often arise in the assessment and treatment of sleep disturbances in PTSD are described. Finally, we will present some perspectives on future multidisciplinary clinical and experimental research to develop new, more effective sleep therapies to improve both sleep and PTSD.

Epidemic area contact history and sleep quality associated with posttraumatic stress symptoms in the first phase of COVID-19 outbreak in China

The impact of 2019 coronavirus disease (COVID-19) outbreak on mental health was of widespread concern recently. The present study aimed to exam sleep quality and posttraumatic stress symptoms (PTSS) and potential influence factors in the first phases of COVID-19 massive outbreak in China. A snowball sampling technique was used and a total of 2027 Chinese participated in the present study. Demographic information, epidemic area contact history, sleep quality and PTSS data were collected with an internet-based cross-sectional survey. Results suggested that 59.7% participants were not fully satisfied with their sleep quality, and 50.9% participants had various degrees of short sleep duration problems. 44.1% and 33.0% participants had sleep disturbance and sleep onset latency problems. Also, the prevalence of PTSS reached 4.7% in the self-rating survey. Epidemic area contact history affected PTSS and latency onset of sleep under the influence of COVID-19. Epidemic area contact history and sleep quality had interaction effects on PTSS. The present study was one of the first to evaluate acute psychological responses and possible risk factors during the peak of COVID-19 in China and results indicate that keeping good sleep quality in individuals with pandemic exposure experiences is a way to prevent PTSS.

Cortisol awakening response over the course of humanitarian aid deployment: a prospective cohort study

Background: Internationally deployed humanitarian aid (HA) workers are routinely confronted with potentially traumatic stressors. However, it remains unknown whether HA deployment and related traumatic stress are associated with long-term changes in hypothalamic-pituitary-adrenal (HPA) axis function. Therefore, we investigated whether cortisol awakening response (CAR) decreased upon deployment and whether this was moderated by previous and recent trauma exposure and parallel changes in symptom severity and perceived social support. Methods: In this prospective study, n = 86 HA workers (68% females) completed questionnaires regarding trauma exposure, posttraumatic stress disorder (PTSD), anxiety and depressive symptoms and perceived social support, as well as salivary cortisol assessments at awakening and 30 minutes post-awakening at before, early and 3-6 months post-deployment. Results: Linear mixed models showed significantly decreased CAR (b(SE) = -.036(.011), p = .002) and awakening cortisol over time (b(SE) = -.007(.003), p = .014). The extent of awakening cortisol change was significantly moderated by interactions between previous and recent trauma exposure. Also, a steeper awakening cortisol decrease was significantly associated with higher mean anxiety and PTSD symptoms across assessments. No significant effects were found for social support. Conclusions: We observed attenuated CAR and awakening cortisol upon HA deployment, with a dose-response effect between trauma exposure before and during the recent deployment on awakening cortisol. Awakening cortisol change was associated with PTSD and anxiety symptom levels across assessments. Our findings support the need for organizational awareness that work-related exposures may have long-lasting biological effects. Further research assessing symptoms and biological measures in parallel is needed to translate current findings into guidelines on the individual level.

Longitudinal investigation of the relationships between trauma exposure, post-migration stress, sleep disturbance, and mental health in Syrian refugees

Background High prevalence of sleep disturbance, which is associated with poor mental health, has been observed among non-treatment seeking refugees. However, no longitudinal research has investigated the chronicity of untreated sleep disturbance and its impact on refugees' mental health.

OBJECTIVE

This longitudinal study investigated associations between mental health (posttraumatic stress disorder, anxiety, depression), sleep symptoms (insomnia severity, pre-sleep arousal), and factors predicting mental health, over a 12-month period.

METHOD

Syrian refugees (N = 69) from a cross-sectional study (Time 1) participated in the current 12-month (Time 2) follow-up study. Participants completed a series of questionnaires examining sleep, trauma exposure, post-migration living difficulties, and mental health at both time points.

RESULTS

When compared to Time 1, participants showed a significant increase in post-migration stress at Time 2. However, there was an improvement in their mental health and levels of sleep disturbance. Half of the participants met criteria for moderate (36%) or severe sleep disturbance (15%) at Time 2. Forty-two per cent of the participants had moderate to severe sleep disturbance at both Time 1 and Time 2. When predicting mental health at 12-month follow-up, only pre-sleep arousal at Time 1 uniquely predicted mental health at Time 2. Mediation analysis indicated that change in pre-sleep arousal (from Time 1 to Time 2) significantly mediated the relationship between change in post-migration stress and change in mental health symptoms.

CONCLUSIONS

This study demonstrated that sleep symptoms have an indirect and long-term impact on mental health among refugees. Understanding modifiable factors, such as sleep, mediating the relationship between trauma exposure and PTSD symptoms is important, as such factors can be targeted in psychological interventions for refugees.

Increased oscillatory frequency of sleep spindles in combat-exposed veteran men with post-traumatic stress disorder

STUDY OBJECTIVES

Sleep disturbances are core symptoms of post-traumatic stress disorder (PTSD), but reliable sleep markers of PTSD have yet to be identified. Sleep spindles are important brain waves associated with sleep protection and sleep-dependent memory consolidation. The present study tested whether sleep spindles are altered in individuals with PTSD and whether the findings are reproducible across nights and subsamples of the study.

METHODS

Seventy-eight combat-exposed veteran men with (n = 31) and without (n = 47) PTSD completed two consecutive nights of high-density EEG recordings in a laboratory. We identified slow (10-13 Hz) and fast (13-16 Hz) sleep spindles during N2 and N3 sleep stages and performed topographical analyses of spindle parameters (amplitude, duration, oscillatory frequency, and density) on both nights. To assess reproducibility, we used the first 47 consecutive participants (18 with PTSD) for initial discovery and the remaining 31 participants (13 with PTSD) for replication assessment.

RESULTS

In the discovery analysis, compared to non-PTSD participants, PTSD participants exhibited (1) higher slow-spindle oscillatory frequency over the antero-frontal regions on both nights and (2) higher fast-spindle oscillatory frequency over the centro-parietal regions on the second night. The first finding was preserved in the replication analysis. We found no significant group differences in the amplitude, duration, or density of slow or fast spindles.

CONCLUSIONS

The elevated spindle oscillatory frequency in PTSD may indicate a deficient sensory-gating mechanism responsible for preserving sleep continuity. Our findings, if independently validated, may assist in the development of sleep-focused PTSD diagnostics and interventions.

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.

Sleep disturbance in post-traumatic stress disorder (PTSD): a systematic review and meta-analysis of actigraphy studies

BACKGROUND

Sleep disturbance has been described as a 'hallmark' symptom of posttraumatic stress disorder (PTSD). Although there are robust findings of self-reported sleep disturbance in PTSD, evidence of sleep disturbance measured using actigraphy is less certain.

OBJECTIVE

To conduct a systematic review and meta-analysis to determine whether there are any significant differences between individuals with and without PTSD in actigraph-derived sleep measures.

METHOD

Case-control studies comparing participants with current PTSD to those without PTSD were eligible for inclusion. Sleep parameters of interest were: (1) total sleep time; (2) sleep onset latency; (3) wake after sleep onset (WASO); and (4) sleep efficiency. Data were meta-analysed as standardised mean differences (SMDs) and potential sources of heterogeneity were explored through meta-regression. Six actigraphy studies with 405 participants were included.

RESULTS

There was no evidence of a statistically significant difference between those with and without PTSD in total sleep time (SMD 0.09, 95%CI -0.23 to 0.42); WASO (SMD 0.18, 95%CI -0.06 to 0.43); sleep latency (SMD 0.32, 95%CI -0.04 to 0.69); or sleep efficiency (SMD -0.28, 95%CI -0.78 to 0.21).

CONCLUSIONS

Further high-quality research is required to determine whether there is a true difference in sleep between those with and without PTSD.

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.

The relationship between the pattern of shift work and sleep disturbances in Korean firefighters

PURPOSE

Sleep disturbances are prevalent in firefighters, but the relationship between patterns of shift work and sleep disturbances has not yet been investigated. Here, this relationship has been evaluated in Korean firefighters.

METHODS

A cross-sectional study was conducted using an online questionnaire, which captured demographic, psychosocial and work-related characteristics. Sleep disturbance was assessed using the insomnia severity index (ISI). The relationship between insomnia and work-related factors (including type of shift work and the frequency of emergency events and off-duty work which means overtime work on off days) was analyzed.

RESULTS

A total of 9810 firefighters completed the survey, representing approximately 21.5% of all Korean firefighters; data from 9738 subjects were included in the analysis. All firefighter roles were significantly associated with insomnia; the odds ratio (OR) was 2.456 (95% confidence interval [CI] 1.461-4.128) for fire suppression and 1.871 (95% CI 1.105-3.167) for the emergency medical services and rescue. However, the pattern of shift work did not show a statistically significant relationship. The OR increased along with the frequency of emergency events and off-duty work (p value for trend < 0.05).

CONCLUSIONS

This study found a significant association between the frequency of emergency and off-duty work and insomnia in Korean firefighters, whereas the pattern of shift work showed no significant relationship. Therefore, measures to reduce the frequency of emergency and off-duty work are required to prevent sleep disturbances in firefighters.

Examining sleep over time in a randomized control trial comparing two integrated PTSD and alcohol use disorder treatments

STUDY OBJECTIVES

Insomnia is highly co-occurring with both posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). This is concerning since insomnia contributes to worse substance abuse and PTSD, and a host of negative health consequences. No study has tracked how sleep indices and insomnia change related to integrated PTSD and AUD treatment using evidence-based exposure therapy. This study examined how insomnia changes over time in a randomized control trial of two integrated PTSD and AUD treatments.

METHODS

Participants were 119 adult veterans (90 % male) seeking treatment for AUD and PTSD at a large urban VA. Participants were randomized to either COPE (integrated treatment using prolonged exposure) or Seeking Safety (integrated therapy using cognitive behavioral, interpersonal techniques and case management). Assessments were done at pre- and post-treatment and include: Clinician Administered PTSD Scale, Timeline Follow-back calendar-assisted interview for AU, insomnia severity index (ISI), sleep diary and actigraphy for 7 days.

RESULTS

ISI showed significant decreases, but a majority remained above the clinical cutoff at post-treatment. Wake after sleep onset decreased, but only by 8 min, remaining above clinical thresholds. Decreases in PTSD, but not in heavy drinking, predicted change in ISI. No significant changes were observed in other sleep variables measured.

CONCLUSIONS

Findings suggested some statistical improvements in sleep quality, but sleep indices remained above clinical cut-offs. This study provides evidence that insomnia is an independent disorder and not responsive to PTSD or AUD treatments alone. Sleep symptoms should be assessed and treated in patients with comorbid mental health conditions.

Sleep in the United States Military

The military lifestyle often includes continuous operations whether in training or deployed environments. These stressful environments present unique challenges for service members attempting to achieve consolidated, restorative sleep. The significant mental and physical derangements caused by degraded metabolic, cardiovascular, skeletomuscular, and cognitive health often result from insufficient sleep and/or circadian misalignment. Insufficient sleep and resulting fatigue compromises personal safety, mission success, and even national security. In the long-term, chronic insufficient sleep and circadian rhythm disorders have been associated with other sleep disorders (e.g., insomnia, obstructive sleep apnea, and parasomnias). Other physiologic and psychologic diagnoses such as post-traumatic stress disorder, cardiovascular disease, and dementia have also been associated with chronic, insufficient sleep. Increased co-morbidity and mortality are compounded by traumatic brain injury resulting from blunt trauma, blast exposure, and highly physically demanding tasks under load. We present the current state of science in human and animal models specific to service members during- and post-military career. We focus on mission requirements of night shift work, sustained operations, and rapid re-entrainment to time zones. We then propose targeted pharmacological and non-pharmacological countermeasures to optimize performance that are mission- and symptom-specific. We recognize a critical gap in research involving service members, but provide tailored interventions for military health care providers based on the large body of research in health care and public service workers.

Cortical hyperarousal in NREM sleep normalizes from pre- to post- REM periods in individuals with frequent nightmares

Study Objectives

Frequent nightmares have a high prevalence and constitute a risk factor for psychiatric conditions, but their pathophysiology is poorly understood. Our aim was to examine sleep architecture and electroencephalographic markers—with a specific focus on state transitions—related to sleep regulation and hyperarousal in participants with frequent nightmares (NM participants) versus healthy controls.

Methods

Healthy controls and NM participants spent two consecutive nights in the sleep laboratory. Second night spectral power during NREM to REM sleep (pre-REM) and REM to NREM (post-REM) transitions as well as during NREM and REM periods were evaluated for 22 NM participants compared to 22 healthy controls with a similar distribution of age, gender, and dream recall frequency.

Results

We found significant differences between the groups in the pre-REM to post-REM changes in low- and high-frequency domains. NM participants experienced a lower amount of slow-wave sleep and showed increased beta and gamma power during NREM and pre-REM periods. No difference was present during REM and post-REM phases. Furthermore, while increased pre-REM high-frequency power seems to be mainly driven by post-traumatic stress disorder (PTSD) symptom intensity, decreased low-frequency activity occurred regardless of PTSD symptom severity.

Conclusion

Our findings indicate that NM participants had increased high-frequency spectral power during NREM and pre-REM periods, as well as relatively reduced slow frequency and increased fast frequency spectral power across pre-and post-REM periods. This combination of reduced sleep-protective activity and increased hyperarousal suggests an imbalance between sleep regulatory and wake-promoting systems in NM participants.

Predicting Attentional Impairment in Women With Posttraumatic Stress Disorder Using Self-Reported and Objective Measures of Sleep

STUDY OBJECTIVES

There is growing evidence to support sleep impairment as a core feature of posttraumatic stress disorder (PTSD). Sleep impairment in PTSD is associated with severe distress and poorer treatment outcomes. Therefore, specific attention to this symptom of PTSD is warranted and accurate assessment of sleep impairment is critical. The current study investigated the association between self-reported and objective assessment of sleep and sustained attention in women with PTSD.

METHODS

Study participants include 50 treatment-seeking, female, interpersonal violence survivors who have PTSD. Nocturnal sleep duration was measured with self-report sleep diaries and objective actigraphy assessment over the course of 7 nights. Sustained attention during daytime was measured by the Psychomotor Vigilance Task (PVT).

RESULTS

Results indicated that self-reported nocturnal sleep duration, but not objective or global sleep quality measures, best predicted attentional deficits as indicated by lapses and inverse reaction time on the PVT. Daily sleep diaries predicted 19% and 14% of the variance in attentional lapses and inverse reaction time, respectively.

CONCLUSIONS

In a sample of women with PTSD, self-reported nocturnal sleep duration predicted deficits in sustained attention. Conversely, sleep duration as measured by actigraphy and global sleep quality, did not predict sustained attention. Findings suggest that assessing sleep impairment on a daily basis may provide clinically relevant information in evaluating daytime symptoms and provide guidance in targeting this particularly troublesome symptom in the treatment of PTSD.

CITATION

Werner KB, Arditte Hall KA, Griffin MG, Galovski TE. Predicting attentional impairment in women with posttraumatic stress disorder using self-reported and objective measures of sleep. J Clin Sleep Med. 2019;15(9):1329-1336.

Expansion of hippocampal and amygdala shape in posttraumatic stress and early life stress

OBJECTIVE

The aim of this study was to examine the effect of Posttraumatic Stress Disorder (PTSD) and childhood adversity on brain structure. We assessed hippocampal and amygdala shape in veterans with varying levels of PTSD symptom severity and exposure to early life stressors (ELS).

METHODS

A total of 70 male veterans, who were deployed to a combat area during OIF/OEF/OND and who had been exposed to trauma during deployment, were included in the study. We applied a vertex-wise shape analysis of 3T MRI scans to measure indentation or expansion in hippocampal and amygdala shape.

RESULTS

Analyses showed a positive correlation between number of ELS and vertices in the right amygdala and the right hippocampus, as well as a positive correlation between PTSD symptom severity and right hippocampal vertices. There were no significant interactions between PTSD symptoms, ELS, and brain shape.

DISCUSSION

Results indicate a relationship between exposure to more childhood adversity and expansion in amygdala and hippocampal shape as well as between more severe PTSD symptoms and expansion in hippocampal shape. These findings may have important implications for the pathophysiology of trauma-related disorders.

Pediatrician's Practical Approach to Sleep Disturbances in Children Who Have Experienced Trauma

Sleep difficulties are a common challenge among children who have experienced trauma. Pediatricians are best positioned to work with families to address sleep challenges after traumatic events and help families return to healthy sleep patterns. In this article, we review the underlying concepts that connect trauma to disturbed sleep, types of sleep difficulties seen in children exposed to trauma, and explore ways in which pediatricians can support families as they help their child return to a normal sleep cycle, including the identification of co-occurring conditions and the use of medications. [Pediatr Ann. 2019;48(7):e280-e285.].

A Review of the Relationship Between Emotional Learning and Memory, Sleep, and PTSD

PURPOSE OF REVIEW

The emotional memory and learning model of PTSD posits maladaptive fear conditioning, extinction learning, extinction recall, and safety learning as central mechanisms to PTSD. There is increasingly convincing support that sleep disturbance plays a mechanistic role in these processes. The current review consolidates the evidence on the relationships between emotional memory and learning, disturbed sleep, and PTSD acquisition, maintenance, and treatment.

RECENT FINDINGS

While disrupted sleep prior to trauma predicts PTSD onset, maladaptive fear acquisition does not seem to be the mechanism through which PTSD is acquired. Rather, poor extinction learning/recall and safety learning seem to better account for who maintains acute stress responses from trauma versus who naturally recovers; there is convincing evidence that this process is, at least in part, mediated by REM fragmentation. Individuals with PTSD had higher "fear load" during extinction, worse extinction learning, poorer extinction recall, and worse safety learning. Evidence suggests that these processes are also mediated by fragmented REM. Finally, PTSD treatments that require extinction and safety learning may also be affected by REM fragmentation. Addressing fragmented sleep or sleep architecture could be used to increase emotional memory and learning processes and thus ameliorate responses to trauma exposure, reduce PTSD severity, and improve treatment. Future studies should examine relationships between emotional memory and learning and disturbed sleep in clinical PTSD patients.

Piloting cognitive-behavioral therapy for insomnia integrated with prolonged exposure

OBJECTIVE

Approximately 35-61% of individuals with posttraumatic stress disorder (PTSD) report insomnia. Further, upward of 70% report clinically significant insomnia following PTSD treatment. There are converging lines of evidence suggesting that insomnia not only independently affects daytime functioning and worsens PTSD symptoms but also may compromise response to PTSD treatment, such as prolonged exposure (PE). Taken together, integrated insomnia and PTSD treatment may increase client-centered care and treatment outcomes.

METHOD

This article reviews the theory and evidence for treating sleep prior to PTSD treatment, describes the key elements of integrated cognitive-behavioral treatment for insomnia (CBT-I) and PE (2NITE protocol), and presents pilot data from a sample of 12 treatment-seeking veterans with PTSD and insomnia who completed the 2NITE protocol. Sleep data were collected with sleep diaries and actigraphy watches.

RESULTS

The Client Satisfaction Questionnaire indicated high satisfaction with the 2NITE protocol (mean score 29.66 out of 32 points). On average, there were statistical and clinically significant changes in all measures, including a 20.17-point decrease in the PTSD Checklist DSM-5, a 11.75-point decrease in the insomnia severity index, an 18.58-point increase in the World Health Organization Quality of Life index, a 11% increase in sleep efficiency, and a 51-min increase in total sleep time from the actigraphy data.

CONCLUSIONS

Among individuals with insomnia and PTSD, integrating CBT-I and PE with the 2NITE protocol represents a logical, innovative, and empirically informed method for augmenting existing treatments and optimizing outcomes that justifies further investigation. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Sleep in psychogenic nonepileptic seizures: Time to raise a red flag

Poor sleep is a frequent complaint in patients with psychogenic nonepileptic seizures (PNES). However, few studies have examined sleep problems in this population. We aimed to compare sleep complaints in patients with PNES with those with epilepsy. Subjects diagnosed as having PNES by experts using video-electroencephalography (vEEG) were recruited through the Brigham and Women's Hospital epilepsy monitoring unit (EMU) between 3/25/2013 and 3/29/2018. Controls were patients with epilepsy recruited through the EMU and subspecialty clinics. All subjects were given the Beck Depression Inventory, 2nd Edition (BDI-II) and the Quality of Life in Epilepsy Inventory-10 (QOLIE-10). Subjective sleep problems were identified from item 16 (changes in sleep patterns) of the BDI-II. Independent sample t-test, chi-square test, and Spearman correlation were used. A total of 149 patients with PNES and 82 patients with epilepsy completed the BDI-II and QOLIE-10. Compared with control subjects with epilepsy, patients with PNES more frequently reported moderate-severe changes in sleep patterns, notably sleeping less than usual, waking up 1-2 h too early, and having trouble returning to sleep. These changes in sleep patterns were associated with worse quality of life. Our findings suggest that sleep is more commonly reported as a problem in PNES compared with epilepsy. Because sleep plays a major role in good health, understanding the specific sleep problem in PNES may provide insight for improving quality of life for this challenging disorder.

Recent Advancements in Treating Sleep Disorders in Co-Occurring PTSD

PURPOSE OF REVIEW

Comorbidity of posttraumatic stress disorder (PTSD) and insomnia, nightmares, and obstructive sleep apnea (OSA) is high. We review recent research on psychotherapeutic and pharmacological interventions for sleep disorders in PTSD.

RECENT FINDINGS

PTSD treatments decrease PTSD severity and nightmare frequency, but do not resolve OSA or insomnia. Research on whether insomnia hinders PTSD treatment shows mixed results; untreated OSA does interfere with PTSD treatment. Cognitive behavioral therapy for insomnia is the recommended treatment for insomnia; however, optimal ordering with PTSD treatment is unclear. PTSD treatment may be most useful for PTSD-related nightmares. CPAP therapy is recommended for OSA but adherence can be low. Targeted treatment of sleep disorders in the context of PTSD offers a unique and underutilized opportunity to advance clinical care and research. Research is needed to create screening protocols, determine optimal order of treatment, and elucidate mechanisms between sleep and PTSD treatments.

The potential influence of LED lighting on mental illness

OBJECTIVES

Two recent scientific breakthroughs may alter the treatment of mental illness, as discussed in this narrative review. The first was the invention of white light-emitting diodes (LEDs), which enabled an ongoing, rapid transition to energy-efficient LEDs for lighting, and the use of LEDs to backlight digital devices. The second was the discovery of melanopsin-expressing photosensitive retinal ganglion cells, which detect environmental irradiance and mediate non-image forming (NIF) functions including circadian entrainment, melatonin secretion, alertness, sleep regulation and the pupillary light reflex. These two breakthroughs are interrelated because unlike conventional lighting, white LEDs have a dominant spectral wavelength in the blue light range, near the peak sensitivity for the melanopsin system.

METHODS

Pertinent articles were identified.

RESULTS

Blue light exposure may suppress melatonin, increase alertness, and interfere with sleep in young, healthy volunteers and in animals. Areas of concern in mental illness include the influence of blue light on sleep, other circadian-mediated symptoms, prescribed treatments that target the circadian system, measurement using digital apps and devices, and adolescent sensitivity to blue light.

CONCLUSIONS

While knowledge in both fields is expanding rapidly, future developments must address the potential impact of blue light on NIF functions for healthy individuals and those with mental illness.

Development of a Measure of Postpartum PTSD: The City Birth Trauma Scale

Post-traumatic stress disorder (PTSD) affects 4% of women after birth yet there are very few questionnaire measures of postpartum PTSD that have been validated in this population. In addition, none of the available questionnaires assess postpartum PTSD in accordance with criteria specified in the latest edition of the Diagnostic and Statistical Manual [DSM-5, (1)]. The City Birth Trauma Scale is a 29-item questionnaire developed to measure birth-related PTSD according to DSM-5 criteria of: stressor criteria (A), symptoms of re-experiencing (B), avoidance (C), negative cognitions and mood (D), and hyperarousal (E), as well as duration of symptoms (F), significant distress or impairment (E), and exclusion criteria or other causes (H). Two additional items from DSM-IV were also included on the basis of evidence suggesting they might be important in this population. The first was criterion A2 that women responded to events during birth with intense fear, helplessness or horror. The second was symptoms of emotional numbing. Items were first reviewed by researchers (n = 9) and postpartum women (n = 8) and revised accordingly. The questionnaire was then completed by 950 women recruited online. Results showed the City Birth Trauma Scale had excellent reliability (Cronbach's α = 0.92) and is easy to understand (Flesch reading score 64.17). Exploratory factor analysis found two factors which together accounted for 56% of the variance: (i) Birth-related symptoms (40.8% variance) and (ii) General symptoms (15.5% variance). PTSD symptoms were highly associated with distress, impaired functioning, and women reporting they wanted treatment (r = 0.50-0.61). Removing DSM-IV A2 criteria only increased births classified as traumatic by 2%. Adding the item on emotional numbing did not change the psychometric properties of the scale. These items were therefore removed. The City Birth Trauma Scale has good psychometric properties and the two symptom clusters identified are consistent with previous research on symptoms of postpartum PTSD. This scale therefore provides a promising measure of PTSD following childbirth that can be used in research and clinical practice. Future research should examine the scale's predictive validity using clinical interviews.