Exploring the role of insomnia in the relation between PTSD and pain in veterans with polytrauma injuries

Associations of Posttraumatic Stress Disorder Symptom Clusters and Pain Interference in Post-9/11 Veterans: Exploring Sleep Impairment and Physical Activity as Underlying Mechanisms

BACKGROUND

Posttraumatic stress disorder (PTSD) symptoms and pain are highly prevalent and comorbid, particularly in veterans, but mechanisms explaining their linkage remain unclear. The aims of this study were to determine: (1) whether sleep impairment and physical activity (PA) mediate relations between PTSD symptoms and pain interference (assessed both longitudinally and as residual change) and (2) the unique roles of each PTSD symptom cluster in those relationships.

METHODS

The present study is a secondary analysis of a longitudinal observational investigation of 673 post-9/11 veterans (45.8% women). Surveys were administered at baseline and 3-month and 6-month follow-ups.

RESULTS

PTSD symptoms were significantly associated with pain interference longitudinally and worsening pain interference over time. Sleep impairment, but not PA, significantly mediated the relationship between PTSD symptoms and subsequent pain interference. Hyperarousal symptoms were found to be the primary driver of the relationship between PTSD symptoms and pain interference and re-experiencing symptoms were associated with change in pain interference via sleep impairment. Men and women did not differ on any of the study variables with the exception of PA.

CONCLUSION

Findings underscore the importance of targeting sleep as a key modifiable health factor linking PTSD symptoms to pain interference in post-9/11 veterans.

The role of veterans' PTSD symptoms in veteran couples' insomnia

Insomnia contributes to individual mental and physical health and relationship well-being. Veterans' PTSD symptoms are associated with their own insomnia. However, research has not explored whether and how veterans' PTSD symptoms are associated with their partners' insomnia. The present study examined the association between veterans' PTSD symptom severity and veterans' and partners' insomnia. Veterans (n = 192) and their partners (n = 192; total N = 384) completed baseline assessments in a PTSD treatment study for veterans with PTSD and their partners. Path analysis was used to examine the relation between veterans' PTSD symptom severity, as measured by the PTSD symptom checklist-5 (PCL-5) and veterans' and partners' insomnia, as measured by the Insomnia Severity Index (ISI). Veterans' full-scale PCL-5 was positively related to veterans' and partners' insomnia. For veterans, intrusion and arousal symptoms were positively related to their own insomnia severity, while veterans' negative alterations in cognition and mood were associated with partners' insomnia severity. In exploratory analyses, partners' depressive symptoms fully mediated the relation between veterans' negative cognitions and mood and partners' insomnia. PTSD symptoms impact both veterans' and partners' insomnia. However, different PTSD symptom clusters were related to insomnia for each partner, and the link for partners was explained by their own depression symptoms. PTSD, insomnia, and integrated treatments should consider strategies for including partners in treatment to address these interconnected problems.

Scoping Review on the Diagnosis, Prognosis, and Treatment of Pediatric Disorders of Consciousness

BACKGROUND AND OBJECTIVES

Comprehensive guidelines for the diagnosis, prognosis, and treatment of disorders of consciousness (DoC) in pediatric patients have not yet been released. We aimed to summarize available evidence for DoC with >14 days duration to support the future development of guidelines for children, adolescents and young adults aged 6 months-18 years.

METHODS

This scoping review was reported based on Preferred Reporting Items for Systematic reviews and Meta-Analyses-extension for Scoping Reviews guidelines. A systematic search identified records from 4 databases: PubMed, Embase, Cochrane Library, and Web of Science. Abstracts received 3 blind reviews. Corresponding full-text articles rated as "in-scope" and reporting data not published in any other retained article (i.e., no double reporting) were identified and assigned to 5 thematic evaluating teams. Full-text articles were reviewed using a double-blind standardized form. Level of evidence was graded, and summative statements were generated.

RESULTS

On November 9, 2022, 2,167 documents had been identified; 132 articles were retained, of which 33 (25%) were published over the past 5 years. Overall, 2,161 individuals met the inclusion criteria; female patients were 527 of 1,554 (33.9%) cases included, whose sex was identifiable. Of 132 articles, 57 (43.2%) were single case reports and only 5 (3.8%) clinical trials; the level of evidence was prevalently low (80/132; 60.6%). Most studies included neurobehavioral measures (84/127; 66.1%) and neuroimaging (81/127; 63.8%); 59 (46.5%) were mainly related to diagnosis, 56 (44.1%) to prognosis, and 44 (34.6%) to treatment. Most frequently used neurobehavioral tools included the Coma Recovery Scale-Revised, Coma/Near-Coma Scale, Level of Cognitive Functioning Assessment Scale, and Post-Acute Level of Consciousness scale. EEG, event-related potentials, structural CT, and MRI were the most frequently used instrumental techniques. In 29/53 (54.7%) cases, DoC improvement was observed, which was associated with treatment with amantadine.

DISCUSSION

The literature on pediatric DoCs is mainly observational, and clinical details are either inconsistently presented or absent. Conclusions drawn from many studies convey insubstantial evidence and have limited validity and low potential for translation in clinical practice. Despite these limitations, our work summarizes the extant literature and constitutes a base for future guidelines related to the diagnosis, prognosis, and treatment of pediatric DoC.

The role of pain and socioenvironmental factors on posttraumatic stress disorder symptoms in traumatically injured adults: A 1-year prospective study

Approximately 20% of individuals who experience a traumatic injury will subsequently develop posttraumatic stress disorder (PTSD). Physical pain following traumatic injury has received increasing attention as both a distinct, functionally debilitating disorder and a comorbid symptom related to PTSD. Studies have demonstrated that both clinician-assessed injury severity and patient pain ratings can be important predictors of nonremitting PTSD; however, few have examined pain and PTSD alongside socioenvironmental factors. We postulated that both area- and individual-level socioeconomic circumstances and lifetime trauma history would be uniquely associated with PTSD symptoms and interact with the pain-PTSD association. To test these effects, pain and PTSD symptoms were assessed at four visits across a 1-year period in a sample of 219 traumatically injured participants recruited from a Level 1 trauma center. We used a hierarchal linear modeling approach to evaluate whether (a) patient-reported pain ratings were a better predictor of PTSD than clinician-assessed injury severity scores and (b) socioenvironmental factors, specifically neighborhood socioeconomic disadvantage, individual income, and lifetime trauma history, influenced the pain-PTSD association. Results demonstrated associations between patient-reported pain ratings, but not clinician-assessed injury severity scores, and PTSD symptoms, R^{2( fvm )} = .65. There was a significant interaction between neighborhood socioeconomic disadvantage and pain such that higher disadvantage decreased the strength of the pain-PTSD association but only among White participants, R^{2( fvm )} = .69. Future directions include testing this question in a larger, more diverse sample of trauma survivors (e.g., geographically diverse) and examining factors that may alleviate both pain and PTSD symptoms.

Longing for sleep after violence: The impact of PTSD symptoms, avoidance, and pain on insomnia among female veterans

Women survivors of intimate partner violence often struggle with mental and physical problems that arise from incidents of violence. Beyond posttraumatic stress disorder (PTSD), the most common outcome, women also may suffer from debilitating chronic pain due to physical injuries sustained during particularly violent physical and/or sexual encounters. This may be a key interaction to explore as PTSD can lead to avoidance of distressing experiences, including chronic pain, resulting in enduring medical problems such as extreme sleep difficulties. This study aimed to identify if posttraumatic stress disorder (PTSD) symptoms from intimate partner violence (IPV) experiences had a conditional indirect effect on insomnia via chronic pain severity moderated by experiential avoidance among women. Female Veterans of at least 18 years of age completed online surveys at three timepoints (T1-T3) between 2014 and 2017 that included measures of PTSD, chronic pain, experiential avoidance, and insomnia. A total of 411 women participated in the initial survey at T1; 208 had a lifetime history of IPV experiences. The conditional indirect effect of PTSD symptoms (T1) on insomnia (T3) via chronic pain (T2) contingent upon experiential avoidance (T2) was also significant, demonstrating a significant moderated mediation model. This model was not significant for women without a history of IPV at T1. The findings indicate that women with IPV-related PTSD symptoms who are highly avoidant are more likely to experience chronic pain, leading to worse insomnia. Women without IPV experiences did not exhibit this same pattern. Findings have implications for improving trauma-focused treatment, approach coping strategies, pain management, and sleep interventions to address these deleterious psychological and medical issues.

Neurobehavioral Symptoms in U.S. Special Operations Forces in Rehabilitation After Traumatic Brain Injury: A TBI Model Systems Study

INTRODUCTION

Special Operations Forces (SOF) personnel are at increased risk for traumatic brain injury (TBI), when compared with conventional forces (CF). Prior studies of TBI in military samples have not typically investigated SOF vs. CF as specific subgroups, despite documented differences in premorbid resilience and post-injury comorbidity burden. The aim of the current study was to compare SOF vs. CF on the presence of neurobehavioral symptoms after TBI, as well as factors influencing perception of symptom intensity.

MATERIALS AND METHODS

This study conducted an analysis of the prospective veterans affairs (VA) TBI Model Systems Cohort, which includes service members and veterans (SM/V) who received inpatient rehabilitation for TBI at one of the five VA Polytrauma Rehabilitation Centers. Of those with known SOF status (N = 342), 129 participants identified as SOF (average age = 43 years, 98% male) and 213 identified as CF (average age = 38.7 years, 91% male). SOF vs. CF were compared on demographics, injury characteristics, and psychological and behavioral health symptoms. These variables were then used to predict neurobehavioral symptom severity in univariable and multivariable analyses.

RESULTS

SOF personnel reported significantly greater posttraumatic stress disorder (PTSD) symptoms but less alcohol and drug use than the CF. SOF also reported greater neurobehavioral symptoms. When examining those with TBIs of all severities, SOF status was not associated with neurobehavioral symptom severity, while race, mechanism of TBI, and PTSD symptoms were. When examining only those with mTBI, SOF status was associated with lower neurobehavioral symptoms, while PTSD severity, white race, and certain mechanisms of injury were associated with greater neurobehavioral symptoms.

CONCLUSIONS

Among those receiving inpatient treatment for TBI, SOF SM/V reported higher neurobehavioral and symptom severity. PTSD was the strongest predictor of neurobehavioral symptoms and should be considered an important treatment target in both SOF and CF with co-morbid PTSD/TBI. A proactive human performance approach towards identification and treatment of psychological and neurobehavioral symptoms is recommended for SOF.

Correlates of sleep disturbance in Veterans with traumatic brain injury and chronic pain: A cross-sectional study

BACKGROUND

Few studies have investigated sleep in Veterans with comorbid traumatic brain injury (TBI) and chronic pain.

OBJECTIVE

To describe mood and cognitive correlates with sleep disturbance in a sample of Veterans with both TBI and chronic pain.

RESEARCH METHOD

Cross-sectional, correlational analyses were completed using baseline data from a randomized controlled trial comparing psychosocial treatments for pain in Veterans with TBI. Enrollment occurred between July 2015 and January 2017. Self-report measures of hours slept, insomnia severity, depression and PTSD symptoms were collected along with a brief neuropsychological assessment.

RESULTS

Participants (n = 221) were an average age of 37.2 years (SD = 8.2) and mostly male (89%). Participants reported sleeping an average of 4.9 h a night (SD = 1.4) with an average Insomnia Severity Index (ISI) score of 17.4 (SD = 5.4) suggesting moderate insomnia symptoms. Fewer hours slept was associated with higher depression scores (r = -0.28, p < 0.001) and slower processing speed (r = 0.23, p < 0.001). Increasing insomnia severity was associated with greater depression (r = 0.57, p < 0.001) and PTSD symptoms (r = 0.44, p < 0.001), and slower processing speed (r = -0.22, p < 0.001).

CONCLUSIONS

The average ISI score was above the clinical cut off for insomnia diagnosis. Results suggest that those with more severe insomnia symptoms report higher depression and PTSD symptoms as well as exhibit slower processing speed. Improving sleep in this population may be important for improving outcome following TBI.

Perceived benefits of a brief acupuncture for sleep disturbances in post-deployment military service members

STUDY OBJECTIVES

The purpose of this study was to describe the perceived benefits of a manual standardized stress acupuncture (MSSA) for sleep disturbances (SD) in service members with deployment exposure.

METHODS

This qualitative study was imbedded in a two-arm randomized controlled trial, mixed-methods research that evaluated the effect of weekly MSSA for four weeks as an adjunct treatment with an abbreviated cognitive behavioral therapy for insomnia (CBTi) for SD in service members. Participants were randomized to either the experimental group (CBTi and MSSA) and control group (CBTi only). CBTi consisted of one group psychotherapy for 60 minutes, a follow-up telephone therapy for 30 minutes, and additional four 30-minute follow-up sessions via telephone. Participants provided written journal entries by answering five open-ended questions about their treatment experiences at week five during the posttreatment assessment. Journal log entries were transcribed verbatim in the Dedoose software. A thematic content analysis method was used to code emerging themes.

RESULTS

Three overarching categories were found from the qualitative data: personal challenges in implementing the CBTi sleep strategies, no perception of improvement from treatment, and perceived benefits of treatment. The CBTi/MSSA group reported greater benefits in sleep and in other life areas including mental, physical, and social functioning using thematic content analysis.

CONCLUSIONS

Findings of this study showed greater improvements in participants' sleep, mood, physical health, and occupational and social functioning after receiving the combination of CBTi and MSSA. Future research that investigates the long-term effects of CBTi and MSSA may be beneficial among post-deployment service members.

CLINICAL TRIAL REGISTRATION

Our study was conducted as part of a mixed-methods study registered with clinicaltrials.gov identifier: NCT04031365.

Trauma-Related Sleep Problems and Associated Health Outcomes in Police Officers: A Path Analysis

Police officers are frequently exposed to two different types of potentially traumatic events: one dealing with physical threats to self and the other involving the witnessing of harm to others. These different types of traumatic experiences are thought to produce various posttraumatic reactions. Furthermore, sleep problems are also reported as a hallmark of posttraumatic stress disorder. There is evidence, however, that sleep problems may mediate the relationship between posttraumatic stress disorder symptoms and health outcomes, especially physical health and depression. Previous research has shown this to be the case among officers from large urban agencies. The purpose of the present study was to test a model involving a pathway from trauma type and posttraumatic stress disorder symptoms to physical health and depression that is mediated by sleep quality in officers (N = 193) using data from small- to mid-size police agencies. Results revealed that sleep problems served as a mediator between posttraumatic stress disorder hyperarousal and avoidance symptoms and health outcomes, that the trauma types are related to different posttraumatic stress disorder symptoms, and that complicated relationships exist between the study variables. In addition, the results indicated that approximately 25% of our sample displayed probable partial posttraumatic stress disorder or probable full posttraumatic stress disorder, causing substantial functional impairment. Suggestions for improving officer health and performance in the field are provided. Specifically, it appears that interventions designed to address posttraumatic stress disorder hyperarousal symptoms related to personal life threat and the posttraumatic stress disorder avoidance symptoms related to the witnessing of human suffering may maximize officer sleep quality and ultimately overall wellness. In particular, mindfulness-based interventions are well suited for addressing these symptom clusters.

The influence of sleep disturbances and sleep disorders on pain outcomes among veterans: A systematic scoping review

Chronic nonmalignant pain, sleep disturbances and sleep disorders are highly prevalent conditions among U.S. military veterans. Evidence summaries highlight the influence of sleep on pain outcomes in the general adult population but not for the military veteran population. This is a significant gap as U.S. military veterans are an exceedingly high-risk population for both chronic pain and sleep disturbances and/or disorders. We aimed to review the influence of sleep disturbances and sleep disorders on pain outcomes among veterans with chronic nonmalignant pain. A systematic scoping review was conducted using PubMed/Medline, EMBASE, Scopus, CINAHL, and PsycINFO. Twenty-six out of 1450 studies from initial search were included in this review resulting in a combined sample size of N = 923,434 participants. Sleep disturbances and sleep disorders were associated with worse pain outcomes among veterans with chronic pain. Treatment-induced sleep improvements ameliorated pain outcomes in veterans with sleep disorders and sleep disturbances. Research is indicated to address an overlooked pain treatment opportunity - that of sleep disturbance and sleep disorder management.

Pain interference and quality of life in combat veterans: Examining the roles of posttraumatic stress disorder, traumatic brain injury, and sleep quality

OBJECTIVE

The goal of this study was to examine the associations among posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), sleep quality, pain interference, and quality of life in combat veterans.

METHOD

Veterans (N = 289, 86.51% male) completed the Mid-Atlantic MIRECC Assessment of Traumatic Brain Injury, the Clinician-Administered PTSD Scale for DSM-5, and measures of sleep quality, pain interference, and quality of life.

RESULTS

Hierarchical linear regressions evaluated associations between PTSD severity, deployment TBI severity, sleep quality, and the outcomes of pain interference and quality of life after adjusting for demographic variables and the number of nondeployment TBIs. PTSD severity, B = 0.15, SE B = 0.04, deployment TBI severity, B = 3.98, SE B = 1.01, and sleep quality, B = 0.74, SE B = 0.13, were significantly associated with pain interference, p < .001. PTSD severity, B = -0.57, SE B = 0.07, and pain interference, B = -0.45, SE B = 0.11, were significantly, independently associated with quality of life, p < .001. However, pain interference, B = -0.24, SE B = 0.11, was no longer significantly associated with quality of life when sleep quality, B = -1.56, SE B = 0.25, was included in the model. There was no significant association between deployment TBI severity and quality of life. Interactions among the studied variables were not significant for either of the outcome variables.

CONCLUSIONS

PTSD symptom severity, deployment TBI history, and sleep quality may be important to consider in treatment planning for veterans experiencing pain-related functional interference. For veterans with numerous conditions comorbid with pain, treatment plans may include interventions targeting sleep and PTSD to maximize quality of life improvements. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Traumatic brain injury and sleep disturbances in combat-exposed service members and veterans: Where to go next?

OBJECTIVE

To synthesize the current evidence on sleep disturbances in military service members (SMs) and veterans with traumatic brain injury (TBI).

METHODS

An electronic literature search first identified abstracts published from 2008-2018 inclusively referencing sleep, TBI, and military personnel from Operation Enduring Freedom, Operation Iraqi Freedom, Operation New Dawn, and Persian Gulf veterans. Selection criteria eliminated studies on non-combat TBI, open or penetrating injuries, and articles where the relationship between sleep and TBI was not directly examined. Articles on all military branches and components, those currently serving and veterans-ranging from medical chart reviews to clinical trials, were included. Forty-one articles were selected for full text-review.

RESULTS

Twenty-four papers estimated the prevalence of sleep disturbances in TBI. Eight studies demonstrated the contribution of common co-occurring conditions, most notably posttraumatic stress disorder, to the relationship between disrupted sleep and TBI. Ten studies differentiated sleep profiles between military SMs and veterans with and without acute TBI and detected significant differences in sleep disturbances across the course of injury. Longitudinal studies were scarce but helped to establish the temporal relationship between sleep disturbances and TBI and isolate sleep-related mechanisms influencing TBI prognosis. Only three studies reported on interventions for improving sleep quality and TBI symptoms. Systematic research testing assessments and interventions that target sleep disturbances for improving sleep, TBI symptoms, and long-term functional outcomes were identified as critical knowledge gaps.

CONCLUSION

Findings unequivocally establish that sleep disturbances are highly prevalent in SMs and veterans with TBI. However, studies testing the effectiveness of treatments for improving sleep in military groups with TBI have been limited and their results inconsistent. This review highlights a critical opportunity for advancing military medicine through future research aimed at identifying and testing sleep-focused treatments in SMs and veterans with combat-related TBI.

Equine-assisted interventions for veterans with service-related health conditions: a systematic mapping review

BACKGROUND

Evidence-based treatments for service-related health conditions such as posttraumatic stress disorder (PTSD), depression, and traumatic brain injury (TBI) are not effective for all veterans. Equine-assisted interventions are emerging as an additional treatment modality, but little is known regarding the safe and effective delivery of these interventions. This study aimed to describe the following features of the body of literature concerning equine-assisted interventions among veterans: 1) veterans who have participated in equine-assisted interventions; 2) specific characteristics of equine-assisted interventions in veterans; and 3) the specific characteristics of research on equine-assisted interventions in veterans.

METHODS

We conducted a systematic mapping review of peer-reviewed literature reporting on equine-assisted interventions among veterans between 1980 and 2017. Searches of nine databases yielded 3336 unique records, six of which met the inclusion criteria and were reviewed. Data relevant to the study aims were extracted and analyzed.

RESULTS

Equine-assisted interventions among veterans disproportionately targeted psychosocial outcomes and yielded promising results. The detailed methods of EAI varied in the reported studies, ranging from communicating with the horse to mounted exercises. There was also great diversity in outcome measurement. The state of theoretical development regarding the mechanisms by which equine-assisted interventions benefit the veteran population is currently underdeveloped. Studies provided insufficient detail with respect to the description of the intervention, reasons for attrition, and the dose-response relationship.

CONCLUSIONS

Scientific development of equine-assisted interventions targeting psychosocial outcomes among veterans is warranted to establish their efficacy. Targeted outcomes should be expanded, including outcomes more closely aligned with the nature of polytraumatic injuries. Future research must also emphasize the theoretical development of equine-assisted interventions for veterans and thoroughly describe the participants, components of the intervention, factors contributing to attrition, and optimal dose-response relationships.

Complementary and Integrated Health Approaches: What Do Veterans Use and Want

OBJECTIVES

Non-pharmacological treatment options for common conditions such as chronic pain, anxiety, and depression are being given increased consideration in healthcare, especially given the recent emphasis to address the opioid crisis. One set of non-pharmacological treatment options are evidence-based complementary and integrative health (CIH) approaches, such as yoga, acupuncture, and meditation. The Veterans Health Administration (VHA), the nation's largest healthcare system, has been at the forefront of implementing CIH approaches, given their patients' high prevalence of pain, anxiety, and depression. We aimed to conduct the first national survey of veterans' interest in and use of CIH approaches.

METHODS

Using a large national convenience sample of veterans who regularly use the VHA, we conducted the first national survey of veterans' interest in, frequency of and reasons for use of, and satisfaction with 26 CIH approaches (n = 3346, 37% response rate) in July 2017.

RESULTS

In the past year, 52% used any CIH approach, with 44% using massage therapy, 37% using chiropractic, 34% using mindfulness, 24% using other meditation, and 25% using yoga. For nine CIH approaches, pain and stress reduction/relaxation were the two most frequent reasons veterans gave for using them. Overall, 84% said they were interested in trying/learning more about at least one CIH approach, with about half being interested in six individual CIH approaches (e.g., massage therapy, chiropractic, acupuncture, acupressure, reflexology, and progressive relaxation). Veterans appeared to be much more likely to use each CIH approach outside the VHA vs. within the VHA.

CONCLUSIONS

Veterans report relatively high past-year use of CIH approaches and many more report interest in CIH approaches. To address this gap between patients' level of interest in and use of CIH approaches, primary care providers might want to discuss evidence-based CIH options to their patients for relevant health conditions, given most CIH approaches are safe.

A Mobile and Web-Based Self-Directed Complementary and Integrative Health Program for Veterans and Their Partners (Mission Reconnect): Protocol for a Mixed-Methods Randomized Controlled Trial

Background

Complementary and integrative health (CIH) is a viable solution to PTSD and chronic pain. Many veterans believe CIH can be performed only by licensed professionals in a health care setting. Health information technology can bring effective CIH to veterans and their partners.

Objective

This paper describes the rationale, design, and methods of the Mission Reconnect protocol to deliver mobile and Web-based complementary and integrative health programs to veterans and their partners (eg, spouse, significant other, caregiver, or family member).

Methods

This three-site, 4-year mixed-methods randomized controlled trial uses a wait-list control to determine the effects of mobile and Web-based CIH programs for veterans and their partners, or dyads. The study will use two arms (ie, treatment intervention arm and wait-list control arm) in a clinical sample of veterans with comorbid pain and posttraumatic stress disorder, and their partners. The study will evaluate the effectiveness and perceived value of the Mission Reconnect program in relation to physical and psychological symptoms, global health, and social outcomes.

Results

Funding for the study began in November 2018, and we are currently in the process of recruitment screening and data randomization for the study. Primary data collection will begin in May 2019 and continue through May 2021. Projected participants per site will be 76 partners/dyads, for a total of 456 study participants. Anticipated study results will be published in November 2022.

Conclusions

This work highlights innovative delivery of CIH to veterans and their partners for treatment of posttraumatic stress disorder and chronic pain.

Trial Registration

ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/ct2/show/NCT03593772 (Archived by WebCite at http://www.webcitation.org/77Q2giwtw)

International Registered Report Identifier (IRRID)

PRR1-10.2196/13666

Increased Sleep Disturbances and Pain in Veterans With Comorbid Traumatic Brain Injury and Posttraumatic Stress Disorder

STUDY OBJECTIVES

Veterans are at an increased risk for traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), both of which are associated with sleep disturbances and increased pain. Furthermore, sleep disturbances and pain are reciprocally related such that each can exacerbate the other. Although both TBI and PTSD are independently linked to sleep disturbances and pain, it remains unclear whether Veterans with comorbid TBI+PTSD show worse sleep disturbances and pain compared to those with only TBI or PTSD. We hypothesized that sleep and pain would be worse in Veterans with comorbid TBI+PTSD compared to Veterans with only TBI or PTSD.

METHODS

Veterans (n = 639) from the VA Portland Health Care System completed overnight polysomnography and self-report questionnaires. Primary outcome variables were self-reported sleep disturbances and current pain intensity. Participants were categorized into four trauma-exposure groups: (1) neither: without TBI or PTSD (n = 383); (2) TBI: only TBI (n = 67); (3) PTSD: only PTSD (n = 126); and (4) TBI+PTSD: TBI and PTSD (n = 63).

RESULTS

The PTSD and TBI+PTSD groups reported worse sleep compared to the TBI and neither groups. The TBI+PTSD group reported the greatest pain intensity compared to the other groups.

CONCLUSIONS

These data suggest sleep and pain are worst in Veterans with TBI and PTSD, and that sleep is similarly impaired in Veterans with PTSD despite not having as much pain. Thus, although this is a complex relationship, these data suggest PTSD may be driving sleep disturbances, and the added effect of TBI in the comorbid group may be driving pain in this population.

The Association of Dry Eye Symptom Severity and Comorbid Insomnia in US Veterans

PURPOSE

To investigate the association between dry eye (DE) and insomnia symptom severity.

METHODS

Cross-sectional study of 187 individuals seen in the Miami Veterans Affairs eye clinic. An evaluation was performed consisting of questionnaires regarding insomnia (insomnia severity index [ISI]) and DE symptoms, including ocular pain, followed by a comprehensive ocular surface examination. Using a two-step cluster analysis based on intensity ratings of ocular pain, the patient population was divided into two groups (high and low ocular pain groups: HOP and LOP). A control group was ascertained at the same time from the same clinic as defined by no symptoms of DE (Dry Eye Questionnaire 5 [DEQ5], <6). The main outcome measure was the frequency of moderate or greater insomnia in the DE groups.

RESULTS

The mean age of the study sample was 63 years, and 93% were male. All insomnia complaints were rated higher in the HOP group compared with the LOP and control groups (P<0.0005). Most (61%) individuals in the HOP group experienced insomnia of at least moderate severity (ISI≥15) compared with the LOP (41%) and control groups (18%) (P<0.0005). Black race (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.2-6.0; P=0.02), depression severity (OR, 1.2; 95% CI, 1.1-1.3; P<0.0005), and DE symptom severity (DEQ5; OR, 1.1; 95% CI, 1.01-1.2; P=0.03) were significantly associated with clinical insomnia (ISI≥15) after controlling for potential confounders.

CONCLUSIONS

After adjusting for demographics and medical comorbidities, we show that DE symptom severity is positively associated with insomnia severity.

Medical-encounter mental health diagnoses, non-fatal injury and polypharmacy indicators of risk for accident death in the US Army enlisted soldiers, 2004-2009

Accidents are a leading cause of deaths in U.S. active duty personnel. Understanding accident deaths during wartime could facilitate future operational planning and inform risk prevention efforts. This study expands prior research, identifying health risk factors associated with U.S. Army accident deaths during the Afghanistan and Iraq war. Military records for 2004-2009 enlisted, active duty, Regular Army soldiers were analyzed using logistic regression modeling to identify mental health, injury, and polypharmacy (multiple narcotic and/or psychotropic medications) predictors of accident deaths for current, previously, and never deployed groups. Deployed soldiers with anxiety diagnoses showed higher risk for accident deaths. Over half had anxiety diagnoses prior to being deployed, suggesting anticipatory anxiety or symptom recurrence may contribute to high risk. For previously deployed soldiers, traumatic brain injury (TBI) indicated higher risk. Two-thirds of these soldiers had first TBI medical-encounter while non-deployed, but mild, combat-related TBIs may have been undetected during deployments. Post-Traumatic Stress Disorder (PTSD) predicted higher risk for never deployed soldiers, as did polypharmacy which may relate to reasons for deployment ineligibility. Health risk predictors for Army accident deaths are identified and potential practice and policy implications discussed. Further research could test for replicability and expand models to include unobserved factors or modifiable mechanisms related to high risk. PTSD predicted high risk among those never deployed, suggesting importance of identification, treatment, and prevention of non-combat traumatic events. Finally, risk predictors overlapped with those identified for suicides, suggesting effective intervention might reduce both types of deaths.

The Explanatory Role of Insomnia in the Relationship between Pain Intensity and Posttraumatic Stress Symptom Severity among Trauma-Exposed Latinos in a Federally Qualified Health Center

Latinos, one of the fastest growing populations in the United States, suffer from high rates of posttraumatic stress symptoms (PTS) and its clinical correlates (e.g., disability). Although research suggests the experience of pain is closely related to PTS among trauma-exposed groups, there has been little exploration of the processes that may link pain intensity to greater PTS among trauma-exposed Latinos. The current study explored insomnia, a common problem associated with both pain intensity and PTS, as a mechanism in the association between pain intensity and PTS among trauma-exposed Latinos (N = 208, M_age = 39.39 years, SD = 11.48) attending a Federally Qualified Health Center. Results indicated that insomnia partially explained the relationship between pain intensity and PTS total score (B = 0.25, 95% CI [0.12, 0.43]), as well as re-experiencing (B = 0.09, 95% CI [0.04, 0.17]), avoidance (B = 0.09, 95% CI [0.04, 0.17]), and arousal symptoms (B = 0.10, 95% CI [0.04, 0.17]). Future work is needed to explore the extent to which insomnia accounts for relations between pain and PTS using longitudinal designs to further clarify theoretical health disparity models involving these comorbid conditions.

Chronic Pain Types Differ in Their Reported Prevalence of Post -Traumatic Stress Disorder (PTSD) and There Is Consistent Evidence That Chronic Pain Is Associated with PTSD: An Evidence-Based Structured Systematic Review

Objectives

The hypotheses of this systematic review were the following: 1) Prevalence of post-traumatic stress disorder (PTSD) will differ between various types of chronic pain (CP), and 2) there will be consistent evidence that CP is associated with PTSD.

Methods

Of 477 studies, 40 fulfilled the inclusion/exclusion criteria of this review and were grouped according to the type of CP. The reported prevalence of PTSD for each grouping was determined by aggregating all the patients in all the studies in that group. Additionally all patients in all groupings were combined. Percentage of studies that had found an association between CP and PTSD was determined. The consistency of the evidence represented by the percentage of studies finding an association was rated according to the Agency for Health Care Policy and Research guidelines.

Results

Grouping PTSD prevalence differed ranging from a low of 0.69% for chronic low back pain to a high of 50.1% in veterans. Prevalence in the general population with CP was 9.8%. Of 19 studies, 16 had found an association between CP and PTSD (84.2%) generating an A consistency rating (consistent multiple studies). Three of the groupings had an A or B (generally consistent) rating. The veterans grouping received a C (finding inconsistent) rating.

Conclusion

The results of this systematic review confirmed the hypotheses of this review.

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.

Targets for the Treatment of Insomnia in Veterans With Serious Mental Illness

STUDY OBJECTIVES

Insomnia is pervasive among people with serious mental illnesses (SMI) and has a profound negative impact on their psychiatric symptom management and recovery. However, little is known about the factors that affect severity of insomnia in those with SMI. In addition, very few studies have explored whether evidence-based interventions developed for those without SMI are appropriate for or applicable to individuals with SMI. The purpose of this study was to test the role of arousal, dysfunctional cognitions about sleep, and sleep-related behaviors in predicting severity of insomnia in a sample of 60 Veterans who were receiving care in Veterans Health Administration mental health and psychosocial rehabilitation programs and who reported subjective insomnia. In addition, information was collected regarding the types of insomnia treatments provided to these Veterans.

METHODS

Participants completed assessments of insomnia severity and sleep-related arousal, behaviors, and cognitions. Medical records were reviewed to determine whether participants had been screened/assessed for insomnia and whether treatments for insomnia were provided before the date of referral to the study. Multiple regression was used to predict insomnia severity on the basis of these factors.

RESULTS

Most participants (81.7%) reported moderate to severe insomnia, although only 3.3% had a diagnosis of insomnia in their medical records. Worry and helplessness about sleep were predictive of insomnia severity; better self-reported sleep hygiene and higher levels of arousal were also associated with greater severity of insomnia. Education about sleep hygiene and medication were the only types of insomnia treatment received.

CONCLUSIONS

Similar to insomnia among individuals without SMI, insomnia in Veterans with SMI is associated with dysfunctional sleep-related behaviors and cognitions. Many of the Veterans also lacked access to settings and resources conducive to healthy sleep. Veterans with SMI should be regularly assessed for insomnia. Research is needed concerning optimal evidence-based insomnia interventions for addressing behaviors and cognitions in this population in the context of these challenges.

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

PURPOSE OF REVIEW

The goal of this review is to integrate recent findings on sleep disturbance and PTSD, examine sleep disturbance as a causal factor in the development of PTSD, and identify future directions for research, treatment, and prevention.

RECENT FINDINGS

Recent research highlights a relationship between both objective and subjective sleep disturbance and PTSD across diverse samples. Sleep disturbance also predicts PTSD over time. Finally, treatments targeting sleep disturbance lead to decreased PTSD symptoms, while standard PTSD treatments conclude with residual sleep disturbance. Sleep disturbance may be more than a mere epiphenomenon of PTSD. Future research examining the causal role of sleep disturbance in the development of PTSD, as well as the utility of targeting sleep disturbance in prevention and treatment, is necessary to fully understand the likely bidirectional relationship between sleep disturbance and PTSD.

Predictors of PTSD Symptom Change Among Outpatients in the U.S. Department of Veterans Affairs Health Care System

Although the U.S. Department of Veterans Affairs (VA) has prioritized care for posttraumatic stress disorder (PTSD), many patients with PTSD remain symptomatic. Patterns of PTSD symptom change are not well understood. Thus, the current study was designed to categorize and investigate potential predictors of symptom trajectories in patients with PTSD. The sample comprised 2,237 VA patients who were diagnosed with PTSD in 2013 and completed at least 4 PTSD Checklist (PCL) assessments over 12 weeks. Latent trajectory analysis was used to identify latent classes of patients based on PCL scores. Based on model fit indices, 3 trajectories were identified. Compared to patients in the mild-improving trajectory (21.9%), those in the severe-stable trajectory (34.3%) were more likely to be male, relative risk ratio (RRR) = 1.48, 95% CI [1.08, 2.02]; non-White, RRR = 1.77, 95% CI [1.33, 2.35]; Hispanic, RRR = 2.07, 95% CI [1.40, 3.04]; and have comorbid depression, RRR = 1.58, 95% CI [1.25, 1.99]. Compared to patients in the moderate-improving trajectory (43.8%), those in the severe-stable trajectory were more likely to have sleep disorders, RRR = 1.25, 95% CI [1.01, 1.55]. Our findings suggest that male veterans, minority veterans, and veterans with certain comorbid conditions may be less likely to achieve improved PTSD symptoms. Targeted efforts are needed to improve outcomes for PTSD patients on nonremitting trajectories and to improve the consistency of PTSD assessment across the VA health care system.

Combat-Acquired Traumatic Brain Injury, Posttraumatic Stress Disorder, and Their Relative Associations With Postdeployment Binge Drinking

OBJECTIVE

To examine whether experiencing a traumatic brain injury (TBI) on a recent combat deployment was associated with postdeployment binge drinking, independent of posttraumatic stress disorder (PTSD).

METHODS

Using the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel, an anonymous survey completed by 28 546 personnel, the study sample included 6824 personnel who had a combat deployment in the past year. Path analysis was used to examine whether PTSD accounted for the total association between TBI and binge drinking.

MAIN MEASURES

The dependent variable, binge drinking days, was an ordinal measure capturing the number of times personnel drank 5+ drinks on one occasion (4+ for women) in the past month. Traumatic brain injury level captured the severity of TBI after a combat injury event exposure: TBI-AC (altered consciousness only), TBI-LOC of 20 or less (loss of consciousness up to 20 minutes), and TBI-LOC of more than 20 (loss of consciousness >20 minutes). A PTSD-positive screen relied on the standard diagnostic cutoff of 50+ on the PTSD Checklist-Civilian.

RESULTS

The final path model found that while the direct effect of TBI (0.097) on binge drinking was smaller than that of PTSD (0.156), both were significant. Almost 70% of the total effect of TBI on binge drinking was from the direct effect; only 30% represented the indirect effect through PTSD.

CONCLUSION

Further research is needed to replicate these findings and to understand the underlying mechanisms that explain the relationship between TBI and increased postdeployment drinking.

Pathophysiological links between traumatic brain injury and post-traumatic headaches

This article reviews possible ways that traumatic brain injury (TBI) can induce migraine-type post-traumatic headaches (PTHs) in children, adults, civilians, and military personnel. Several cerebral alterations resulting from TBI can foster the development of PTH, including neuroinflammation that can activate neural systems associated with migraine. TBI can also compromise the intrinsic pain modulation system and this would increase the level of perceived pain associated with PTH. Depression and anxiety disorders, especially post-traumatic stress disorder (PTSD), are associated with TBI and these psychological conditions can directly intensify PTH. Additionally, depression and PTSD alter sleep and this will increase headache severity and foster the genesis of PTH. This article also reviews the anatomic loci of injury associated with TBI and notes the overlap between areas of injury associated with TBI and PTSD.

A systematic review of sleep disturbance in anxiety and related disorders

Recent research suggests that sleep disturbance may be a transdiagnostic process, and there is increasing interest in examining how sleep disturbance may contribute to anxiety and related disorders. The current review summarizes and synthesizes the extant research assessing sleep in anxiety and related disorders. The findings suggest that sleep disturbance exacerbates symptom severity in the majority of anxiety and related disorders. However, the nature of sleep disturbance often varies as a function of objective versus subjective assessment. Although sleep disturbance is a correlate of most anxiety and related disorders, a causal role for sleep disturbance is less clear. A model of potential mechanisms by which sleep disturbance may confer risk for the development of anxiety and related disorders is discussed. Future research integrating findings from basic sleep research with current knowledge of anxiety and related disorders may facilitate the development of novel treatments for comorbid sleep disturbance and clinical anxiety.

Insomnia in the Military: Application and Effectiveness of Cognitive and Pharmacologic Therapies

Insomnia is one of the most common complaints of US armed service members. Diagnosis and treatment of insomnia in active duty and veteran populations are often complicated by comorbid disorders experienced by military personnel, such as post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). Cognitive behavioral therapy for insomnia (CBTi), pharmacologic interventions, and alternative therapies are discussed as relevant to their applications within military populations. Future directions in research are suggested.

Sleep Quality and Reexperiencing Symptoms of PTSD Are Associated With Current Pain in U.S. OEF/OIF/OND Veterans With and Without mTBIs

Pain, a debilitating condition, is frequently reported by U.S. veterans returning from Afghanistan and Iraq. This study investigated how commonly reported clinical factors were associated with pain and whether these associations differed for individuals with a history of chronic pain. From the Boston metropolitan area, 171 veterans enrolled in the Veterans Affairs Center of Excellence were assessed for current posttraumatic stress disorder (PTSD) symptom severity, current mood and anxiety diagnoses, lifetime traumatic brain injury, combat experiences, sleep quality, and alcohol use. Hierarchical regression models were used to determine the association of these conditions with current pain. Average pain for the previous 30 days, assessed with the McGill Pain Questionnaire, was 30.07 out of 100 (SD = 25.43). Sleep quality, PTSD symptom severity, and alcohol use were significantly associated with pain (R(2) = .24), as were reexperiencing symptoms of PTSD (R(2) = .25). For participants with a history of chronic pain (n = 65), only PTSD symptoms were associated with pain (R(2) = .19). Current pain severity was associated with increased PTSD severity (notably, reexperiencing symptoms), poor sleep quality, and increased alcohol use. These data support the hypothesis that PTSD symptoms influence pain, but suggest that problems with sleep and alcohol use may exacerbate the relationship.

Sleep disturbances, TBI and PTSD: Implications for treatment and recovery

Post-Traumatic Stress Disorder (PTSD), traumatic brain injury (TBI), and sleep problems significantly affect recovery and functional status in military personnel and Veterans returning from combat. Despite recent attention, sleep is understudied in the Veteran population. Few treatments and rehabilitation protocols target sleep, although poor sleep remains at clinical levels and continues to adversely impact functioning even after the resolution of PTSD or mild TBI symptoms. Recent developments in non-pharmacologic sleep treatments have proven efficacious as stand-alone interventions and have potential to improve treatment outcomes by augmenting traditional behavioral and cognitive therapies. This review discusses the extensive scope of work in the area of sleep as it relates to TBI and PTSD, including pathophysiology and neurobiology of sleep; existing and emerging treatment options; as well as methodological issues in sleep measurements for TBI and PTSD. Understanding sleep problems and their role in the development and maintenance of PTSD and TBI symptoms may lead to improvement in overall treatment outcomes while offering a non-stigmatizing entry in mental health services and make current treatments more comprehensive by helping to address a broader spectrum of difficulties.

Neurobiology of Sleep Disturbances in PTSD Patients and Traumatized Controls: MRI and SPECT Findings

OBJECTIVE

Sleep disturbances such as insomnia and nightmares are core components of post-traumatic stress disorder (PTSD), yet their neurobiological relationship is still largely unknown. We investigated brain alterations related to sleep disturbances in PTSD patients and controls by using both structural and functional neuroimaging techniques.

METHOD

Thirty-nine subjects either developing (n = 21) or not developing (n = 18) PTSD underwent magnetic resonance imaging and a symptom-provocation protocol followed by the injection of 99mTc-hexamethylpropyleneamineoxime. Subjects were also tested with diagnostic and self-rating scales on the basis of which a Sleep Disturbances Score (SDS; i.e., amount of insomnia/nightmares) was computed.

RESULTS

Correlations between SDS and gray matter volume (GMV)/regional cerebral blood flow (rCBF) were computed in the whole sample and separately in the PTSD and control groups. In the whole sample, higher sleep disturbances were associated with significantly reduced GMV in amygdala, hippocampus, anterior cingulate, and insula; increased rCBF in midbrain, precuneus, and insula; and decreased rCBF in anterior cingulate. This pattern was substantially confirmed in the PTSD group, but not in controls.

CONCLUSION

Sleep disturbances are associated with GMV loss in anterior limbic/paralimbic, PTSD-sensitive structures and with functional alterations in regions implicated in rapid eye movement-sleep control, supporting the existence of a link between PTSD and sleep disturbance.

Using information from the electronic health record to improve measurement of unemployment in service members and veterans with mTBI and post-deployment stress

OBJECTIVE

The purpose of this pilot study is 1) to develop an annotation schema and a training set of annotated notes to support the future development of a natural language processing (NLP) system to automatically extract employment information, and 2) to determine if information about employment status, goals and work-related challenges reported by service members and Veterans with mild traumatic brain injury (mTBI) and post-deployment stress can be identified in the Electronic Health Record (EHR).

DESIGN

Retrospective cohort study using data from selected progress notes stored in the EHR.

SETTING

Post-deployment Rehabilitation and Evaluation Program (PREP), an in-patient rehabilitation program for Veterans with TBI at the James A. Haley Veterans' Hospital in Tampa, Florida.

PARTICIPANTS

Service members and Veterans with TBI who participated in the PREP program (N = 60).

MAIN OUTCOME MEASURES

Documentation of employment status, goals, and work-related challenges reported by service members and recorded in the EHR.

RESULTS

Two hundred notes were examined and unique vocational information was found indicating a variety of self-reported employment challenges. Current employment status and future vocational goals along with information about cognitive, physical, and behavioral symptoms that may affect return-to-work were extracted from the EHR. The annotation schema developed for this study provides an excellent tool upon which NLP studies can be developed.

CONCLUSIONS

Information related to employment status and vocational history is stored in text notes in the EHR system. Information stored in text does not lend itself to easy extraction or summarization for research and rehabilitation planning purposes. Development of NLP systems to automatically extract text-based employment information provides data that may improve the understanding and measurement of employment in this important cohort.