Predictors of insomnia symptoms and nightmares among individuals with post-traumatic stress disorder: an ecological momentary assessment study

The associations between repetitive negative thinking, insomnia symptoms, and sleep quality in adults with a history of trauma

BACKGROUND

Posttraumatic stress disorder (PTSD) and sleep disturbance are highly comorbid and repetitive negative thinking (RNT) is associated with both sleep disturbance and PTSD. However, few studies have examined the association between RNT and sleep disturbance in individuals exposed to trauma, with and without PTSD.

METHOD

Associations between trait-level and trauma-related RNT, insomnia, and sleep quality were investigated in a trauma-exposed MTurk (N = 342) sample. Additionally, PTSD symptom severity was tested as a moderator of the associations between RNT and insomnia and sleep quality.

RESULTS

Trait-level RNT predicted poorer sleep quality and greater insomnia, regardless of PTSD severity. Trauma-related RNT was also associated with greater insomnia, though the effect was moderated by PTSD severity such that it was significant for participants with low and moderate, but not severe, PTSD. Both trait- and trauma-related RNT were associated with several specific aspects of sleep quality, including: sleep disturbances, daytime dysfunction, use of sleep medications, sleep onset latency, and subjective sleep quality.

CONCLUSIONS

This study demonstrates significant associations linking RNT with insomnia and sleep disturbance in trauma-exposed individuals. Clinically, results suggest that it may be helpful to target both general and trauma-related RNT in sleep interventions for trauma-exposed individuals with insomnia.

Exposure to war, war nightmares, insomnia, and war-related posttraumatic stress disorder: A network analysis among university students during the war in Ukraine

INTRODUCTION

Little is known about the prevalence and associations between war-related variables among Ukrainians during the Russian invasion. The present study assesses the prevalence and associations between exposure to war (EW), nightmares of war (NW), insomnia, and war-related post-traumatic stress disorder (WPTSD) among university students from Ukraine.

METHODS

During the war, an online cross-sectional study was performed among university students (N = 1072) from western Ukraine. Newly developed questions evaluated EW and NW, while insomnia was measured using Athens Insomnia Scale (AIS), and for assessing war-related PTSD symptoms, we adopted an abbreviated six-item PTSD checklist (PCL-6). The associations between exposure to war, nightmares of war, and symptoms of insomnia and PTSD were examined using network analysis (NA).

RESULTS

Among university students, 98 % declared exposure to war, 86 % dreamed nightmares of war, 49 % experienced insomnia symptoms, and 27 % presented symptoms of PTSD. A network analysis found that war-related PTSD has a central and the greatest impact on the frequency of war nightmares and the severity of insomnia symptoms.

LIMITATIONS

Self-report measurements were applied to a gender-unbalanced sample of university students from the western regions of Ukraine, so it would be inappropriate to generalize to the population directly affected by the war.

CONCLUSIONS

War-related PTSD symptoms had the most significant impact on the other variables. Therefore, war-related PTSD should be a priority in treatment among university students in Ukraine. However, multidisciplinary integrative intervention programs that treat nightmares, insomnia, and PTSD, can be the most effective.

A path model of associations between war-related exposure to trauma, nightmares, fear, insomnia, and posttraumatic stress among Ukrainian students during the Russian invasion

The present study examined the associations between war-related exposure, nightmares, fear, insomnia, and PTSD symptoms among university students from Western Ukraine. An online cross-sectional study was performed among 1,072 university students (80% of whom were women) during the war. Eight questions were developed to assess exposure to war, and seven items were designed regarding nightmares of war. War-related PTSD symptoms were assessed using an abbreviated six-item PTSD checklist (PCL-6), insomnia was measured using the Athens Insomnia Scale (AIS), and to examine fear of war, the Fear of COVID-19 Scale (FoCV-19S) was adopted. Positive correlations were found between exposure to war, nightmares of war, fear of war, insomnia, and war-related PTSD. The path model using structural equation modelling (SEM) analysis showed that the chain mediation partially explains the relationship between war exposure and war-related PTSD symptoms via nightmares of war, fear of war, and insomnia among university students during the Russian invasion of Ukraine. Women scored significantly higher than men in fear of war and symptoms of insomnia and PTSD, but the path model was invariant across genders. Young adults require treatment focused primarily on nightmares, insomnia, and fear of war to prevent PTSD symptoms.

Nightmares: an independent risk factor for cardiovascular disease?

STUDY OBJECTIVES

Prior work has established associations between post-traumatic stress disorder (PTSD), disrupted sleep, and cardiovascular disease (CVD), but few studies have examined health correlates of nightmares beyond risks conferred by PTSD. This study examined associations between nightmares and CVD in military veterans.

METHODS

Participants were veterans (N = 3468; 77% male) serving since September 11, 2001, aged 38 years (SD = 10.4); approximately 30% were diagnosed with PTSD. Nightmare frequency and severity were assessed using the Davidson Trauma Scale (DTS). Self-reported medical issues were assessed using the National Vietnam Veterans Readjustment Study Self-report Medical Questionnaire. Mental health disorders were established using the Structured Clinical Interview for DSM-IV. The sample was stratified by the presence or absence of PTSD. Within-group associations between nightmare frequency and severity and self-reported CVD conditions, adjusting for age, sex, race, current smoking, depression, and sleep duration.

RESULTS

Frequent and severe nightmares during the past week were endorsed by 32% and 35% of participants, respectively. Those endorsing nightmares that were frequent, severe, and the combination thereof were more likely to also evidence high blood pressure (ORs 1.42, OR 1.56, and OR 1.47, respectively) and heart problems (OR 1.43, OR 1.48, and OR 1.59, respectively) after adjusting for PTSD diagnosis and other covariates.

CONCLUSIONS

Nightmare frequency and severity among veterans are associated with cardiovascular conditions, even after controlling for PTSD diagnosis. Study findings suggest that nightmares may be an independent risk factor for CVD. Additional research is needed to validate these findings using confirmed diagnoses and explore potential mechanisms.

The role of positive affect processes in the association between posttraumatic stress disorder symptoms and sleep: A multi-study design

OBJECTIVES

Posttraumatic stress disorder (PTSD) symptoms have been linked to sleep disturbances. Limited work has explored how positive affect processes may account for this relationship. Advancing research in this area, we utilized a multi-study design to investigate the role of positive affect processes (levels of positive affect, positive emotionality, hedonic deficits, negative affect interference) in the PTSD-sleep association.

METHODS

Data from 149 trauma-exposed firefighters (M_age = 38.93 ± 9.65, 5.40 % women) were collected between September 2021 and November 2021, and data from 119 trauma-exposed community members (M_age = 29.60 ± 8.67, 68.10 % women) were collected between February 2021 and December 2021. Participants completed an online survey on PTSD symptoms, sleep disturbances, and positive affect processes.

RESULTS

Positive affect levels (b = 0.03, 95 % confidence interval [CI] [0.01, 0.06]; firefighter sample), positive emotionality (b = 0.07, CI [0.03, 0.13]; community sample), and negative affect interference (b = 0.06, CI [0.01, 0.14]; community sample) significantly accounted for the associations between PTSD symptom severity and sleep disturbances controlling for the effects of gender and age.

CONCLUSION

Findings highlight the role of positive affect processes in the link between PTSD and sleep, and support addressing positive affect processes as potential targets in clinical interventions for co-occurring PTSD-sleep problems.

Sleep and day-to-day PTSD symptom variability: an ecological momentary assessment and actigraphy monitored study in trauma-exposed young adults

BACKGROUND

Disrupted sleep and post-traumatic stress disorder (PTSD) are bi-directionally linked and have been found to mutually reinforce each other on a day-to-day basis. However, most of the previous research has focused on subjective measures of sleep only.

OBJECTIVE

Here, we investigated the temporal relationship between sleep and PTSD symptoms using both subjective (sleep diary) and objective measures of sleep (actigraphy).

METHODS

Forty-one non-treatment seeking, trauma exposed young adults (age M = 24.68, SD = 8.15) with a range of PTSD symptom severities (PTSS, 0-53 on PCL-5) were recruited. Participants completed two surveys per day over four weeks to measure day-time PTSD symptoms (i.e. PTSS and number of intrusions) and night-time sleep subjectively, while wearing an actigraphy watch to measure sleep objectively.

RESULTS

Linear mixed models revealed that subjectively reported sleep disruptions were associated with elevated next-day PTSS and increasing number of intrusive memories both within and between participants. Similar results were found for daytime PTSD symptoms on night-time sleep. However, these associations were not found using objective sleep data. Exploratory moderator analyses including sex (male vs. female) found that these associations differed in strength between sexes but were generally in the same direction.

DISCUSSION

These results were in line with our hypothesis with regards to the sleep diary (subjective sleep), but not actigraphy (objective sleep). Several factors which have implications on both PTSD and sleep, such as the COVID-19 pandemic and/ or sleep-state misperception, may be potential reasons behind those discrepancies. However, this study had limited power and needs to be replicated in larger samples. Nonetheless, these results add to the current literature about the bi-directional relationship between sleep and PTSD and have clinical implications for treatment strategies.

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.

What goes around comes around: Nightmares and daily stress are bidirectionally associated in nurses

Nurses may experience frequent nightmares due to stressful work environments. Nightmares may also exacerbate stress among nurses, although this has yet to be tested empirically. We examined daily bidirectional associations between stress severity and nightmares, and moderation by post-traumatic stress disorder (PTSD) symptoms. 392 nurses (92% female; 78% White) completed 14 days of sleep diaries to assess previous-day stress severity and nightmare occurrence and severity. PTSD symptoms were assessed at baseline. Multilevel models were used to examine bidirectional, within-person associations between daily stress and nightmares, and cross-level moderation by baseline PTSD symptoms. 47.2% of nurses reported at least one nightmare across the two weeks. Days with greater stress were associated with higher odds of experiencing a nightmare (OR = 1.22, p = 0.001), as well as greater nightmare severity (b = 0.09, p = 0.033). Nightmare occurrence was associated with greater next-day stress severity (b = 0.15, p < 0.001). Daily stress and nightmare associations were similar for those with and without PTSD symptoms. Nightmares and stress may occur in a bidirectional fashion. Nurses face intense occupational demands and frequent exposure to potentially traumatic events. Studies should explore whether targeting nightmares and stress may improve nurses' health and well-being.

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

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

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.

Relationship between eHealth literacy and psychological status during COVID-19 pandemic: A survey of Chinese residents

Aims

To investigate the eHealth literacy and the psychological status of Chinese residents during the COVID‐19 pandemic and explore their interrelationship.

Background

The COVID‐19 outbreak has placed intense psychological pressure on community residents. Their psychological status may be affected by eHealth literacy due to home isolation during this rampant pandemic.

Methods

This is a Web‐based cross‐sectional survey conducted on the JD Health platform, which resulted in 15,000 respondents having participated in this survey. The eHealth Literacy Questionnaire (EHLQ), Patient Health Questionnaire‐9 (PHQ‐9), Insomnia Severity Index (ISI) and Impact of Event Scale‐Revised (IES‐R) were used. The Pearson correlation was used to analyse the relationship between eHealth literacy and depression, insomnia and post‐traumatic stress disorder.

Results

The score of eHealth literacy was 48.88 ± 8.46, and 11.4%, 6.8% and 20.1% of respondents experienced moderate to severe depression, insomnia and post‐traumatic stress disorder. eHealth literacy negatively correlated with depression (r = −0.331), insomnia (r = −0.366) and post‐traumatic stress disorder (r = −0.320).

Conclusion

eHealth literacy is closely related to psychological status. Improving eHealth literacy may contribute to maintaining good psychological well‐being.

Implications for Nursing Management

It is necessary to strengthen the education of primary health care providers to enhance their ability to help community residents effectively use eHealth information.

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.

An integrated model of chronic trauma-induced insomnia

Insomnia is the most commonly reported symptom of posttraumatic stress disorder (PTSD), with at least 70% of patients with PTSD reporting disturbed sleep. Although posttraumatic insomnia has traditionally been conceptualized as a consequence of PTSD, it is the most likely symptom to not remit following otherwise successful PTSD treatment. This suggests that the relationship between PTSD and insomnia is more complex, such that they likely share underlying pathological mechanisms and that factors non-specific to PTSD maintain chronic trauma-induced insomnia. Although several theories and hypotheses have been presented to explain the relationship between PTSD and insomnia, neurobiological and psychological models have not been integrated, thereby limiting their comprehensiveness and abilities to inform effective intervention. Further, existing models have not addressed how acute trauma-induced insomnia becomes chronic. The present review examined models of PTSD and insomnia separately, as well as existing theorized mechanisms of their co-morbidity. The distinct characteristics of trauma-induced insomnia were also reviewed and presented to describe the unique clinical presentation of trauma-induced insomnia. Review and integration of the literature were used to propose an integrated model of chronic trauma-induced insomnia informed by a neuropsychobiological framework. Clinical implications and future research directions are presented and discussed.

In-the-moment experiences of mothers of children with autism spectrum disorder: a comparison by household status and region of residence

Purpose: This study compared the in-the-moment experiences among mothers of children with Autism Spectrum Disorders (ASD) by their household status (i.e., single versus coupled) and region of residence (i.e., regional versus major city area).Methods: An experience sampling method was employed to collect data, and a total of 40 mothers used an iOS device to record activity types and in-the-moment experiences for one week during school term. Mann-Whitney U test and multilevel analysis were conducted to compare the experiences of these mothers.Results: The analyses found the following results: 1) mothers spent most time in childcare and least time in self-care activities; 2) coupled mothers were more likely to feel supported; 3) coupled mothers were less likely to feel supported in domestic tasks; 4) mothers from major city were more likely to feel challenged in self-care activities; and 5) mothers from major city were more likely to feel supported in productivity tasks.Conclusion: Limited but significant differences between single and coupled mothers, as well as mothers from regional and major city areas, were found. Future research direction and service provisions were suggested.Implications for rehabilitationThis study shows that all mothers spent the most time on childcare and the least amount of time on self-care activities.In-the-moment experiences between single and coupled mothers, as well as mothers from major cities and mothers from regional areas, differ somewhat; however, this study builds evidence to support that these mothers' experiences are similar.The result of the study indicates that single mothers require extra support as they carry similar levels of responsibilities as coupled mothers, but without the support of a partner.Promoting a sense of control may assist all mothers to fully engage in parenting activities.

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

Background

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

Method

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

Results

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

Conclusions

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

Post traumatic stress symptom variation associated with sleep characteristics

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sleep disturbance in PTSD and other anxiety-related disorders: an updated review of clinical features, physiological characteristics, and psychological and neurobiological mechanisms

The current report provides an updated review of sleep disturbance in posttraumatic stress disorder and anxiety-related disorders. First, this review provides a summary description of the unique and overlapping clinical characteristics and physiological features of sleep disturbance in specific DSM anxiety-related disorders. Second, this review presents evidence of a bidirectional relationship between sleep disturbance and anxiety-related disorders, and provides a model to explain this relationship by integrating research on psychological and neurocognitive processes with a current understanding of neurobiological pathways. A heuristic neurobiological framework for understanding the bidirectional relationship between abnormalities in sleep and anxiety-related brain pathways is presented. Directions for future research are suggested.

Center Predictors of Long-Term Benzodiazepine Use in Chronic Obstructive Pulmonary Disease and Post-traumatic Stress Disorder

Rationale: Symptoms of insomnia and anxiety are common among patients with chronic obstructive pulmonary disease (COPD), especially among patients with comorbid mental health disorders such as post-traumatic stress disorder (PTSD). Benzodiazepines provide temporary relief of these symptoms, but guidelines discourage routine use of benzodiazepines because of the serious risks posed by these medications. A more thorough understanding of guideline-discordant benzodiazepine use will be critical to reduce potentially inappropriate prescribing and its associated risks.Objectives: Examine the national prevalence, variability, and center correlates of long-term benzodiazepine prescriptions for patients with COPD and comorbid PTSD.Methods: We identified patients with COPD and PTSD between 2010 and 2012 who received care within the Department of Veterans Affairs. We used a mixed-effects logistic regression model to assess center predictors of long-term benzodiazepine prescriptions (≥90 d), while accounting for patient characteristics.Results: Of 43,979 patients diagnosed with COPD and PTSD at 129 centers, 24.4% were prescribed benzodiazepines long term, with use varying from 9.5% to 49.4% by medical center. Patients with long-term prescriptions were more likely to be white (90.1% vs. 80.7%) and have other mental health comorbidities, including generalized anxiety disorder (31.3% vs. 16.5%). Accounting for patient mix and characteristics, long-term benzodiazepine use was associated with lower patient-reported access to mental health care (odds ratio, 0.54; 95% confidence interval, 0.37-0.80).Conclusions: Long-term benzodiazepine prescribing is common among patients at high risk for complications, although this practice varies substantially from center to center. Poor access to mental health care is a potential driver of this guideline inconsistent use.

Bidirectional associations between insomnia, posttraumatic stress disorder, and depressive symptoms among adolescent earthquake survivors: a longitudinal multiwave cohort study

Study Objectives

To assess insomnia symptoms in adolescents with probable posttraumatic stress disorder (PTSD) and to determine whether there are longitudinal and reciprocal associations between insomnia, PTSD, and depressive symptoms.

Methods

Participants were 1,492 adolescent survivors who had been exposed to the 2008 Wenchuan earthquake in China. Insomnia, PTSD, and depressive symptoms were measured at 12 months (T1, n = 1407), 18 months (T2, n = 1335), and 24 months (T3, n = 1361) postearthquake by self-report questionnaires. Generalized estimating equation (GEE) models were used to examine the cross-sectional and longitudinal associations of insomnia with PTSD and depression.

Results

Insomnia, PTSD, and depressive symptoms were common among adolescent survivors. Among participants with probable PTSD, approximately 47% (48.5%, T1; 48.1%, T2; and 44.2%, T3) reported difficulty falling asleep or difficulty maintaining sleep. Cross-sectional analyses showed that insomnia co-occurred with PTSD (odds ratio [OR] = 2.04) and depressive symptoms (OR = 2.10). Longitudinal analyses revealed that probable PTSD (OR = 1.50) and depression (OR = 1.42) predicted the incidence of insomnia; in turn, insomnia predicted the incidence of depression (OR = 1.65) over time. Furthermore, PTSD predicted (OR = 3.11) and was predicted (OR = 3.25) by depressive symptoms.

Conclusions

There is a bidirectional relationship between insomnia, PTSD, and depressive symptoms. This suggests that insomnia, PTSD, and depression are intertwined over time.

Prospective associations between insomnia symptoms and alcohol use problems among former and current military service personnel

BACKGROUND

Despite evidence that insomnia symptoms exacerbate alcohol use disorder symptoms, there is a dearth of prospective research testing bidirectional associations between these variables. Furthermore, no studies have prospectively examined these associations among military personnel, a vulnerable population for sleep- and alcohol-related problems. Thus, the current study examined whether insomnia symptoms prospectively predicted increased alcohol use disorder symptoms among a sample of military service members and veterans over a 6-month follow-up period, as well as whether alcohol use disorder symptoms led to increases in insomnia.

METHOD

Hypotheses were tested among a sample of 274 current and past military service members who participated in a baseline and 6-month assessment using self-report measures.

RESULTS

Path analyses revealed that insomnia symptoms significantly prospectively predicted increased month-6 heavy drinking and alcohol-related problems, but not days drinking or being bothered by drinking. None of the alcohol variables significantly predicted insomnia.

CONCLUSION

Results support a model in which insomnia symptoms exacerbate alcohol use disorder symptoms, specifically heavy drinking and alcohol-related problems. Future research should seek to examine these findings in diverse populations and test potential mechanisms and clinical implications of these results.

Predictors of cognitive behavioral therapy outcomes for insomnia in veterans with post-traumatic stress disorder

BACKGROUND

Insomnia is a well-recognized co-morbid condition in veterans with post-traumatic stress disorder (PTSD) with negative personal and social consequences. Cognitive behavioral therapy (CBT) is considered an efficacious treatment, yet little attention has been devoted to treatment response in this population. The aim of this study was to identify factors that may predict clinical response to CBT for insomnia (CBT-I) in veterans with PTSD.

METHODS

A retrospective chart review of 136 veterans with PTSD-related insomnia was conducted. Epworth Sleepiness Score (ESS), PTSD Checklist (PCL), and Insomnia Severity Index (ISI) were assessed at baseline. We converted prescribed antidepressant and hypnotic dosages before and after CBT-I to dose equivalent of fluoxetine diazepam, respectively. A 6-point reduction or greater in ISI scores at 6-month follow-up visit was defined as CBT-I responsiveness.

RESULTS

CBT-I responsiveness was observed in 47% of veterans with PTSD. Seventy-seven percent completed treatment. Lack of perceived benefit was the most given reason for failure to return for follow-up. In contrast to hypnotics, antidepressants usage decreased in those who had experienced benefit from CBT-I (p = 0.001). Younger age, non-white race, and use of hypnotics prior to behavioral therapy were independently associated with lack of response to CBT-I.

CONCLUSIONS

While CBT-I ameliorates insomnia in veterans with PTSD, the use of hypnotics prior to instituting behavioral therapy may negatively affect the response rate to CBT-I. Future studies should examine whether racial and cultural influences on the generation of insomnia in veterans with PTSD affects the response to CBT-I.

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

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

Night-time rumination in PTSD: development and validation of a brief measure

Background: Pre-sleep cognitive activity and arousal have long been implicated in the maintenance of insomnia. However, despite high comorbidity between insomnia and posttraumatic stress disorder (PTSD), pre-sleep thoughts in PTSD and their associations with disturbed sleep, have not yet been investigated. Objective: This study presents the development and preliminary validation of a brief self-report measure of the content of trauma-related pre-sleep thoughts: the Trauma Thoughts before Sleep Inventory (TTSI). Methods: Participants (N = 285) were recruited online into five groups: three groups with clinical symptoms, 1) PTSD; 2) depression without PTSD; 3) insomnia without depression or PTSD; and two healthy control groups 4) nontrauma-exposed controls; 5) trauma-exposed controls. The questionnaire was administered at baseline, and for a subsample (n = 157) again one week later to assess test-retest reliability. At baseline, participants also completed questionnaires of sleep quality, PTSD and depression symptoms, and insomnia-related thoughts. Results: The TTSI had good reliability and validity; it discriminated participants with PTSD from those with depression and insomnia, those with depression from insomnia, and correlated with existing measures of pre-sleep thoughts, self-reported pre-sleep arousal and poor sleep. Conclusions: The results support the utility of the TTSI for measuring thoughts that keep people with PTSD awake, although replication in an independent clinical sample is required.

Two Independent Predictors of Nightmares in Posttraumatic Stress Disorder

STUDY OBJECTIVES

Understanding nightmares (NM) and disturbing dreams (DD) in posttraumatic stress disorder (PTSD) has been limited by the unpredictability of these events and their nonappearance in the sleep laboratory. This study used intensive, longitudinal, ambulatory methods to predict morning reports of NM/DD in veterans in whom chronic, severe PTSD was diagnosed.

METHODS

Participants were 31 male United States military veterans engaged in residential treatment for PTSD and participating in a service animal training intervention. Participants slept on mattress actigraphs and provided reports of momentary mood, as well as morning NM/DD reports, for up to 6 weeks. Mattress actigraphy provided sleep-period heart rate and respiratory sinus arrhythmia (RSA), and an actigraphic estimate of sleep efficiency. On one night, a respiratory event index (REI) was obtained using an ambulatory system.

RESULTS

A total of 468 morning reports were obtained, of which 282 endorsed NM/DD during the prior night, and 186 did not. After accounting for multiple predictors, only elevated REI and lower prior-night sleep RSA predicted morning endorsement of NM/DD. These two predictors did not interact.

CONCLUSIONS

Elevated REI and lower sleep period RSA were independently predictive of NM/DD. The former result is consistent with studies showing that sleep-disordered breathing (SDB) is a factor in NM/DD, and that continuous positive airway pressure (CPAP) can reduce these symptoms in patients with comorbid PTSD and SDB. The latter result implicates dysregulated arousal modulation during sleep in trauma-related NM/DD. It is consistent with findings that NM/DD are reported in patients without SDB and can persist in patients with comorbid PTSD and SDB even when CPAP successfully remediates SDB.

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL TRIAL REGISTRATION

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

Sleep Disorders in Patients With Posttraumatic Stress Disorder

A growing body of evidence supports a bidirectional relationship between posttraumatic stress disorder (PTSD) and sleep disturbances. Fragmented sleep induced by sleep-related breathing disorders, insomnia, and nightmares impacts recovery and treatment outcomes and worsens PTSD symptoms. Despite recent attention, management of these disorders has been unrewarding in the setting of PTSD. This review summarizes the evidence for empirically supported treatments of these sleep ailments, including psychotherapeutic and pharmacologic interventions, as it relates to PTSD. Recent advances in positive airway pressure technology have made treatment of OSA more acceptable; however, adherence to CPAP therapy presents a substantial challenge. Concomitant insomnia, which engenders psychiatric and medical conditions, including depression, suicide, and alcohol and substance abuse, can be managed with cognitive behavioral therapy. Hypnotic agents are considered an alternative therapy, but concerns about adverse events and lack of high-level evidence supporting their efficacy in PTSD treatment have limited their use to resistant cases or as adjuncts to behavioral therapy when the response is less than desirable. Intrusion of nightmares can complicate PTSD treatment and exert serious strain on social, occupational, and marital relations. Imagery rehearsal therapy has shown significant reduction in nightmare intensity and frequency. The success of noradrenergic blocking agents has not been consistent among studies, with one-half reporting treatment failure. An integrated stepped care approach that includes components of both behavioral and pharmacologic interventions customized to patients' sleep-maladaptive behaviors may offer a solution to delivering accessible, effective, and efficient services for individuals with PTSD.

Noradrenergic Modulation of Fear Conditioning and Extinction

The locus coeruleus norepinephrine (LC-NE) system plays a broad role in learning and memory. Here we begin with an overview of the LC-NE system. We then consider how both direct and indirect manipulations of the LC-NE system affect cued and contextual aversive learning and memory. We propose that NE dynamically modulates Pavlovian conditioning and extinction, either promoting or impairing learning aversive processes under different levels of behavioral arousal. We suggest that under high levels of stress (e.g., during/soon after fear conditioning) the locus coeruleus (LC) promotes cued fear learning by enhancing amygdala function while simultaneously blunting prefrontal function. Under low levels of arousal, the LC promotes PFC function to promote downstream inhibition of the amygdala and foster the extinction of cued fear. Thus, LC-NE action on the medial prefrontal cortex (mPFC) might be described by an inverted-U function such that it can either enhance or hinder learning depending on arousal states. In addition, LC-NE seems to be particularly important for the acquisition, consolidation and extinction of contextual fear memories. This may be due to dense adrenoceptor expression in the hippocampus (HPC) which encodes contextual information, and the ability of NE to regulate long-term potentiation (LTP). Moreover, recent work reveals that the diversity of LC-NE functions in aversive learning and memory are mediated by functionally heterogeneous populations of LC neurons that are defined by their projection targets. Hence, LC-NE function in learning and memory is determined by projection-specific neuromodulation that accompanies various states of behavioral arousal.