The Role of Trauma Type in the Risk for Insomnia

Investigation of the relationship between disasters and sleep problems in adolescents

This study was conducted to determine relationship between disasters and sleep problems in adolescents. In this descriptive and cross-sectional study, 407 adolescents aged 10-18 years were included. The data were collected with Descriptive Characteristics Form, Disaster Fear Form, and Bergen Insomnia Scale. 86.5% of the adolescents had experienced at least one disaster. It was found that 67.3% of adolescents experienced sleep problems after disasters. A positive correlation was found between the mean scores of Fear Disaster Form and Bergen Insomnia Scale. In addition, mean Bergen Insomnia Scale scores of adolescents who experienced earthquakes, pandemic disease, traffic accidents, and floods were statistically higher than those who did not (p < 0.05). By screening for sleep problems in adolescents who have experienced disasters and planning and implementing appropriate interventions, adolescents who are already at risk for sleep problems can develop healthy sleep habits and prevent physiological, mental, and cognitive problems due to sleep problems.

Afraid and Awake: The Interaction Between Trauma and Sleep in Children and Adolescents

Traumatic experiences and sleep disturbances are both common in children and adolescents. Because of the reciprocal relationship between sleep complaints and trauma, a mental health evaluation should include not only an assessment of posttraumatic stress disorder and other trauma symptoms but also a specific evaluation of sleep-related complaints. Similarly, if a history of both trauma and sleep complaints is identified, an effective trauma-informed intervention, whether psychological, psychopharmacologic, or a combination of the two, should directly address sleep issues.

Predictors of early adulthood insomnia following exposure to a single mass violence attack during adolescence: 7-13 year follow-up from the Utøya and HUNT studies

Background: The long-term impact of mass violence attacks is practically unknown, especially in children and adolescents. In a previous study, we found that 8.5 years after a terror attack targeting mainly adolescents, nearly half of the survivors met diagnostic criteria for insomnia.Objectives: The aims of this study were to investigate: (1) whether exposure to a single mass violence event during adolescence increases the risk of insomnia almost a decade later above that expected for a non-exposed population; and (2) whether prior interpersonal violence exposure and early post-traumatic reactions predict later insomnia.Method: Participants were survivors of the 2011 Utøya Island terrorist attack (n = 279) and controls from the HUNT Norwegian general population study (n = 35,664). Early adulthood insomnia was assessed using four items from the Karolinska Sleep Questionnaire 8.5 years after the attack. Participants who had also completed earlier data collection waves for both studies (n = 116 and 2382, respectively) were included in logistic regression models testing the associations between predictors during adolescence and later insomnia.Results: Nearly a decade after the Utøya attack, 38.4% (n = 56) of the survivors reported symptoms of insomnia indicative of probable insomnia compared to 20.5% (n = 5771) of controls. Terror exposure during adolescence was a significant predictor of later insomnia [odds ratio (OR) = 3.18, 95% confidence interval (CI) = 2.05-4.87, p < .001]. Early post-trauma symptoms of anxiety and depression (OR = 1.34, 95% CI = 1.02-1.76, p = .033) and weekly headaches (OR = 1.64, 95% CI = 1.08-2.47, p = .018) were also significant predictors while controlling for background factors and other predictors.Conclusion: Long-term assessment and treatment are needed for survivors of mass violence to improve resilience and recovery.

The role of affect in associations between sleep disturbances and posttraumatic stress disorder symptoms: A systematic review

Strong evidence supports a bidirectional association between sleep disturbances and posttraumatic stress disorder (PTSD). Affect - temporary internal states experienced as feeling good or bad, energized or enervated - may play a central role in explaining this link. The current systematic review summarizes the literature on associations between sleep, PTSD, and affect among trauma-exposed adults. We systematically searched five electronic databases (PubMed, PsycInfo, PTSDpubs, Web of Science, CINAHL) using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Of 2656 screened articles, 6 studies met inclusion criteria. Four findings emerged: (1) greater insomnia symptom severity predicted greater PTSD symptom severity above the influence of negative affect, (2) negative affect mediated the effect of sleep quality on next-day PTSD symptom severity, (3) positive affect mediated the effect of PTSD symptom severity on insomnia symptom severity and sleep disturbances, and (4) greater negative affect (specifically, greater anger) was associated with greater severity of PTSD and sleep disturbances. Findings highlight areas for future research, such as the need to investigate more dimensions, timescales, and methods of studies simultaneously assessing affect, sleep, and PTSD, as well as the need for more longitudinal and experimental work to determine causality across these constructs.

Improved resilience following digital cognitive behavioral therapy for insomnia protects against insomnia and depression one year later

BACKGROUND

While the negative consequences of insomnia are well-documented, a strengths-based understanding of how sleep can increase health promotion is still emerging and much-needed. Correlational evidence has connected sleep and insomnia to resilience; however, this relationship has not yet been experimentally tested. This study examined resilience as a mediator of treatment outcomes in a randomized clinical trial with insomnia patients.

METHODS

Participants were randomized to either digital cognitive behavioral therapy for insomnia (dCBT-I; n = 358) or sleep education control (n = 300), and assessed at pre-treatment, post-treatment, and 1-year follow-up. A structural equation modeling framework was utilized to test resilience as a mediator of insomnia and depression. Risk for insomnia and depression was also tested in the model, operationalized as a latent factor with sleep reactivity, stress, and rumination as indicators (aligned with the 3-P model). Sensitivity analyses tested the impact of change in resilience on the insomnia relapse and incident depression at 1-year follow-up.

RESULTS

dCBT-I resulted in greater improvements in resilience compared to the sleep education control. Furthermore, improved resilience following dCBT-I lowered latent risk, which was further associated with reduced insomnia and depression at 1-year follow-up. Sensitivity analyses indicated that each point improvement in resilience following treatment reduced the odds of insomnia relapse and incident depression 1 year later by 76% and 65%, respectively.

CONCLUSIONS

Improved resilience is likely a contributing mechanism to treatment gains following insomnia therapy, which may then reduce longer-term risk for insomnia relapse and depression.

Modeling integrated stress, sleep, fear and neuroimmune responses: Relevance for understanding trauma and stress-related disorders

Sleep and stress have complex interactions that are implicated in both physical diseases and psychiatric disorders. These interactions can be modulated by learning and memory, and involve additional interactions with the neuroimmune system. In this paper, we propose that stressful challenges induce integrated responses across multiple systems that can vary depending on situational variables in which the initial stress was experienced, and with the ability of the individual to cope with stress- and fear-inducing challenges. Differences in coping may involve differences in resilience and vulnerability and/or whether the stressful context allows adaptive learning and responses. We provide data demonstrating both common (corticosterone, SIH and fear behaviors) and distinguishing (sleep and neuroimmune) responses that are associated with an individual's ability to respond and relative resilience and vulnerability. We discuss neurocircuitry regulating integrated stress, sleep, neuroimmune and fear responses, and show that responses can be modulated at the neural level. Finally, we discuss factors that need to be considered in models of integrated stress responses and their relevance for understanding stress-related disorders in humans.

Trauma exposure, alcohol consumption, and sleep quality: a latent growth curve model

This study examined the relations among precollege trauma exposure, alcohol use upon entering college, growth in alcohol use, and sleep quality in a sample of undergraduate students. Participants were 932 students from a large, urban, public university. Participants completed a survey upon entering college and then subsequent follow-up surveys each Spring semester. Precollege trauma exposure was associated with both baseline and growth in alcohol use, whereby higher levels of trauma were associated with higher baseline alcohol use, but with less steep increases in growth rate, as compared to those with lower levels of trauma. Baseline alcohol use was associated with sleep quality whereby those with higher levels of consumption demonstrated worsened sleep quality. This study provides longitudinal evidence for the relations among trauma, alcohol use, and sleep quality. Although the relationship between trauma and alcohol is well-established, further work is needed to identify how this relationship impacts additional health outcomes.

Trauma type as a risk factor for insomnia in a military population

BACKGROUND

This study evaluated whether lifetime traumatic stress compared to deployment-related traumatic stress differentially affected the likelihood of insomnia in military personnel.

METHODS

Data were obtained from the Army Study to Assess Risk and Resilience in Servicemembers (unweighted N = 21,499; weighted N = 670,335; 18-61 years; 13.5% Female). DSM-5 criteria were applied to the Brief Insomnia Questionnaire to determine past month insomnia diagnostic status. A lifetime stress survey was used to assess traumatic stress encountered outside of the military, and a deployment-related stress survey assessed for various types of deployment-related traumatic stress.

RESULTS

Adjusting for sex and psychiatric disorders, lifetime traumatic stress increased the prevalence for insomnia among those who endorsed combat death of close friend or relative, 1.021 (95% CI, 1.02-1.02), followed by those who reported other experiences that put them at risk of death or serious injury, 1.013 (95% CI, 1.01-1.01), whereas deployment-related traumatic stress showed that the prevalence for insomnia was highest for those who reported being sexually assaulted or raped, 1.059 (95% CI, 1.04-1.08), followed by those who endorsed being hazed or bullied by one or more members of their unit 1.042 (95% CI, 1.04-1.05).

LIMITATIONS

The cross-sectional nature of the assessment limits causal inferences and there was no clinician determined diagnosis for insomnia.

CONCLUSION

Findings suggest that traumas over both one's lifetime and during deployment are associated with a higher prevalence for insomnia among Army soldiers. Results highlight the importance of considering both lifetime and deployment traumas into mental health assessment and treatment for active-duty soldiers.

Effects of Sleep Deficiency on Risk, Course, and Treatment of Psychopathology

This article reviews the literature on the relationship between sleep deficiency and unipolar and bipolar depression, anxiety disorders, and posttraumatic stress disorder. We consider the evidence for sleep as a contributory causal factor in the development of psychiatric disorders, as well as sleep as an influential factor related to the outcome and recurrence of psychopathology. A case for sleep deficiency being an important treatment target when sleep and psychiatric disorders are comorbid is also made. Our recommendation is that sleep deficiency is recognized as a means to positively impact the development and course of psychopathology and, as such, is routinely assessed and treated in clinical practice.

Adaptability Protects University Students From Anxiety, Depression, and Insomnia During Remote Learning: A Three-Wave Longitudinal Study From China

The longitudinal relationship between students' pre-existing adaptability and subsequent sleep and mental health during the COVID-19 pandemic has not been studied. The present study examines the relationship between adaptability and students' anxiety, depression, and insomnia during and after the lockdown related to COVID-19. 5,235 university students participated in a longitudinal study with three time points. Students completed the Adaptability Scale before the outbreak (October 2019; Time 1), the Insomnia Severity Index (ISI) both during (April 2020; Time 2) and after lockdown (March 2021; Time 3), the Anxiety and Depression subscales of the SCL-90 (at Time 1 and 3), and the SAS/SDS (at Time 2). The results showed that self-reported adaptability is significantly negatively correlated with anxiety and depression, and that anxiety and depression are positively correlated with insomnia. Furthermore, adaptability protects from insomnia both directly and through its negative relationship with anxiety and depression. This study sheds light on the internal mechanisms mediating the relationship between students' adaptability and experience of insomnia in challenging circumstances. Implications for curtailing the negative effects of stressful events on students' sleep health by improving their adaptability and reducing their anxiety and depression are discussed.

Epidemiology of childhood trauma and its association with insomnia and psychotic-like experiences in Chinese Zhuang adolescents

BACKGROUND

Adolescents who have experienced childhood trauma are more likely to have insomnia and psychotic-like experiences (PLEs) than adolescents from other ethnic groups. However, little is known about the youth of ethnic minorities. This study aimed to investigate the epidemiology of childhood trauma and its relationship with insomnia and PLEs in Chinese Zhuang adolescents, focusing on the role of a specific type of trauma and accumulation.

METHODS

A questionnaire of Childhood Trauma Questionnaire-Short Form (CTQ-SF), Athens Insomnia Scale (AIS), and Chinese Version Community assessment psychic experiences-8 (CCAPE- 8) were all completed by 1,493 Chinese Zhuang adolescents. Chi-square and multivariate logistic regression analyses examined the association between childhood trauma and insomnia/PLEs.

RESULTS

The incidences of emotional abuse (EA), physical abuse (PA), sexual abuse (SA), emotional neglect (EN), and physical neglect (PN) occurred at rates of 5.63, 5.02, 6.56, 23.98, and 33.15%, respectively. EA, SA, EN, and PN were all positively related to insomnia (OR: 1.314-7.720, all p < 0.05). EA and SA were positively associated with PLEs (OR: 2.131-3.202, all p < 0.001). Adolescents who had experienced three or more types of traumas were more likely to have insomnia (OR = 6.961, p < 0.001) and PLEs (OR = 3.558, p < 0.001).

CONCLUSION

The most common type of childhood trauma is PN. Childhood trauma has the primary effect on insomnia/PLE. A significant dose-response relationship was found between Childhood trauma and insomnia/ PLEs. This association varied depending on the type and accumulation of exposure.

Ketamine-assisted psychotherapy for trauma-exposed patients in an outpatient setting: A clinical chart review study

Trauma exposure across the lifespan produces risks for posttraumatic stress disorder (PTSD), depression, anxiety, as well as global disability in functioning. This retrospective clinical chart review is the first of its kind to assess the utility of sublingual ketamine-assisted body-centered psychotherapy in trauma-exposed patients in a real world clinic setting. De-identified clinical records data on self-reported symptom measures were retrospectively analyzed for patients (N = 18; M age = 45.22, SD = 12.90) entering ketamine-assisted psychotherapy treatment in an outpatient clinic between 2018 and 2020. Patients who completed six sessions of ketamine therapy reported meaningful (e.g., medium effect size) improvements in PTSD symptoms (P = 0.058; d = −0.48) and global disability in functioning (P = 0.050; d = −0.52) and statistically significant and meaningful improvements in depression (P = 0.019; d = −0.53). There were no improvements in anxiety symptoms. Sublingual ketamine-assisted psychotherapy was associated with heterogenous clinical utility among patients with trauma-exposure in an outpatient setting. This study was underpowered and unrepresentative of the population of ketamine patients in the United States. Replication of these findings is needed with larger and more diverse patient samples.

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.

Afraid and Awake: The Interaction Between Trauma and Sleep in Children and Adolescents

Traumatic experiences and sleep disturbances are both common in children and adolescents. Because of the reciprocal relationship between sleep complaints and trauma, a mental health evaluation should include not only an assessment of posttraumatic stress disorder and other trauma symptoms but also a specific evaluation of sleep-related complaints. Similarly, if a history of both trauma and sleep complaints is identified, an effective trauma-informed intervention, whether psychological, psychopharmacologic, or a combination of the two, should directly address sleep issues.

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.

The immediate impact of the 2019 novel coronavirus (COVID-19) outbreak on subjective sleep status

Background

An outbreak of the 2019 novel coronavirus (COVID-19) has been ongoing in China since January 2020. The threat of infection affects the work and life of most of the population and may also damage sleep. This study aims to examine the subjective sleep status and mental health of the population during the peak of the COVID-19 epidemic.

Method

The data were collected through an online questionnaire with a sample of 5461 individuals in China from February 5, 2020, to February 23, 2020. Participants were divided into four groups based on their degree of threat from COVID-19: Group 1 was most closely associated with COVID-19, including inpatients diagnosed with COVID-19, first-line hospital workers and first-line management staff; Group 2 included outpatients diagnosed with COVID-19 and patients who developed a fever and visited the hospital; Group 3 included people related to Group 1 or 2, such as their colleagues, relatives, friends and rescuers; and Group 4 was the farthest removed from contact with COVID-19, covering the general public affected by COVID-19 prevention strategies. The Insomnia Severity Index (ISI), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7) and Acute Stress Disorder Scale (ASDS) were used.

Results

Threat degree of COVID-19 (groups) had significant correlations with insomnia, depression, anxiety, and stress (p < 0.05, p < 0.01). Age, gender, and area (Hubei province or other provinces) had significant correlations with insomnia (p < 0.01). A total of 1380 (24.46%) participants were suspected of having major depression based on the PHQ-9. Additionally, 1042 (18.47%) participants were suspected of having generalized anxiety disorder based on the GAD-7. A total of 892 (15.8%) of the participants had Acute Stress Disorder (ASD) according to the ASDS. The prevalence of clinical insomnia during the outbreak was 20.05% (1131) according to the ISI. The factors of satisfaction with the current sleep pattern and how perceptible the symptoms of the current sleep pattern are to other people (p < 0.05) and the middle (difficulty staying asleep) and terminal (waking up too early) (p < 0.01) factors of the ISI were significantly different across groups. A total of 1129 (20.01%) participants spent more than one hour awake in bed.

Conclusion

The results indicated that insomnia is more severe in people who are female, young, living in the epicenter and experiencing a high degree of threat from COVID-19. As prevention and treatment efforts continue with regard to COVID-19, the general public has developed poor sleep hygiene habits, which deserve attention.

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

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

Traumatic Event Exposure, Posttraumatic Stress Disorder, and Sleep Disturbances in a National Sample of U.S. Adults

Posttraumatic stress disorder (PTSD) is a highly prevalent, debilitating disorder found to develop after exposure to a potentially traumatic event (PTE). Individuals with PTSD often report sleep disturbances, specifically nightmares and insomnia, which are listed within the criteria for PTSD. This research examined prevalence of insomnia and nightmares within a national sample of 2,647 adults (data weighted by age and sex to correct for differences in sample distribution) who had been exposed to one or more PTEs. Prevalence of self-reported sleep disturbance, sleep disturbances by PTE type, and gender differences were examined. All participants completed a self-administered, structured online interview that assessed exposure to stressful events and PTSD symptoms. Among individuals who met DSM-5 criteria for PTSD, a large majority (more than 92%) reported at least one sleep disturbance. Insomnia was relatively more prevalent than PTE-related nightmares among individuals with PTSD and among all PTE-exposed individuals. A higher number of PTEs experienced significantly increased the likelihood of both trauma-related nightmares and insomnia, McFadden's pseudo R² = .07, p < .001. Women exposed to PTEs were more likely to endorse experience of insomnia, χ² (1, N = 2,647) = 99.13, p < .001, φ = .194, and nightmares compared to men, χ² (1, N = 2,648) = 82.98, p < .001, φ = .177, but this gender difference was not significant among individuals with PTSD, ps = .130 and .050, respectively. Differences in sleep disturbance prevalence by PTE type were also examined. Implications for treatment and intervention and future directions are discussed.

Differential effects of sleep on explicit and implicit memory for potential trauma reminders: findings from an analogue study

Background: Recent findings suggest that disruptions of sleep-related memory processing are involved in the development of posttraumatic stress symptoms. More specifically, exposure to an analogue traumatic event resulted in fewer intrusive memories, when it was followed by sleep instead of continued wakefulness. However, competing evidence suggests that sleep deprivation may reduce intrusive re-experiencing. To address these conflicting accounts, we examined how sleep - as opposed to partial sleep deprivation - modulates explicit and implicit trauma memory using an analogue procedure. Methods: Healthy participants (N = 41) were assigned to a Sleep or Partial sleep deprivation group. Prior to nocturnal sleep, both groups were exposed to "traumatic" picture stories. After sleep or partial sleep deprivation, participants were subjected to tests of explicit and implicit memory for potential trauma reminders. Thereafter, participants completed an intrusion triggering task that was embedded in a distractor task. Results: Analyses revealed higher explicit memory for potential trauma reminders after sleep as compared to partial sleep deprivation. No group differences were found for implicit memory. Participants responded with fewer intrusions after sleep than following partial sleep deprivation. Conclusions: The current findings support a protective role of sleep in trauma memory processing, which may be evident after the first night of sleep post-trauma. Although more research is needed, our results corroborate the importance of promoting restful sleep in trauma-exposed individuals.

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.

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

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

Post-Traumatic Sleep-Wake Disorders

All living organisms that face a traumatic life event are susceptible to sleep-wake disturbances. Stress, which can result in trauma, evokes a high level of physiological arousal associated with sympathetic nervous system activation, during both sleep and wakefulness. Heredity, sex hormones, early losses, developmental factors and intra- and interpersonal conflicts, contribute to the level of baseline physiological arousal, producing either subclinical, clinical or complex clinical traits, acutely and at any time after exposure to a traumatic event. The risk of acute sleep-wake disturbances becoming disorders and syndromes depends on the type of traumatic event and all of the aforementioned factors. Taken together, with consideration for behavioural and environmental heterogeneity, in research, will aid identification and understanding of susceptibility factors in long-term sleep and wakefulness pathology after exposure to traumatic events.

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.

Relationships between potentially traumatic events, sleep disturbances, and symptoms of PTSD and alcohol use disorder in a young adult sample

OBJECTIVE

Traumatic events, particularly those that are interpersonal in nature, are associated with increased risk for co-occurring sequelae, including sleep disturbances, posttraumatic stress disorder (PTSD), and alcohol use disorder (AUD). However, the associations between these phenotypes have not been explored among college students.

METHODS

We examined relationships between type of potentially traumatic event (PTE) exposure (pre-college) and sleep disturbances, as well as mediating effects of lifetime PTSD and AUD symptoms on these relationships, in a large undergraduate sample (N = 1599, 64.7% female). Hierarchical linear regressions were conducted, beginning with demographics and then adding interpersonal and accidental PTEs in a stepwise regression; mediation analyses were run.

RESULTS

Within the sample, 33.7% endorsed at least one interpersonal PTE, while 64.4% endorsed at least one accidental PTE. Hierarchical regressions demonstrated that interpersonal (β = 0.202, p = 0.000), but not accidental PTE exposure significantly predicted disturbed sleep. Both PTSD and AUD symptoms significantly mediated (p values < 0.001) the relationship between interpersonal PTE exposure and sleep, with indirect effects accounting for 61% and 17% of total effects, respectively. In the correlated mediation model, both disorders remained significant mediators (p < 0.001), with indirect effects accounting for 56% (PTSD symptoms) and 14% (AUD symptoms) of total effects on sleep.

CONCLUSIONS

Results suggest that interpersonal PTEs are more potent predictors of sleep problems than accidental PTEs. Further, trauma exposure psychiatric symptom sequelae (PTSD, AUD) account for part of the relationship between interpersonal PTE exposure and disturbed sleep, which both independently and jointly suggests that treating PTSD and AUD symptoms in college students may also improve sleep.

Occupational Health and Sleep Issues in Underserved Populations

Sleep disorders and occupational hazards, injuries, and illnesses impact an individual's overall health. In the United States, substantial racial, ethnic, and socioeconomic disparities exist in sleep and occupational health. Primary care physicians working in underserved communities should be aware of this disparity and target these higher-risk populations for focused evaluation and intervention.