Sleep Disturbances in Australian Vietnam Veterans With and Without Posttraumatic Stress Disorder

[Poor sleep quality contributes to occurrence of posttraumatic stress disorder in trauma patients]

OBJECTIVE

To evaluate the impact of poor sleep quality on occurrence of post-traumatic stress disorder (PTSD) in trauma patients.

METHODS

We prospectively recruited 256 trauma patients hospitalized in 4 general hospitals in Zunyi during the period from October, 2021 to November, 2022, and 226 of the participants completed the PTSD survey and assessment. The patients' sleep quality within a month before trauma was estimated using Pittsburgh Sleep Quality Index (PSQI), and their sleep quality within 7 days after admission was monitored by smart bracelet sleep monitoring; the PTSD Checklist-Civilian Version (PCL-C) was used to detect the occurrence of PTSD during the follow-up.

RESULTS

The detection rate of PTSD in the patients was 19.47% at 1 month and 17.61% at 3 months after trauma. The patients who developed PTSD had poorer sleep quality before the trauma, as shown by significantly higher PSQI scale scores (P < 0.001), than those without PTSD, and they showed a sleep abnormality rate as high as 72.73% prior to PTSD onset. Within 7 days after admission, the patients developing PTSD had lower sleep quality scores with more frequent night awakenings (P < 0.05). A 1 month and 3 months after trauma, the patients with PTSD had significantly higher PSQI scores than those without PTSD (P < 0.05).

CONCLUSION

PTSD is more likely to occur in trauma patients with poor sleep quality before trauma.

The obstructive sleep apnoea endotypes are similar in elderly trauma-exposed veterans with and without diagnosed PTSD

BACKGROUND

Approximately 60% of veterans living with posttraumatic stress disorder (PTSD) experience obstructive sleep apnoea (OSA). Why OSA is so prevalent in individuals with PTSD remains unknown, though PTSD may influence the underlying endotypes known to cause OSA. We examined whether these endotypes (upper airway collapsibility, muscle compensation, loop gain, and the arousal threshold) differ between those with comorbid OSA and PTSD relative to their counterparts with OSA-only.

METHODS

Using the ventilatory flow pattern from diagnostic polysomnography, the OSA endotypes were measured in a retrospective cohort of 21 OSA patients with PTSD and 27 OSA-only patients. All participants were trauma exposed elderly male Australian Vietnam War veterans with mild-to-severe OSA (median Apnoea-Hypopnea index: 20.2 vs. 23.6 events/h). Age and BMI were similar between groups (70.7 vs. 71.7 years, and 28.4 vs. 28.4 kg/m2).

RESULTS

There were no significant differences in the OSA endotype traits between PTSD + OSA and OSA-only patients for upper airway collapsibility (76.68 [71.53-83.56] vs. 78.35 [72.81-83.82] %Veupnea, median [IQR]), muscle compensation (4.27 [0.34-9.18] vs. 5.41 [1.83-7.21] %Veupnea), loop gain (0.56(0.17) vs. 0.60(0.14)), and arousal threshold (135.76 [126.59-147.54] vs. 146.95 [128.64-151.28] %Veupnea).

CONCLUSION

The OSA endotypes in veterans with PTSD were similar to their trauma exposed OSA-only counterparts. PTSD appears to exert little influence on the OSA endotypes beyond the effect that age and trauma exposure may have. The aetiology of increased prevalence of OSA in PTSD remains unclear. Further work examining OSA endotypes using larger and more diverse samples is needed before robust conclusions can be made.

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.

Prevalence, risk correlates, and health comorbidities of insomnia in US military veterans: results from the 2019-2020 National Health and Resilience in Veterans Study

STUDY OBJECTIVES

Veterans experience high levels of trauma, psychiatric, and medical conditions that may increase their risk for insomnia. To date, however, no known study has examined the prevalence, risk correlates, and comorbidities of insomnia in a nationally representative sample of veterans.

METHODS

A nationally representative sample of 4,069 US military veterans completed a survey assessing insomnia severity; military, trauma, medical, and psychiatric histories; and health and psychosocial functioning. Multivariable analyses examined the association between insomnia severity, psychiatric and medical comorbidities, suicidality, and functioning.

RESULTS

A total of 11.4% of veterans screened positive for clinical insomnia and 26.0% for subthreshold insomnia. Greater age and retirement were associated with a lower likelihood of insomnia. Adverse childhood experiences, traumatic life events, lower education and income were associated with greater risk for insomnia. A "dose-response" association was observed for health comorbidities, with increasing levels of insomnia associated with elevated odds of psychiatric and medical conditions (clinical vs no insomnia odds ratio = 1.8-13.4) and greater reductions in health and psychosocial functioning (clinical vs no insomnia Cohen's d = 0.2-0.4). The prevalence of current suicidal ideation was 3-5 times higher in veterans with clinical and subthreshold insomnia relative to those without insomnia (23.9% and 13.6% vs 4.5%, respectively).

CONCLUSIONS

Nearly 2 in 5 US veterans experience clinical or subthreshold insomnia, which is associated with substantial health burden and independent risk for suicidal ideation. Results underscore the importance of assessment, monitoring, and treatment of insomnia in veterans as they transition from the military.

The risk factors for insomnia and sleep-disordered breathing in military communities: A meta-analysis

BACKGROUND

Many reviews and meta-analyses had been conducted to investigate risk factors for sleep disorders in the general population. However, no similar research has been performed in the military population though insomnia and sleep-disordered breathing are quite prevalent in that population.

OBJECTIVES

To investigate risk factors for insomnia and sleep-disordered breathing in military personnel.

METHODS

A systematic literature search was performed from inception to March 2021 and 6496 records were produced. Two authors independently screened records for eligibility. Results were presented as odds ratios, and a random-effect model was used to pool results. Data analysis was performed respectively according to military personnel type (i.e., veteran, active-duty personnel). Risk factors were sorted into three categories: sociodemographic, army-specific, and comorbidity. This meta-analysis was registered in PROSPERO before data analysis (registration No: CRD42020221696).

RESULTS

Twenty-seven articles were finally included in the quantitative analysis. For sleep-disordered breathing in active-duty personnel, four sociodemographic (i.e., overweight/obesity, higher body mass index, male gender, >35 years old) and one comorbidity (i.e., depression) risk factors were identified. For insomnia in active-duty personnel, four sociodemographic (i.e., aging, alcohol dependence, white race, and female gender), two army-specific (i.e., deployment experience, combat experience), and four comorbidity (i.e., depression, post-traumatic stress disorder, traumatic brain injury, and anxiety) risk factors were identified. For insomnia in veterans, one army-specific (i.e., combat experience) and one comorbidity (i.e., post-traumatic stress disorder) risk factor was identified.

CONCLUSIONS

Several risk factors were identified for insomnia and sleep-disordered breathing in the current meta-analysis. Risk factors for veterans and active-duty personnel were partially different. Research on sleep breathing disorders remains limited, and more convincing evidence would be obtained with more relevant studies in the future.

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

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Trauma Associated Sleep Disorder: Clinical Developments 5 Years After Discovery

PURPOSE OF REVIEW

We review recent and growing evidence that provides support for a novel parasomnia, trauma associated sleep disorder (TASD). Based on these findings, we further develop the clinical and polysomnographic (PSG) characteristics of TASD. We also address factors that precipitate TASD, develop a differential diagnosis, discuss therapy, and propose future directions for research.

RECENT FINDINGS

Nightmares, classically a REM phenomenon, are prevalent and underreported, even in individuals with trauma exposure. When specifically queried, trauma-related nightmares (TRN) are frequently associated with disruptive nocturnal behaviors (DNB), consistent with TASD. Capture of DNB in the lab is rare but ambulatory monitoring reveals dynamic autonomic concomitants associated with disturbed dreaming. TRN may be reported in NREM as well as REM sleep, though associated respiratory events may confound this finding. Further, dream content is more distressing in REM. Therapy for this complex disorder likely requires addressing not only the specific TASD components of TRN and DNB but comorbid sleep disorders. TASD is a unique parasomnia developing after trauma. Trauma-exposed individuals should be specifically asked about their sleep and if they have nightmares with or without DNB. Patients who report TRN warrant in-lab PSG as part of their evaluation.

Comparison of Sleep Patterns in Vietnam Veterans With and Without Posttraumatic Stress Disorder Using Wrist Actigraphy

STUDY OBJECTIVES

Disturbed sleep is a hallmark feature of posttraumatic stress disorder (PTSD). However, few studies have examined sleep objectively in individuals with PTSD compared to trauma-exposed controls. This study used wrist actigraphy to measure and compare sleep patterns in trauma-exposed Australian Vietnam veterans (VV) with and without PTSD.

METHODS

Trauma-exposed Australian VV with and without PTSD were recruited from the PTSD Initiative. VV wore wrist accelerometers over 14 days and completed daily sleep diaries. Sleep parameters were compared between groups including sleep latency (SL), time in bed (TIB), total sleep time (TST), wake after sleep onset (WASO), and movement index (MI). Night-to-night and overall within-individual variability were assessed by root mean squared successive differences and comparison of individual standard deviations. Correlations between sleep diary (self-reported) and wrist actigraphy (objective) variables were also assessed.

RESULTS

A total of 40 male VV (20 with PTSD) participated in the study. We found no difference in sleep patterns determined by wrist actigraphy between groups with the exception of reduced SL in VV with PTSD (3.9 ± 0.9 versus 4.9 ± 1.4 minutes, P < .05). Overall within-individual variability was significantly greater in VV with PTSD for TIB, TST, WASO, and MI. Self-reported and objective TST and WASO were more strongly correlated in VV without PTSD than those with PTSD.

CONCLUSIONS

Although there were no significant differences in sleep parameters, VV with PTSD had increased within-individual overall sleep variability and reduced correlation between self-reported and objective sleep parameters compared to trauma-exposed controls. Further evaluation of extended sleep patterns by actigraphy in VV with PTSD is warranted.

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.

Reduced gamma-amino butyric acid (GABA) and glutamine in the anterior cingulate cortex (ACC) of veterans exposed to trauma

BACKGROUND

Trauma-related diagnoses such as posttraumatic stress disorder (PTSD) are prevalent in veterans. The identification of mechanisms related to stress vulnerability and development of PTSD specifically in a veteran population may aid in the prevention of PTSD and identification of novel treatment targets.

METHODS

Veterans with PTSD (n = 27), trauma-exposed veterans with no PTSD (TEC, n = 18) and non-trauma-exposed controls (NTEC, n = 28) underwent single-voxel proton (¹H) magnetic resonance spectroscopy (MRS) at 3 Tesla in the dorsal anterior cingulate cortex (dACC) using a two-dimensional (2D) J-resolved point spectroscopy sequence in addition to completing a clinical battery.

RESULTS

The PTSD and TEC groups demonstrated lower gamma-amino butyric acid (GABA)/H₂O (p = 0.02) and glutamine (Gln)/H₂O (p = 0.02) in the dACC as compared to the NTEC group. The PTSD group showed a trend towards higher Glu/GABA (p = 0.053) than the NTEC group. Further, GABA/H₂O in the dACC correlated negatively with sleep symptoms in the PTSD group (p = 0.03) but not in the TEC and NTEC groups.

LIMITATIONS

Cross-sectional study design, concomitant medications, single voxel measurement as opposed to global changes, absence of measure of childhood or severity of trauma and objective sleep measures, female participants not matched for menstrual cycle phase.

CONCLUSIONS

Exposure to trauma in veterans may be associated with lower GABA/H₂O and Gln/H₂O in the dACC, suggesting disruption in the GABA-Gln-glutamate cycle. Further, altered Glu/GABA in the dACC in the PTSD group may indicate an excitatory-inhibitory imbalance. Further, lower GABA/H₂O in the ACC was associated with poor sleep in the PTSD group. Treatments that restore GABAergic balance may be particularly effective in reducing sleep symptoms in PTSD.