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van der Heijden AC, van den Heuvel OA, van der Werf YD, Talamini LM, van Marle HJF. Sleep as a window to target traumatic memories. Neurosci Biobehav Rev 2022; 140:104765. [PMID: 35803396 DOI: 10.1016/j.neubiorev.2022.104765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/20/2022] [Accepted: 07/01/2022] [Indexed: 10/17/2022]
Abstract
Post-traumatic stress disorder (PTSD) is a severe psychiatric disorder in which traumatic memories result in flashbacks and nightmares. With one-third of patients not responding to standard exposure-based psychotherapy, new treatment strategies are needed. Sleep offers a unique time window to enhance therapeutic efficacy. Traumatic memories that are neutralized in therapy need to be stored back into memory (consolidated) during sleep to solidify the treatment effect. New basic research shows that memory consolidation can be enhanced by presenting sounds or scents that were linked to the memory at encoding, again during sleep. This procedure, termed targeted memory reactivation (TMR), has, despite its clinical potential, not been tested in (PTSD) patients. In this narrative review, we explore the potential of TMR as a new sleep-based treatment for PTSD. First we provide the necessary background on the memory and sleep principles underlying PTSD as well as the present applications and conditional factors of TMR. Then, we will discuss the outstanding questions and most promising experimental avenues when testing TMR to treat traumatic memories.
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Affiliation(s)
- A C van der Heijden
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Psychiatry, Department Anatomy & Neuroscience, Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Neuroscience, Mood Anxiety Psychosis Stress Sleep, Amsterdam, the Netherlands.
| | - O A van den Heuvel
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Psychiatry, Department Anatomy & Neuroscience, Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Neuroscience, Compulsivity Impulsivity and Attention, Amsterdam, the Netherlands
| | - Y D van der Werf
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Psychiatry, Department Anatomy & Neuroscience, Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Neuroscience, Compulsivity Impulsivity and Attention, Amsterdam, the Netherlands
| | - L M Talamini
- University of Amsterdam, Dept. of Psychology, Brain & Cognition, Nieuwe Achtergracht 129B, 1018 WS Amsterdam, the Netherlands
| | - H J F van Marle
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Psychiatry, Department Anatomy & Neuroscience, Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Neuroscience, Mood Anxiety Psychosis Stress Sleep, Amsterdam, the Netherlands; GGZ inGeest Mental Health Care, Amstelveenseweg 589, 1081 JC Amsterdam, the Netherlands
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Kobayashi I, Mellman TA, Cannon A, Brown I, Boadi L, Howell MK, Lavela P, Sandhu I. Blocking the orexin system following therapeutic exposure promoted between session habituation, but not PTSD symptom reduction. J Psychiatr Res 2021; 145:222-229. [PMID: 34933185 PMCID: PMC9192822 DOI: 10.1016/j.jpsychires.2021.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/06/2021] [Accepted: 12/11/2021] [Indexed: 11/24/2022]
Abstract
There is a need to identify strategies to increase the effectiveness of treatments for posttraumatic stress disorder (PTSD). Sleep is often disturbed in PTSD and has been implicated in learning processes that underlie recovery from PTSD, including extinction of conditioned fear. Our prior study suggested that diminished arousal during sleep may enhance benefits of therapeutic exposure for PTSD. The orexin system regulates arousal, and blocking the system diminishes arousal and promotes sleep. We, therefore, examined whether a dual orexin receptor antagonist, suvorexant, administered following evening exposure sessions, would enhance their therapeutic effectiveness for PTSD. In this randomized double-blind placebo-controlled trial, adults with PTSD completed four written narrative exposure (WNE) sessions, two of which took place in the evening, and two the next morning. Participants received either suvorexant or placebo after each evening WNE. We found that suvorexant increased N3 sleep and decreased N2 sleep and rapid-eye-movement latency measured by polysomnography. Between session habituation indexed by subjective distress ratings was greater with suvorexant, but there was no group difference in the reduction of PTSD severity from baseline to 1-week follow-up. No safety concerns emerged. The present findings provide preliminary support for enhancement of an effect of therapeutic exposure for PTSD by suvorexant. Further studies with larger samples are needed to translate the present findings into clinical applications, including studies to develop optimal suvorexant administration and exposure session schedules to achieve persistent benefits to sleep and possibly greater treatment augmentation.
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Affiliation(s)
- Ihori Kobayashi
- Department of Psychiatry and Behavioral Sciences, Howard University, Washington, DC, USA.
| | - Thomas A Mellman
- Department of Psychiatry and Behavioral Sciences, Howard University, Washington, DC, USA
| | - Ashley Cannon
- Department of Psychiatry and Behavioral Sciences, Howard University, Washington, DC, USA
| | - Imani Brown
- Department of Psychiatry and Behavioral Sciences, Howard University, Washington, DC, USA
| | - Linda Boadi
- Department of Psychiatry and Behavioral Sciences, Howard University, Washington, DC, USA
| | | | - Pewu Lavela
- Department of Psychiatry and Behavioral Sciences, Howard University, Washington, DC, USA
| | - Ishaan Sandhu
- Department of Psychiatry and Behavioral Sciences, Howard University, Washington, DC, USA
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Lee J, Jeon S, Kim S, Seo Y, Park J, Lee YJ, Kim SJ. Polysomnographic Sleep and Attentional Deficits in Traumatized North Korean Refugees. Nat Sci Sleep 2021; 13:635-645. [PMID: 34079408 PMCID: PMC8163968 DOI: 10.2147/nss.s308968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/29/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Attentional deficits and sleep problems are common in refugees who have experienced trauma. In the present study, we used polysomnography (PSG) to investigate the relationship between attentional deficits and objective measures of sleep structure in traumatized North Korean refugees. METHODS We recruited 32 North Korean refugees (mean age = 33.78 ± 14.33 years) and 39 South Korean participants (mean age = 35.03 ± 11.08 years). Sustained attention and divided attention were assessed using the Computerized Attention Test. We conducted an overnight PSG to objectively assess sleep structure. The participants also completed the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Impact of Event Scale-Revised (IES-R), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), and Insomnia Severity Index (ISI). RESULTS The North Korean refugees showed more commission errors (CEs, p < 0.05) and a larger standard deviation (SD) of the reaction time (RT) (p < 0.05) in the sustained attention task compared to the South Korean participants. Furthermore, the North Korean refugees showed a shorter period of wake after sleep onset (WASO, p < 0.01), less time spent in N1 (p < 0.05), and more time spent in N2 (p < 0.05). The larger SD of RT in the sustained attention task in the North Korean refugees was positively correlated with WASO (r = 0.62, p < 0.01) and N1 stage (r = 0.47, p < 0.05) after controlling for age, sex, BDI, BAI, and IES-R. CONCLUSION The North Korean refugees showed poorer performance on the sustained attention task. Nocturnal PSG revealed shorter WASO and time spent in N1 in this population, which are independently associated with the preservation of attentional capacity. These data suggest that traumatized refugees may compensate for attentional deficits induced by their traumatic experiences via increased sleep continuity.
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Affiliation(s)
- Jooyoung Lee
- Department of Psychiatry, Sungkyunkwan University College of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Sehyun Jeon
- Department of Psychiatry, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Somin Kim
- Department of Psychiatry, Sungkyunkwan University College of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Yumin Seo
- Department of Psychiatry, Sungkyunkwan University College of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Jinme Park
- Department of Psychology, University of Konstanz, Konstanz, Germany
| | - Yu Jin Lee
- Department of Psychiatry and Center for Sleep and Chronobiology, Seoul National University, College of Medicine and Hospital, Seoul, Republic of Korea
| | - Seog Ju Kim
- Department of Psychiatry, Sungkyunkwan University College of Medicine, Samsung Medical Center, Seoul, Republic of Korea
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Sleep parameters improvement in PTSD soldiers after symptoms remission. Sci Rep 2021; 11:8873. [PMID: 33893376 PMCID: PMC8065125 DOI: 10.1038/s41598-021-88337-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 04/06/2021] [Indexed: 11/08/2022] Open
Abstract
Eye movement desensitization and reprocessing (EMDR) is a psychotherapy for the treatment of posttraumatic stress disorder (PTSD). It is still unclear whether symptoms remission through EMDR therapy is associated with a beneficial effect on one of the PTSD symptoms, sleep disturbance. Our objective was therefore to study sleep parameters before and after symptom remission in soldiers with PTSD. The control group consisted of 20 healthy active duty military men who slept in a sleep lab with standard polysomnography (PSG) on two sessions separated by one month. The patient group consisted of 17 active duty military with PTSD who underwent EMDR therapy. PSG-recorded sleep was assessed 1 week before the EMDR therapy began and 1 week after PTSD remission. We found that the increased REMs density after remission was positively correlated with a greater decrease of symptoms. Also, the number of EMDR sessions required to reach remission was correlated with intra-sleep awakenings before treatment. These results confirm the improvement of some sleep parameters in PTSD after symptoms remission in a soldier's population and provide a possible predictor of treatment success. Further experiments will be required to establish whether this effect is specific to the EMDR therapy.
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Jones S, Castelnovo A, Riedner B, Flaherty B, Prehn-Kristensen A, Benca R, Tononi G, Herringa R. Sleep and emotion processing in paediatric posttraumatic stress disorder: A pilot investigation. J Sleep Res 2021; 30:e13261. [PMID: 33442931 PMCID: PMC8365752 DOI: 10.1111/jsr.13261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/29/2020] [Accepted: 11/23/2020] [Indexed: 11/28/2022]
Abstract
Emotion processing abnormalities and sleep pathology are central to the phenomenology of paediatric posttraumatic stress disorder, and sleep disturbance has been linked to the development, maintenance and severity of the disorder. Given emerging evidence indicating a role for sleep in emotional brain function, it has been proposed that dysfunctional processing of emotional experiences during sleep may play a significant role in affective disorders, including posttraumatic stress disorder. Here we sought to examine the relationship between sleep and emotion processing in typically developing youth, and youth with a diagnosis of posttraumatic stress disorder . We use high-density electroencephalogram to compare baseline sleep with sleep following performance on a task designed to assess both memory for and reactivity to negative and neutral imagery in 10 youths with posttraumatic stress disorder, and 10 age- and sex-matched non-traumatized typically developing youths. Subjective ratings of arousal to negative imagery (ΔArousal = post-sleep minus pre-sleep arousal ratings) remain unchanged in youth with posttraumatic stress disorder following sleep (mean increase 0.15, CI -0.28 to +0.58), but decreased in TD youth (mean decrease -1.0, 95% CI -1.44 to -0.58). ΔArousal, or affective habituation, was negatively correlated with global change in slow-wave activity power (ρ = -0.58, p = .008). When considered topographically, the correlation between Δslow-wave activity power and affective habituation was most significant in a frontal cluster of 27 electrodes (Spearman, ρ = -0.51, p = .021). Our results highlight the importance of slow-wave sleep for adaptive emotional processing in youth, and have implications for symptom persistence in paediatric posttraumatic stress disorder. Impairments in slow-wave activity may represent a modifiable risk factor in paediatric posttraumatic stress disorder.
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Affiliation(s)
- Stephanie Jones
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, USA.,Wisconsin Institute for Sleep and Consciousness, University of Wisconsin-Madison, Madison, WI, USA
| | - Anna Castelnovo
- Sleep and Epilepsy Center, Neurocenter of the Southern Switzerland, Regional Hospital (EOC) of Lugano, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Brady Riedner
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, USA.,Wisconsin Institute for Sleep and Consciousness, University of Wisconsin-Madison, Madison, WI, USA
| | - Bethany Flaherty
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, USA.,Wisconsin Institute for Sleep and Consciousness, University of Wisconsin-Madison, Madison, WI, USA
| | - Alexander Prehn-Kristensen
- Department of Child and Adolescent Psychiatry and Psychotherapy, Centre for Integrative Psychiatry, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Ruth Benca
- Department of Psychiatry & Human Behavior, School of Medicine, University of California-Irvine, Irvine, CA, USA
| | - Giulio Tononi
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, USA.,Wisconsin Institute for Sleep and Consciousness, University of Wisconsin-Madison, Madison, WI, USA
| | - Ryan Herringa
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, USA
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Lancel M, van Marle HJF, Van Veen MM, van Schagen AM. Disturbed Sleep in PTSD: Thinking Beyond Nightmares. Front Psychiatry 2021; 12:767760. [PMID: 34899428 PMCID: PMC8654347 DOI: 10.3389/fpsyt.2021.767760] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/02/2021] [Indexed: 11/13/2022] Open
Abstract
Sleep disturbances frequently co-occur with posttraumatic stress disorder (PTSD). Insomnia and nightmares are viewed as core symptoms of PTSD. Yet, relations between disturbed sleep and PTSD are far more complex: PTSD is linked to a broad range of sleep disorders and disturbed sleep markedly affects PTSD-outcome. This article provides a concise overview of the literature on prevalent comorbid sleep disorders, their reciprocal relation with PTSD and possible underlying neurophysiological mechanisms. Furthermore, diagnostic procedures, standard interventions-particularly first choice non-pharmacological therapies-and practical problems that often arise in the assessment and treatment of sleep disturbances in PTSD are described. Finally, we will present some perspectives on future multidisciplinary clinical and experimental research to develop new, more effective sleep therapies to improve both sleep and PTSD.
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Affiliation(s)
- Marike Lancel
- Centre of Expertise on Sleep and Psychiatry, GGZ Drenthe Mental Health Institute, Assen, Netherlands.,Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, Netherlands
| | - Hein J F van Marle
- Department of Psychiatry, Amsterdam Neuroscience, Vrije Universiteit, Amsterdam UMC, Amsterdam, Netherlands.,GGZ InGeest Specialized Mental Health Care, Amsterdam, Netherlands
| | - Maaike M Van Veen
- Centre of Expertise on Sleep and Psychiatry, GGZ Drenthe Mental Health Institute, Assen, Netherlands
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Richards A, Kanady JC, Neylan TC. Sleep disturbance in PTSD and other anxiety-related disorders: an updated review of clinical features, physiological characteristics, and psychological and neurobiological mechanisms. Neuropsychopharmacology 2020; 45:55-73. [PMID: 31443103 PMCID: PMC6879567 DOI: 10.1038/s41386-019-0486-5] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Anne Richards
- The San Francisco VA Health Care System, San Francisco, CA, USA.
- The University of California, San Francisco, San Francisco, CA, USA.
| | - Jennifer C Kanady
- The San Francisco VA Health Care System, San Francisco, CA, USA
- The University of California, San Francisco, San Francisco, CA, USA
| | - Thomas C Neylan
- The San Francisco VA Health Care System, San Francisco, CA, USA
- The University of California, San Francisco, San Francisco, CA, USA
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Woodward E, Hackmann A, Wild J, Grey N, Clark DM, Ehlers A. Effects of psychotherapies for posttraumatic stress disorder on sleep disturbances: Results from a randomized clinical trial. Behav Res Ther 2017; 97:75-85. [PMID: 28732289 PMCID: PMC5608018 DOI: 10.1016/j.brat.2017.07.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 05/16/2017] [Accepted: 07/05/2017] [Indexed: 12/04/2022]
Abstract
The effectiveness and mechanisms of psychotherapies for posttraumatic stress disorder (PTSD) in treating sleep problems is of interest. This study compared the effects of a trauma-focused and a non-trauma-focused psychotherapy on sleep, to investigate whether 1) sleep improves with psychotherapy for PTSD; 2) the degree of sleep improvement depends on whether the intervention is trauma or nontrauma-focused; 3) the memory-updating procedure in cognitive therapy for PTSD (CT-PTSD) is associated with sleep improvements; 4) initial sleep duration affects PTSD treatment outcome; and 5) which symptom changes are associated with sleep duration improvements. Self-reported sleep was assessed during a randomized controlled trial (Ehlers et al., 2014) comparing CT-PTSD (delivered weekly or intensively over 7-days) with emotion-focused supportive therapy, and a waitlist. Sleep duration was reported daily in sleep diaries during intensive CT-PTSD. CT-PTSD led to greater increases in sleep duration (55.2 min) and reductions in insomnia symptoms and nightmares than supportive therapy and the waitlist. In intensive CT-PTSD, sleep duration improved within 7 days, and sleep diaries indicated a 40-min sleep duration increase after updating trauma memories. Initial sleep duration was not related to CT-PTSD treatment outcome when initial PTSD symptom severity was controlled. The results suggest that trauma-focused psychotherapy for PTSD is more effective than nontrauma-focused therapy in improving self-reported sleep, and that CT-PTSD can still be effective in the presence of reduced sleep duration.
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Affiliation(s)
- Elizabeth Woodward
- Department of Experimental Psychology, University of Oxford, UK; National Institute for Health Research (NIHR), Oxford Health Biomedical Research Centre, Oxford, UK.
| | - Ann Hackmann
- National Institute for Health Research (NIHR), Oxford Health Biomedical Research Centre, Oxford, UK
| | - Jennifer Wild
- Department of Experimental Psychology, University of Oxford, UK; National Institute for Health Research (NIHR), Oxford Health Biomedical Research Centre, Oxford, UK
| | - Nick Grey
- National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre, South London Maudsley NHS Foundation Trust, King's College London, UK
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, UK; National Institute for Health Research (NIHR), Oxford Health Biomedical Research Centre, Oxford, UK; National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre, South London Maudsley NHS Foundation Trust, King's College London, UK
| | - Anke Ehlers
- Department of Experimental Psychology, University of Oxford, UK; National Institute for Health Research (NIHR), Oxford Health Biomedical Research Centre, Oxford, UK; National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre, South London Maudsley NHS Foundation Trust, King's College London, UK.
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