Recent Advancements in Treating Sleep Disorders in Co-Occurring PTSD

Trajectories and comorbid symptom networks of posttraumatic stress symptoms in frontline rescuers: A longitudinal study

BACKGROUND

Previous research has largely lacked studies that explore the trajectories of Posttraumatic stress symptoms (PTSS) and the structure of comorbid psychiatric symptom networks following traumatic event, while controlling for the severity of traumatic exposure. The present study aims to explore the characteristic trajectories of PTSS, in the context of ensuring controlled levels of traumatic exposure. Furthermore, the PTSS, depressive, and anxiety comorbid symptom networks of different PTSS trajectory subgroups are also investigated.

METHODS

A total of 296 frontline rescue personnel were enrolled into our study. In an effort to control for variations in traumatic exposure severity, this study ensured that all participants had same responsibilities and cumulative operational duration at the post-disaster rescue circumstance. Growth mixture models (GMMs) were employed to scrutinize the trajectories of PTSS. Additionally, network analysis was used to examine the comorbid symptom network of PTSS, depression, and anxiety.

RESULTS

Four distinct PTSS trajectories were identified, namely Persisting Symptom, Gradual Recovery, Gradual Aggravation, and Asymptomatic. Although both the Persisting Symptom and Gradual Aggravation groups belong to the high-risk subgroups for persistent PTSS, they exhibit differences in core symptoms within their respective networks. The core symptom for the Persisting Symptom Network is flashbacks, while for the Gradual Aggravation Network, it is sleep disturbances.

CONCLUSION

To the best of our knowledge, the present study represents the first research endeavor to integrate longitudinal trajectory analysis of PTSS with longitudinal symptom network analysis, clarifying the evolving features of PTSS but also offering valuable insights for early screening and intervention strategies.

A phase 3, randomized, placebo-controlled, trial to evaluate the efficacy and safety of bedtime sublingual cyclobenzaprine (TNX-102 SL) in military-related posttraumatic stress disorder

Sleep disturbances in posttraumatic stress disorder (PTSD) are a potential target for improving PTSD severity with pharmacotherapy. TNX-102 SL is a bedtime sublingual formulation of cyclobenzaprine with potent binding and antagonist activity at 5-HT2A, α1-adrenergic, H1 histaminergic, and M1 muscarinic receptors, which play roles in the pharmacological management of sleep disturbances. This Phase 3 trial evaluated the efficacy and safety of TNX-102 SL in patients with military-related PTSD. Early and sustained improvements in sleep were associated with TNX-102 SL treatment by PROMIS Sleep Disturbance scale and Clinician Administered PTSD Scale (CAPS-5) "sleep disturbance" item, establishing a sleep quality benefit. Primary analysis comparing change from baseline in CAPS-5 total severity between TNX-102 SL and placebo at week 12 was not significant; however, week 4 was associated with an improvement. Secondary analyses showed TNX-102 SL treatment was associated with benefits on the Clinician Global Impression of Improvement at week 4 and the Patient Global Impression of Change at week 12. Time since trauma exposure was a discriminator of CAPS-5 treatment response in the subgroup ≤ 9 years since the index event. This study provides preliminary evidence that TNX-102 SL is well-tolerated and may promote recovery from PTSD by addressing sleep-related symptoms.

Sleep disorders in a naturalistic cohort of Dutch psychiatric outpatients: prevalence rates and associations with psychopathology symptom severity and well-being

Sleep problems are very common in individuals with a mental disorder. Given the abundant evidence indicating the negative impact of disturbed sleep on mental health outcome, insight into the prevalence of all types of sleep disorders in specific mental disorders and neurodevelopmental conditions is of practical importance. Therefore, we estimated the prevalence of six types of sleep disorders with the Holland Sleep Disorders Questionnaire in an overall mental health sample (n = 1082) and separately for different mental and neurodevelopmental conditions. Furthermore, associations between specific sleep disorders, psychopathology and well-being were studied. The impact of the total number of sleep disorders on these associations was examined. Overall, 46.2% of all participants scored above the cut-off for having a sleep disorder. Specifically, 26.8% scored on insomnia, 12.1% on sleep breathing disorders, 9.7% on hypersomnia, 13.7% on circadian rhythm sleep-wake disorders, 11.2% on parasomnia, and 17.9% on sleep-related movement disorders. Most sleep disorders were associated with greater severity of psychopathology and lower well-being. These associations got stronger with an increasing number of sleep disorders. Our study revealed higher suspected prevalence of most sleep disorders in a mental disorder sample compared to the general population. Moreover, the presence of sleep disorder(s) was strongly associated with symptom severity and reduced well-being. These findings extend the notion that early detection and treatment of sleep disorders in mental health populations is essential for psychiatric outcome.

Polysomnography and Neuropsychological Analysis of Patients With Post-Traumatic Stress Disorder Two Years After the COVID-19 Pandemic in Wuhan

OBJECTIVE

We used polysomnography (PSG) monitoring and neuropsychological scales to explore the characteristics of coronavirus disease-2019 (COVID-19) patients diagnosed with post-traumatic stress disorder (PTSD) in Wuhan, two years after the onset of the COVID-19 pandemic.

METHODS

A total of 42 patients in the Sleep Medicine Center were diagnosed with insomnia between December 2021 and May 2022; they were divided into the PTSD group (patients with PTSD diagnosed with insomnia after COVID-19 infection) and the non-PTSD group (patients with insomnia without PTSD). A healthy control group was simultaneously included.

RESULTS

The PTSD group was more significant than the non-PTSD group in partial manifestations of sleep disorders, neuropsychological clinical symptoms, and partial PSG data. Patients with different COVID-19 subtypes showed significant differences in the course of disease, sleep disorders, neuropsychological clinical symptoms, relevant scale scores, and PSG data analysis.

CONCLUSION

The emotional anxiety and depression of COVID-19 patients diagnosed with PTSD two years after the COVID-19 pandemic in Wuhan are more significant, and will not be self-alleviated with the passage of time. It is necessary to continue to pay attention to the PTSD symptoms and sleep psychology of COVID-19 infected patients, and take appropriate measures. Patients with severe and critical COVID-19 have more severe sleep and mental disorders, and there is a significant correlation between the duration of the disease and the severity of mental and mental disorders and sleep disorders after recovery.

Feasibility of a breath robot intervention to reduce sleep problems in posttraumatic stress disorder: protocol for a randomized controlled study

BACKGROUND

Many patients with posttraumatic stress disorder (PTSD) suffer from sleep problems. Robot-based interventions might be an innovative approach to reduce sleep problems and hyperarousal in PTSD. However, the feasibility and effectiveness of a breath robot in patients with PTSD have never been empirically tested. The aim of this study is to investigate the feasibility of a breath robot to reduce sleep problems and hyperarousal in patients with PTSD.

METHODS

This randomized controlled feasibility study will include N = 30 adult patients with at least subsyndromal PTSD (PTSD Symptom Scale - Interview-5 (PSSI-5)) according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) and impaired sleep quality (Pittsburgh Sleep Quality Index (PSQI) > 5). Patients with organic sleep disorders or currently in psychotherapeutic treatment are excluded. Study participants are randomized to receive either a 4-week Somnox 2 robot intervention including simulation of human breath or a 4-week Somnox 2 robot intervention without human breath simulation. The primary outcome will be the proportion of randomized participants providing outcome data at post-treatment. We consider a proportion of > 50% to indicate feasibility. Additional feasibility outcomes include eligibility rate, recruitment speed, uptake, retention, treatment adherence, and dropout. Potential outcomes of effectiveness (sleep quality, PSQI; severity of PTSD symptoms, PSSI-5) will be assessed at two time points, before (T0) and after (T1) the intervention. Sleep characteristics (Consensus Sleep Diary (CSD)) are measured daily.

DISCUSSION

This study is the first to investigate the feasibility of a novel breath robot intervention for reducing sleep problems and hyperarousal in PTSD patients, with effectiveness considered as a secondary outcome. If feasible and effective, the use of a breath robot could be a nonintrusive and flexible intervention to supplement psychotherapy or to bridge treatment gaps.

TRIAL REGISTRATION

DRKS, DRKS00031063. Registered on 10/012023.

Role of sleep in asthenospermia induced by di (2-ethyl-hexyl) phthalate

Di (2-ethyl-hexyl) phthalate (DEHP) mainly enters the human body through the digestive tract, respiratory tract, and skin. At the same time, it has reproductive and developmental toxicity, neurotoxicity, and so on, which can cause the decrease of sperm motility. Asthenospermia is also known as low sperm motility, and the semen quality of men in some areas of China is declining year by year. Interestingly, previous studies have shown that sleep disorders can also lead to asthenospermia. However, the relationship between sleep, DEHP, and asthenospermia is still unclear. Analysis of the National Health and Nutrition Examination Survey (NHANES) population database showed that DEHP was associated with sleep disorders, and subsequent experiments in mice and Drosophila indicated that DEHP exposure had certain effects on sleep and asthenospermia. Furthermore, we analyzed the Comparative Toxicogenomics Database (CTD) to find out the common signaling pathway among the three: hypoxia-inducible factor 1(HIF-1). Then Search Tool for the Retrieval of Interacting Genes/Proteins (STRING) was used to screen out the proteins that DEHP affected the HIF-1 pathway: glyceraldehyde-3-phosphate dehydrogenase (GAPDH), serine/threonine-protein kinase (AKT1), epidermal growth factor receptor (EGFR), and finally Western blot analysis was used to detect the expression levels of the three proteins. Compared with the control group, DEHP decreased the protein expression levels of GAPDH and AKT1 in the HIF-1 pathway, and caused sleep disorders and decreased sperm motility. This study provides preliminary evidence for exploring the mechanism among DEHP, sleep disorders, and asthenospermia.

Evaluation of sleep and therapeutic education needs of military with PTSD

Sleep disorders in post-traumatic stress disorder (PTSD) are both diagnostic (nocturnal reliving) and prognostic. Poor sleep worsens the daytime symptomatology of PTSD and makes it resistant to treatment. However, no specific treatment is codified in France to treat these sleep disorders although sleep therapies (cognitive behavioural therapy for insomnia, psychoeducation and relaxation) have proven for years to be effective in treating insomnia. Therapeutic sessions can be part of a therapeutic patient education program, which is a model for the management of chronic pathologies. It allows for an improvement in a patient's quality of life and enhanced medication compliance. We therefore carried out an inventory of sleep disorders of patients with PTSD. First, we collected data by means of sleep diaries concerning the population's sleep disorders at home. Then we assessed the population's expectations and needs regarding its management of sleep, thanks to a semi-qualitative interview. The data from sleep diaries, which was consistent with the literature, showed that our patients suffered from severe sleep disorders that strongly impact their daily lives, with 87% of patients having an increased sleep onset latency, and 88% having nightmares. We observed a strong demand from patients for specific support for these symptoms, 91% expressing an interest in a TPE program targeting sleep disorders. Thanks to the data collected, the emerging themes for a future therapeutic patient education program targeting sleep disorders of soldiers with PTSD are: sleep hygiene; management of nocturnal awakenings, including nightmares; and psychotropic drugs.

The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study

STUDY OBJECTIVES

Intranasal administration of esketamine is Food and Drug Administration-approved for treatment-resistant depression. In a recent retrospective case series, we show that it has promise in reducing symptoms of posttraumatic stress disorder (PTSD) as well. Untreated obstructive sleep apnea (OSA) is prevalent among veterans with PTSD and has been shown to interfere with other PTSD treatments. In the current study, we examined whether OSA impacts esketamine's effectiveness in reducing symptoms of PTSD or depression.

METHODS

Participants were 60 veterans with a diagnosis of major depressive disorder and PTSD who received intranasal esketamine treatment at the San Diego Veterans Affairs (VA) Medical Center. We used growth-curve modeling to examine changes in depression and PTSD symptoms following esketamine treatments and, in the subset of individuals screened for OSA (n = 24, all prescribed positive airway pressure therapy), examined the impacts of OSA severity on these trajectories.

RESULTS

We first showed that both PTSD and depressive symptoms significantly decreased over the course of esketamine treatment. In the subset of veterans screened for OSA, individuals with lower OSA severity reported the greatest reduction in PTSD symptoms, while veterans with the most severe OSA reported the least reduction in PTSD symptoms. Depression response was not affected by severity of OSA in this analysis.

CONCLUSIONS

Veterans with PTSD and depression tend to benefit from esketamine treatment, but OSA may interfere with esketamine effectiveness. Comorbid OSA should be assessed for and treated to maximize esketamine's benefits in PTSD.

CITATION

Titone MK, Hunt C, Bismark A, et al. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med. 2023;19(12):2043-2051.

Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares

STUDY OBJECTIVES

This study's objective was to evaluate the effect of nightmares (NMs) on attrition and symptom change following cognitive behavioral therapy for insomnia (CBT-I) treatment using data from a successful CBT-I randomized controlled trial delivered to participants with recent interpersonal violence exposure.

METHODS

The study randomized 110 participants (107 women; mean age: 35.5 years) to CBT-I or to an attention-control group. Participants were assessed at 3 time periods: baseline, post-CBT-I (or attention control), and at time 3 (T3) post-cognitive processing therapy received by all participants. NM reports were extracted from the Fear of Sleep Inventory. Participants with weekly NMs were compared with those with fewer than weekly NMs on outcomes including attrition, insomnia, posttraumatic stress disorder, and depression. Change in NM frequency was examined.

RESULTS

Participants with weekly NMs (55%) were significantly more likely to be lost to follow-up post-CBT-I (37%) compared with participants with infrequent NMs (15.6%) and were less likely to complete T3 (43%) than patients with less frequent NMs (62.5%). NMs were unrelated to differential treatment response in insomnia, depression, or posttraumatic stress disorder. Treatment with CBT-I was not associated with reduced NM frequency; however, change in sleep-onset latency from post-CBT-I to T3 predicted fewer NMs at T3.

CONCLUSIONS

Weekly NMs were associated with attrition but not a reduced change in insomnia symptoms following CBT-I. NM symptoms did not change as a function of CBT-I, but change in sleep-onset latency predicted lower NM frequency. CBT-I trials should screen for NMs and consider augmenting CBT-I to specifically address NMs.

CITATION

Hamilton NA, Russell JA, Youngren WA, et al. Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares. J Clin Sleep Med. 2023;19(11):1913-1921.

Sleep Disturbances Associated With Posttraumatic Stress Disorder

Sleep disturbances, namely insomnia and recurrent nightmares, are ubiquitous following trauma exposure and are considered hallmarks of posttraumatic stress disorder (PTSD). Other sleep disorders frequently co-occur with PTSD. This article describes research examining sleep problems most common in PTSD, including prevalence and clinical characteristics. Sleep disturbances are often robust to trauma-focused treatment; thus, evidence for psychological and pharmacological interventions for insomnia and nightmares in PTSD are discussed. Given the high prevalence of sleep problems in PTSD, more work is needed to empirically study putative mechanisms linking trauma exposure and sleep, as well as how to best target these symptoms in patients with PTSD.

Posttraumatic sleep disturbances in veterans: A pilot randomized controlled trial of cognitive behavioral therapy for insomnia and imagery rehearsal therapy

OBJECTIVES

Posttraumatic stress disorder (PTSD) is associated with sleep disturbances including insomnia and nightmares. This study compared cognitive behavioral therapy for insomnia (CBT-I) with CBT-I combined with imagery rehearsal therapy (IRT) for nightmares to evaluate if the combined treatment led to greater reductions in trauma-related sleep disturbances in Australian veterans.

METHODS

Veterans with diagnosed PTSD, high insomnia symptom severity, and nightmares (N = 31) were randomized to eight group CBT-I sessions or eight group CBT-I + IRT sessions. Self-reported sleep, nightmare, and psychological measures (primary outcome: Pittsburgh Sleep Quality Index), and objective actigraphy data were collected; the effect of obstructive sleep apnea (OSA) risk on treatment outcomes was also examined.

RESULTS

No treatment condition effects were detected for the combined treatment compared to CBT-I alone, and no moderating effect of OSA risk was detected. On average, participants from both groups improved on various self-report measures over time (baseline to 3 months posttreatment). Despite the improvements, mean scores for sleep-specific measures remained indicative of poor sleep quality. There were also no significant differences between the groups on the actigraphy indices.

CONCLUSIONS

The findings indicate that there is potential to optimize both treatments for veterans with trauma-related sleep disturbances.

Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial

STUDY OBJECTIVES

Sleep disturbances are common in military personnel with posttraumatic stress disorder (PTSD) and may persist following treatment. This study examined service members seeking treatment for PTSD, reporting insomnia symptoms, nightmares, excessive daytime sleepiness, and potential obstructive sleep apnea at baseline and the impact of sleep disturbances on a course of PTSD treatment.

METHODS

In this secondary analysis, sleep was evaluated in 223 service members who participated in a randomized clinical trial comparing Cognitive Processing Therapy for PTSD delivered in individual or group formats. Sleep assessments included the Insomnia Severity Index, the Trauma-Related Nightmare Survey, and Epworth Sleepiness Scale administered at baseline and 2 weeks posttreatment.

RESULTS

Following PTSD treatment, there were significant improvements for insomnia symptoms (MΔ = -1.49; d = -0.27), nightmares (MΔ = -0.35; d = -0.27), and excessive daytime sleepiness (MΔ = -0.91; d = -0.16). However, mean scores remained in clinical ranges at posttreatment. Participants with baseline insomnia symptoms had worse PTSD severity throughout treatment. Participants with baseline excessive daytime sleepiness or probable obstructive sleep apnea had greater PTSD severity reductions when treated with Cognitive Processing Therapy individually vs. in a group. Those with insomnia symptoms, nightmare disorder, and sleep apnea had greater depressive symptoms throughout treatment.

CONCLUSIONS

Insomnia symptoms, nightmares, and excessive daytime sleepiness were high at baseline in service members seeking treatment for PTSD. While sleep symptoms improved with PTSD treatment, these sleep disorders were related to worse treatment outcomes with regards to symptoms of PTSD and depression. Individual Cognitive Processing Therapy is recommended over group Cognitive Processing Therapy for patients with either excessive daytime sleepiness or probable obstructive sleep apnea.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Group vs. Individual Cognitive Processing Therapy for Combat-related PTSD; URL: https://clinicaltrials.gov/ct2/show/NCT02173561; Identifier: NCT02173561.

CITATION

Puriksma KE, Taylor DJ, Wachen JS, et al. Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial. J Clin Sleep Med. 2023;19(8):1389-1398.

Effects of sleep disturbance on trauma-focused psychotherapy outcomes in posttraumatic stress disorder: A systematic review

This study aimed to synthesize existing research on the effects of sleep disturbances on trauma-focused psychotherapy outcomes in adults with posttraumatic stress disorder (PTSD). A systematic review using PubMed, PsycINFO, Embase, Web of Science, and PTSDpubs was performed up to April 2021. Two independent reviewers screened articles for inclusion, performed data extraction, and assessed risk of bias and certainty of the evidence. Narrative synthesis was conducted based on the type of sleep disorder symptom assessed. Sixteen primary studies were included in this review, the majority of which had a high overall risk of bias. Results suggested that sleep disorder symptoms were associated with higher overall PTSD severity across treatment; however, they did not interfere with treatment effectiveness, with the exception of sleep-disordered breathing. Improvements in insomnia, sleep duration, and sleep quality during treatment were associated with greater treatment gains. Certainty of the evidence ranged from low to very low. These results suggest that it may not be necessary to address sleep disorder symptoms prior to initiating trauma-focused psychotherapy. Instead, concurrent treatment of sleep- and trauma-related symptoms may be most beneficial. Continued research is needed to clarify the mechanistic relationship between sleep and treatment outcomes and to guide clinical decision-making.

FKBP5 genetic variants are associated with respiratory- and sleep-related parameters in Chinese patients with obstructive sleep apnea

Introduction

Obstructive sleep apnea (OSA) has been associated with psychiatric disorders, especially depression and posttraumatic stress disorder (PTSD). FKBP5 genetic variants have been previously reported to confer the risk of depression and PTSD. This study aimed to investigate the association of single nucleotide polymorphisms (SNPs) in the FKBP5 gene with OSA and OSA-related quantitative traits.

Methods

Four SNPs within the FKBP5 gene (rs1360780, rs3800373, rs9296158, rs9470080) were genotyped in 5773 participants with anthropometric and polysomnography data. Linear regression and logistic regression analyses were performed to evaluate the relationship between FKBP5 SNPs and OSA-related traits. Binary logistic regression was used to assess the effect of SNPs on OSA susceptibility. Interacting genes of SNPs were assessed based on the 3DSNP database, and expression quantitative trait loci (eQTL) analysis for SNPs was adopted to examine the correlation of SNPs with gene expression. Gene expression analyses in human brains were performed with the aid of Brain Atlas.

Results

In moderate-to-severe OSA patients, all four SNPs were positively associated with AHI_REM, and rs9296158 showed the strongest association (ß = 1.724, p = 0.001). Further stratified analyses showed that in men with moderate OSA, rs1360780, rs3800373 and rs9470080 were positively associated with wake time (p = 0.0267, p = 0.0254 and p = 0.0043, respectively). Rs1360780 and rs3800373 were 28 and 29.4%more likely to rate a higher ordered MAI category (OR (95% CI) = 1.280 (1.042 - 1.575), p = 0.019; OR (95% CI) = 1.294 (1.052 - 1.592), p = 0.015, respectively). Rs9296158 and rs9470080 increased the risk of low sleep efficiency by 25.7 and 28.1% (OR (95% CI) = 1.257 (1.003 - 1.575), p = 0.047; OR (95% CI) = 1.281 (1.026-1.6), p = 0.029, respectively). Integrated analysis of eQTL and gene expression patterns revealed that four SNPs may exert their effects by regulating FKBP5, TULP1, and ARMC12.

Conclusion

Single nucleotide polymorphisms in the FKBP5 gene were associated with sleep respiratory events in moderate-to-severe OSA patients during REM sleep and associated with sleep architecture variables in men with moderate OSA. FKBP5 variants may be a potential predisposing factor for sleep disorders, especially in REM sleep.

Examining the bidirectional relationship between posttraumatic stress disorder symptom clusters and PAP adherence

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a common sleep disturbance in individuals with posttraumatic stress disorder (PTSD), with an emerging literature showing that treating OSA with positive airway pressure (PAP) therapy has a moderate effect on decreasing PTSD severity. Unfortunately, PAP adherence among individuals with PTSD is low. Our study examined how baseline PTSD cluster subscores predict 6-month PAP adherence and how PAP adherence predicts change in PTSD cluster subscores over time.

METHODS

We examined PTSD and PAP adherence in 41 veterans with PTSD newly diagnosed with OSA over 6 months of PAP use (mean age = 50.27 years; 73.7% White; 13.6% female). The Posttraumatic Stress Disorder Checklist-Specific (PCL-S) was used to examine PTSD and subscales (re-experiencing, avoidance, and hyperarousal). We used longitudinal analyses to examine PTSD subscores on PAP adherence and PAP adherence predicting changes in PTSD subscores at 6-month follow-up.

RESULTS

Among veterans with PTSD, higher levels of re-experiencing and hyperarousal, but not avoidance, predicted lower PAP use. Overall, the high-adherent group showed a 14.36-point decrease on the PCL-S, while the low-adherent group averaged just a 3.66-point decrease. More days of PAP use were associated with greater improvement in hyperarousal and avoidance subscores but not re-experiencing.

CONCLUSIONS

Our findings reaffirm the importance of PAP use among patients with comorbid PTSD and sleep apnea, as well as the difficulty in achieving adherent PAP use in this population. Directly addressing heightened re-experiencing and hyperarousal in PTSD may increase PAP adherence among veterans with PTSD and requires future research.

CITATION

Colvonen PJ, Goldstein LA, Sarmiento KF. Examining the bidirectional relationship between posttraumatic stress disorder symptom clusters and PAP adherence. J Clin Sleep Med. 2023;19(5):857-863.

Moving toward Equitable Care for Sleep Apnea in the United States: Positive Airway Pressure Adherence Thresholds: An Official American Thoracic Society Policy Statement

Background: Positive airway pressure (PAP) is a highly effective treatment for obstructive sleep apnea (OSA), but adherence limits its efficacy. In addition, coverage of PAP by CMS (Centers for Medicare & Medicaid Services) and other insurers in the United States depends on adherence. This leaves many beneficiaries without PAP, disproportionally impacting non-white and low socioeconomic position patients with OSA and exacerbating sleep health disparities. Methods: An inter-professional, multidisciplinary, international committee with various stakeholders was formed. Three working groups (the historical policy origins, impact of current policy, and international PAP coverage models) met and performed literature reviews and discussions. Using surveys and an iterative discussion-based consensus process, the policy statement recommendations were created. Results: In this position paper, we advocate for policy change to CMS PAP coverage requirements to reduce inequities and align with patient-centered goals. We specifically call for eradicating repeat polysomnography, eliminating the 4-hour rule, and focusing on patient-oriented outcomes such as improved sleepiness and sleep quality. Conclusions: Modifications to the current policies for PAP insurance coverage could improve health disparities.

Sleep Latency and Post-Traumatic Stress Disorder Among Retired Career Florida Firefighters: Evidence From the Advancing Epidemiology of Retired Firefighters Aging Longitudinally Cohort

OBJECTIVE

Our objective was to estimate the association of post-traumatic stress disorder (PTSD) and sleep latency among retired firefighters.

METHODS

Baseline health survey data collected from retried career Florida firefighters participating in an ongoing prospective cohort study from 2017 to 2021 were analyzed. Risk for PTSD was assessed using a four-item primary care PTSD screening construct, and sleep onset latency was assessed by self-reported length of time to fall asleep.

RESULTS

Among the 500 participants, 8.0% screened positive for PTSD risk and 37.6% had prolonged sleep onset latency (≥20 minutes to fall asleep). Retired firefighters with PTSD risk were 2.7 times more likely (adjusted odds ratio, 2.70; 95% confidence interval, 1.27-5.75) to have prolonged sleep latency compared with those without PTSD risk while controlling for covariates.

CONCLUSIONS

Retired firefighters who screen positive for PTSD risk are three times more likely to report delayed sleep onset latency.

Call to action: Addressing sleep disturbances, a hallmark symptom of PTSD, for refugees, asylum seekers, and internally displaced persons

Sleep difficulty is a recognized hallmark symptom of post-traumatic stress disorder (PTSD) yet often remains an enduring and neglected problem post-treatment. Around 4.4%- 88.0% of refugees, asylum seekers, and internally displaced persons report PTSD, of which 39%- 99% report sleep difficulties. These percentages substantially exceed those of the general population. Yet there has been a lack of research examining evidence-based stand-alone and add-on treatments for PTSD and related sleep disturbances among this population. Barriers to treatment encountered by this population often vary by their legal status or location, but generally include lack of access due to insufficient evidence-based treatments or mental health practitioner shortages, lack of psychoeducation on mental health, cultural stigma, language barriers, situational instability, and racial bias. The refugee population has been on the rise over the past 10 years, and the United Nations estimated the recent Ukraine-Russia conflict would lead to an additional 12 million people needing humanitarian assistance inside Ukraine and more than 6.9 million refugees fleeing to neighboring countries in the coming months. Given that refugees, asylum seekers, and internally displaced persons repeatedly encounter barriers to mental health care specific to their predicament, interventions designed to accommodate their situation are imperative for improving their sleep and mental health. We therefore call for there to be more research on integrative programs incorporating evidence-based treatments that allow for scalability, adaptability, and rapid dissemination to maximize impact in this population. Further, we encourage trainings among clinicians and researchers to increase knowledge and confidence in working with this population.

An examination of volumetric and cortical thickness correlates of posttraumatic nightmares in male active duty service members

Posttraumatic nightmares commonly occur after a traumatic experience. Despite significant deleterious effects on well-being and their role in posttraumatic stress disorder, posttraumatic nightmares remain understudied. The neuroanatomical structures of the amygdala, medial prefrontal cortex, hippocampus, and anterior cingulate cortex constitute the AMPHAC model (Levin and Nielsen, 2007), which is implicated in the neurophysiology of disturbing dreams of which posttraumatic nightmares is a part. However, this model has not been investigated using neuroimaging data. The present study sought to determine whether there are structural differences in the AMPHAC regions in relation to the occurrence of posttraumatic nightmares. Data were obtained from treatment-seeking male active duty service members (N = 351). Posttraumatic nightmares were not significantly related to gray matter volume, cortical surface area, or cortical thickness of any the AMPHAC regions when controlling for age and history of mild traumatic brain injury. Although the present analyses do not support an association between structural measures of AMPHAC regions and posttraumatic nightmares, we suggest that functional differences within and/or between these brain regions may be related to the occurrence of posttraumatic nightmares because functional and structural associations are distinct. Future research should examine whether functional differences may be associated with posttraumatic nightmares.

Alexithymia and post-traumatic stress disorder symptoms in Chinese undergraduate students during the COVID-19 national lockdown: The mediating role of sleep problems and the moderating role of self-esteem

OBJECTIVE

This study examined whether sleep disturbance was a mediator between alexithymic traits and post-traumatic stress disorder (PTSD) COVID-19 pandemic-related stress symptoms, and explored whether self-esteem moderated the alexithymic contribution to poor sleep and PTSD symptoms.

METHOD

A representative sample of young adults (N = 2,485) from six universities in Southwest China completed online self-report surveys on alexithymia, sleep, PTSD, self-esteem, sociodemographic information, and health-related behaviors.

RESULTS

High alexithymic young adults were found to be more likely to have higher sleep problems and higher PTSD symptoms. The moderated mediation model showed that sleep problems mediated the associations between alexithymia and PTSD symptoms. Alexithymic people with lower self-esteem were more likely to have elevated PTSD symptoms and sleep problems than those with higher self-esteem.

CONCLUSION

Targeted psychological interventions for young people who have difficulty expressing and identifying emotions are recommended as these could assist in reducing their post-traumatic psychophysical and psychological problems. Improving self-esteem could also offer some protection for trauma-exposed individuals.

Italian Validation of the Pittsburgh Sleep Quality Index (PSQI) in a Population of Healthy Children: A Cross Sectional Study

Background: Sleep disorders are one of the most discussed topics in scientific literature every year. Although they are one of the most studied topics, in both adults and children, knowledge of sleep disorders and their treatment is still not completely clear, and there is a need to deepen and analyze these disorders on a country-by-country basis. However, research in the Italian literature reveals a scarce quantity of tools to evaluate sleep quality in children. The Pittsburgh Sleep Quality Index (PSQI) is probably the most commonly used retrospective self-assessment questionnaire in the adult population. Purpose: We aimed to validate and analyze the psychometric characteristics of this tool in order to detect and explore the presence of sleep disorders in a healthy Italian population of children throughout the country. Methods: Individuals aged between 3 and 16 years without symptoms of insomnia were included in this study. The reliability and construct validity of the PSQI were assessed according to Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines. Results: We enrolled 222 individuals in this study (mean age 11 years). The PSQI demonstrated good internal consistency (Cronbach’s α = 0.719). Test–retest reliability was assessed on a randomized subgroup of the sample (n = 35). The PSQI showed good test–retest reliability with an intraclass correlation coefficient of 0.829 for the total score (95% confidence interval: 0.662–0.914). The Pearson correlation coefficient, used for construct validity, showed a statistically significant positive correlation with the Sleep Disturbance Scale for Children (SDSC). Conclusion: The PSQI proved to be a very reliable and valid tool to investigate sleep experiences in children.

Pharmacological Management of Nightmares Associated with Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) can be a chronic and disabling condition. Post-traumatic nightmares (PTNs) form a core component of PTSD and are highly prevalent in this patient population. Nightmares in PTSD have been associated with significant distress, functional impairment, poor health outcomes, and decreased quality of life. Nightmares in PTSD are also an independent risk factor for suicide. Nightmare cessation can lead to improved quality of life, fewer hospital admissions, lower healthcare costs, and reduced all-cause mortality. Effective treatment of nightmares is critical and often leads to improvement of other PTSD symptomatology. However, approved pharmacological agents for the treatment of PTSD have modest effects on sleep and nightmares, and may cause adverse effects. No pharmacological agent has been approved specifically for the treatment of PTNs, but multiple agents have been studied. This current narrative review aimed to critically appraise proven as well as novel pharmacological agents used in the treatment of PTNs. Evidence of varying quality exists for the use of prazosin, doxazosin, clonidine, tricyclic antidepressants, trazodone, mirtazapine, atypical antipsychotics (especially risperidone, olanzapine and quetiapine), gabapentin, topiramate, and cyproheptadine. Evidence does not support the use of venlafaxine, β-blockers, benzodiazepines, or sedative hypnotics. Novel agents such as ramelteon, cannabinoids, ketamine, psychedelic agents, and trihexyphenidyl have shown promising results. Large randomized controlled trials (RCTs) are needed to evaluate the use of these novel agents. Future research directions are identified to optimize the treatment of nightmares in patients with PTSD.

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.

Sleep disturbance and psychiatric disorders: a bidirectional Mendelian randomisation study

AIMS

Sleep disturbance is an important factor in the pathophysiology and progression of psychiatric disorders, but whether it is a cause, or a downstream effect is still not clear.

METHODS

To investigate causal relationships between three sleep-associated traits and seven psychiatric diseases, we used genetic variants related to insomnia, chronotype and sleep duration to perform a two-sample bidirectional Mendelian randomisation analysis. Summary-level data on psychiatric disorders were extracted from the Psychiatric Genomics Consortium. Effect estimates were obtained by using the inverse-variance-weighted (IVW), weights modified IVW, weighted-median methods, MR-Egger regression, MR pleiotropy residual sum and outlier (MR-PRESSO) test and Robust Adjusted Profile Score (RAPS).

RESULTS

The causal odds ratio (OR) estimate of genetically determined insomnia was 1.33 (95% confidence interval (CI) 1.22-1.45; p = 5.03 × 10-11) for attention-deficit/hyperactivity disorder (ADHD), 1.31 (95% CI 1.25-1.37; p = 6.88 × 10-31) for major depressive disorder (MDD) and 1.32 (95% CI 1.23-1.40; p = 1.42 × 10-16) for post-traumatic stress disorder (PTSD). There were suggestive inverse associations of morningness chronotype with risk of MDD and schizophrenia (SCZ). Genetically predicted sleep duration was also nominally associated with the risk of bipolar disorder (BD). Conversely, PTSD and MDD were associated with an increased risk of insomnia (OR = 1.06, 95% CI 1.03-1.10, p = 7.85 × 10-4 for PTSD; OR = 1.37, 95% CI 1.14-1.64; p = 0.001 for MDD). A suggestive inverse association of ADHD and MDD with sleep duration was also observed.

CONCLUSIONS

Our findings provide evidence of potential causal relationships between sleep disturbance and psychiatric disorders. This suggests that abnormal sleep patterns may serve as markers for psychiatric disorders and offer opportunities for prevention and management in psychiatric disorders.

The Many Faces of Sleep Disorders in Post-Traumatic Stress Disorder: An Update on Clinical Features and Treatment

Sleep disorders and nightmares are core symptoms of post-traumatic stress disorder (PTSD). The relationship seems to be bidirectional, and persistent disturbed sleep may influence the course of the disorder. With regard to sleep quality, insomnia and nocturnal anxiety symptoms, as well as nightmares and stressful dreams, are the most prominent sleep symptoms. Polysomnographic measurements reveal alterations of the sleep architecture and fragmentation of rapid eye movement sleep. In addition, sleep disorders, such as sleep-related breathing disorders and parasomnias are frequent comorbid conditions. The complex etiology and symptomatology of trauma-related sleep disorders with frequent psychiatric comorbidity require the application of multimodal treatment concepts, including psychological and pharmacological interventions. However, there is little empirical evidence on the effectiveness of long-term drug treatment for insomnia and nightmares. For nondrug interventions, challenges arise from the current lack of PTSD-treatment concepts integrating sleep- and trauma-focused therapies. Effective therapy for sleep disturbances may consequently also improve well-being during the day and probably even the course of PTSD. Whether early sleep interventions exert a preventive effect on the development of PTSD remains to be clarified in future studies.

Characteristics of Posttraumatic Nightmares and Their Relationship to PTSD Severity Among Combat Veterans With PTSD and Hazardous Alcohol Use

ABSTRACT

Although nightmares are known to predict the clinical course of posttraumatic stress disorder (PTSD), research on the relationship between specific nightmare characteristics and PTSD severity is sparse. This study conducted a secondary analysis to explore how five nightmare characteristics are cross-sectionally related to PTSD severity in 76 combat veterans with PTSD and at-risk alcohol use. Consistent with emotional processing theory, we hypothesized that more replicative, threatening, realistic, and easily recalled nightmares would be associated with more severe PTSD, whereas those with greater symbolism would predict lower PTSD severity. Nightmares narratives were audio-recorded and rated by multiple coders. Multiple analyses of variance explored the relationship between nightmare characteristics and PTSD clinical indicators. Most nightmares were realistic, easily recalled, and involved significant threat. Greater realism and replication were associated with greater PTSD severity. Realistic and replicative nightmares may be markers of more severe PTSD and may indicate that less emotional processing of the trauma has occurred.

Sleepless in Solitude-Insomnia Symptoms Severity and Psychopathological Symptoms among University Students during the COVID-19 Pandemic in Poland

Since 25 March 2020, all schools, colleges, and universities in Poland have indefinitely closed and, where possible, have activated distance learning because of the COVID-19 pandemic. Considering that the undergraduate years are usually characterized by a high prevalence of emotional disorders and sleep problems, it can be expected that the current situation may have a remarkable impact on the student population. This study aimed to investigate the occurrence of sleep problems among Polish university students as well as the relationship of insomnia symptoms severity with psychopathological symptoms, posttraumatic stress disorder (PTSD) symptoms, and behavioral factors, such as substance use, changes in the amount of sleep, and the level of physical activity during the COVID-19 pandemic. Data were collected from 1111 Polish university students via an online survey conducted between IV and VI 2020. The survey included demographic variables, the level of psychopathological symptoms (General Health Questionnaire, GHQ-28), insomnia (Insomnia Severity Index, ISI), and symptoms of posttraumatic stress (Impact of Events Scale-Revised, IES-R). The results showed that over half of the studied group of students had some form of sleep disturbances during the period of data collection, with moderate-to-severe insomnia symptoms noted in 21.6%. At the same time, the majority of the sample declared they slept more during the pandemic. A significant positive correlation was observed between the severity of insomnia symptoms and PTSD symptoms, as well as GHQ scores, increased substance use, and decreased physical activity. An additional association between the presence of dreams related to the event and insomnia symptoms as well as GHQ scores has been found. The results suggest that sleep problems may be prevalent among university students during the pandemic. Moreover, although the symptoms of insomnia, as well as the severity of sleep disturbance, significantly correlated with all the investigated variables, the direction of those associations remains to be established.

Diagnosing obstructive sleep apnea in a residential treatment program for veterans with substance use disorder and PTSD

BACKGROUND

Obstructive sleep apnea (OSA) is often comorbid with both substance use disorders (SUD) and posttraumatic stress disorder (PTSD), yet frequently goes undiagnosed and untreated. We present data on the feasibility and acceptability of objective OSA diagnosis procedures, findings on OSA prevalence, and the relationship between OSA and baseline SUD/PTSD symptoms among veterans in residential treatment for comorbid PTSD/SUD.

METHODS

Participants were 47 veterans admitted to residential PTSD/SUD treatment. Participants completed questionnaires assessing PTSD and sleep symptoms, and filled out a sleep diary for seven days. Apnea-hypopnea index (AHI) was recorded using the overnight Home Sleep Apnea test (HSAT; OSA was diagnosed with AHI ≥ 5).

RESULTS

Objective OSA diagnostic testing was successfully completed in 95.7% of participants. Of the 45 veterans who went through HSAT, 46.7% had no OSA, 35.6% received a new OSA diagnosis, and 8.9% were previously diagnosed with OSA and were using positive airway pressure treatment (PAP); an additional 8.9% were previously diagnosed with OSA, reconfirmed with the HSAT, but were not using PAP. One hundred percent of respondents during follow-up deemed the testing protocol's usefulness as "Good" or "Excellent."

CONCLUSION

OSA diagnostic testing on the residential unit was feasible and acceptable by participants and was effective in diagnosing OSA. OSA testing should be considered for everyone entering a SUD and PTSD residential unit. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

STOP-BANG screener vs objective obstructive sleep apnea testing among younger veterans with PTSD and insomnia: STOP-BANG does not sufficiently detect risk

STUDY OBJECTIVES

Posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) cooccur even in veterans who are younger with lower body mass index. The STOP-BANG screener for OSA relies heavily on high blood pressure, age, and body mass index and may not generalize to veterans with PTSD. The inability to effectively screen veterans for OSA is problematic given negative outcomes of untreated OSA.

METHODS

Our study compared the STOP-BANG to objective OSA diagnostic testing in 48 younger veterans (mean age 43.7 years; 43.8% Caucasian; 20.8% female) seeking treatment for PTSD and insomnia. Apnea-hypopnea events per hour (apnea-hypopnea index), recorded by NOX T3 sleep monitors, were used to diagnose OSA (apnea-hypopnea index ≥ 5 events/h). Logistic regressions examined how STOP-BANG cut-off scores (≥ 3 and ≥ 5) classified OSA status (apnea-hypopnea index ≥ 5 events/h). Follow-up chi-square goodness-of-fit tests examined single-item STOP-BANG performance in the OSA-positive subsample (n = 28).

RESULTS

The STOP-BANG (≥ 3) had good sensitivity (92.6%) but poor specificity (47.6%) and negative (0.16) and positive (1.77) likelihood ratios. The STOP-BANG (≥ 5) led to improved specificity (76.19%), but sensitivity (37.04%) and positive (1.56)/negative likelihood ratios (0.83) were poor. Single-item OSA subgroup analyses revealed that body mass index, age, and neck circumference performed poorly, while tiredness and sex performed well.

CONCLUSIONS

Findings suggest that the STOP-BANG correctly diagnosed OSA in some veterans but missed OSA in large number of younger veterans with PTSD. This suggests objective diagnostic OSA testing is needed in veterans with PTSD. Future research is needed to develop more accurate OSA screening measures in this population.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Integrated CBT-I on PE and PTSD Outcomes (Impact Study); URL: https://www.clinicaltrials.gov/ct2/show/NCT02774642; Identifier: NCT02774642.

CITATION

Lyons R, Barbir LA, Owens R, Colvonen PJ. STOP-BANG screener vs objective obstructive sleep apnea testing among younger veterans with PTSD and insomnia: STOP-BANG does not sufficiently detect risk. J Clin Sleep Med. 2022;18(1):67-73.

Lifetime Trauma Exposure and Posttraumatic Stress Disorder Among African Americans and Black Caribbeans by Sex and Ethnicity

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a debilitating disorder requiring timely diagnosis and treatment, with special attention needed for Black populations in the U.S. Yet, stakeholders often fail to recognize Black communities' heterogeneous ethnic composition, thus not allowing diverse sociocultural realities to inform PTSD interventions. This study aims to characterize sex and ethnic differences in lifetime trauma exposure, lifetime PTSD diagnosis and symptoms, and help-seeking among the African Americans and Black Caribbeans in the U.S.

METHOD

This study relied on data from the National Survey of American Life 2001-2003 (NSAL) to investigate the lifetime exposure to traumatic events and prevalence of a clinical PTSD diagnosis based on the DSM-IV among African American (n = 3,570) and Black Caribbean (n = 1,623) adults. 44.5% of respondents were men and 55.5% were women. Logistic regression was utilized to investigate the impact of traumatic events on PTSD.

RESULTS

Several ethnic and sex differences in exposure to potentially traumatic events were identified. African American respondents were more likely to experience spousal abuse and toxin exposure than their Black Caribbean counterparts. Black Caribbeans reported higher lifetime exposure to muggings, natural disasters, harsh parental discipline, being a civilian living in terror and/or being a refugee than African American respondents. Specific to sex, Black men reported more events of combat, a peacekeeper/relief worker, being mugged, toxin exposure, seeing atrocities, and/or injuring someone. Black women were more likely to have been rape/sexual assault and/or intimate partner violence victims. The assaultive violence trauma type was most predictive of lifetime PTSD diagnosis among Black Americans. African American women were more likely to report PTSD symptoms than men, with almost no significant differences in Black Caribbean men and women. Approximately half of Black Americans sought help for their worst traumatic event, commonly engaging family/friends, psychiatrists, and mental health professionals. Further, there were almost no ethnic and sex differences related to professional and non-professional help sought.

CONCLUSION

Future PTSD-related research should aim to characterize the heterogenous experiences of potentially traumatic events within different Black communities. Clinicians working with Black clients should strive to understand the limitations within their tools/interventions in meeting the needs of diverse groups.

Longitudinal associations between hair cortisol, PTSD symptoms, and sleep disturbances in a sample of firefighters with duty-related trauma exposure

Several studies have found evidence of altered cortisol levels in patients with posttraumatic stress disorder (PTSD). Based on these findings, it is assumed that these patients may show signs of cortisol dysregulation after trauma. Posttrauma cortisol levels are thus considered a potential biomarker of PTSD. However, longitudinal studies using indicators of long-term cortisol secretion such as hair cortisol concentrations (HCC) are scarce. The current study investigated prospective associations between HCC and PTSD symptoms in a sample of Dutch firefighters taking into account varying levels of work-related trauma severity. In addition, we assessed posttraumatic sleep disturbances as a secondary outcome measure to investigate whether effects generalize to this frequent comorbidity of PTSD. Three hundred seventy-one Dutch firefighters with a mean of 14.01 years of work experience were included in the analyses. Baseline assessment included the collection of hair samples and the measurement of work-related trauma severity, PTSD symptoms, and sleep disturbances. PTSD symptoms and sleep disturbance were re-assessed after six and twelve months. Multilevel analyses indicate a significant positive correlation between HCC and baseline PTSD symptoms in those with average or above-average work-related trauma severity. A similar pattern was evident for posttraumatic sleep disturbances at baseline. Moreover, higher HCC predicted more posttraumatic sleep disturbances after 6 months in participants with above-average work-related trauma severity. No other associations emerged for PTSD symptoms or posttraumatic sleep disturbances at six or twelve months. As such, our study supports the existence of a cross-sectional association between HCC and trauma symptoms, which may vary for different levels of subjective trauma severity. The longitudinal stability of this association should be reinvestigated by future research.

Sleep and PTSD in the Military Forces: A Reciprocal Relationship and a Psychiatric Approach

Sleep disturbances are well-recognised symptoms of Post-Traumatic Stress Disorder (PTSD). This review updates knowledge regarding the relationship between sleep during deployment, combat-related trauma, and PTSD in military personnel, from which the importance of restorative sleep results. The description of the characteristics of sleep in military forces with the considerable roles of the operational and training contexts highlights the important consequences of degraded sleep. Indeed, a lot of data suggest a dynamic link between sleep and the onset and chronicity of PTSD. We propose a reciprocal relationship model with strategies strongly recommended or already adopted by the military to promote restorative sleep before and after combat exposure. Among the alterations in a variety of sleep architecture and sleep patterns described in PTSD, the physiological hypothesis of REM sleep fragmentation in the development of PTSD symptoms may be important because REM sleep is generally associated with emotional memory. Finally, we address clinical and research perspectives that could be used to detect or restore sleep continuity before and during military deployment to possibly alleviate nightmares and insomnia related to combat exposure and PTSD occurrence and improve our understanding of sleep in PTSD.

Social zeitgebers and circadian dysrhythmia are associated with severity of symptoms of PTSD and depression in trauma-affected refugees

The relation of aspects of rest-activity patterns, i.e., social zeitgebers, physical activity and circadian rhythm, to the severity of PTSD and depressive symptoms has not previously been studied. Doing so could provide valuable insight into possible targets for treatment. Our study explored these links in a population of 219 trauma-affected refugees diagnosed with PTSD who were seeking treatment. Data regarding social zeitgebers, such as affiliation with the labor market and contact with social network, and symptoms of PTSD and depression were collected from them. Furthermore, their levels of physical activity and circadian rest-activity parameters were calculated from actigraphy data. Bivariate correlation analyses and multiple linear regression analyses were performed to examine various aspects of rest-activity regarding relation to severity of PTSD and depressive symptoms. Several social zeitgebers were associated with severity of PTSD and depressive symptoms. The level of physical activity was unrelated to symptom severity, whereas a rest-activity pattern, with early onset of the most active 10 h, was associated with severity of PTSD, and a circadian rhythm with a large difference between periods of rest and activity was associated with severity of depression. Social zeitgebers, levels of physical activity and circadian rhythm parameters were all associated with each other. Social zeitgebers and circadian rhythm parameters were significantly related to the severity of PTSD and depressive symptoms-a relationship indicating that interventions targeting regularity of daily routines have a potential role in treating PTSD and depression in trauma-affected refugees.Trial registration: ClinicalTrials.gov, ID: NCT02761161, April 27, 2016.

A Systematic Review of the Impact of Wildfires on Sleep Disturbances

Wildfires present a serious risk to humans as well as to the environment. Wildfires cause loss of lives, economic losses, expose people to personal as well as collective trauma, and compromise the mental health of survivors. Sleep disturbances are highly prevalent following a traumatic event; however, their prevalence is not well established amongst those confronted by natural disasters such as wildfires. The aim of this systematic review is to synthesise the empirical findings pertaining to wildfires and the prevalence of sleep disturbances in the general community affected by this natural disaster. We searched EBSCO, PsychINFO, Medline, SpringerLink, CINAHL Complete, EMBASE, PubMed, Scopus and Cochrane Library between January 2012 and March 2021. Five studies met the inclusion criteria. Findings from this systematic review suggest that sleep disturbances, assessed one to ten months following the fires, are highly prevalent in wildfire survivors, with insomnia (ranging between 63–72.5%) and nightmares (ranging between 33.3–46.5%), being the most prevalent sleep disturbances reported in this cohort. Results also highlight the significant associations between sleep disturbances and post-traumatic symptoms following the trauma of wildfires. There is a possible link between sleep disturbance prevalence, severity of, and proximity to fires.

Effectiveness of an internet-based intervention to improve sleep difficulties in a culturally diverse sample of international students: A randomised controlled pilot study

Sleep difficulties are widespread among international students. Internet-based interventions are suggested as a low-threshold treatment option but may require cultural adaptation among culturally diverse populations. The present pilot study investigated the effectiveness and acceptance of an internet-based intervention to improve sleep difficulties in international students. A total of 81 international students of 36 nationalities were randomly assigned to the intervention (n = 41) or waitlist control group (n = 40). The intervention group received immediate access to a culturally non-adapted unguided internet-based sleep intervention consisting of three modules based on sleep hygiene and cognitive techniques to reduce rumination. At baseline, 4 and 12 weeks after randomisation, insomnia severity, measured by the Insomnia Severity Index, and secondary outcomes (sleep quality, depression, anxiety, perceived stress, well-being, presenteeism, mental health literacy) were assessed. Data were analysed using linear multi-level analyses. Additionally, satisfaction and perceived cultural appropriateness of the intervention were evaluated by international students after 4 weeks, and compared with ratings of German students, who represent the original target group. Insomnia severity improved over time in the intervention group compared to the control group, revealing a significant estimated mean difference of -5.60 (Hedges' g = 0.84, p < 0.001) after 12 weeks. Satisfaction and perceived cultural appropriateness was high and comparable to that of German students. The present study shows that a culturally non-adapted internet-based sleep intervention can be a low-threshold treatment option to help meet the high demand for mental healthcare among international students. It thus indicates that cultural adaptation might not represent a precondition for providing effective internet-based sleep interventions to this target group.

The mediation effect of depression and alcohol use disorders on the association between post-traumatic stress disorder and obstructive sleep apnea risk in 51,149 Korean firefighters: PTSD and OSA in Korean firefighters

BACKGROUND

Post-traumatic stress disorder (PTSD) is shown to be linked to a higher risk of obstructive sleep apnea (OSA). Firefighters are at high risk for PTSD given the increased exposure to trauma.  However, the relationship between PTSD and OSA remains unclear in firefighters. Moreover, alcohol use disorders (AUDs) and depression - also common in firefighters - show a high comorbidity rate with both PTSD and OSA. The purpose of this study was to investigate the association of PTSD, depression, and AUDs with OSA in a national sample of Korean firefighters.

METHODS

A total of 51,149 Korean firefighters completed self-reported questionnaires, assessing the severity of PTSD, OSA, depression, and alcohol misuse. Multivariable logistic regression and mediation analyses were performed.

RESULTS

PTSD, depression, and AUDs were significantly associated with OSA. In the mediation analyses, PTSD had both direct and indirect effects mediated by depression and AUDs on OSA. Depression had both direct and indirect effects on OSA, with the latter mediated by AUDs.

LIMITATIONS

First, high-risk of OSA was measured using the Berlin Questionnaire. Second, other medical comorbidities or mediation use were not considered. Third, self-report questionnaires were used for assessment, which are prone to subjectivity and recollection bias. Finally, the majority of the study population were male and all Korean, limiting generalizability.

CONCLUSIONS

PTSD had both direct and indirect effects on OSA, mediated by depression and AUDs. In patients with both PTSD and OSA, depression and AUD symptoms should be screened routinely.

Insomnia predicts treatment engagement and symptom change: a secondary analysis of a web-based CBT intervention for veterans with PTSD symptoms and hazardous alcohol use

Posttraumatic Stress Disorder (PTSD) and hazardous drinking are highly comorbid, and often more severe than PTSD or hazardous drinking alone. Integrated, web-based interventions for PTSD/hazardous drinking may increase access to care, but have demonstrated equivocal results in reducing PTSD and hazardous drinking. One factor that may explain treatment engagement and symptom change is the presence of insomnia symptoms. The current study conducted secondary data analysis of a randomized controlled trial of an integrated web-based intervention for PTSD symptoms and hazardous drinking to examine insomnia symptoms as predictors of PTSD symptoms, alcohol use, and treatment engagement. In the parent study, 162 veterans in primary care reporting PTSD symptoms and hazardous drinking were randomized to receive either the intervention or treatment as usual. The current study examined insomnia among veterans who received the intervention (n = 81). Regression models tested baseline insomnia symptoms as predictors of treatment engagement, follow-up PTSD symptoms, and alcohol use. Hierarchical regression models tested change in insomnia during treatment as a predictor of follow-up PTSD symptoms and alcohol use. Results showed baseline insomnia predicted treatment engagement and follow-up drinking days, but not PTSD symptoms or heavy drinking days. Although overall change in insomnia was small, it predicted follow-up PTSD and heavy drinking days, but not drinking days. Results are consistent with previous research highlighting the importance of identifying and treating insomnia in the course of integrated treatment for PTSD/hazardous drinking. Future research should investigate how to best integrate insomnia, PTSD, and/or hazardous drinking interventions to maximize treatment engagement.

Insomnia disorder and long-term mortality in adult patients treated with extracorporeal membrane oxygenation in South Korea

We investigated the prevalence of insomnia in extracorporeal membrane oxygenation (ECMO)-treated patients and examined the association between post-ECMO insomnia disorder and long-term mortality. In the present population-based cohort study, we used data from the National Health Insurance Claims database in South Korea. All adult patients who underwent ECMO between 2006 and 2014 were included, and ECMO-treated patients were defined as those who survived >365 days after ECMO. Insomnia disorder was identified using the International Classification of Diseases 10th Revision codes G47.0 and F51.0. Overall, 3,055 ECMO-treated patients were included in the final analysis: 431 (14.1%) had pre-ECMO insomnia disorder, while 148 (4.8%) were newly diagnosed with insomnia disorder up to 1 year after ECMO. In multivariable Cox regression model, patients with post-ECMO insomnia disorder had higher 5-year all-cause mortality (ACM) than controls (hazard ratio [HR] 1.71, 95% confidence interval [CI] 1.21-2.42; p = 0.003); however, those with pre-ECMO insomnia disorder did not (p = 0.655). In sensitivity analysis, post-ECMO insomnia disorder with underlying psychiatric illness was associated with a 2.39-fold higher 5-year ACM in ECMO-treated patients (HR 2.39, 95% CI 1.52-3.75; p < 0.001). In conclusion, at 1-year after ECMO, 4.8% of ECMO-treated patients were newly diagnosed with insomnia disorder, and post-ECMO insomnia disorder was associated with higher 5-year ACM, especially in those with underlying psychiatric illness. Our present results suggest that the development of insomnia disorder might be related to poorer long-term survival in ECMO-treated patients, especially in case of underlying psychiatric illness.

Cross-Lagged Relationships Between Insomnia and Posttraumatic Stress Disorder in Treatment-Receiving Veterans

Insomnia is a risk factor for the development of posttraumatic stress disorder (PTSD) while it is also plausible that PTSD symptoms can maintain insomnia symptoms. The present study examined longitudinal bidirectional relationships between insomnia and PTSD symptoms in treatment-seeking veterans. Participants were 693 ex-serving members of the Australian Defence Force who participated in an accredited, hospital-based outpatient PTSD program. Participants completed self-reported assessments of PTSD and insomnia symptoms at four time points: intake, discharge, 3-month, and 9-months posttreatment follow-up. Cross-lagged pathway analyses indicated significant bi-directional pathways between insomnia symptoms and PTSD symptoms at most time points. A final cross-lagged model between insomnia symptoms and the PTSD symptom clusters indicated that the PTSD symptom paths on insomnia symptoms, between intake and discharge, were attributable to reexperiencing PTSD symptoms. In contrast, across posttreatment follow-up time points there were significant paths of insomnia symptoms on all PTSD symptom clusters except from insomnia at 3-months to avoidance symptom at 9-months. PTSD symptoms and insomnia symptoms have bidirectional associations over time that may lead to the mutual maintenance or exacerbation of each condition following PTSD treatment. Where residual insomnia symptoms are present post-treatment, a sleep-focussed intervention is indicated and a sequenced approach to treatment recommended.

Baseline sleep quality moderates symptom improvement in veterans with comorbid PTSD and TBI receiving trauma-focused treatment

Poor sleep quality is common among Veterans with posttraumatic stress disorder (PTSD) and history of traumatic brain injury (TBI). However, the relationship between sleep quality and treatment outcomes following trauma-focused interventions is less well-understood in this population. We sought to better understand whether 1) sleep quality changed as a result of trauma-focused treatment and 2) if baseline sleep quality moderated psychological and neurobehavioral treatment outcomes. Our sample consisted of 100 Iraq/Afghanistan era Veterans with PTSD and history of mild to moderate TBI who were randomized to one of two trauma-focused treatments: 1) Cognitive Processing Therapy (CPT) or 2) combined CPT and Cognitive Symptom Management and Rehabilitation Therapy (SMART-CPT). Self-reported sleep quality, psychiatric symptoms (PTSD and depression), and neurobehavioral concerns were assessed at multiple timepoints throughout the study. Multilevel modeling showed sleep quality did not improve, regardless of treatment condition. However, worse baseline sleep quality was associated with less improvement in PTSD symptoms and cognitive complaints. There was no effect of baseline sleep quality on change in depression symptoms. These findings suggest that more targeted treatments to address sleep quality either prior to or in conjunction with trauma-focused therapy may help to improve treatment outcomes for Veterans with comorbid PTSD and TBI history.

Molecular genetic overlap between posttraumatic stress disorder and sleep phenotypes

STUDY OBJECTIVES

Sleep problems are common, serving as both a predictor and symptom of posttraumatic stress disorder (PTSD), with these bidirectional relationships well established in the literature. While both sleep phenotypes and PTSD are moderately heritable, there has been a paucity of investigation into potential genetic overlap between sleep and PTSD. Here, we estimate genetic correlations between multiple sleep phenotypes (including insomnia symptoms, sleep duration, daytime sleepiness, and chronotype) and PTSD, using results from the largest genome-wide association study (GWAS) to date of PTSD, as well as publicly available GWAS results for sleep phenotypes within UK Biobank data (23 variations, encompassing four main phenotypes).

METHODS

Genetic correlations were estimated utilizing linkage disequilibrium score regression (LDSC), an approach that uses GWAS summary statistics to compute genetic correlations across traits, and Mendelian randomization (MR) analyses were conducted to follow up on significant correlations.

RESULTS

Significant, moderate genetic correlations were found between insomnia symptoms (rg range 0.36-0.49), oversleeping (rg range 0.32-0.44), undersleeping (rg range 0.48-0.49), and PTSD. In contrast, there were mixed results for continuous sleep duration and daytime sleepiness phenotypes, and chronotype was not correlated with PTSD. MR analyses did not provide evidence for casual effects of sleep phenotypes on PTSD.

CONCLUSION

Sleep phenotypes, particularly insomnia symptoms and extremes of sleep duration, have shared genetic etiology with PTSD, but causal relationships were not identified. This highlights the importance of further investigation into the overlapping influences on these phenotypes as sample sizes increase and new methods to investigate directionality and causality become available.

Nightmares and Insomnia in the US National Guard: Mental and Physical Health Correlates

BACKGROUND

Nightmares and insomnia are significant concerns that commonly co-occur with each other and with other health disorders. Limited research has examined the unique and shared aspects of insomnia and nightmares, and little is known about sleep in US National Guard personnel. This study sought to determine the prevalence and psychosocial correlates of nightmares with and without insomnia in US National Guard personnel.

METHOD

National Guard personnel (N = 841) completed an online survey and were classified as having nightmares only, insomnia only, both, or neither, using a minimum nightmare frequency of "less than once a week" and an Insomnia Severity Index cutoff of ≥ 15. Analyses examined differences in demographics, physical health, and psychosocial variables and in the prevalence of nightmares and insomnia in personnel with physical and mental health problems.

RESULTS

In this sample, 32% reported nightmares only, 4% reported insomnia only, and 12% reported both. Those in the youngest age group (18-21) were more likely to have no nightmares or insomnia. Those with both nightmares and insomnia had more deployments. Nightmares and insomnia were associated with poorer physical and mental health and greater prevalence of comorbid physical and mental health conditions. Personnel with both insomnia and nightmares reported the greatest severity of comorbid conditions.

CONCLUSION

US National Guard personnel with nightmares and/or insomnia reported worse mental and physical health impairment than those without these conditions. Personnel may benefit from screening for nightmares and insomnia and referrals for evidence-based treatment.

The role of insomnia in the association between posttraumatic stress disorder and hypertension

OBJECTIVE

Posttraumatic stress disorder (PTSD) is associated with incident hypertension. Although this relationship is poorly understood, PTSD is also associated with insomnia symptoms, which increases the risk for hypertension. Whether insomnia contributes to PTSD-associated risk for hypertension is unknown.

METHODS

We examined self-report survey and electronic health record data from 1109 participants in the Women Veterans Cohort Study (mean age: 43.8 ± 10.9 years; 52% women, 81% White) to assess the cross-sectional associations between PTSD symptom severity, recent symptoms of insomnia, and hypertension, defined as self-reported treatment for high blood pressure in the last year. Structural equation modeling was used to examine whether insomnia symptoms mediate the association between PTSD and hypertension.

RESULTS

PTSD symptom severity was associated with hypertension (r = 0.09, P < 0.001). PTSD symptom severity and hypertension were each associated with the insomnia symptoms difficulty falling asleep, difficulty staying asleep, and worry/distress about sleep problems (PTSD: rs = 0.58--0.62, P <  0.001; hypertension: rs = 0.07--0.10, P <  0.001). A latent variable derived from those symptoms mediated 9% of the association between PTSD symptom severity and hypertension (P = 0.02).

CONCLUSION

In this study of young and middle-aged Veterans, insomnia symptoms mediated the association between PTSD and hypertension. Difficulties falling asleep and maintaining sleep and related distress may be particularly deleterious for cardiovascular health in Veterans. Longitudinal data is required to further investigate the associations between PTSD, insomnia, and hypertension.

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.

Written exposure therapy and app-delivered mindfulness-based meditation for PTSD and subthreshold PTSD in China: Design of a randomized controlled trial

Background

Posttraumatic stress disorder (PTSD) and subthreshold PTSD are still major global concerns, especially in developing areas short of mental health resources. Written exposure therapy (WET), a brief 5-session treatment, has been found to be effective in reducing PTSD symptoms, but no studies have examined it in an Eastern context. Mindfulness-based meditation mobile application may be a promising approach to reduce insomnia comorbid with PTSD. The current study aims to: 1) examine the effectiveness of WET for Chinese PTSD and subthreshold PTSD patients, and 2) examine the effectiveness of adding a mindfulness-based application (MBA) to WET for reducing comorbid insomnia.

Methods

The randomized controlled trial will enroll 150 adults with subthreshold/full PTSD and comorbid insomnia. Participants will be randomly assigned to written exposure therapy plus mindfulness-based application condition (WET + MBA, n = 50), written exposure therapy alone (WET, n = 50), or minimal contact control (MMC, n = 50). Clinical interview of the primary outcome (PTSD symptoms) will be administrated at baseline, posttreatment, 3- and 6- month follow-up, while self-reported PTSD symptoms and secondary outcomes (insomnia severity) will be administrated at baseline, every week and all follow-ups.

Discussion

This is the first study applying WET in Chinese PTSD patients, as well as examining a mindfulness-based mobile application as a treatment add-on for comorbid insomnia. Study findings will contribute to the knowledge of the effectiveness of WET and a mindfulness-based mobile application, and the development of a culture-adapted treatment protocol.

Trial registration

ChiCTR, ChiCTR2000034119. Registered 24 June 2020, http://www.chictr.org.cn/showproj.aspx?proj&equals;55,467.

Treatment of Sleep Comorbidities in Posttraumatic Stress Disorder

Purpose of the review

Sleep disturbances, insomnia and recurrent nightmares in particular, are among the most frequently endorsed symptoms of posttraumatic stress disorder (PTSD). The present review provides a summary of the prevalence estimates and methodological challenges presented by sleep disturbances in PTSD, highlights the recent evidence for empirically supported psychotherapeutic and pharmacological interventions for comorbid sleep disturbances implicated in PTSD, and provides a summary of recent findings on integrated and sequential treatment approaches to ameliorate comorbid sleep disturbances in PTSD.

Recent Findings

Insomnia, recurrent nightmares, and other sleep disorders are commonly endorsed among individuals with PTSD; however, several methodological challenges contribute to the varying prevalence estimates. Targeted sleep-focused therapeutic interventions can improve sleep symptoms and mitigate daytime PTSD symptoms. Recently, attention has focused on the role of integrated and sequential approaches, suggesting that comprehensively treating sleep disturbances in PTSD is likely to require novel treatment modalities.

Summary

Evidence is growing on the development, course, and treatment of comorbid sleep disturbances in PTSD. Further, interventions targeting sleep disturbances in PTSD show promise in reducing symptoms. However, longitudinal investigations and additional rigorous controlled trials with diverse populations are needed to identify key features associated with treatment response in order to alleviate symptoms.

Advances in the Treatment of Chronic Insomnia: A Narrative Review of New Nonpharmacologic and Pharmacologic Therapies

Chronic insomnia disorder, which affects 6-10% of the population, is diagnostically characterized by ongoing difficulties with initiating or maintaining sleep occurring at least three times per week, persisting for at least 3 months, and associated with daytime impairment. While chronic insomnia is often considered a condition primarily related to impaired sleep, the disorder can also adversely affect domains of physical and mental health, quality of life, and daytime function, which highlights the importance of treating the multidimensional sleep disorder. Owing to misperceptions about the safety and effectiveness of treatment options, many individuals with insomnia may not seek professional treatment, and alternatively use ineffective home remedies or over-the-counter medications to improve sleep. Some physicians may even believe that insomnia is remediated by simply having the patient "get more sleep". Unfortunately, treatment of insomnia is not always that simple. The disorder's complex underlying pathophysiology warrants consideration of different nonpharmacologic and pharmacologic treatment options. Indeed, recent insights gained from research into the pathophysiology of insomnia have facilitated development of newer treatment approaches with more efficacious outcomes. This narrative review provides a summary of the diagnostic criteria and pathophysiology of insomnia and its subtypes. Further, this review emphasizes new and emerging nonpharmacologic and pharmacologic treatments for chronic insomnia, including recent enhancements in approaches to cognitive behavioral therapy for insomnia (CBT-I) and the new dual orexin receptor antagonist (DORA) pharmacologics. These advances in treatment have expanded the treatment options and are likely to result in improved outcomes in patients with chronic insomnia.

Disturbed Sleep in PTSD: Thinking Beyond Nightmares

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.