Post-traumatic stress disorder and sleep-what a nightmare!

The daily reciprocal associations between electroencephalography measured sleep and affect

Self-report studies show that sleep and positive and negative affect are closely and bidirectionally linked. However, studies assessing sleep objectively yield more inconsistent results. This study assessed the reciprocal, daily relationship between sleep as measured with electroencephalography (EEG) and affect (measured in the evening) in a natural setting. We assessed sleep both on the macrolevel (i.e., rapid eye movement [REM] sleep and slow-wave sleep [SWS] duration) and on the microlevel (i.e., REM sleep fragmentation). In this study, 33 participants (i.e., healthy college students, mean [standard deviation] age 21.55 [3.73] years, 67% female) were followed for 2 weeks. Each participant wore an EEG headband for 15 nights and had polysomnography during 3 of the 15 nights providing 72 analysable nights of polysomnography and 271 analysable nights with the EEG headband. Every evening participants reported their momentary negative and positive affect. We examined the relationship between pre-sleep affect and the sleep variables, as well as the reverse relationship, with sleep variables predicting evening affect the next day. We detected that higher negative affect in the evening was related to more fragmented REM sleep. However, this result was only found with polysomnography and not with the EEG headband. No significant associations were found between affect and time spent in REM sleep and SWS. Overall, no support was found for the reciprocal association between negative and positive affect and EEG measured sleep. Only limited support was found for an association in one direction (i.e., evening negative affect was associated with more REM sleep fragmentation at night).

Breathlessness, but not breathing instability, varies with posttraumatic stress symptoms in university students

Obstructive sleep apnea (OSA) is a chronic sleep-related breathing disorder that is highly prevalent in individuals with posttraumatic stress disorder (PTSD). The reason for this high prevalence remains unclear. We hypothesized that breathing instability, one of the key contributors to OSA, may be altered in PTSD and predispose OSA. Healthy participants (214 females, 98 males) aged 17 to 42 (M = 19.92; SD = 2.85) completed online questionnaires measuring PTSD symptomatology, sleep disturbances, and self-reported breathlessness. A subset of these participants (16 females, 14 males) aged 18 to 42 (M = 23.50; SD = 7.18) completed an in-lab breathing instability assessment, whereby they performed a series of 20-second and maximal duration breath-holds. PTSD severity positively predicted subjective perceptions of breathlessness (P < 0.001) but not objective measures of breathing instability, namely ventilation following 20-s breath-holds (P = 0.93) and maximal breath-hold duration (P = 0.41). These results suggest that breathing instability may not be the driving factor behind the high prevalence of OSA in PTSD. Instead, other factors such as a low arousal threshold, elevated ventilatory responses to arousal, or coexisting insomnia may explain the high rates of OSA in PTSD. One explanation for the discrepancy between subjective breathlessness and breathing stability measures relating to PTSD severity may be that hypervigilance and increased anxiety impacted self-perceptions of breathlessness while not altering breathing instability per se.NEW & NOTEWORTHY Obstructive sleep apnea (OSA) is more common in individuals with posttraumatic stress disorder (PTSD) than the general population for unknown reasons. This study assessed one of the key contributors to OSA, respiratory control instability, in young students with a range of posttraumatic stress symptoms. Although individuals with high PTSD symptoms reported increased subjective breathlessness, objectively measured breathing instability was not altered, suggesting respiratory instability is unlikely to increase the risk of OSA in PTSD.

Subjective sleep parameters: A marker to PTSD symptoms evolution? A 4-year longitudinal study

Disturbed sleep is a common feature after exposure to a traumatic event, especially when PTSD develops. However, although there is evidence suggesting a potential role of sleep disturbance in the progression of PTSD symptoms, the interrelationship between sleep and PTSD symptoms has yet to be determined. In order to address this knowledge gap, we have investigated the influence of initial sleep characteristics on the evolution of post-traumatic stress disorder (PTSD) symptoms over 4 years of follow-up among individuals exposed to the Brazilian Kiss nightclub fire. Participants were individuals exposed to the 2013 Kiss nightclub fire in Brazil. Sleep characteristics and PTSD symptoms were measured within the 4 years following the fire by self-report questionnaires, such as The Pittsburgh Sleep Quality Index (PSQI), and PTSD Checklist - Civilian version (PCL-C). Generalized estimating equations (GEE) models were used to examine the longitudinal associations (by estimating the relative effects of initial sleep problems on PTSD symptoms after adjusting for covariates). Comprehensive information concerning socio-demographic factors, health status, and sleep complaints were obtained. A total of 232 individuals were included. In GEE models, no significant interactions were observed between sociodemographic variables and PTSD symptoms in the follow-up period, however, associations were found between PTSD at baseline and the following factors: the female gender, the victim individuals and the existence of prior psychiatric disease. Initial subjective sleep parameters were strongly associated with PTSD symptoms over 4 years, mainly the presence of disturbed dreams (p = 0.012), increased sleep latency (p = 0.029), and reduced sleep duration (p = 0.012). Sleep complaints and PTSD symptoms were common among individuals after the disaster. The current study has found that the presence of sleep complaints, especially increased sleep latency, presence of disturbed dreams and short sleep duration, in the initial presentation after the fire was consistently associated with the perpetration of PTSD symptoms in the next 4 years of follow-up. These findings suggest that interventions addressing these sleep complaints have the potential to reduce the persistence and/or severity of PTSD symptoms.

The relationships between the family impact and distress of the coronavirus disease-19 pandemic, parent insomnia, infant temperamental negative affectivity, and parent-reported infant sleep: a path analysis

Study Objectives

The coronavirus disease 2019 (COVID-19) pandemic impact on infant sleep (IS) is understudied. The purpose of this study was to examine the relationships between family impact and distress from COVID-19 pandemic stressors, parental insomnia symptoms, infant temperamental negative affectivity, and parent-reported IS.

Methods

Parents from the Phoenix metropolitan area with a full-term healthy infant (<1 year) were recruited from February 27, 2021, to August 7, 2021. A sample of 70 parents (baby age 5.5 ± 3.5 months; parental age: 31.7 ± 5.0 years) completed the COVID-19 Exposure and Family Impact Survey (CEFIS) Impact and Distress scales, the Insomnia Severity Index (ISI), the Infant Behavioral Questionnaire-Revised Negative Affectivity subscale (IBQ-R-NA), and the Brief Infant Sleep Questionnaire-Revised (BISQ-R). Based on the transactional model of IS, path analyses were conducted to identify the direct effect of CEFIS scores and the indirect effects of parental ISI and infant IBQ-R-NA scores on BISQ-R scores.

Results

The parent sample was predominantly female (94.3%), white (72.9%), and married or in a domestic partnership (98.6%). Although COVID-19 pandemic impact and distress were not directly related to parent-reported IS, pandemic distress was negatively related to parent-reported IS indirectly through infant negative affectivity, including BISQ-R total score (β = -0.14, 95% CI [-0.32, -0.01]) and IS subscale score (β = -0.12, 95% CI [-0.27, -0.01]).

Conclusions

Heightened COVID-19 pandemic family distress was related to poorer parent-reported IS through greater parent-reported infant negative affectivity, suggesting the importance of addressing family stress and emotional regulation during crises.

The mediating effect of sleep quality on exposure to community violence and posttraumatic stress symptoms in the United States

Objectives

The role of sleep quality is not yet fully understood in the context of posttraumatic stress disorder (PTSD) following exposure to community violence. Thus, the primary aim of this study is to examine the mediating effect of sleep quality in the relationship between community violence exposure and posttraumatic stress symptoms.

Methods

Utilizing a cross-sectional survey administered to an online opt-in panel of adults in the United States in 2023 (age ≥ 18 years) (N = 342), respondents reported on their exposure to community violence, sleep quality, and posttraumatic stress symptoms. Covariate-adjusted regressions were used to test these relationships.

Results

Directly experiencing community violence was associated with poorer sleep quality (β = 0.11, 95 % CI [0.02, 0.20], p = 0.022) and posttraumatic stress symptoms (β = 0.33, 95 % CI [0.17, 0.48], p = < 0.001), and poorer sleep quality predicted greater posttraumatic stress symptoms (β = 0.74, 95 % CI [0.58, 0.91], p = 0<.001). Further, sleep quality was a partial mediator (β = 0.24, 95 % CI [0.04, 0.50], p = 0.028), accounting for 24 % of the relationship.

Conclusions

Findings from this study help deepen understanding of the processes that contribute to the development of PTSD and provide insights into possible interventions, including treatment for sleep problems in the aftermath of violence exposure as a means for lessening the mental health burdens of community violence.

Neural and psychological correlates of post-traumatic stress symptoms in a community adult sample

A multitude of factors are associated with the symptoms of post-traumatic stress disorder. However, establishing which predictors are most strongly associated with post-traumatic stress disorder symptoms is complicated because few studies are able to consider multiple factors simultaneously across the biopsychosocial domains that are implicated by existing theoretical models. Further, post-traumatic stress disorder is heterogeneous, and studies using case-control designs may obscure which factors relate uniquely to symptom dimensions. Here we used Bayesian variable selection to identify the most important predictors for overall post-traumatic stress disorder symptoms and individual symptom dimensions in a community sample of 569 adults (18 to 85 yr of age). Candidate predictors were selected from previously established risk factors relevant for post-traumatic stress disorder and included psychological measures, behavioral measures, and resting state functional connectivity among brain regions. In a follow-up analysis, we compared results controlling for current depression symptoms in order to examine specificity. Poor sleep quality and dimensions of temperament and impulsivity were consistently associated with greater post-traumatic stress disorder symptom severity. In addition to self-report measures, brain functional connectivity among regions commonly ascribed to the default mode network, central executive network, and salience network explained the unique variability of post-traumatic stress disorder symptoms. This study demonstrates the unique contributions of psychological measures and neural substrates to post-traumatic stress disorder symptoms.

Dyadic Investigation of Posttraumatic Stress Symptoms and Daily Sleep Health in Patients With Cancer and Their Caregivers

OBJECTIVE

Cancer can be a traumatic experience affecting multidimensional aspects of sleep among patients and caregivers. This study examined the differential associations of cancer-related posttraumatic stress symptoms (PTSS) with various sleep markers in this population.

METHODS

Patients newly diagnosed with colorectal cancer ( n = 138, mean age = 56.93 years, 31.88% female, 60.14% Hispanic, 6.53 months after diagnosis) and their sleep-partner caregivers ( n = 138, mean age = 55.32 years, 68.12% female, 57.97% Hispanic) completed questionnaires assessing the four PTSS clusters (intrusion, avoidance, alterations in arousal and reactivity, negative alterations in cognitions and mood). Participants also completed daily sleep diaries for 14 consecutive days, from which sleep onset latency (SOL), wake after sleep onset (WASO), and sleep duration were derived.

RESULTS

Actor-partner interdependence model revealed that caregivers' greater alterations in arousal and reactivity were associated with their own longer SOL ( b = 15.59, p < .001) and their patients' longer sleep duration ( b = 0.61, p = .014), whereas patients' arousal and reactivity were associated with their caregivers' shorter SOL ( b = -8.47, p = .050). Patients' and caregivers' greater negative alterations in cognitions and mood were associated with patients' longer SOL ( b = 9.15, p = .014) and shorter sleep duration ( b = -0.41, p = .050), respectively. Caregivers' greater intrusion was related to their own shorter SOL ( b = -10.14, p = .004).

CONCLUSIONS

The four PTSS clusters, particularly arousal and reactivity and negative cognitions and mood, have distinct associations with sleep markers individually and dyadically in patients and caregivers affected by cancer. Investigations of psychosocial and biobehavioral pathways underlying these relations are warranted. Tailored trauma treatments and sleep interventions may improve the well-being of this population.

Posttraumatic Stress Disorder Symptoms and Sleep Disturbances Among Asian Indians: A Systematic Review

Substantial comorbidity exists between posttraumatic stress disorder and sleep disturbances/disorders. Such comorbidities are understudied in minority groups, including Asian Indians residing in countries outside India. Thus, we synthesized the existing literature specific to this group of Asian Indians to determine (a) prevalence estimates of posttraumatic stress disorder (PTSD) and sleep disturbances/disorders; and (b) PTSD-sleep comorbidity estimates. For this systematic review, we searched four databases (PubMed, PsycInfo, PTSDpubs, Web of Science) using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of 3,796 screened articles, 9 articles (10 studies) met inclusion criteria. Study sample sizes ranged from 11 to 2,112 Asian Indians; studies were conducted in Singapore or Malaysia. No reviewed study examined PTSD. All studies examined sleep disturbances/disorders among Asian Indians; prevalence estimates were: 8.3% to 70.4% for short sleep duration, 2.0% to 22.9% for long sleep duration, 25.9% to 56.3% for poor sleep quality, 3.4% to 67.5% for insomnia diagnosis or probable insomnia, 7.7% for excessive daytime sleepiness, 3.8% to 54.6% for obstructive sleep apnea (OSA) diagnosis or high OSA risk, and 5.1% to 11.1% for sleep-disordered breathing. Specific to Asian Indians residing in countries outside India, this review advances PTSD-sleep literature by (a) suggesting substantial prevalence of sleep disturbances/disorders; (b) highlighting the need for culturally relevant sleep interventions; and (c) highlighting research gaps (e.g., no PTSD-focused research).

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

INTRODUCTION

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

The sleep justice study - a prospective cohort study assessing sleep as a cardiometabolic risk factor after incarceration: a protocol paper

BACKGROUND

An estimated 11 million individuals are released from U.S. jails and prisons each year. Individuals with a history of incarceration have higher rates of cardiovascular disease (CVD) events and mortality compared to the general population, especially in the weeks following release from carceral facilities. Healthy sleep, associated with cardiovascular health, is an underexplored factor in the epidemiology of CVD in this population. Incarcerated people may have unique individual, environmental, and institutional policy-level reasons for being sleep deficient. The social and physical environment within carceral facilities and post-release housing may synergistically affect sleep, creating disparities in sleep and cardiovascular health. Since carceral facilities disproportionately house poor and minoritized groups, population-specific risk factors that impact sleep may also contribute to inequities in cardiovascular outcomes.

METHODS

This study is ancillary to an ongoing prospective cohort recruiting 500 individuals with known cardiovascular risk factors within three months of release from incarceration, the Justice-Involved Individuals Cardiovascular Disease Epidemiology (JUSTICE) study. The Sleep Justice study will measure sleep health among participants at baseline and six months using three validated surveys: the Pittsburgh Sleep Quality Index (PSQI), the STOP-Bang, and the Brief Index of Sleep Control. In a subsample of 100 individuals, we will assess sleep over the course of one week using wrist actigraphy, a validated objective measure of sleep that collects data on rest-activity patterns, sleep, and ambient light levels. Using this data, we will estimate and compare sleep health and its association with CVD risk factor control in individuals recently released from carceral facilities.

DISCUSSION

The incarceration of millions of poor and minoritized groups presents an urgent need to understand how incarceration affects CVD epidemiology. This study will improve our understanding of sleep health among people released from carceral facilities and its potential relationship to CVD risk factor control. Using subjective and objective measures of sleep will allow us to identify unique targets to improve sleep health and mitigate cardiovascular risk in an otherwise understudied population.

An ecological approach to clinically assess nightmares in military service members with severe PTSD

BACKGROUND

Trauma-related nightmares (TRNs) are distressing events which contribute to insomnia severity, chronicity and treatment resistance of PTSD. Therefore, recording TRNs is a crucial technical challenge in order to understand their physiopathological patterns and their impact on sleep. However, TRNs are difficult to record during a single night in a sleep laboratory, which, moreover, is likely to be considered by patients as a protective sleep environment that is therefore not representative of home sleep conditions.

METHOD

In the present study, we investigate if objective sleep measures acquired at-home using two ambulatory devices is of clinical value by correlating with PTSD patients' complaints about sleep and nightmares. A secondary objective is to relate awakenings associated with TRNs to sleep stages and to provide new insights into the use of electrodermal activity (EDA) as a potential physiological marker of TRNs. Sixty veterans and active-duty service members were assessed by questionnaires and recorded for 5 consecutive nights in their homes.

RESULTS

Our approach firstly identified positive correlations between subjective and objective sleep parameters (total sleep time, sleep-onset latency and TRNs frequency). We also developed a method of synchronization between the two ambulatory devices that allowed us to match 200 TRNs (reported by event marker push button) with sleep stages corresponding to 91 nights and 37 patients. Most awakenings associated with TRNs occurred during NREM sleep (65.5% versus 34.5% during REM sleep). Our results also reveal significant differences in the frequency of EDA peaks 10 min before the reported events, with a lower frequency in REM (13.7 peaks) than in NREM (24.8 peaks) awakenings associated with TRNs. This EDA peaks frequency in REM sleep is not statistically different from that in REM sleep preceding awakenings that are not associated with TRNs.

CONCLUSION

The development of wearable devices to collect physiological parameters is of interest in clinical practice to improve our knowledge of sleep and trauma-related nightmares in patients with PTSD.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Exploratory Study on the Associations between Lifetime Post-Traumatic Stress Spectrum, Sleep, and Circadian Rhythm Parameters in Patients with Bipolar Disorder

The present study aimed at exploring whether lifetime post-traumatic stress spectrum symptoms are associated with chronotype in patients with bipolar disorder (BD). Moreover, we explored whether the chronotype can moderate the potential associations between lifetime post-traumatic stress spectrum symptoms and rest-activity circadian and sleep-related parameters. A total of 74 BD patients were administered the Trauma and Loss Spectrum Self-Report (TALS-SR) lifetime version for lifetime post-traumatic stress spectrum symptoms, the Pittsburgh Sleep Quality Index (PSQI) for self-reported sleep quality, and the Reduced Morningness-Eveningness Questionnaire (rMEQ) to discriminate evening chronotypes (ETs), neither chronotype (NT), and morning chronotype (MT). Actigraphic monitoring was used to objectively evaluate sleep and circadian parameters. Patients classified as ET reported significantly higher scores in the re-experiencing domain, as well as poorer sleep quality, lower sleep efficiency, increased wake after sleep onset, and delayed mid-sleep point compared with both NT and MT (p-value ≤ 0.05). Moreover, ET presented significantly higher scores in the TALS-SR maladaptive coping domain than NT and lower relative amplitude than MT (p-value ≤ 0.05). Moreover, higher TALS-SR total symptomatic domains scores were significantly correlated with poor self-reported sleep quality. Regression analyses showed that the PSQI score maintained the association with the TALS total symptomatic domains scores after adjusting for potentially confounding factors (age and sex) and that no interaction effect was observed between the chronotype and the PSQI. Conclusions: This exploratory study suggests that patients with BD classified as ET showed significantly higher lifetime post-traumatic stress spectrum symptoms and more disrupted sleep and circadian rhythmicity with respect to other chronotypes. Moreover, poorer self-reported sleep quality was significantly associated with lifetime post-traumatic stress spectrum symptoms. Further studies are required to confirm our results and to evaluate whether targeting sleep disturbances and eveningness can mitigate post-traumatic stress symptoms in BD.

Heterogeneity in patterns of posttraumatic stress disorder symptoms and sleep disturbances among firefighters: Latent profile analyses

Firefighters are at increased risk for posttraumatic stress disorder (PTSD) symptoms and sleep disturbances due to occupational trauma exposure as well as the nature of their job (e.g., shift work, workplace stress). PTSD symptoms co-occur with sleep disturbances, including poor sleep quality, short sleep duration, and low sleep efficiency. No published studies have examined subgroups of firefighters based on PTSD symptoms and sleep disturbances. Thus, we used latent profile analysis to identify the best-fitting class solution to categorize firefighters based on endorsed PTSD symptoms and sleep disturbances and examined relations between the optimal class solution and health covariates (i.e., anger reactions, depression symptoms, emotion regulation difficulties, number of traumatic event types). The sample included 815 trauma-exposed firefighters (M_age = 38.63; 93.20% male). Results indicated three latent subgroups: High PTSD-Sleep Disturbances, Moderate PTSD-Sleep Disturbances, and Low PTSD-Sleep Disturbances. Multinomial logistic regression indicated that endorsing greater anger reactions, depression symptoms, and emotion regulation difficulties increased the chances of being in the more severe classes. Endorsing greater number of traumatic event types increased the chances of being in the Moderate vs. Low PTSD-Sleep Disturbances Classes. Findings improve our understanding of subgroups of firefighters based on PTSD and sleep disturbances and underscore the importance of addressing depression symptoms, anger management, and emotion regulation skills for firefighters reporting more severe PTSD symptoms and sleep disturbances.

Post-traumatic stress disorder prevalence and sleep quality in fire victims and rescue workers in southern Brazil: a cross-sectional study

OBJECTIVES

This survey was conducted to evaluate the prevalence of post-traumatic stress disorder (PTSD) and the sleep quality in victims and rescue team of the third deadliest nightclub fire in the world.

STUDY DESIGN

A cross-sectional study.

METHODS

Participants were victims and rescue workers exposed to a fire at a nightclub, which occurred in January 2013 in Southern Brazil. The Pittsburgh Sleep Quality Index (PSQI), composed of seven subjective sleep variables (including daytime dysfunction), and PTSD Checklist - Civilian version (PCL-C) were applied to all people who sought medical attention at the local reference center in the first year after the event. Comprehensive information was obtained concerning sociodemographic factors, health status, and sleep complaints.

RESULTS

A total of 370 individuals, 190 victims and 180 rescue workers, were included. Participants were 70% male, with an average age of 29 years. The prevalence of PTSD was 31.9%, ranging from 24.4% for rescue workers to 38.9% for victims. The prevalence of poor sleep quality was 65.9%, ranging from 56.1% for rescue workers to 75.3% for victims. Most of the participants with PTSD (91.5%) had PSQI scores >5 (poor sleepers), against 54.0% of the non-PTSD individuals. All seven PSQI subscores showed significant differences between PTSD and non-PTSD individuals, especially daytime dysfunction. Sex, shift work, previous psychiatric disease, and sleep quality remained associated with PTSD in adjusted models, with a prevalence ratio (95% CI) of 1.76 (1.28-2.43) in females, 1.73 (1.17-2.55) in shift workers, 1.36 (1.03-1.80) in individuals with psychiatric disease history, and 5.42 (2.55-11.52) in poor sleepers.

CONCLUSIONS

The presence of daytime dysfunction increased by at least tenfold the prevalence of PTSD in this sample. Considering that daytime dysfunction was shown to be strongly associated with PTSD, sleep-related issues should be addressed in the assessment of individuals exposed to traumatic events, both victims and rescuers. Factors like shift work and female sex were also associated with PTSD, especially among victims.

Memory reconsolidation impairment using the β-adrenergic receptor blocker propranolol reduces nightmare severity in patients with post-traumatic stress disorder: a preliminary study

STUDY OBJECTIVES

Post-traumatic nightmares may exacerbate and perpetuate the daytime symptoms of post-traumatic stress disorder (PTSD) and might represent a therapeutic target. The therapeutic strategy of memory reconsolidation using the β-adrenergic receptor blocker propranolol associated with re-exposure psychotherapy is a promising treatment in PTSD patients. Previous studies have established this therapy is effective in reducing overall clinician-assessed PTSD symptoms but to date no previous study has specifically focused on posttraumatic nightmares in this therapy. This study provides a preliminary assessment of the evolution of nightmares severity during this therapy protocol, compared with the decrease of the other PTSD symptoms. It evaluates the incidence of side effects and examines the relative effects on posttraumatic nightmares.

METHODS

Patients were recruited as part of the Paris Mémoire Vive study. Data were collected using a prospective longitudinal design including one baseline visit, six therapeutic visits, and two follow-up visits. During the six therapeutic visits, propranolol was administered orally 60 to 75 minutes prior to the psychotherapeutic session.

RESULTS

On average, nightmare severity decreased from "severe" to "mild" during the protocol and remained stable two months after the last session. Whereas 85% of patients reported nightmares at baseline, only 50% still had them after the protocol. The protocol was generally well tolerated and, did not increase nightmare severity for any patient in the study.

CONCLUSIONS

Memory reconsolidation therapy with propranolol seems promising in reducing nightmare severity, up to and including remission. However, research using a randomized controlled design, and assessing maintenance of nightmare extinction, is warranted.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Using Reconsolidation Blockade to Treat Trauma Related Disorders After Paris Attacks: An Effectiveness Study (PARIS-MEM); Identifier: NCT02789982; URL: https://www.clinicaltrials.gov/ct2/show/NCT02789982.

Treatment Adherence Interventions for Burn Patients: What Works and What Role Can Motivational Interviewing Play?

The unique challenges burn patients face along the trajectory of recovery necessitate an interdisciplinary team approach to care. As much as providers rely on care-team members for delivery of optimal treatment, the patient must be an active collaborator in their care. Optimal burn recovery outcomes hinge on treatment adherence. In addition to general challenges faced in ubiquity by burn patients, there are specific patient populations for whom treatment adherence is particularly challenging. Although psychological interventions have been used successfully with burn patients, very few are appropriate for both inpatient and outpatient care environments and most do not focus on treatment adherence. This paper reviews unique facets of Motivational Interviewing (MI) that may be applicable in interdisciplinary burn treatment teams across inpatient and outpatient settings to optimize treatment adherence.

Emotional and Environmental Factors Aggravating Dream Enactment Behaviors in Patients with Isolated REM Sleep Behavior Disorder

OBJECTIVE

To identify emotional and environmental factors that aggravate dream enactment behaviors (DEBs) in isolated rapid eye movement (REM) sleep behavior disorder (iRBD).

METHODS

In this cross-sectional study, a total of 96 polysomnography-confirmed iRBD patients (mean age, 68.5 years; men, 68%) and their caregivers completed questionnaires regarding potential aggravating factors related to DEBs, including emotion/feelings (stress, anger, anxiety, depressive mood, fatigue, pain), food (alcohol, caffeine, overeating in the evening, fasting/hunger), activities and sleep patterns (strenuous exercise, sex before bed, conflict/fighting, sleep deprivation, oversleeping, sleeping away from home, watching TV before bed), weather/environmental factors (cloudy or rainy weather, heat, cold, noise) and medication (skipping medication, taking hypnotics).

RESULTS

The patients reported that stress (61%) was the most aggravating factor for DEBs, followed by anxiety (56%), anger (51%), fatigue (49%), and watching TV before bed (46%). Similarly, the caregivers reported that these factors were most relevant to the aggravation of DEBs in the patients, although some factors were ranked differently. In the subgroup analyses, aggravating factors for DEBs did not differ by RBD symptom severity. Interestingly, the proportion of patients experiencing DEB aggravation by stress, anxiety and depressive mood was significantly higher in women than in men. Furthermore, depressed patients reported that stress and cloudy or rainy weather made DEBs worse than nondepressed patients.

CONCLUSION

Our results suggest that DEBs in iRBD patients may be mainly aggravated by emotional factors. These negative effects appeared to be more prominent in female and depressed patients.

Nightmare Rescripting: Using Imagery Techniques to Treat Sleep Disturbances in Post-traumatic Stress Disorder

Besides affecting 8% of the general population, nightmares are one of the most frequent symptoms of traumatized individuals. This can be a significant factor in the treatment of post-traumatic disorders; indeed, several studies demonstrated its strong predictive and prognostic value. Sleep disorders, nightmares in particular, could be very distressing for individuals and need targeted interventions, especially if they are associated with a PTSD diagnosis. To date, the best technique for the treatment of traumatic sleep disturbances seems to be Imagery Rehearsal Therapy (IRT), an empirically supported method. Through a review of the literature on this matter, this article aims to outline the incidence and consequences of nightmares in PTSD, illustrate how IRT could prove useful in their treatment, and investigate its clinical applications.

Louis EK. Abnormal rapid eye movement sleep atonia control in chronic post-traumatic stress disorder

STUDY OBJECTIVES

Post-traumatic stress disorder (PTSD) and rapid eye movement (REM) sleep behavior disorder (RBD) share some common features including prominent nightmares and sleep disturbances. We aimed to comparatively analyze REM sleep without atonia (RSWA) between patients with chronic PTSD with and without dream enactment behavior (DEB), isolated RBD (iRBD), and controls.

METHODS

In this retrospective study, we comparatively analyzed 18 PTSD with DEB (PTSD+DEB), 18 PTSD without DEB, 15 iRBD, and 51 controls matched for age and sex. We reviewed medical records to determine PTSD clinical features and quantitatively analyzed RSWA. We used nonparametric analyses to compare clinical and polysomnographic features.

RESULTS

PTSD patients, both with and without DEB, had significantly higher RSWA than controls (all p < .025, excepting submentalis phasic duration in PTSD+DEB). Most RSWA measures were also higher in PTSD+DEB than in PTSD without DEB patients (all p < .025).

CONCLUSIONS

PTSD patients have higher RSWA than controls, whether DEB is present or not, indicating that REM sleep atonia control is abnormal in chronic PTSD. Further prospective studies are needed to determine whether neurodegenerative risk and disease markers similar to RBD might occur in PTSD patients.

Sleep and anxiety: From mechanisms to interventions

Anxiety is the most common mental health problem worldwide. Epidemiological studies show that sleep disturbances, particularly insomnia, affect ∼50% of individuals with anxiety, and that insufficient sleep can instigate or further exacerbate it. This review outlines brain mechanisms underlying sleep and anxiety, by addressing recent human functional/structural imaging studies on brain networks underlying the anxiogenic impact of sleep loss, and the beneficial effect of sleep on these brain networks. We discuss recent developments from human molecular imaging studies that highlight the role of specific brain neurotransmitter mechanisms, such as the adenosinergic receptor system, on anxiety, arousal, and sleep. This review further discusses frontline sleep interventions aimed at enhancing sleep in individuals experiencing anxiety, such as nonbenzodiazepines/antidepressants, lifestyle and sleep interventions and cognitive behavioral therapy for insomnia. Notwithstanding therapeutic success, up to ∼30% of individuals with anxiety can be nonresponsive to frontline treatments. Thus, we address novel non-invasive brain stimulation techniques that can enhance electroencephalographic slow waves, and might help alleviate sleep and anxiety symptoms. Collectively, these findings contribute to an emerging biological framework that elucidates the interrelationship between sleep and anxiety, and highlight the prospect of slow wave sleep as a potential therapeutic target for reducing anxiety.

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.

How our Dreams Changed During the COVID-19 Pandemic: Effects and Correlates of Dream Recall Frequency - a Multinational Study on 19,355 Adults

OBJECTIVE

Many have reported odd dreams during the pandemic. Given that dreams are associated with mental health, understanding these changes could provide crucial information about wellbeing during the pandemic. This study explored associations between COVID-19 and dream recall frequency (DRF), and related social, health, and mental health factors.

METHODS

We conducted a cross-sectional web survey of 19,355 individuals in 14 countries from May to July 2020. We collected data on COVID-19, mental health, sleep and DRF during the pandemic. We performed McNemar Tests to compare low (<3 nights per week) and high DRF (≥3 nights per week) before and during COVID-19 and to evaluate changes in sleep variables segmented by DRF. Chi-square tests were conducted to compare characteristics between low and high DRF. Logistic regression analyses were conducted to examine associations between various independent variables and DRF.

RESULTS

Reports of high DRF during the pandemic were higher than before the pandemic (P<0.001). Female gender (aOR=1.25, 95% CI 1.10-1.41), nightmares (aOR=4.22, 95% CI 3.45-5.17), sleep talking (aOR= 2.36, 1.73-3.23), sleep maintenance problems (aOR=1.34, 95% CI 1.15-1.56), symptoms of REM sleep behavior disorder (RBD; aOR=1.24, 95% CI 1.09-1.41) and repeated disturbing thoughts (posttraumatic stress disorder (PTSD) symptoms) were associated with high DRF. Age group 55-64 years (aOR=0.69, 95% CI 0.58-0.83) reported less high DRF than younger participants. Unadjusted OR showed associations between depression, anxiety, and DRF; however, in adjusted regression depression (aOR= 0.71, 0.59-0.86) and anxiety (aOR=0.79, 95% CI 0.66-0.94) were negatively associated with high DRF.

CONCLUSION AND RELEVANCE

DRF was higher than pre-pandemic levels across four continents. DRF was associated with gender and parasomnias like nightmares and RBD symptoms, sleep maintenance problems, PTSD symptoms and negatively associated with depression and anxiety. The results implicate that COVID-19 is reflected in our dreams as an expression of the emotional intensity of the pandemic.

Anxiogenic Potential of Experimental Sleep Fragmentation Is Duration-Dependent and Mediated via Oxidative Stress State

Sleep architecture alterations, among which sleep fragmentation is highly prevalent, represent risk factors for a variety of diseases, ranging from cardiovascular to brain disorders, including anxiety. What mediates anxiety occurrence upon sleep fragmentation is still a matter of debate. We hypothesized that the sleep fragmentation effects on anxiety are dependent on its duration and mediated by increased oxidative stress and alterations in the number of parvalbumin (PV+) interneurons in the hippocampus. Sleep was fragmented in rats by the treadmill method during a period of 14 days (SF group). Rats with undisturbed sleep in the treadmill (TC group) and those receiving equal amounts of treadmill belt motion (EC group) served as controls. To assess anxiety, we subjected rats to the open field, elevated plus maze, and light-dark tests on the 0, 7^th, and 14^th day. Upon the last test, brain structures were sampled for oxidative stress assessment and PV+ interneuron immunohistochemistry. The results of ethological tests of anxiety-linked behavior suggested duration-dependent anxiogenic potential of sleep fragmentation. Rats' anxiety-linked behavior upon sleep fragmentation significantly correlated with oxidative stress. The rats with fragmented sleep (SF) showed significantly higher oxidative stress in the hippocampus, thalamus, and cortex, compared to controls (TC and EC), while the antioxidant enzymes' activity was significantly decreased. No significant differences were observed in hippocampal PV+ interneurons among these groups. Our results showed that duration of sleep fragmentation is a significant determinant of anxiety-linked behavior, and these effects are mediated through oxidative distress in the brain. Herein, it is revealed that the sleep fragmentation-oxidative stress-anxiety axis contributes to our better understanding of pathophysiological processes, occurring due to disrupted sleep patterns.

Moderating effects of sleep difficulties on relations between posttraumatic stress disorder symptoms and positive memory count

OBJECTIVES

Posttraumatic stress disorder (PTSD) severity relates to positive memory retrieval difficulties. One variable potentially influencing this relation is sleep difficulties. We examined moderating effects of sleep difficulties (duration and quality) on relations between PTSD severity and count of specific positive memories covarying for age, gender, and depression.

METHODS

Participants were an Amazon Mechanical Turk-recruited trauma-exposed community sample of 205 respondents (M age  = 35.44; 61.40% women).

RESULTS

Moderated regression analyses indicated significant interaction effects between sleep quality (b = 0.03; p = 0.036) and PTSD severity on specific positive memory count. Among individuals reporting better sleep quality, there were negative associations between PTSD severity and specific positive memory count (b = -0.04, SE = 0.02, p = 0.010). Similar results were obtained for PTSD's intrusion and arousal clusters.

CONCLUSION

Results support targeting sleep quality and PTSD severity to improve positive memory retrieval in PTSD and memory interventions, and the importance of considering sleep when examining links between PTSD and positive memory retrieval.

Collision Every Night: Treating Nightmares with Trauma-focused Methods: Case Report

Introduction

We would like to present the case of a young patient with acute stress disorder and recurrent nightmares following the psychological trauma caused by a severe road traffic accident. The comprehensive therapy carried out at the Department of Traumatology included medication, trauma processing and a psychological method whose aim is to cease the development of nightmares.

Case Presentation

Psychiatric assessment and treatment was asked for a polytraumatised female patient at the Intensive Care Unit after she had undergone a neurosurgical intervention. Her medicinal treatment was continued at the Department of Traumatology. Besides the antidepressant venlafaxine she was treated in accordance with the EMDR protocol for acute stress disorder, and we also applied imagery rescripting to prevent her from having recurrent (daily) nightmares. As a result of the therapy, her symptoms were fast relieved, the nightmares stopped almost instantly, her mood improved, rumination and anxiety decreased significantly.

Conclusions

In view of the fast and significant symptomatic improvement, we can expect that the EMDR therapy and its protocol for acute stress disorder have successfully reactivated information processing, and besides the subjective relief we have managed to prevent a mental crisis that could lead to a suicide risk as well as the development of post-traumatic stress disorder. We also hope that the improvement will be long-lasting.

Cancer and stress: NextGen strategies

Chronic stress is well-known to cause physiological distress that leads to body balance perturbations by altering signaling pathways in the neuroendocrine and sympathetic nervous systems. This increases allostatic load, which is the cost of physiological fluctuations that are required to cope with psychological challenges as well as changes in the physical environment. Recent studies have enriched our knowledge about the role of chronic stress in disease development, especially carcinogenesis. Stress stimulates the hypothalamic-pituitaryadrenal (HPA) axis and the sympathetic nervous system (SNS), resulting in an abnormal release of hormones. These activate signaling pathways that elevate expression of downstream oncogenes. This occurs by activation of specific receptors that promote numerous cancer biological processes, including proliferation, genomic instability, angiogenesis, metastasis, immune evasion and metabolic disorders. Moreover, accumulating evidence has revealed that β-adrenergic receptor (ADRB) antagonists and downstream target inhibitors exhibit remarkable anti-tumor effects. Psychosomatic behavioral interventions (PBI) and traditional Chinese medicine (TCM) also effectively relieve the impact of stress in cancer patients. In this review, we discuss recent advances in the underlying mechanisms that are responsible for stress in promoting malignancies. Collectively, these data provide approaches for NextGen pharmacological therapies, PBI and TCM to reduce the burden of tumorigenesis.

Sleep problems in children and adolescents following traumatic life events

Rates of childhood trauma exposure are extremely high, with approximately 70% of children and adolescents experiencing at least one traumatic event. Among the most common non-specific consequences of stress and trauma are disruptions of sleep. Sleep problems, such as shorter sleep duration, difficulty falling asleep, frequent awakenings, nightmares, sleepless nights, and early-morning wakefulness appear to have a higher prevalence among children and adolescents following traumatic events. This review will illustrate the role of sleep problems in traumatized children and adolescents, and emphasize the need to consider a wide range of etiological mechanisms for these symptoms. However, the relationship of trauma exposure to sleep problems among children and adolescents needs further investigation in future research. Moreover, in view of the adverse consequences of long-term disrupted sleep on mental health outcomes following trauma, the need to effectively address sleep disturbances in traumatized children and adolescents is crucial.

Associations between daily affect and sleep vary by sleep assessment type: What can ambulatory EEG add to the picture?

OBJECTIVE/BACKGROUND

Disrupted sleep can be a cause and a consequence of affective experiences. However, daily longitudinal studies show sleep assessed via sleep diaries is more consistently associated with positive and negative affect than sleep assessed via actigraphy. The objective of the study was to test whether sleep parameters derived from ambulatory electroencephalography (EEG) in a naturalistic setting were associated with day-to-day changes in affect.

PARTICIPANTS/METHOD

Eighty adults (mean age = 32.65 years, 63% female) completed 7 days of affect and sleep assessments. We examined bidirectional associations between morning positive affect and negative affect with sleep assessed via diary, actigraphy, and ambulatory EEG.

RESULTS

Mornings with lower positive affect than average were associated with higher diary- and actigraphy-determined sleep efficiency that night. Mornings with higher negative affect than average were associated with longer actigraphy-determined total sleep time that night. Nights with longer diary-determined total sleep time, greater sleep efficiency, and shorter sleep onset latency than average were associated with higher next-morning positive affect, and nights with lower diary-determined wake-after-sleep-onset were associated with lower next-morning negative affect. EEG-determined sleep and affect results were generally null in both directions: only higher morning negative affect was associated with longer rapid eye movement (REM) sleep that night.

CONCLUSIONS

Self-reported sleep and affect may occur in a bidirectional fashion for some sleep parameters. EEG-determined sleep and affect associations were inconsistent but may still be important to assess in future studies to holistically capture sleep. Single-channel EEG represents a novel, ecologically valid tool that may provide information beyond diaries and actigraphy.

Sleep, circadian system and traumatic stress

The human circadian system creates and maintains cellular and systemic rhythmicity essential for the temporal organization of physiological processes promoting homeostasis and environmental adaptation. Sleep disruption and loss of circadian rhythmicity fundamentally affects master homeostasic regulating systems at the crossroads of peripheral and central susceptibility pathways, similar to acute or chronic stress and, thus, may play a central role in the development of stress-related disorders. Direct and indirect human and animal PTSD research accordingly suggests circadian-system-linked sleep, neuroendocrine, immune, metabolic and autonomic dysregulation, linking circadian misalignment to PTSD pathophysiology. Additionally, there is evidence that sleep and circadian disruption may represent a vital pre-existing risk factor in the prediction of PTSD development, while sleep-related symptoms are among the most prominent in trauma-associated disorders. These facts may represent a need for a shift towards a more chronobiological understanding of traumatic sequel and could support better prevention, evaluation and treatment of sleep and circadian disruption as first steps in PTSD management. In this special issue, we highlight and review recent advances from human sleep and chronobiological research that enhances our understanding of the development and maintenance of trauma-related disorders.

Earthquake Exposure and PTSD Symptoms Among Disaster-Exposed Adolescents: A Moderated Mediation Model of Sleep Problems and Resilience

Considerable studies have explored the potential mechanisms between trauma exposure and PTSD, but little is known about the role of sleep problems and resilience in this relationship. To address this research gap, the present study examined whether sleep problems mediated the relationship between earthquake exposure and PTSD symptoms, and whether this mediating process was moderated by resilience. A sample of 1,342 adolescents (M _age = 15.54 years, SD = 1.26) completed questionnaires regarding earthquake exposure, sleep problems, resilience, and PTSD symptoms 12 months after a devastating earthquake in China. After controlling for demographic variables, earthquake exposure was significantly, and positively associated with PTSD symptoms, and sleep problems partially mediated this relationship. Tests of moderated mediation further revealed that resilience moderated the relationship between earthquake exposure and PTSD symptoms as well as sleep problems and PTSD symptoms. Specifically, the relationship between earthquake exposure and PTSD symptoms was only significant for adolescents with a lower level of resilience; meanwhile, the positive relationship between sleep problems and PTSD symptoms was stronger among low-resilient adolescents. Therefore, sleep-targeted and resilience-based interventions may be effective in alleviating PTSD symptoms resulted from the earthquake.

Traumatic stress and the circadian system: neurobiology, timing and treatment of posttraumatic chronodisruption

Background: Humans have an evolutionary need for a well-preserved internal 'clock', adjusted to the 24-hour rotation period of our planet. This intrinsic circadian timing system enables the temporal organization of numerous physiologic processes, from gene expression to behaviour. The human circadian system is tightly and bidirectionally interconnected to the human stress system, as both systems regulate each other's activity along the anticipated diurnal challenges. The understanding of the temporal relationship between stressors and stress responses is critical in the molecular pathophysiology of stress-and trauma-related diseases, such as posttraumatic stress disorder (PTSD). Objectives/Methods: In this narrative review, we present the functional components of the stress and circadian system and their multilevel interactions and discuss how traumatic stress can affect the harmonious interplay between the two systems. Results: Circadian dysregulation after trauma exposure (posttraumatic chronodisruption) may represent a core feature of trauma-related disorders mediating enduring neurobiological correlates of traumatic stress through a loss of the temporal order at different organizational levels. Posttraumatic chronodisruption may, thus, affect fundamental properties of neuroendocrine, immune and autonomic systems, leading to a breakdown of biobehavioral adaptive mechanisms with increased stress sensitivity and vulnerability. Given that many traumatic events occur in the late evening or night hours, we also describe how the time of day of trauma exposure can differentially affect the stress system and, finally, discuss potential chronotherapeutic interventions. Conclusion: Understanding the stress-related mechanisms susceptible to chronodisruption and their role in PTSD could deliver new insights into stress pathophysiology, provide better psychochronobiological treatment alternatives and enhance preventive strategies in stress-exposed populations.

The Development of a Sleep Intervention for Firefighters: The FIT-IN (Firefighter's Therapy for Insomnia and Nightmares) Study

Background: Firefighters are vulnerable to irregular sleep patterns and sleep disturbance due to work characteristics such as shift work and frequent dispatch. However, there are few studies investigating intervention targeting sleep for firefighters. This preliminary study aimed to develop and test a sleep intervention, namely FIT-IN (Firefighter’s Therapy for Insomnia and Nightmares), which was based on existing evidence-based treatment tailored to firefighters in consideration of their occupational characteristics. Methods: This study implemented a single-group pre-post study design, utilizing an intervention developed based on brief behavior therapy for insomnia with imagery rehearsal therapy components. FIT-IN consisted of a total of three sessions (two face-to-face group sessions and one telephone session). Participants were recruited from Korean fire stations, and a total of 39 firefighters participated. Participants completed a sleep diary for two weeks, as well as the following questionnaires to assess their sleep and psychological factors: insomnia severity index (ISI), disturbing dream and nightmare severity index (DDNSI), Epworth sleepiness scale (ESS), depressive symptom inventory-suicidality subscale (DSI), and Patient Health Questionnaire-9 (PHQ-9). These questionnaires were administered before the first session and at the end of the second session. Results: The FIT-IN program produced improvements in sleep indices. There was a significant increase in sleep efficiency (p < 0.01), and a decrease in sleep onset latency, number of awakenings, and time in bed (p < 0.05), as derived from weekly sleep diaries. In addition, significant decreases were shown for insomnia (p < 0.001) and nightmare severity (p < 0.01). Conclusion: There were significant improvements in sleep and other clinical indices (depression, PTSD scores) when comparing pre-and post-intervention scores. FIT-IN may be a feasible and practical option in alleviating sleep disturbance in this population. Further studies will be needed to ascertain FIT-IN’s effectiveness.

Mediators of the association between COVID-19-related stressors and parents' psychological flexibility and inflexibility: The roles of perceived sleep quality and energy

Background

The COVID-19 pandemic has forced parents across the United States to quickly transition to a new way of living. These transitions present new stressors, including the stress associated with physical health, with the demands of social distancing placed on families, and with the possibility of losing a job or not being able to pay bills. Such stressors have the potential to disrupt basic functioning, such as sleep and daily energy levels. Furthermore, the impact of stress might have repercussions on parents' capacities to be psychologically flexible, thus putting their psychological functioning at risk. Drawing upon a contextual behavioral science perspective, the current study sought to examine links between COVID-19-related stressors and psychological flexibility/inflexibility through such basic processes as parents' perceived sleep quality and daily energy level.

Methods

A total of 1003 parents (97% from the US; 74% female; M = 40.9 years old, SD = 8.5) of children (ages 5-18) completed an online survey from the end of March to the end of April of 2020.

Results

Path analyses suggested that, after controlling health-related stress and the stress of work and parenting demands due to the pandemic directly predicting greater inflexibility and lower inflexibility, two mediation paths emerged. Specifically, higher levels of health-related stress were associated with lower levels of energy, which, in turn predicted lower levels of psychological flexibility. In addition, higher levels of health-related stress were associated with lower perceived sleep quality, which, in turn, was associated with higher levels of psychological inflexibility. In secondary analyses on the specific dimensions of flexibility and inflexibility, results suggested that lower energy levels indirectly linked health-related stress to lower levels of all 6 dimensions of flexibility and poorer sleep quality indirectly linked health-related stress to higher levels of self-as-content, fusion, and inaction.

Conclusions

The stressors associated with COVID-19 pandemic have the potential to disrupt parents' perceived sleep quality and daily energy levels, reducing their abilities to respond to difficult or challenging experiences in a flexible manner and instead promoting more reactive and inflexible responses.

Identifying Trajectories and Predictors of Response to Psychotherapy for Post-Traumatic Stress Disorder in Adults: A Systematic Review of Literature

OBJECTIVE

There exists considerable individual variability in the development and progression of pathological stress reactions after experiencing trauma, as well as in individuals' response to psychological interventions. Yet until recently, such individual differences had not been considered when evaluating the efficacy of therapeutic interventions for post-traumatic stress disorder (PTSD). This systematic review aims to examine the emerging literature on this subject and, specifically, to identify trajectories and predictors of psychotherapeutic response in adults with PTSD.

METHOD

Four databases were searched using specific keywords without date or language restrictions. For each study, independent reviewers systematically evaluated whether it met eligibility criteria and assessed risk of bias. For included studies, reviewers completed data extraction using standard formats. Those examining how subgroups of adults respond to therapy for clinical PTSD using trajectory modeling were deemed eligible. Demographic, PTSD, clinical, and trauma-related factors associated to particular trajectories were also examined.

RESULTS

Of the 1,727 papers identified, 11 were included in this analysis. Of these studies, six focused on military-related traumas and five on civilian ones. Although studies found between two and five trajectories, most supported a three-trajectory model of response categorized as responders, nonresponders, and subclinical participants. Over 22 predictors of treatment trajectories were examined. Comorbid depression, anxiety, and alcohol abuse were the strongest predictors of poor therapeutic response. Age, combat exposure, social support, and hyperarousal were moderate predictors.

CONCLUSION

This review provides valuable insight into the treatment of PTSD, as it supports the heterogeneous trajectories of psychotherapeutic responses and provides avenues for the development of interventions that consider individual-level factors in treatment response.

Mobile App Use for Insomnia Self-Management: Pilot Findings on Sleep Outcomes in Veterans

Background

Sleep disturbance is a major health concern among US veterans who have served since 2001 in a combat theater in Iraq or Afghanistan. We report subjective and objective sleep results from a pilot trial assessing self-management–guided use of a mobile app (CBT-i Coach, which is based on cognitive behavioral therapy for insomnia) as an intervention for insomnia in military veterans.

Objective

The primary aim of this study was to evaluate changes in subjective and objective sleep outcomes from pre to postintervention.

Methods

Subjective outcomes included the Insomnia Severity Index, the Pittsburgh Sleep Quality Inventory, and sleep-related functional status. A wearable sleep monitor (WatchPAT) measured objective sleep outcomes, including sleep efficiency, percent rapid eye movement (REM) during sleep, sleep time, and sleep apnea. A total of 38 participants were enrolled in the study, with 18 participants being withdrawn per the protocol because of moderate or severe sleep apnea and 9 others who dropped out or withdrew. Thus, 11 participants completed the full 6-week CBT-i Coach self-management intervention (ie, completers).

Results

Completer results indicated significant changes in subjective sleep measures, including reduced reports of insomnia (Z=–2.68, P=.007) from pre (mean 16.63, SD 5.55) to postintervention (mean 12.82, SD 3.74), improved sleep quality (Z=–2.37, P=.02) from pre (mean 12.82, SD 4.60) to postintervention (mean 10.73, SD 3.32), and sleep-related functioning (Z=2.675, P=.007) from pre (mean 13.86, SD 3.69) to postintervention (mean 15.379, SD 2.94). Among the objective measures, unexpectedly, objective sleep time significantly decreased from pre to postintervention (χ²₂=7.8, P=.02). There were no significant changes in percent REM sleep or sleep efficiency.

Conclusions

These findings suggest that the CBT-i Coach app can improve subjective sleep and that incorporating objective sleep measures into future, larger clinical trials or clinical practice may yield important information, particularly by detecting previously undetected sleep apnea.

Trial Registration

ClinicalTrials.gov NCT02392000; http://clinicaltrials.gov/ct2/show/NCT02392000

Sleep quality problems three decades post-disaster

STUDY OBJECTIVES

Sleep quality problems are a core feature of posttraumatic stress disorder (PTSD). The aims of this study were to describe and evaluate possible differences regarding sleep quality problems and hyperarousal symptoms between exposed and unexposed survivors after an avalanche. Further, we wanted to describe any association between avalanche exposure and survivors' self-reported sleep quality problems and posttraumatic stress (disorder) symptoms with and without hyperarousal symptoms.

METHOD

The participants were soldiers who had survived an avalanche (n = 12) and a sample of unexposed soldiers (n = 9). Subjective sleep quality problems and posttraumatic stress (disorder) symptoms were assessed using well-validated measures: Pittsburgh Sleep Quality Index (PSQI), Posttraumatic Symptom Scale-10 (PTSS-10), and Impact of Event Scale-15 (IES-15). Hyperarousal symptoms were assessed using a 3-item hyperarousal-index from PTSS-10 (PTSS-10/Hyp index).

RESULTS

No significant difference in sleep quality problems was revealed between the exposed and unexposed groups. There was a significant association between those with PTSS-10 ≥ 4 combined with hyperarousal symptoms and sleep quality problems (p = .046), 30 years after the avalanche. Likewise, no significant associations was revaled between those with sleep quality problems and IES-15 ≥ 26 with and without hyperarousal. Binary logistic regression showed that those with sleep quality problems (PSQI > 5) 30 years post-disaster, had 2.5 times greater odds (OR = 2.49, 95%CI [0.95-6.55], p = .064) of having hyperarousal symptoms during the whole follow-up period compared to those without sleep quality problems.

CONCLUSION

Our findings may indicate an association between sleep quality problems (PSQI > 5) and hyperarousal symptoms in soldiers with scores above cut-off point for posttraumatic stress (disorder) symptoms.

Multilevel Interactions of Stress and Circadian System: Implications for Traumatic Stress

The dramatic fluctuations in energy demands by the rhythmic succession of night and day on our planet has prompted a geophysical evolutionary need for biological temporal organization across phylogeny. The intrinsic circadian timing system (CS) represents a highly conserved and sophisticated internal "clock," adjusted to the 24-h rotation period of the earth, enabling a nyctohemeral coordination of numerous physiologic processes, from gene expression to behavior. The human CS is tightly and bidirectionally interconnected to the stress system (SS). Both systems are fundamental for survival and regulate each other's activity in order to prepare the organism for the anticipated cyclic challenges. Thereby, the understanding of the temporal relationship between stressors and stress responses is critical for the comprehension of the molecular basis of physiology and pathogenesis of disease. A critical loss of the harmonious timed order at different organizational levels may affect the fundamental properties of neuroendocrine, immune, and autonomic systems, leading to a breakdown of biobehavioral adaptative mechanisms with increased stress sensitivity and vulnerability. In this review, following an overview of the functional components of the SS and CS, we present their multilevel interactions and discuss how traumatic stress can alter the interplay between the two systems. Circadian dysregulation after traumatic stress exposure may represent a core feature of trauma-related disorders mediating enduring neurobiological correlates of trauma through maladaptive stress regulation. Understanding the mechanisms susceptible to circadian dysregulation and their role in stress-related disorders could provide new insights into disease mechanisms, advancing psychochronobiological treatment possibilities and preventive strategies in stress-exposed populations.

Effects of Social Defeat Stress on Sleep in Mice

Stress plays a key role in the development of psychiatric disorders and has a negative impact on sleep integrity. In mice, chronic social defeat stress (CSDS) is an ethologically valid model of stress-related disorders but little is known about its effects on sleep regulation. Here, we investigated the immediate and long-term effects of 10 consecutive days of social defeat (SD) on vigilance states in C57Bl/6J male mice. Social behavior was assessed to identify susceptible mice, i.e., mice that develop long-lasting social avoidance, and unsusceptible mice. Sleep-wake stages in mice of both groups were analyzed by means of polysomnographic recordings at baseline, after the first, third, and tenth stress sessions and on the 5th recovery day (R5) following the 10-day CSDS. In susceptible mice, each SD session produced biphasic changes in sleep-wake states that were preserved all along 10-day CSDS. These sessions elicited a short-term enhancement of wake time while rapid eye-movement (REM) sleep was strongly inhibited. Concomitantly, delta power was increased during non REM (NREM) sleep. During the following dark period, an increase in total sleep time, as well as wake fragmentation, were observed after each analyzed SD session. Similar changes were observed in unsusceptible mice. At R5, elevated high-frequency EEG activity, as observed in insomniacs, emerged during NREM sleep in both susceptible and unsusceptible groups suggesting that CSDS impaired sleep quality. Furthermore, susceptible but not unsusceptible mice displayed stress-anticipatory arousal during recovery, a common feature of anxiety disorders. Altogether, our findings show that CSDS has profound impacts on vigilance states and further support that sleep is tightly regulated by exposure to stressful events. They also revealed that susceptibility to chronic psychological stress is associated with heightened arousal, a physiological feature of stress vulnerability.

Emotion, emotion regulation and sleep: An intimate relationship

In recent years, research has witnessed an increasing interest in the bidirectional relationship between emotion and sleep. Sleep seems important for restoring daily functioning, whereas deprivation of sleep makes us more emotionally aroused and sensitive to stressful stimuli and events. Sleep appears to be essential to our ability to cope with emotional stress in everyday life. However, when daily stress is insufficiently regulated, it may result in mental health problems and sleep disturbances too. Not only does emotion impact sleep, but there is also evidence that sleep plays a key role in regulating emotion. Emotional events during waking hours affect sleep, and the quality and amount of sleep influences the way we react to these events impacting our general well-being. Although we know that daytime emotional stress affects sleep by influencing sleep physiology, dream patterns, dream content and the emotion within a dream, its exact role is still unclear. Other effects that have been found are the exaggeration of the startle response, decrease in dream recall and elevation of awakening thresholds from rapid eye movement (REM), REM-sleep, increased or decreased latency to REM-sleep, increase in percentage of REM-density, REM-sleep duration, as well as the occurrence of arousals in sleep as a marker of sleep disruption. Equally, the way an individual copes with emotional stress, or the way in which an individual regulates emotion may modulate the effects of emotional stress on sleep. The research presented here supports the idea that adaptive emotion regulation benefits our follow-up sleep. We thus conclude the current review with a call for future research in order to clarify further the precise relationship between sleep, emotion and emotion regulation, as well as to explain further how sleep dissolves our emotional stress.

Effects of Social Defeat Stress on Sleep in Mice

Stress plays a key role in the development of psychiatric disorders and has a negative impact on sleep integrity. In mice, chronic social defeat stress (CSDS) is an ethologically valid model of stress-related disorders but little is known about its effects on sleep regulation. Here, we investigated the immediate and long-term effects of 10 consecutive days of social defeat (SD) on vigilance states in C57Bl/6J male mice. Social behavior was assessed to identify susceptible mice, i.e., mice that develop long-lasting social avoidance, and unsusceptible mice. Sleep-wake stages in mice of both groups were analyzed by means of polysomnographic recordings at baseline, after the first, third, and tenth stress sessions and on the 5th recovery day (R5) following the 10-day CSDS. In susceptible mice, each SD session produced biphasic changes in sleep-wake states that were preserved all along 10-day CSDS. These sessions elicited a short-term enhancement of wake time while rapid eye-movement (REM) sleep was strongly inhibited. Concomitantly, delta power was increased during non REM (NREM) sleep. During the following dark period, an increase in total sleep time, as well as wake fragmentation, were observed after each analyzed SD session. Similar changes were observed in unsusceptible mice. At R5, elevated high-frequency EEG activity, as observed in insomniacs, emerged during NREM sleep in both susceptible and unsusceptible groups suggesting that CSDS impaired sleep quality. Furthermore, susceptible but not unsusceptible mice displayed stress-anticipatory arousal during recovery, a common feature of anxiety disorders. Altogether, our findings show that CSDS has profound impacts on vigilance states and further support that sleep is tightly regulated by exposure to stressful events. They also revealed that susceptibility to chronic psychological stress is associated with heightened arousal, a physiological feature of stress vulnerability.

Sleep Disorders Among Holocaust Survivors: A Review of Selected Publications

After World War II, traumatic after effects often caused persistent sleep disorders for Holocaust survivors (HSs). This is a review of studies reporting on sleep disturbances and nightmares (as primary or secondary outcomes) among HSs between 1939 and 2015, conducted in various countries and contexts (clinical settings, pension claims, community surveys, sleep laboratories). Most studies revealed various sleep disturbances among HSs. Some studies found those disturbances in the absence of clinical disorders. Both men and women reported similar frequencies of sleep disturbances, although posttraumatic stress disorder and depression were more frequent in women. Sleep laboratory studies provided the single most direct and detailed sources of information. Findings included a) long-standing changes in sleep architecture, for example, decreased rapid eye movement (REM) sleep, and b) contrasting patterns of dreaming and recall among better versus poorly adjusted survivors. These results are of importance to both HSs and their families and for medical and mental health professionals.

Why did adolescents have sleep problems after earthquakes? Understanding the role of traumatic exposure, fear, and PTSD

To examine the relationships between trauma exposure, fear, post-traumatic stress disorder, and sleep problems in adolescents, 746 adolescent survivors of the 2008 Wenchuan earthquake in China were assessed at 1 year (T1) and 1.5 years (T2) after the earthquake using a trauma exposure questionnaire, a fear questionnaire, a child posttraumatic stress disorder symptom scale, and a subscale on child sleep problems. The results showed that T1 trauma exposure were not directly associated with sleep problems at T1 and T2, but played a positive role in sleep problems at both T1 and T2 indirectly through T1 posttraumatic stress disorder and T1 fear. T1 trauma exposure was also positively and indirectly associated with T2 sleep problems through T1 posttraumatic stress disorder via T1 sleep problems, or through T1 fear via the path from T1 posttraumatic stress disorder to T1 sleep problems. These findings indicated that fear and posttraumatic stress disorder 1 year after the earthquake played a mediating role in the relationship between trauma exposure at 1 year after the earthquake, and sleep problems at both 1 year and 1.5 years after the earthquake, respectively. In particular, posttraumatic stress disorder also had a multiple mediating effect in the path from trauma exposure to sleep problems via fear. Furthermore, the findings indicated that sleep problems were relatively stable between 1 and 1.5 years after an earthquake.