Posttraumatic stress disorder increases the odds of REM sleep behavior disorder and other parasomnias in Veterans with and without comorbid traumatic brain injury

REM sleep behaviour disorder (RBD): Personal perspectives and research priorities

The formal identification and naming of rapid eye movement (REM) sleep behaviour disorder (RBD) in 1985-1987 is described; the historical background of RBD from 1966 to 1985 is briefly discussed; and RBD milestones are presented. Current knowledge on RBD is identified with reference to recent comprehensive reviews, allowing for a focus on research priorities for RBD: factors and predictors of neurodegenerative phenoconversion from isolated RBD and patient enrolment in neuroprotective trials; isolated RBD clinical research cohorts; epidemiology of RBD; traumatic brain injury, post-traumatic stress disorder, RBD and neurodegeneration; depression, RBD and synucleinopathy; evolution of prodromal RBD to neurodegeneration; gut microbiome dysbiosis and colonic synuclein histopathology in isolated RBD; other alpha-synuclein research in isolated RBD; narcolepsy-RBD; dreams and nightmares in RBD; phasic REM sleep in isolated RBD; RBD, periodic limb movements, periodic limb movement disorder pseudo-RBD; other neurophysiology research in RBD; cardiac scintigraphy (123I-MIBG) in isolated RBD; brain magnetic resonance imaging biomarkers in isolated RBD; microRNAs as biomarkers in isolated RBD; actigraphic, other automated digital monitoring and machine learning research in RBD; prognostic counselling and ethical considerations in isolated RBD; and REM sleep basic science research. RBD research is flourishing, and is strategically situated at an ever-expanding crossroads of clinical (sleep) medicine, neurology, psychiatry and neuroscience.

Rates and Predictors of Rapid Eye Movement Sleep Behavior Disorder Symptoms Among Post-9/11 Veterans

OBJECTIVE

Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), which are prevalent conditions among post-9/11 veterans, increase risks of rapid eye movement (REM) sleep behavior disorder (RBD) and degenerative synucleinopathy. Rates and predictors of RBD symptoms were investigated by screening post-9/11 veterans for RBD with a validated questionnaire.

METHODS

In this cross-sectional analysis, consecutive patients in the Houston Translational Research Center for TBI and Stress Disorders (TRACTS) were screened with the English translation of the RBD Questionnaire-Hong Kong (RBDQ-HK). In addition to data from the standard TRACTS battery, systematic chart review was used to identify known sleep disorders mimicking or manifesting RBD.

RESULTS

Of the 119 patients with available RBDQ-HK scores, 71 (60%) and 65 (55%) screened positive for RBD, when a total score ≥21 and a factor 2 score ≥8 were used as cutoff scores, respectively. Univariable analyses with both cutoffs showed consistent associations between a positive RBDQ-HK screen and global sleep quality, number of TBI exposures, and PTSD severity. Multivariable logistic regression with total score ≥21 as a cutoff indicated that PTSD severity (odds ratio=1.06, 95% CI=1.02-1.10) and number of TBIs (odds ratio=1.63, 95% CI=1.16-2.41) were independent predictors of a positive screen, whereas global sleep quality was no longer significant. Multivariable logistic regression with factor 2 score ≥8 as a cutoff showed similar results.

CONCLUSIONS

Interdisciplinary parasomnia assessment, further validation of RBD screens, and standardized reporting of REM sleep without atonia could provide necessary information on the pathophysiological relationships linking PTSD, TBI, RBD symptoms, and ultimately synucleinopathy risk among post-9/11 veterans.

Secondary RBD: Not just neurodegeneration

Rapid eye movement sleep behavior disorder is a parasomnia characterized by excessive muscle activity during rapid eye movement sleep (rapid eye movement sleep without atonia), along with dream enactment behavior. Isolated rapid eye movement sleep behavior disorder tends to occur in older males and is of concern due to the known link to Parkinson's disease and other synucleinopathies. When rapid eye movement sleep behavior disorder occurs in association with other neurological or general medical conditions, or resulting from the use of various substances, it is called secondary rapid eye movement sleep behavior disorder; the most common cause is neurodegenerative illness, specifically the synucleinopathies. Here, the focus will be on the subset of secondary rapid eye movement sleep behavior disorder in which there is no neurodegenerative disease.

Trauma-Associated Sleep Disorder

Trauma-associated sleep disorder (TASD) is a recently described parasomnia that develops following a traumatic event. It consists of trauma-related nightmares, disruptive nocturnal behaviors, and autonomic disturbances, and shares similarities with post-traumatic stress disorder and rapid eye movement behavior disorder. The underlying pathophysiology of TASD and how it relates to other parasomnias are still not entirely understood; proposed treatment is similarly nebulous, with prazosin at the forefront along with management of comorbid sleep disorders. The purpose of this article is to characterize and highlight the clinical features of this condition.

Comorbid neurotrauma increases neurodegenerative-relevant cognitive, motor, and autonomic dysfunction in patients with REM sleep behavior disorder: A substudy of the North American Prodromal Synucleinopathy Consortium

STUDY OBJECTIVES

Rapid eye movement (REM) sleep behavior disorder (RBD) is strongly associated with phenoconversion to an overt synucleinopathy, e.g., Parkinson's disease (PD), Lewy Body Dementia (LBD), and related disorders. Comorbid traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) - henceforth "neurotrauma" (NT) - increase the odds of RBD by ~2.5-fold and is associated with an increased rate of service-connected PD in Veterans. Thus, RBD and NT are both independently associated with PD; however, it is unclear how NT influences neurological function in patients with RBD.

METHODS

Participants ≥18 years with overnight-polysomnogram-confirmed RBD were enrolled between 8/2018 to 4/2021 through the North American Prodromal Synucleinopathy (NAPS) Consortium. Standardized assessments for RBD, TBI, and PTSD history, as well as cognitive, motor, sensory and autonomic function were completed. This cross-sectional analysis compared cases (n=24; RBD+NT) to controls (n=96; RBD), matched for age (~60 years), sex (15% female), and years of education (~15 years).

RESULTS

RBD+NT reported earlier RBD symptom onset (37.5±11.9 vs. 52.2±15.1 years of age) and a more severe RBD phenotype. Similarly, RBD+NT reported more severe anxiety and depression, greater frequency of hypertension, and significantly worse cognitive, motor, and autonomic function compared to RBD. No differences in olfaction or color vision were observed.

CONCLUSION

This cross-sectional, matched case:control study shows individuals with RBD+NT have significantly worse neurological measures related to common features of an overt synucleinopathy. Confirmatory longitudinal studies are ongoing; however, these results suggest RBD+NT may be associated with more advanced neurological symptoms related to an evolving neurodegenerative process.

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.

Post-Traumatic Stress Disorder and Risk of Degenerative Synucleinopathies: Systematic Review and Meta-Analysis

OBJECTIVE

A systematic review was conducted to answer whether adult-onset post-traumatic stress disorder (PTSD) is associated with increased risk of Parkinson's disease (PD) and related synucleinopathies.

DESIGN

A systematic search of Medline (Ovid), Embase (Elsevier), PsycInfo (Ovid), Cochrane Library (Wiley), and Web of Science (Clarivate) was performed using MeSH headings and equivalent terms for PTSD, PD, DLB, and related disorders.

SETTING

No restrictions.

PARTICIPANTS

Eligible articles were published in peer-reviewed journals, sampled adult human populations, and treated PTSD and degenerative synucleinopathies as exposures and outcomes, respectively.

MEASUREMENTS

Extracted data included diagnostic methods, sample characteristics, matching procedures, covariates, and effect estimates. Bias assessment was performed with the Newcastle-Ottawa scale. Hazard ratios were pooled using the random effects model, and the Hartung-Knapp adjustment was applied due to the small number of studies.

RESULTS

A total of six articles comprising seven unique samples (total n = 1,747,378) met eligibility criteria. The risk of PD was reported in three retrospective cohort studies and one case-control study. Risk of DLB was reported in one retrospective cohort, one case-control, and one prospective cohort study. No studies addressed potential relationships with multiple system atrophy or pure autonomic failure. Meta-analysis of hazard ratios from four retrospective cohort studies supported the hypothesis that incident PTSD was associated with PD and DLB risk (pooled HR 1.88, 95% C.I. 1.08-3.24; p = 0.035).

CONCLUSIONS

The sparse literature to-date supports further investigations on the association of mid- to late-life PTSD with Parkinson's and related neurodegenerative disorders.

Probable Parasomnias and Mortality: A Prospective Study in US Men

OBJECTIVE

To examine the association between parasomnias, including rapid eye movement sleep behavior disorder (RBD) and sleep walking (SW), and mortality risk in a large-scale population-based cohort.

METHODS

This prospective cohort study was based on 25,695 participants from the Health Professionals Follow-up Study, a population-based cohort of male health professionals in the United States. Probable SW (pSW) and probable RBD (pRBD) were measured by questions adapted from the Mayo Sleep Questionnaire in 2012. All-cause mortality and cause-specific mortality were ascertained through the national registry, reports by the families, and the postal system from January 1, 2012, through June 30, 2018.

RESULTS

Of the studied population, 223 reported pSW and 2720 reported pRBD. During 6 years of follow-up (2012 to 2018), 4743 mortality cases were documented. The co-occurrence of both probable parasomnias was associated with higher all-cause mortality risk (Ptrend=.008), and the adjusted hazard ratio (HR) of mortality was 1.65 (95% CI, 1.20 to 2.28) compared with participants without either probable parasomnia after adjustment for major lifestyle, sleep, and metabolic risk factors, and chronic diseases. Significant associations were found for mortality attributed to neurodegenerative diseases (adjusted HR for both parasomnias vs none, 4.57; 95% CI, 2.62 to 7.97) and accidents (adjusted HR for both parasomnias vs none, 7.36; 95% CI, 2.95 to 18.4). Having pSW alone was associated with all-cause mortality, and pSW and pRBD were individually associated with mortality attributed to neurodegenerative diseases and accidents too (P<.05 for all).

CONCLUSION

Probable parasomnia was associated with a higher risk of all-cause mortality and mortality attributed to neurodegenerative diseases and accidents.

Lifelong Association of Disorders Related to Military Trauma with Subsequent Parkinson's Disease

BACKGROUND

Trauma-related disorders such as traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) are emerging as risk factors for Parkinson's disease (PD), but their association with development of PD and independence from comorbid disorders remains unknown.

OBJECTIVE

To examine TBI and PTSD related to early trauma in military veterans using a case-control study.

METHODS

PD was identified by International Classification of Diseases (ICD) code, recurrent PD-specific prescriptions, and availability of 5+ years of earlier records. Validation was performed by chart review by a movement disorder-trained neurologist. Control subjects were matched 4:1 by age, duration of preceding health care, race, ethnicity, birth year, and sex. TBI and PTSD were identified by ICD code and onset based on active duty. Association and interaction were measured for TBI and PTSD with PD going back 60 years. Interaction was measured for comorbid disorders.

RESULTS

A total of 71,933 cases and 287,732 controls were identified. TBI and PTSD increased odds of subsequent PD at all preceding 5-year intervals back to year -60 (odds ratio range: 1.5 [1.4, 1.7] to 2.1 [2.0, 2.1]). TBI and PTSD showed synergism (synergy index range: 1.14 [1.09, 1.29] to 1.28 [1.09, 1.51]) and additive association (odds ratio range: 2.2 [1.6, 2.8] to 2.7 [2.5, 2.8]). Chronic pain and migraine showed greatest synergy with PTSD and TBI. Effect sizes for trauma-related disorders were comparable with established prodromal disorders.

CONCLUSIONS

TBI and PTSD are associated with later PD and are synergistic with chronic pain and migraine. These findings provide evidence for TBI and PTSD as risk factors preceding PD by decades and could aid in prognostic calculation and earlier intervention. © 2023 International Parkinson and Movement Disorder Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

REM Sleep Behavior Disorder and Other REM Parasomnias

OBJECTIVE

This article reviews rapid eye movement (REM) sleep behavior disorder (RBD) and other REM sleep parasomnias, particularly recurrent isolated sleep paralysis and nightmare disorder.

LATEST DEVELOPMENTS

People with RBD have dream enactment behaviors that can be distressing and cause injuries to themselves or a bed partner. Diagnosis of RBD still requires video polysomnography but new evaluative techniques are emerging. Automatic scoring of REM sleep without atonia, the polysomnographic RBD feature, has led to clearer diagnostic cutoff values. Isolated RBD is strongly linked with neurodegenerative disorders, particularly α-synucleinopathies, with a median latency to neurodegenerative disease diagnosis of 8 years. Mounting imaging, electrophysiologic, and pathologic evidence supports neurodegenerative changes in patients with isolated RBD. Safety precautions should be reviewed with patients to reduce the risk of injury. Clonazepam and melatonin are first-line agents for RBD symptoms, and rivastigmine appears to be beneficial for RBD in people with mild cognitive impairment. For nightmare disorder, image rehearsal therapy is effective and can be delivered through online platforms.

ESSENTIAL POINTS

While RBD symptoms can often be managed, patients with isolated RBD should be monitored for signs and symptoms of impending neurodegenerative disease. Individuals who wish to know about the associated risk should be counseled accordingly to allow planning and involvement in research if they choose. Exercise may have some neuroprotective effects, although no treatment has been shown to modify the neurodegenerative risk.

Screening and Targeting Risk Factors for Prodromal Synucleinopathy: Taking Steps toward a Prescriptive Multi-modal Framework

As the prevalence of Parkinson's disease (PD) grows, so too does the population at-risk of developing PD, those in the so-called prodromal period. This period can span from those experiencing subtle motor deficits yet not meeting full diagnostic criteria or those with physiologic markers of disease alone. Several disease-modifying therapies have failed to show a neuroprotective effect. A common criticism is that neurodegeneration, even in the early motor stages, has advanced too far for neuro-restoration-based interventions to be effective. Therefore, identifying this early population is essential. Once identified, these patients could then potentially benefit from sweeping lifestyle modifications to alter their disease trajectory. Herein, we review the literature on risk factors for, and prodromal symptoms of, PD with an emphasis on ones which may be modifiable in the earliest possible stages. We propose a process for identifying this population and speculate on some strategies which may modulate disease trajectory. Ultimately, this proposal warrants prospective studies.

Biomarkers of Neurodegeneration in Post-Traumatic Stress Disorder: An Integrative Review

Post-Traumatic Stress Disorder (PTSD) is a chronic psychiatric disorder that occurs following exposure to traumatic events. Recent evidence suggests that PTSD may be a risk factor for the development of subsequent neurodegenerative disorders, including Alzheimer's dementia and Parkinson's disease. Identification of biomarkers known to be associated with neurodegeneration in patients with PTSD would shed light on the pathophysiological mechanisms linking these disorders and would also help in the development of preventive strategies for neurodegenerative disorders in PTSD. With this background, the PubMed and Scopus databases were searched for studies designed to identify biomarkers that could be associated with an increased risk of neurodegenerative disorders in patients with PTSD. Out of a total of 342 citations retrieved, 29 studies were identified for inclusion in the review. The results of these studies suggest that biomarkers such as cerebral cortical thinning, disrupted white matter integrity, specific genetic polymorphisms, immune-inflammatory alterations, vitamin D deficiency, metabolic syndrome, and objectively documented parasomnias are significantly associated with PTSD and may predict an increased risk of subsequent neurodegenerative disorders. The biological mechanisms underlying these changes, and the interactions between them, are also explored. Though requiring replication, these findings highlight a number of biological pathways that plausibly link PTSD with neurodegenerative disorders and suggest potentially valuable avenues for prevention and early intervention.

Louis EK, Forsberg LK, Fields JA, Huddleston DE, Bliwise DL, Avidan AY, Howell MJ, Schenck CH, McLeland J, Criswell SR, Videnovic A, During EH, Miglis MG, Shprecher DR, Lee‐Iannotti JK, Boeve BF, Ju YS. Baseline characteristics of the North American prodromal Synucleinopathy cohort

OBJECTIVE

Rapid eye movement (REM) sleep behavior disorder (RBD) is widely considered a prodromal synucleinopathy, as most with RBD develop overt synucleinopathy within ~10 years. Accordingly, RBD offers an opportunity to test potential treatments at the earliest stages of synucleinopathy. The North American Prodromal Synucleinopathy (NAPS) Consortium has created a multisite RBD participant, primarily clinic-based cohort to better understand characteristics at diagnosis, and in future work, identify predictors of phenoconversion, develop synucleinopathy biomarkers, and enable early stage clinical trial enrollment.

METHODS

Participants ≥18 years of age with overnight polysomnogram-confirmed RBD without Parkinson's disease, dementia, multiple system atrophy, or narcolepsy were enrolled from nine sites across North America (8/2018 to 4/2021). Data collection included family/personal history of RBD and standardized assessments of cognitive, motor, sensory, and autonomic function.

RESULTS

Outcomes are primarily reported based on sex (361 total: n = 295 male, n = 66 female), and secondarily based on history of antidepressant use (n = 200 with, n = 154 without; with correction for sex differences) and based on extent of synucleinopathy burden (n = 56 defined as isolated RBD, n = 305 defined as RBD+ [i.e., exhibiting ≥1 abnormality]). Overall, these participants commonly demonstrated abnormalities in global cognition (MoCA; 38%), motor function (alternate tap test; 48%), sensory (BSIT; 57%), autonomic function (orthostatic hypotension, 38.8%), and anxiety/depression (BAI and PHQ-9; 39.3% and 31%, respectively).

INTERPRETATION

These RBD participants, assessed with extensive history, demographic, cognitive, motor, sensory, and autonomic function demonstrated a lack of sex differences and high frequency of concomitant neurological abnormalities. These participants will be valuable for future longitudinal study and neuroprotective clinical trials.

Challenges in the study of individuals at risk for Parkinson disease

Identifying individuals at high risk for developing neurodegenerative disease opens the possibility of conducting clinical trials that intervene at an earlier stage of neurodegeneration than has been possible to date, and in doing so hopefully improves the odds of efficacy for interventions aimed at slowing or stopping the disease process. The long prodromal phase of Parkinson disease presents opportunities and challenges to establishing cohorts of at-risk individuals. Recruiting people with genetic variants conferring increased risk and people with REM sleep behavior disorder currently constitutes the most promising strategies, but multistage screening of the general population may also be feasible capitalizing on known risk factors and prodromal features. This chapter discusses the challenges involved in identifying, recruiting, and retaining these individuals, and provides insights into possible solutions using examples from studies to date.

Sleep impairments in refugees diagnosed with post-traumatic stress disorder: a polysomnographic and self-report study

Background: Post-traumatic stress disorder (PTSD) is the clinical manifestation of traumatic events and is associated with sleep disturbances. Sleep disturbances, if left untreated, may perpetuate or even worsen symptoms of PTSD. Previous studies of other PTSD populations show a higher incidence of sleep impairments and sleep disorders compared to healthy controls (HCs); however, this has never been investigated in trauma-affected refugees diagnosed with PTSD.Objectives: To examine subjective sleep quality, measure sleep architecture, and identify latent sleep disorders in refugees diagnosed with PTSD compared to HCs.Method: This comparative study included 20 trauma-affected refugees diagnosed with PTSD and 20 HC matched on age, sex, and body mass index. All participants completed self-report questionnaires assessing sleep quality, insomnia severity, and disturbing nocturnal behaviour, and all took part in a one-night polysomnography (PSG) assessment.Results: Patients reported significantly poorer subjective sleep quality, sleep latency, sleep duration, and sleep efficiency compared to HCs. Subjective reports on hours spent in bed were not significantly different between patients and HCs. Patients reported significantly higher nightmare frequency and severity compared to HCs. PSG measures showed that patients had significantly reduced sleep efficiency, more awakenings, and longer REM sleep latency, and spent more time awake, whereas there was no significant differences regarding total time in bed, total sleep time, or sleep latency. The prevalence of sleep disorders was equal between groups.Conclusions: The study identified significant impairments in several sleep domains, with a preponderance of disturbed regulation of sleep resulting in awakenings. These results indicate a need for more focus on hyperarousal and nightmares as key elements of disturbed sleep in PTSD. Furthermore, the study identified a discrepancy between subjective and objective measures concerning total sleep time, raising questions regarding the causes of 'sleep state misperception'.Trial registration: ClinicalTrials.gov identifier: NCT03535636..Trial registration: Sleep Impairments in Refugees Diagnosed with PTSD (PSG-PTSD). URL: https://clinicaltrials.gov/ct2/show/NCT03535636. ClinicalTrials.gov NCT03535636. Date of registration: 24/05/2018.

Clinical and polysomnographic features of trauma associated sleep disorder

STUDY OBJECTIVES

Trauma associated sleep disorder is a proposed parasomnia that develops after trauma with clinical features of trauma related nightmares, disruptive nocturnal behaviors, and autonomic disturbances. The purpose of this case series is to better characterize the clinical and video-polysomnographic features of patients meeting clinical criteria for this proposed parasomnia.

METHODS

Semistructured clinical interview and detailed video-polysomnography review of 40 patients. Movements and vocalizations in rapid eye movement sleep were quantified according to the rapid eye movement sleep behavior disorder severity scale.

RESULTS

Patients (n = 40, 32 males) were service members and veterans with a median age of 38.9 years (range 24-57 years) who reported trauma related nightmares and disruptive nocturnal behaviors at home. On video-polysomnography, 28 (71.8%) patients had disruptive nocturnal behaviors in rapid eye movement sleep consisting of limb, head, and axial movements; vocalizations were present in 8 (20%). On the rapid eye movement sleep behavior disorder severity scale, most (n = 28, 71.8%) had a low rating but those with greater severity (n = 11, 28.2%) had a higher prevalence of posttraumatic stress disorder (P = .013) and markedly less N3 sleep (P = .002). The cohort had a high rate of insomnia (n = 35, 87.5%) and obstructive sleep apnea (n = 19, 47.5%). Most patients were treated with prazosin (n = 29, 72.5%) with concomitant behavioral health interventions (n = 25, 64.1%); 15 (51.7%) patients receiving prazosin reported improved symptomatology.

CONCLUSIONS

Disruptive nocturnal behaviors can be captured on video-polysomnography during rapid eye movement sleep, although they may be less pronounced than what patients report in their habitual sleeping environment. Clinical and video-polysomnographic correlations are invaluable in assessing patients with trauma associated sleep disorder to document objective abnormalities. This case series provides a further basis for establishing trauma associated sleep disorder as a unique parasomnia.

CITATION

Brock MS, Matsangas P, Creamer JL, et al. Clinical and polysomnographic features of trauma associated sleep disorder. J Clin Sleep Med. 2022;18(12):2775-2784.

The bi-directional relationship between post-traumatic stress disorder and obstructive sleep apnea and/or insomnia in a large U.S. military cohort

OBJECTIVES

Determine if a bi-directional relationship exists between the development of sleep disorders (obstructive sleep apnea [OSA] and/or insomnia) and existing post-traumatic stress disorder (PTSD), and vice versa; and examine military-related factors associated with these potential relationships.

DESIGN

Longitudinal analyses of a prospective representative U.S. military cohort.

PARTICIPANTS

Millennium Cohort Study responders in 2011-2013 (Time 1 [T1]) and 2014-2016 (Time 2 [T2]) without insomnia or OSA at T1 (N = 65,915) or without PTSD at T1 (N = 71,256).

MEASUREMENTS

Provider-diagnosed OSA, self-reported items for insomnia, provider-diagnosed PTSD, and current PTSD symptoms were assessed at T1 and T2. Adjusted multivariable models identified military-related factors associated with new-onset PTSD in those with OSA and/or insomnia, and vice versa.

RESULTS

Self-reported history of provider-diagnosed PTSD without current symptoms at T1 was associated with new-onset OSA only and comorbid OSA/insomnia at T2, while current PTSD symptoms and/or diagnosis was associated with new-onset insomnia only. OSA/insomnia at T1 was consistently associated with newly reported PTSD symptoms or diagnosis except that insomnia only was not associated with newly reported provider-diagnosed PTSD. Military-related risk factors significantly associated with the bi-directional relationship for new-onset PTSD or OSA/insomnia included prior deployment with higher combat exposure and recent separation from the military; being an officer was protective for both outcomes.

CONCLUSIONS

In this large military cohort, findings suggest that PTSD and OSA and/or insomnia are bi-directionally predictive for their development, which was sometimes revealed by health care utilization. Relevant military-related risk factors should be considered in efforts to prevent or treat PTSD and/or sleep disorders.

Risk factors for rapid eye-movement sleep-related behavioral disorders (RBDs): A systematic review and a meta-analysis

OBJECTIVE

The present study aimed to systematically analyze the risk factors for RBD.

METHODS

A systematic review and meta-analysis of case-control studies, cohort studies, and cross-sectional studies derived from the articles published in eight electronic databases before December 1, 2021. The primary outcome was the odds ratio (OR) and 95% confidence interval (95% CI), and heterogeneity was quantified using I². Subgroup analyses and meta-regression were used to explore sources of heterogeneity. Egger's test and sensitivity analysis were performed. The PROSPERO ID number of the present study is CRD42021293942.

RESULTS

We identified 26 studies (44,230 subjects) among 2022 citations, and 13 factors were considered. Male sex (OR = 1.36, 95% CI = 1.13-1.64), smoking (OR = 1.37, 95% CI: 1.26-1.50), depression (OR = 2.06, 95% CI = 1.66-2.56), antidepressant use (OR = 2.36, 95% CI = 1.98-2.82), duration of neuropsychiatric disorders(OR = 1.43, 95% CI = 1.13-1.73), levodopa equivalent daily dose (LEDD, OR = 60.15, 95% CI = 23.95-96.35) and observable motor dysfunction (OR = 2.43, 95% CI = 0.65-4.22) were associated with a higher risk of RBD. Tertiary education and above (OR = 0.58, 95% CI = 0.35-0.96) was associated with a lower RBD risk. Men (OR = 1.40, 95% CI: 1.10-1.78, I² = 0%, P = 0.005) and older individual (OR = 2.73, 95% CI: 1.03-4.43, I² = 60%, P = 0.002) were more likely to have iRBD.

CONCLUSION

Six modifiable risk factors and one protective factor were associated with RBD. Further research is required to understand the mechanisms and to develop preventative strategies.

Sleep medicine: Practice, challenges and new frontiers

Sleep medicine is an ambitious cross-disciplinary challenge, requiring the mutual integration between complementary specialists in order to build a solid framework. Although knowledge in the sleep field is growing impressively thanks to technical and brain imaging support and through detailed clinic-epidemiologic observations, several topics are still dominated by outdated paradigms. In this review we explore the main novelties and gaps in the field of sleep medicine, assess the commonest sleep disturbances, provide advices for routine clinical practice and offer alternative insights and perspectives on the future of sleep research.

REM sleep behavior disorder as a complex condition with heterogeneous underlying disorders: clinical management and prognostic implications [Commentary]

PURPOSE

To review how REM sleep behavior disorder (RBD) is a complex condition with heterogeneous underlying disorders; and to review clinical management issues and prognostic implications.

METHODS

PubMed literature search and contents from the first textbook of RBD (2018).

RESULTS

RBD, with its core objective diagnostic feature of REM-without-atonia (RWA) documented by video-polysomnography, can emerge during the entire lifespan, and can initially present as an idiopathic (isolated) condition (iRBD), or can be associated with a broad spectrum of disorders including narcolepsy, alpha-synuclein neurodegenerative disorders (esp. Parkinson's disease [PD] and dementia with Lewy bodies [DLB]), paraneoplastic neurological syndromes and autoimmune disorders, CNS lesions (e.g., tumors, stroke), other neurological disorders, psychiatric disorders (PTSD, mood disorders), can be triggered by antidepressant/other medications, and can emerge acutely with drug withdrawal states, toxic-metabolic states, etc. Important clinical issues include the evolution of iRBD to PD/DLB in most middle-aged and older patients over a period of years to several decades, with compelling prognostic implications, along with the hope of enrolling these patients in future clinical trials to test promising disease-modifying therapies. Also, the strong link of RBD with narcolepsy needs further investigation. Parasomnia overlap disorder involves RBD and NREM parasomnias that can be idiopathic or linked with a broad range of clinical disorders. RBD usually responds to therapy consisting mainly of melatonin and/or clonazepam at bedtime. The complex associations of RBD with OSA are being increasingly investigated. RBD mimics with dream-enactment need to be recognized for diagnostic and management purposes, including severe OSA, NREM parasomnias, PLMD, nocturnal seizures, and other conditions.

CONCLUSIONS

The clinical and research RBD fields span across the disciplines of neurology, pulmonary, psychiatry, psychology, and pediatric sleep medicine, along with physical medicine and rehabilitation medicine, other allied disciplines, and the basic and clinical neurosciences.

The association of polysomnographic sleep on posttraumatic stress disorder symptom clusters in trauma-exposed civilians and veterans

Study Objectives

Self-reported sleep disturbance has been established as a risk factor and predictor for posttraumatic stress disorder (PTSD); however, less is known about the relationship between objective sleep and PTSD symptom clusters, and the specific role of hyperarousal. The present study examined the relationships between sleep continuity and architecture on PTSD symptom clusters.

Methods

Participants underwent two in-laboratory sleep studies to assess sleep continuity and architecture. They also completed the Clinician-Administered PTSD-IV scale and the Structured Clinical Interview for the DSM-IV to assess for PTSD diagnosis and other psychiatric disorders.

Results

Sleep continuity (i.e. total sleep time, sleep efficiency percent, wake after sleep onset, sleep latency) was significantly related to PTSD Cluster B (reexperiencing) symptom severity (R ² = .27, p < .001). Sleep architecture, specifically Stage N1 sleep, was significantly associated with PTSD Cluster B (t = 2.98, p = .004), C (Avoidance; t = 3.11, p = .003), and D (Hyperarosual; t = 3.79, p < .001) symptom severity independently of Stages N2, N3, and REM sleep. REM sleep variables (i.e. REM latency, number of REM periods) significantly predicted Cluster D symptoms (R ² = .17, p = .002).

Conclusions

These data provide evidence for a relationship between objective sleep and PTSD clusters, showing that processes active during Stage N1 sleep may contribute to PTSD symptomatology in civilians and veterans. Further, these data suggest that arousal mechanisms active during REM sleep may also contribute to PTSD hyperarousal symptoms.This paper is part of the War, Trauma, and Sleep Across the Lifespan Collection. This collection is sponsored by the Sleep Research Society.

Patient-reported sleep outcomes in randomized-controlled trials in persons with substance use disorders: A systematic review

BACKGROUND

Sleep disturbances and disorders are a common and sometimes recalcitrant problem in persons recovering from substance use disorders (SUDs). As such, several randomized-controlled trials (RCTs) have been conducted to address sleep disturbances in a variety of SUD subpopulations and clinical scenarios. The goal of this systematic review was to collate patient-reported sleep outcomes used in past SUD-related RCTs to provide guidance for future sleep research in persons with SUDs.

METHODS

This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on May 7th, 2020 (CRD42020182004). Studies were included if they were peer-reviewed manuscripts describing RCTs in an SUD population.

RESULTS

The initial search yielded 13,403 candidate articles, and 76 met a priori criteria and were included in this review. Thirty-five (46.1%) assessed sleep as a primary outcome (i.e., sleep improvement was the primary goal of the research) and 41 (53.9%) assessed sleep as a secondary outcome (i.e., sleep improvement was an important outcome, but not the primary outcome). The most commonly used measures included the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, and sleep diaries. However, multiple additional sleep assessments were also used, including visual analogue and Likert scales.

CONCLUSIONS

The field of addiction medicine would benefit from a streamlined approach in assessing patient-reported sleep in RCTs, including commonly used and validated assessments of sleep quality, inserting daily or repeated measures into RCTs, and including questionnaires that assess clinically relevant insomnia or other sleep disorders.

Dream Enactment Behaviors Associated With Posttraumatic Stress Disorder

The investigators aimed to draw attention to current debates surrounding the etiologies of dream enactment behaviors in patients with posttraumatic stress disorder (PTSD). The phenomenological overlap between PTSD-related nocturnal symptoms, rapid eye movement sleep behavior disorder (RBD), and trauma-associated sleep disorder (TASD) is discussed. Strategies used to diagnose and manage dream enactment behaviors, whether due to RBD or another confounding sleep disorder, are considered. Finally, the need for further research on the pathophysiological overlap and integrated treatment of PTSD, RBD, and, possibly, TASD is highlighted.

Dietary Supplementation With Branched Chain Amino Acids to Improve Sleep in Veterans With Traumatic Brain Injury: A Randomized Double-Blind Placebo-Controlled Pilot and Feasibility Trial

Study Objectives

Traumatic brain injury (TBI) is associated with chronic sleep disturbances and cognitive impairment. Our prior preclinical work demonstrated dietary supplementation with branched chain amino acids (BCAA: leucine, isoleucine, and valine), precursors to de novo glutamate production, restored impairments in glutamate, orexin/hypocretin neurons, sleep, and memory in rodent models of TBI. This pilot study assessed the feasibility and preliminary efficacy of dietary supplementation with BCAA on sleep and cognition in Veterans with TBI.

Methods

Thirty-two Veterans with TBI were prospectively enrolled in a randomized, double-blinded, placebo-controlled trial comparing BCAA (30 g, b.i.d. for 21-days) with one of two placebo arms (microcrystalline cellulose or rice protein, both 30 g, b.i.d. for 21-days). Pre- and post-intervention outcomes included sleep measures (questionnaires, daily sleep/study diaries, and wrist actigraphy), neuropsychological testing, and blood-based biomarkers related to BCAA consumption.

Results

Six subjects withdrew from the study (2/group), leaving 26 remaining subjects who were highly adherent to the protocol (BCAA, 93%; rice protein, 96%; microcrystalline, 95%; actigraphy 87%). BCAA were well-tolerated with few side effects and no adverse events. BCAA significantly improved subjective insomnia symptoms and objective sleep latency and wake after sleep onset on actigraphy.

Conclusion

Dietary supplementation with BCAA is a mechanism-based, promising intervention that shows feasibility, acceptability, and preliminary efficacy to treat insomnia and objective sleep disruption in Veterans with TBI. A larger scale randomized clinical trial is warranted to further evaluate the efficacy, dosing, and duration of BCAA effects on sleep and other related outcome measures in individuals with TBI.

Clinical Trial Registration

[http://clinicaltrials.gov/], identifier [NCT03990909].

Dream-enactment behaviours during the COVID-19 pandemic: an international COVID-19 sleep study

There has been increasing concern about the long-term impact of coronavirus disease 2019 (COVID-19) as evidenced by anecdotal case reports of acute-onset parkinsonism and the polysomnographic feature of increased rapid eye movement sleep electromyographic activity. This study aimed to determine the prevalence and correlates of dream-enactment behaviours, a hallmark of rapid eye movement sleep behaviour disorder, which is a prodrome of α-synucleinopathy. This online survey was conducted between May and August 2020 in 15 countries/regions targeting adult participants (aged ≥18 years) from the general population with a harmonised structured questionnaire on sleep patterns and disorders, COVID-19 diagnosis and symptoms. We assessed dream-enactment behaviours using the Rapid Eye Movement Sleep Behaviour Disorder Single-Question Screen with an additional question on their frequency. Among 26,539 respondents, 21,870 (82.2%) answered all items that were analysed in this study (mean [SD] age 41.6 [15.8] years; female sex 65.5%). The weighted prevalence of lifetime and weekly dream-enactment behaviours was 19.4% and 3.1% and were found to be 1.8- and 2.9-times higher in COVID-19-positive cases, respectively. Both lifetime and weekly dream-enactment behaviours were associated with young age, male sex, smoking, alcohol consumption, higher physical activity level, nightmares, COVID-19 diagnosis, olfactory impairment, obstructive sleep apnea symptoms, mood, and post-traumatic stress disorder features. Among COVID-19-positive cases, weekly dream-enactment behaviours were positively associated with the severity of COVID-19. Dream-enactment behaviours are common among the general population during the COVID-19 pandemic and further increase among patients with COVID-19. Further studies are needed to investigate the potential neurodegenerative effect of COVID-19.

Epidemiological studies of sleep disorder in educational community of Pakistani population, its major risk factors and associated diseases

Sleep is one of the most important functions of the life. The disturbance in sleep or quality of sleep leads to several dysfunctions of the human body. This study aimed to investigate the prevalence of sleep disorders, their possible risk factors and their association with other health problems. The data was collected from the educational community of the Pakistani population. The Insomnia Severity Index (ISI) was used to evaluate the insomnia and the sleep apnea was evaluated through a simple questionnaire method. The blood samples were collected to perform significant blood tests for clinical investigations. Current research revealed that the individuals in the educational community had poor sleep quality. A total of 1998 individuals from the educational community were surveyed, 1584 (79.28%) of whom had a sleep disorders, including insomnia (45.20%) and sleep apnea (34.08%). The measured onset of age for males and females was 30.35 years and 31.07 years respectively. The Clinical investigations showed that the sleep had significant impact on the hematology of the patients. Higher levels of serum uric acid and blood sugar were recorded with a sleep disorder. The individuals of the educational community were using the sleeping pills. The other associated diseases were mild tension, headaches, migraines, depression, diabetes, obesity, and myopia. The use of beverage, bad mood, medical condition, mental stress, disturbed circadian rhythms, workload and extra use of smartphone were major risk factors of sleep disorders. It was concluded that the insomnia was more prevalent than the sleep apnea. Furthermore, life changes events were directly linked with disturbance of sleep. Tension, depression, headaches, and migraine were more associated with sleep disorders than all other health issues.

Feasibility and preliminary efficacy for morning bright light therapy to improve sleep and plasma biomarkers in US Veterans with TBI. A prospective, open-label, single-arm trial

Mild traumatic brain injury (TBI) is associated with persistent sleep-wake dysfunction, including insomnia and circadian rhythm disruption, which can exacerbate functional outcomes including mood, pain, and quality of life. Present therapies to treat sleep-wake disturbances in those with TBI (e.g., cognitive behavioral therapy for insomnia) are limited by marginal efficacy, poor patient acceptability, and/or high patient/provider burden. Thus, this study aimed to assess the feasibility and preliminary efficacy of morning bright light therapy, to improve sleep in Veterans with TBI (NCT03578003). Thirty-three Veterans with history of TBI were prospectively enrolled in a single-arm, open-label intervention using a lightbox (~10,000 lux at the eye) for 60-minutes every morning for 4-weeks. Pre- and post-intervention outcomes included questionnaires related to sleep, mood, TBI, post-traumatic stress disorder (PTSD), and pain; wrist actigraphy as a proxy for objective sleep; and blood-based biomarkers related to TBI/sleep. The protocol was rated favorably by ~75% of participants, with adherence to the lightbox and actigraphy being ~87% and 97%, respectively. Post-intervention improvements were observed in self-reported symptoms related to insomnia, mood, and pain; actigraphy-derived measures of sleep; and blood-based biomarkers related to peripheral inflammatory balance. The severity of comorbid PTSD was a significant positive predictor of response to treatment. Morning bright light therapy is a feasible and acceptable intervention that shows preliminary efficacy to treat disrupted sleep in Veterans with TBI. A full-scale randomized, placebo-controlled study with longitudinal follow-up is warranted to assess the efficacy of morning bright light therapy to improve sleep, biomarkers, and other TBI related symptoms.

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.

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.

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.

Validation of Visually Identified Muscle Potentials during Human Sleep Using High Frequency/Low Frequency Spectral Power Ratios

Surface electromyography (EMG), typically recorded from muscle groups such as the mentalis (chin/mentum) and anterior tibialis (lower leg/crus), is often performed in human subjects undergoing overnight polysomnography. Such signals have great importance, not only in aiding in the definitions of normal sleep stages, but also in defining certain disease states with abnormal EMG activity during rapid eye movement (REM) sleep, e.g., REM sleep behavior disorder and parkinsonism. Gold standard approaches to evaluation of such EMG signals in the clinical realm are typically qualitative, and therefore burdensome and subject to individual interpretation. We originally developed a digitized, signal processing method using the ratio of high frequency to low frequency spectral power and validated this method against expert human scorer interpretation of transient muscle activation of the EMG signal. Herein, we further refine and validate our initial approach, applying this to EMG activity across 1,618,842 s of polysomnography recorded REM sleep acquired from 461 human participants. These data demonstrate a significant association between visual interpretation and the spectrally processed signals, indicating a highly accurate approach to detecting and quantifying abnormally high levels of EMG activity during REM sleep. Accordingly, our automated approach to EMG quantification during human sleep recording is practical, feasible, and may provide a much-needed clinical tool for the screening of REM sleep behavior disorder and parkinsonism.

Different methods for TBI diagnosis influence presence and symptoms of post-concussive syndrome in US Veterans

Common methods for evaluating history of traumatic brain injury (TBI) include self-report, electronic medical record review (EMR), and structured interviews such as the Head Trauma Events Characteristics (HTEC). Each has strengths and weaknesses, but little is known regarding how TBI diagnostic rates or the associated symptom profile differ among them. This study examined 200 Veterans recruited within the VA Portland Health Care System, each evaluated for TBI using self-report, EMR, and HTEC. Participants also completed validated questionnaires assessing chronic symptom severity in broad health-related domains (pain, sleep, quality of life, post-concussive symptoms). The HTEC was more sensitive (80% of participants in our cohort) than either self-report or EMR alone (40%). As expected from the high sensitivity, the HTEC+ group included many people with mild or no post-concussive symptoms. Participants were then grouped according to the degree of concordance across these three diagnostic methods: No-TBI, n=43; or TBI-positive in any one method (TBI-1dx, n=53), any two (TBI-2dx, n=45), or all three (TBI-3dx, n=59). The symptom profile of the TBI-1dx group was indistinguishable from the No TBI group. The TBI-3dx group carried the most severe symptom profile. These data show that understanding the method(s) used to ascertain TBI is essential when interpreting results from other studies, an issue that will be even more salient when interpreting data merged from multiple sources within centralized repositories (e.g., FITBIR). The development of a composite TBI assessment tool including self-report, medical record review, and neuropsychology outcomes is a crucial next step for the field.

Sleep-related (psychogenic) dissociative disorders as parasomnias associated with a psychiatric disorder: update on reported cases

STUDY OBJECTIVES

To update the literature on the diagnostic category of sleep-related dissociative disorders (SRDDs), involving psychogenic dissociation, since the time of their inclusion in the parasomnias section of the International Classification of Sleep Disorders, second edition, in 2005; to summarize the most salient clinical and video-polysomnographic (vPSG) findings and typical clinical profile from all reported cases; and to provide the rationale for the re-inclusion of the group of SRDDs in future editions of the International Classification of Sleep Disorders.

METHODS

A systematic computerized literature search was conducted searching for SRDDs, nocturnal dissociative disorders, and nocturnal dissociation.

RESULTS

Nine additional cases were identified, with sufficient clinical history and vPSG findings to justify the diagnosis of SRDDs, supplementing the 11 cases cited in the International Classification of Sleep Disorders, second edition, for a total of 20 cases. Twenty-six other cases with vPSG testing were found, with 18 cases reported in abstracts and 8 cases reported in a publication with compelling histories of SRDDs and 2 consecutive vPSG studies, but without the vPSG findings explicitly reported for any case. In more than half of all reported cases, there was objective diagnostic confirmation for SRDDs consisting of the hallmark finding of abnormal nocturnal behaviors arising from sustained electroencephalography wakefulness, or during wake-sleep transitions, without epileptiform activity. These nocturnal behaviors often replicated daytime psychogenic dissociative behaviors. A history of trauma (physical, sexual, emotional) was an almost universal finding, along with major psychopathology. All patients, except for one, had prominent histories of daytime dissociative disorders. Many of the patients were referred on account of a presumed parasomnia.

CONCLUSIONS

Cases of SRDDs continue to be reported, often as a "parasomnia mimic," with psychogenic dissociation being clearly distinguished from physiologic sleep-wake dissociation as found in primary sleep disorders such as narcolepsy, rapid eye movement sleep behavior disorder, etc. Eleven reasons are provided for why the category of SRDDs should be re-included in future editions of the International Classification of Sleep Disorders, and in the parasomnias section.

Brainstem Quadruple Aberrant Hyperphosphorylated Tau, Beta-Amyloid, Alpha-Synuclein and TDP-43 Pathology, Stress and Sleep Behavior Disorders

Quadruple aberrant hyperphosphorylated tau (p-τ), amyloid-β peptide, alpha-synuclein and TDP-43 brainstem and supratentorial pathology are documented in forensic ≤40y autopsies in Metropolitan Mexico City (MMC), and p-τ is the major aberrant protein. Post-traumatic stress disorder (PTSD) is associated with an elevated risk of subsequent dementia, and rapid eye movement sleep behavior disorder (RBD) is documented in PD, AD, Lewy body dementia and ALS. This study aimed to identify an association between PTSD and potential pRBD in Mexico. An anonymous online survey of 4502 urban college-educated adults, 29.3 ± 10.3 years; MMC, n = 1865; non-MMC, n = 2637, measured PTSD symptoms using the Impact of Event Scale-Revised (IES-R) and pRBD symptoms using the RBD Single-Question. Over 50% of the participants had IES-R scores ≥33 indicating probable PTSD. pRBD was identified in 22.6% of the participants across Mexico and 32.7% in MMC residents with PTSD. MMC subjects with PTSD had an OR 2.6218 [2.5348, 2.7117] of answering yes to the pRBD. PTSD and pRBD were more common in women. This study showed an association between PTSD and pRBD, strengthening the possibility of a connection with misfolded proteinopathies in young urbanites. We need to confirm the RBD diagnosis using an overnight polysomnogram. Mexican women are at high risk for stress and sleep disorders.

REM sleep behavior disorder: Mimics and variants

Rapid eye movement (REM) sleep behavior disorder (RBD) is a parasomnia with dream-enactment behaviors occurring during REM sleep and associated with the lack of the physiological REM sleep muscle atonia. It can be isolated and secondary to other neurological or medical conditions. Isolated RBD heralds in most cases a neurodegenerative condition due to an underlying synucleinopathy and consequently its recognition is crucial for prognostic implications. REM sleep without atonia on polysomnography is a mandatory diagnostic criterion. Different conditions may mimic RBD, the most frequent being obstructive sleep apnea during sleep, non-REM parasomnia, and sleep-related hypermotor epilepsy. These diseases might also be comorbid with RBD, challenging the evaluation of disease severity, the treatment choices and the response to treatment evaluation. Video-PSG is the gold standard for a correct diagnosis and will distinguish between different or comorbid sleep disorders. Careful history taking together with actigraphy may give important clues for the differential diagnosis. The extreme boundaries of RBD might also be seen in more severe and complex conditions like status dissociatus or in the sleep disorders' scenario of anti IgLON5 disease, but in the latter both clinical and neurophysiological features will differ. A step-by-step approach is suggested to guide the differential diagnosis.

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.

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.

Striatal Dopaminergic Deficit and Sleep in Idiopathic Rapid Eye Movement Behaviour Disorder: An Explorative Study

INTRODUCTION

Idiopathic rapid eye movement (REM) sleep behavior disorder (iRBD) is increasingly recognised as an important precursor disease state of alpha-synucleinopathies. This parasomnia is characterized by a history of recurrent nocturnal dream enactment behaviour, loss of skeletal muscle atonia, and increased phasic muscle activity during REM sleep. Neuroimaging studies of striatal dopamine transporter uptake tracer signaling suggest increasing dopaminergic deficit across the continuum of the alpha-synucleinopathies, with early sleep dysfunction suggestive of early caudate dysfunction. Henceforth, we set out to investigate the relationship between early sleep changes and the striatal dopaminergic availability in iRBD.

METHODS

Twelve patients with iRBD, who had undergone a video polysomnography and a neuroimaging assessment of striatal dopamine transporter (DaT) uptake tracer signaling, and 22 matched controls who had similarly undergone a video polysomnography were retrospectively identified. Data were statistically analyzed to identify altered sleep parameters and correlate them with striatal dopamine transporter uptake tracer signaling.

RESULTS

The iRBD patients exhibited an increased number of periodic limb movements during sleep (P=0.001), compared to 22 age-matched healthy subjects. In addition, several significant links were found between regional DaT-uptakes and sleep architecture. Correlational analyses suggested a strong positive association between sleep fragmentation and dopamine deficiency in left caudate (r=-0.630, P=0.028), whilst an increased uptake in the whole striatum was strongly linked to the sleep efficiency, and to a lesser degree to the length of sleep duration.

DISCUSSION

To the best of our knowledge, this is the first demonstration of a close relationship between dopaminergic availability in striatum and the quality of sleep in iRBD. Taken together, our exploratory findings suggest that subtle but functionally significant striatal changes in early stages of iRBD may contribute to the further shaping of sleep architecture.

Dream enactment behavior: review for the clinician

NONE

Dream enactment behavior commonly occurs on occasion in normal children and adults. Disruptive and frequent dream enactment behavior may come to the attention of the clinician either as the primary reason for consultation or as a prominent characteristic of a patient with other sleep disorders. Questioning patients with chronic neurologic and psychiatric disorders may also reveal previously unrecognized behavior. In the absence of sleep pathology, process of dream enactment likely begins with active, often emotionally charged dream content that may occasionally break through the normal REM sleep motor suppressive activity. Disrupted sleep resulting from many possible causes, such as circadian disruption, sleep apnea, or medications, may also disrupt at least temporarily the motor-suppressive activity in REM sleep, allowing dream enactment to occur. Finally, pathological neurological damage in the context of degenerative, autoimmune, and infectious neurological disorders may lead to chronic recurrent and severe dream enactment behavior. Evaluating the context, frequency, and severity of dream enactment behavior is guided first and foremost by a structured approach to the sleep history. Physical exam and selected testing support the clinical diagnosis. Understanding the context and the likely cause is essential to effective therapy.

Dream enactment behavior-a real nightmare: a review of post-traumatic stress disorder, REM sleep behavior disorder, and trauma-associated sleep disorder

NONE

Dream enactment behavior is a phenomenon demonstrated in patients with post-traumatic stress disorder, rapid eye movement sleep behavior disorder, as well as with a more recently described condition entitled trauma-associated sleep disorder, which shares diagnostic criteria for rapid eye movement sleep behavior disorder. While these conditions share some commonalities, namely dream enactment behavior, they are quite different in pathophysiology and underlying mechanisms. This review will focus on these 3 conditions, with the purpose of increasing awareness for trauma-associated sleep disorder in particular.

REM Sleep Behavior Disorder among Veterans with and without Post-Traumatic Stress Disorder

OBJECTIVE

Among veterans, the prevalence of rapid eye movement sleep behavior disorder (RBD) is higher than among the general population, and some evidence suggests that this is related to post-traumatic stress disorder (PTSD). The purpose of this study was to determine whether the frequency of RBD differs depending on the presence of PTSD or trauma.

METHODS

Patients who underwent nocturnal polysomnography (PSG) and sleep-related questionnaire surveys at the Veteran Health Service Medical Center were reviewed retrospectively. Based on patients with PTSD (n=20; 100% male; 67.9±8.5 years of age), we matched patients exposed to trauma without PTSD (n23; 100% male; age 64.0±13.4) and patients without trauma (n=21; 100% male; age 59.86±10.9).

RESULTS

PTSD patients reported dream enactment behavior more than the trauma-exposed group without PTSD or the control group (p=0.006). After adjusting for age, there were more RBD patients in the PTSD group than in the trauma exposed group (p=0.049).

CONCLUSION

The results showed that RBD occurred significantly more in veterans with PTSD than those exposed to trauma, which suggests that there may be a pathophysiological association between PTSD and RBD.

Pain interference and quality of life in combat veterans: Examining the roles of posttraumatic stress disorder, traumatic brain injury, and sleep quality

OBJECTIVE

The goal of this study was to examine the associations among posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), sleep quality, pain interference, and quality of life in combat veterans.

METHOD

Veterans (N = 289, 86.51% male) completed the Mid-Atlantic MIRECC Assessment of Traumatic Brain Injury, the Clinician-Administered PTSD Scale for DSM-5, and measures of sleep quality, pain interference, and quality of life.

RESULTS

Hierarchical linear regressions evaluated associations between PTSD severity, deployment TBI severity, sleep quality, and the outcomes of pain interference and quality of life after adjusting for demographic variables and the number of nondeployment TBIs. PTSD severity, B = 0.15, SE B = 0.04, deployment TBI severity, B = 3.98, SE B = 1.01, and sleep quality, B = 0.74, SE B = 0.13, were significantly associated with pain interference, p < .001. PTSD severity, B = -0.57, SE B = 0.07, and pain interference, B = -0.45, SE B = 0.11, were significantly, independently associated with quality of life, p < .001. However, pain interference, B = -0.24, SE B = 0.11, was no longer significantly associated with quality of life when sleep quality, B = -1.56, SE B = 0.25, was included in the model. There was no significant association between deployment TBI severity and quality of life. Interactions among the studied variables were not significant for either of the outcome variables.

CONCLUSIONS

PTSD symptom severity, deployment TBI history, and sleep quality may be important to consider in treatment planning for veterans experiencing pain-related functional interference. For veterans with numerous conditions comorbid with pain, treatment plans may include interventions targeting sleep and PTSD to maximize quality of life improvements. (PsycInfo Database Record (c) 2021 APA, all rights reserved).