Trauma-related sleep disturbance and self-reported physical health symptoms in treatment-seeking female rape victims

"There Is No One Way to Get Over It": An Examination of Psychotherapy and Complementary Therapy Use Within a Sample of Survivors Who Experienced Sexual Violence

Literature on sexual violence survivors' service utilization is limited due to examination of singular therapies or narrow timeframes. Using surveys (n = 303) and interviews (n = 20), this study increases understanding of survivors' healing. Results show varied therapy use including psychotherapy (76.9%), yoga (50.2%), and massage (32.1%), among others. Mean number of therapies used was over three. Service utilization was delayed over a decade on average. Latent class analysis divided respondents into classes: psychotherapy and bodywork use (42.66%), high therapy use (9.14%), and minimal therapy use (48.20%). Interviews provide additional insight and describe barriers. Recommendations for policy, practice, and future research are discussed.

Women's strategies for navigating a healthy sex life post-sexual trauma

Sexual trauma is common. Consequences of sexual trauma can include deterioration of mental and physical health and it can also affect future romantic and sexual relationships. Previous studies have identified common healthy and destructive coping mechanisms to recover after experiencing sexual trauma, but few studies have investigated useful strategies to move into a healthy sexual relationship focused on resilience. In-depth semi-structured interviews were conducted with 41 women with a history of sexual trauma who were in a healthy sexual relationship at the time of participation. Participants provided strategies that helped them move beyond the sexually traumatic event(s) toward a healthy sexual relationship. Reflexive thematic analysis identified 5 effective and 6 ineffective strategies reported by the participants. Rich examples of resilience and empowerment were overarching in the effective strategies used for moving toward healthy sexual relationships. Women were also able to reflect on the strategies that were ineffective for them with kindness and understanding for their coping at that time, a normalizing theme for women working through sexual trauma. The results of this study will help therapists and researchers working with women who have experienced sexual trauma learn from their experiences in working beyond trauma toward a healthy sexual relationship.

Prevention of posttraumatic stress during inpatient rehabilitation post spinal cord injury: Study protocol for a randomized controlled trial of Brief Prolonged Exposure Therapy (Brief PE)

Background

Scant research has focused on posttraumatic stress disorder (PTSD) in the SCI population, despite high prevalence estimates. Fortunately, prolonged exposure therapy (PE) is a well-researched and highly effective treatment for PTSD. Our recent clinical trial showed that standard 12-session PE was effective for PTSD treatment among inpatients with SCI. Early intervention with brief PE (3-sessions) delivered in the emergency department has also been effective for PTSD prevention, but has not been tested among people post-SCI. Thus, we aim to conduct the first test of the Brief PE intervention to prevent PTSD among patients with SCI.

Methods

Adults who have experienced a SCI (N = 200) will be randomly assigned during inpatient rehabilitation to either: (a) 3 60-min sessions of Brief PE (intervention group) or (b) treatment as usual (control group).

Results

The primary outcome measure (PTSD symptoms measured by the PSSI-5) and secondary outcome measures (depression, anxiety, pain, quality of life, sleep disturbance, and resilience) will be assessed at baseline, 1-month, 3-months, and 6-months. Hierarchical linear modeling (HLM) will be used to evaluate the effectiveness of the PE intervention on PTSD and secondary outcomes. Descriptive statistics will examine feasibility and will include the number of participants enrolled, the number of sessions completed, fidelity of Brief PE delivery, and average scores for difficulty and helpfulness of the intervention scales for those randomized to intervention.

Conclusions

Successful completion of this study will provide an evidence-based program to alleviate posttraumatic distress post spinal cord injury and prevent long-term development of PTSD.

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.

Structural covariance of the ventral visual stream predicts posttraumatic intrusion and nightmare symptoms: a multivariate data fusion analysis

Visual components of trauma memories are often vividly re-experienced by survivors with deleterious consequences for normal function. Neuroimaging research on trauma has primarily focused on threat-processing circuitry as core to trauma-related dysfunction. Conversely, limited attention has been given to visual circuitry which may be particularly relevant to posttraumatic stress disorder (PTSD). Prior work suggests that the ventral visual stream is directly related to the cognitive and affective disturbances observed in PTSD and may be predictive of later symptom expression. The present study used multimodal magnetic resonance imaging data (n = 278) collected two weeks after trauma exposure from the AURORA study, a longitudinal, multisite investigation of adverse posttraumatic neuropsychiatric sequelae. Indices of gray and white matter were combined using data fusion to identify a structural covariance network (SCN) of the ventral visual stream 2 weeks after trauma. Participant's loadings on the SCN were positively associated with both intrusion symptoms and intensity of nightmares. Further, SCN loadings moderated connectivity between a previously observed amygdala-hippocampal functional covariance network and the inferior temporal gyrus. Follow-up MRI data at 6 months showed an inverse relationship between SCN loadings and negative alterations in cognition in mood. Further, individuals who showed decreased strength of the SCN between 2 weeks and 6 months had generally higher PTSD symptom severity over time. The present findings highlight a role for structural integrity of the ventral visual stream in the development of PTSD. The ventral visual stream may be particularly important for the consolidation or retrieval of trauma memories and may contribute to efficient reactivation of visual components of the trauma memory, thereby exacerbating PTSD symptoms. Potentially chronic engagement of the network may lead to reduced structural integrity which becomes a risk factor for lasting PTSD symptoms.

Systematic Review: Effectiveness of psychosocial interventions on wellbeing outcomes for adolescent or adult victim/survivors of recent rape or sexual assault

Sexual assault and rape are common forms of sexual violence/abuse. The psychological/health consequences represent significant and ongoing harm. It seems imperative that victim/survivors receive evidence-based support within first response settings. To assess what psychosocial interventions work for victim/survivors of a recent sexual assault. Twenty-seven electronic databases were systematically searched. Narrative data synthesis was used to read across studies. Reporting format follows PRISMA checklist. Ten studies were identifed including range of interventions. The evidence is sparse and scientifically weak, common flaws are reviewed. There is some weak evidence for the impact of video and cognitive behavioural therapy (CBT) based interventions, especially trauma processing. There is a gap in the evidence base on psychosocial interventions for victim/survivors of sexual assault and higher quality research is required.

PTSD symptom heterogeneity and alcohol-related outcomes in U.S. military veterans: Indirect associations with coping strategies

INTRODUCTION

This study investigated the role of coping strategies in mediating the relationship between the 7-factor model of posttraumatic stress disorder (PTSD) symptoms and alcohol misuse in veterans.

METHODS

Data were analyzed from 615 veterans from a nationally representative study of U.S. veterans who met criteria for probable full or subthreshold PTSD. Path analyses examined the role of self-sufficient, socially-supported, and avoidant coping strategies in mediating associations between PTSD symptom clusters and alcohol use disorder (AUD), alcohol consumption, and alcohol-related consequences.

RESULTS

Negative affect PTSD symptoms were associated with AUD through increased use of avoidant coping. Additionally, dysphoric arousal PTSD symptoms were associated with AUD; avoidant coping was associated with AUD and increased alcohol consumption; self-sufficient coping was associated with reduced AUD likelihood anhedonia symptoms with decreased use of self-sufficient coping; and negative affect with decreased use of socially-supported coping and increased use of avoidant coping.

CONCLUSIONS

Results underscore the importance of avoidant coping strategies as potential mediators of the relation between PTSD symptoms and AUD. Interventions designed to mitigate engagement in avoidant coping strategies, and to bolster engagement in self-sufficient and socially-supported strategies may help reduce alcohol misuse in veterans with full or subthreshold PTSD.

Disentangling the association between PTSD symptom heterogeneity and alcohol use disorder: Results from the 2019-2020 National Health and Resilience in Veterans Study

Veterans are at increased risk of comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) relative to civilians. Few studies have explored the association between distinct PTSD symptoms and AUD in veterans, and existing findings are highly discrepant. This study aimed to address this gap and equivocal association by evaluating which PTSD symptom clusters are most associated with AUD in a veteran sample using the 7-factor 'hybrid' model of PTSD. Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (NHRVS), a nationally representative survey of 4069 U.S. veterans. Veterans completed self-report measures to assess current PTSD symptoms and AUD. Multivariable logistic regression and relative importance analyses were conducted to examine associations between the 7-factor model of PTSD symptoms and AUD. Adjusting for sociodemographic, military, trauma factors, and depressive symptoms, scores on the dysphoric arousal (20.7% relative variance explained [RVE]) and externalizing behaviors (19.0% RVE) symptom clusters were most strongly associated with AUD in the full sample, while externalizing behaviors (47.7% RVE), anxious arousal (23.9% RVE), and dysphoric arousal (12.4%) accounted for the majority of explained variance in veterans who screened positive for PTSD. Results of this nationally representative study of U.S. veterans highlight the importance of externalizing behaviors and arousal symptoms of PTSD as potential drivers of AUD in this population. The 7-factor hybrid model of PTSD provides a more nuanced understanding of PTSD-AUD associations, and may help inform risk assessment and more personalized treatment approaches for veterans with and at-risk for AUD.

The resting-state functional connectivity of amygdala subregions associated with post-traumatic stress symptom and sleep quality in trauma survivors

Neuroimaging findings suggest that the amygdala plays a primary role in both the psychopathology of posttraumatic stress disorder (PTSD) and poor sleep quality, which are common in trauma survivors. However, the neural mechanisms of these two problems in trauma survivors associated with amygdala remain unclear. In the current study, we aimed to explore the role of functional connectivity of amygdala subregions in both PTSD symptoms and poor sleep quality. A total of 94 trauma-exposed subjects were scanned on a 3T MR system using resting-state functional magnetic resonance imaging. Both Pittsburgh Sleep Quality Index and Clinician-Administered PTSD Scale scores were negatively correlated with the resting-state functional connectivity between the left basolateral amygdala-left medial prefrontal cortex and the right basolateral amygdala-right medial prefrontal cortex. Our findings suggest a shared amygdala subregional neural circuitry underlying the neuropathological mechanisms of PTSD symptoms and poor sleep quality in trauma survivors.

Sleep Quality Improvements After MDMA-Assisted Psychotherapy for the Treatment of Posttraumatic Stress Disorder

Sleep disturbances (SDs) are among the most distressing and commonly reported symptoms in posttraumatic stress disorder (PTSD). Despite increased attention on sleep in clinical PTSD research, SDs remain difficult to treat. In Phase 2 trials, 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy has been shown to greatly improve PTSD symptoms. We hypothesized that MDMA-assisted psychotherapy would improve self-reported sleep quality (SQ) in individuals with PTSD and be associated with declining PTSD symptoms. Participants in four studies (n = 63) were randomized to receive 2-3 sessions of active MDMA (75-125 mg; n = 47) or placebo/control MDMA (0-40 mg, n = 16) during all-day psychotherapy sessions. The PSQI was used to assess change in SQ from baseline to the primary endpoint, 1-2 months after the blinded sessions. Additionally, PSQI scores were measured at treatment exit (TE) and 12-month follow-up. Symptoms of PTSD were measured using the CAPS-IV. At the primary endpoint, CAPS-IV total severity scores dropped more after active MDMA than after placebo/control (-34.0 vs. -12.4), p = .003. Participants in the active dose group showed more improvement in SQ compared to those in the control group (PSQI total score ΔM = -3.5 vs. 0.6), p = .003. Compared to baseline, SQ had improved at TE, p < .001, with further significant gains reported at 12-month follow-up (TE to 12-months ΔM = -1.0), p = .030. Data from these randomized controlled double-blind studies provide evidence for the beneficial effects of MDMA-assisted psychotherapy in treating SDs in individuals with PTSD.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Prolonged exposure therapy for PTSD among spinal cord injury survivors: Study protocol for a randomized controlled trial

The National Spinal Cord Injury Statistical Center estimates 294,000 people in the US live with a spinal cord injury (SCI), with approximately 17,810 new cases each year. Although the physical outcomes associated with SCI have been widely studied, the psychological consequences of sustaining a SCI remain largely unexplored. Scant research has focused on posttraumatic stress disorder (PTSD) in this population, despite prevalence estimates suggesting that up to 60% of individuals with SCI experience PTSD post-injury, compared to only 7% of the general US population. Fortunately, prolonged exposure therapy (PE) is a well-researched and highly effective treatment for PTSD. However, no trauma focused exposure-based therapy for PTSD (e.g. PE) has not yet been tested in a SCI population. Thus, we aim to conduct the first test of an evidence-based intervention for PTSD among patients with SCI. Adults with SCI and PTSD (N = 60) will be randomly assigned to either: (1) 12-sessions of PE (2-3 sessions per week) or (2) a treatment as usual (TAU) control group who will receive the standard inpatient rehabilitation care for SCI patients. Primary outcomes will be assessed at 0, 6, 10, and 32 weeks.

Sleep moderates symptom experience in combat veterans

BACKGROUND

Though sleep disturbance has shown to negatively affect outcomes related to post-deployment conditions, it is unclear whether and how sleep disturbance affects mental health symptoms beyond these conditions. We evaluated the independent and moderating effects of sleep quality on posttraumatic stress disorder (PTSD), depressive, and neurobehavioral symptoms beyond mild traumatic brain injury (TBI) and PTSD diagnosis.

METHODS

Participants were 274 US combat veterans who deployed after 9/11. All completed diagnostic TBI and PTSD interviews and self-report measures of sleep quality, as well as PTSD, depressive, and neurobehavioral symptoms. Only those who passed symptom validity were included in analyses. Hierarchical regression evaluated the contribution of sleep quality to outcomes beyond PTSD and mild TBI. Moderation analyses evaluated interactions between mild TBI, PTSD, and sleep quality on symptom outcomes.

RESULTS

Mild TBI was only significantly associated with PTSD (p = .006) and neurobehavioral (p = .003) symptoms. PTSD diagnosis was associated with PTSD (p < .001), depressive (p < .001), and neurobehavioral symptoms (p < .001) beyond mild TBI. Sleep quality explained additional significant variance in all three outcome measures (p < .001), and also significantly moderated the effects of PTSD diagnosis on neurobehavioral symptoms (ΔR² = .01, p = .023).

LIMITATIONS

Sleep was evaluated subjectively and therefore must be interpreted in this context.

CONCLUSIONS

These results provide support that sleep quality is an independent contributing factor to health outcomes in post-deployment veterans and should be considered in etiology of complaints.

Trauma-Related Sleep Problems and Associated Health Outcomes in Police Officers: A Path Analysis

Police officers are frequently exposed to two different types of potentially traumatic events: one dealing with physical threats to self and the other involving the witnessing of harm to others. These different types of traumatic experiences are thought to produce various posttraumatic reactions. Furthermore, sleep problems are also reported as a hallmark of posttraumatic stress disorder. There is evidence, however, that sleep problems may mediate the relationship between posttraumatic stress disorder symptoms and health outcomes, especially physical health and depression. Previous research has shown this to be the case among officers from large urban agencies. The purpose of the present study was to test a model involving a pathway from trauma type and posttraumatic stress disorder symptoms to physical health and depression that is mediated by sleep quality in officers (N = 193) using data from small- to mid-size police agencies. Results revealed that sleep problems served as a mediator between posttraumatic stress disorder hyperarousal and avoidance symptoms and health outcomes, that the trauma types are related to different posttraumatic stress disorder symptoms, and that complicated relationships exist between the study variables. In addition, the results indicated that approximately 25% of our sample displayed probable partial posttraumatic stress disorder or probable full posttraumatic stress disorder, causing substantial functional impairment. Suggestions for improving officer health and performance in the field are provided. Specifically, it appears that interventions designed to address posttraumatic stress disorder hyperarousal symptoms related to personal life threat and the posttraumatic stress disorder avoidance symptoms related to the witnessing of human suffering may maximize officer sleep quality and ultimately overall wellness. In particular, mindfulness-based interventions are well suited for addressing these symptom clusters.

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.

Premature Aging Among Trauma Survivors-The Longitudinal Implications of Sleep Disruptions on Telomere Length and Cognitive Performance

OBJECTIVES

Sleep is necessary for brain function as well as physical and cognitive processes. Sleep disruptions, common with aging, intensify among trauma survivors. Moreover, former prisoners-of-war (ex-POWs) often experience premature aging. This study investigates the longitudinal effects of sleep disruptions for ex-POWs in relation to cognitive performance and telomere length as well as between cognition and telomeres.

METHOD

This study included Israeli veterans from the 1973 Yom Kippur War who participated in four assessments (1991, 2003, 2008, 2015): (a) ex-POWs (n = 99), and (b) veterans who not were captured (controls) (n = 101). Among both groups, sleep disruptions were assessed using a self-report item in all four assessments. Cognitive performance was assessed using the Montreal Cognitive Assessment (MOCA) and telomere length was assessed via total white blood cells (leukocytes) from whole blood samples using Southern blot, both were measured only among ex-POWs in 2015. We conducted descriptive statistics, repeated measures, correlations, and path analyses.

RESULTS

Sleep disruptions were related to lower cognitive performance but not to shorter telomeres. Moreover, cognitive performance and telomere length were found to be related when sleep disruptions were taken into consideration.

CONCLUSION

Interpersonal trauma was shown to be a unique experience resulting in sleep disruptions over time, leading to cognitive impairment. These findings highlight the importance of viewing trauma survivors at high-risk for sleep disruptions. Therefore, it is imperative to inquire about sleep and diagnose cognitive disorders to help identify and treat premature aging.

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.

Hospitalized Medical Patients With Posttraumatic Stress Disorder (PTSD): Review of the Literature and a Roadmap for Improved Care

Posttraumatic stress disorder (PTSD) is common in the United States, with a prevalence of nearly 8% in the general population and between 10% and 30% in veterans. Despite how common PTSD is, inpatient providers may not be familiar with its manifestations or feel comfortable taking care of patients who may exhibit symptoms related to it. In our combined experience as VA-based hospital medicine care providers, we have cared for thousands of patients hospitalized for a primary medical condition who also have PTSD as a comorbidity. We have noticed in our practices that we only focus our attention on PTSD if a related problem arises during a patient's hospitalization (eg, confrontations with the care team or high levels of anxiety). We contend that a more proactive approach could lead to better care, but little evidence about best practices exists to inform the interdisciplinary team how to optimally care for hospitalized medical patients with PTSD. In this narrative review, we present a synthesis of existing literature, describe how trauma-informed care could be used to guide the approach to patients with PTSD, and generate ideas for changes that inpatient providers could implement now, such as engaging patients to prevent PTSD exacerbations and promoting better sleep in the hospital.

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.

Examining Insomnia During Intensive Treatment for Veterans with Posttraumatic Stress Disorder: Does it Improve and Does it Predict Treatment Outcomes?

Previous research has demonstrated that sleep disturbances show little improvement with evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, sleep improvements are associated with PTSD treatment outcomes. The goal of the current study was to evaluate changes in self-reported insomnia symptoms and the association between insomnia symptoms and treatment outcome during a 3-week intensive treatment program (ITP) for veterans with PTSD that integrated cognitive processing therapy (CPT), mindfulness, yoga, and other ancillary services. As part of standard clinical procedures, veterans (N = 165) completed self-report assessments of insomnia symptoms at pre- and posttreatment as well as self-report assessments of PTSD and depression symptoms approximately every other day during treatment. Most veterans reported at least moderate difficulties with insomnia at both pretreatment (83.0%-95.1%) and posttreatment (69.1-71.3%). Statistically significant reductions in self-reported insomnia severity occurred from pretreatment to posttreatment; however, the effect size was small, d = 0.33. Longitudinal mixed-effects models showed a significant interactive effect of Changes in Insomnia × Time in predicting PTSD and depression symptoms, indicating that patients with more improvements in insomnia had more positive treatment outcomes. These findings suggest that many veterans continued to struggle with sleep disruption after a 3-week ITP, and successful efforts to improve sleep could lead to better PTSD treatment outcomes. Further research is needed to establish how adjunctive sleep interventions can be used to maximize both sleep and PTSD outcomes.

A Preliminary Examination of the Effect of Cognitive Processing Therapy on Sleep Disturbance Among Veterans with Military Sexual Trauma-Related Posttraumatic Stress Disorder

Veterans who have experienced military sexual trauma (MST) report numerous psychosocial difficulties including sleep disturbance and posttraumatic stress disorder (PTSD). Cognitive Processing Therapy (CPT) has been shown to effectively reduce total PTSD symptoms among veterans with MST-related PTSD; however, sleep disturbance may persist after successful treatment. Sleep disturbance is associated with suicidal self-directed violence, substance use, and poorer physical health. Identification of if and when CPT can sufficiently address sleep disturbance may help to determine when adjunctive interventions may be indicated. The current study described the rate of sleep disturbance in a sample of veterans with MST-related PTSD before and after CPT. In an exploratory analysis, potential baseline predictors (i.e., sociodemographic, PTSD symptoms, trauma-related cognitions, depression, physical health) of change in sleep disturbance following CPT were assessed. A secondary analysis of 72 male and female veterans enrolled in a randomized clinical trial examining the efficacy of CPT for MST-related PTSD was conducted. Most veterans reported clinically significant sleep disturbance at baseline (100%) and post-treatment (89%). A significant relationship between clinically significant change in PTSD symptoms and resolution of sleep disturbance was not identified. Using hierarchical multiple linear regression, potential predictors of change in sleep severity following CPT were assessed; however, no significant predictors were identified in this exploratory analysis. These results are consistent with previous research describing high residual rates of sleep disturbance in veterans with PTSD, despite reductions in overall PTSD symptoms. Future research should focus on identifying effective augmentation strategies for CPT to specifically address sleep disturbance.

Examining Insomnia and PTSD Over Time in Veterans in Residential Treatment for Substance Use Disorders and PTSD

Objective/Background: Insomnia occurs in 66-90% of individuals with posttraumatic stress disorder (PTSD) and 36-72% of individuals with substance use disorder (SUD). Individuals with both PTSD and SUD are more likely to have insomnia than individuals with only one disorder. Insomnia is associated with poorer treatment outcomes for both PTSD and SUD, increased daytime symptomology for PTSD, and increased relapse for SUDs. As such, it is important to understand how sleep affects PTSD treatment among patients dually diagnosed with SUD and how sleep changes over time in a residential unit for SUDs. Participants: Participants were 40 veterans with comorbid PTSD and SUD in a 28-day Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) PTSD track. Methods: Analyses used mixed models with Time (baseline, posttreatment, 3-month follow-up) to examine PTSD and insomnia severity over time. Results: Results of the longitudinal mixed model showed that PTSD symptoms improved over time but that insomnia symptoms did not. Although baseline insomnia did not affect follow-up PTSD symptoms, individuals with greater insomnia severity at the start of treatment had more severe baseline PTSD symptomatology. However, there was not an interaction of insomnia and PTSD severity over time such that baseline insomnia did not affect PTSD trajectories. Conclusions: These findings are consistent with the PTSD outpatient treatment findings and further adds evidence that insomnia is unremitting without direct intervention. Given the relationship insomnia has with PTSD severity, SUD, and relapse, directly targeting insomnia may further help improve both PTSD and SUD treatment outcomes.

Nocturnal Olfactory Stimulation for Improvement of Sleep Quality in Patients With Posttraumatic Stress Disorder: A Randomized Exploratory Intervention Trial

Posttraumatic stress disorder (PTSD) is characterized by sleep impairment and nightmares. As pleasant odors presented during sleep affect the emotional tone of dreams without inducing arousal, we investigated whether sleep patterns in PTSD can be improved via nocturnal olfactory stimulation. Participants were 40 inpatients with PTSD (n = 35 women; age range: 20-59 years) who completed a randomized, patient-blind, placebo-controlled trial. Baseline measurement for 5 consecutive nights was followed by a 5-night experimental intervention or placebo trial. During the intervention, patients received nocturnal stimulation with a pleasant odor (odor condition) or clean air (placebo condition) via an olfactometer that delivered inspiration-triggered stimuli in a nasal tube or via an odorized nasal clip. After each night, the patients completed standardized questionnaires that assessed sleep parameters and dream content. Each night, sleep efficiency, sleep onset latency, and wakefulness after sleep onset were monitored with a motion biosensor. Baseline assessment revealed that PTSD severity was associated with poorer sleep outcomes. An interaction effect showed that nocturnal odorization affected dream intensity. Post hoc tests revealed an improvement in the group that used the nasal clip as compared to baseline, d = 0.68. No negative effects were observed after odorization with the nasal clip. Considering the limited sample size, the study indicates that nocturnal olfactory stimulation may serve as a low-cost concomitant intervention to improve sleep quality in PTSD.

Traumatic Event Exposure, Posttraumatic Stress Disorder, and Sleep Disturbances in a National Sample of U.S. Adults

Posttraumatic stress disorder (PTSD) is a highly prevalent, debilitating disorder found to develop after exposure to a potentially traumatic event (PTE). Individuals with PTSD often report sleep disturbances, specifically nightmares and insomnia, which are listed within the criteria for PTSD. This research examined prevalence of insomnia and nightmares within a national sample of 2,647 adults (data weighted by age and sex to correct for differences in sample distribution) who had been exposed to one or more PTEs. Prevalence of self-reported sleep disturbance, sleep disturbances by PTE type, and gender differences were examined. All participants completed a self-administered, structured online interview that assessed exposure to stressful events and PTSD symptoms. Among individuals who met DSM-5 criteria for PTSD, a large majority (more than 92%) reported at least one sleep disturbance. Insomnia was relatively more prevalent than PTE-related nightmares among individuals with PTSD and among all PTE-exposed individuals. A higher number of PTEs experienced significantly increased the likelihood of both trauma-related nightmares and insomnia, McFadden's pseudo R² = .07, p < .001. Women exposed to PTEs were more likely to endorse experience of insomnia, χ² (1, N = 2,647) = 99.13, p < .001, φ = .194, and nightmares compared to men, χ² (1, N = 2,648) = 82.98, p < .001, φ = .177, but this gender difference was not significant among individuals with PTSD, ps = .130 and .050, respectively. Differences in sleep disturbance prevalence by PTE type were also examined. Implications for treatment and intervention and future directions are discussed.

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.

Management of nightmares in patients with posttraumatic stress disorder: current perspectives

Nightmares are considered the hallmark of posttraumatic stress disorder (PTSD). Although the characteristics of these distressing dreams may vary with the type of traumatic event, the pathophysiology exposes central dysfunction of brain structures at the level of the hippocampus, amygdala, and locus coeruleus, modulated by neurochemical imbalance in nor-adrenergic, dopaminergic, and serotonin pathways. Underlying comorbid conditions, including other sleep disorders, may contribute to worsening symptoms. Addressing sleep disruption can alleviate the severity of these nocturnal events and augment the effectiveness of other PTSD treatments. The expansion of behavioral treatment modalities for PTSD-related nightmares has been encouraging, but the core of these interventions is heavily structured around memory manipulation and imagery rescripting. A lack of a standardized delivery and a high dropout rate continue to pose significant challenges in achieving successful outcomes. The efficacy of existing pharmacological studies, such as α-adrenergic blocking agents, antidepressants, and atypical antipsychotics, has been undermined by methodological limitations and absence of large randomized controlled trials. This review is aimed at reviewing the available treatment strategies for alleviating nightmares in subjects with PTSD. Given the intricate relationship between PTSD and nightmares, future clinical trials have to adopt a more pragmatic approach focused not only on efficacy of novel interventions but also on adjunctive iteration of existing therapies tailored to individual socio-cultural background.

Sleep disturbances, posttraumatic stress, and psychological distress among survivors of the 2013 Super Typhoon Haiyan

Sleep disturbances and their relation with posttraumatic stress and general psychological distress were examined after the 2013 Super Typhoon Haiyan. Sleep disturbances were hypothesized to be associated with posttraumatic stress and general psychological distress in two samples of survivors across two time points (N = 361) in the Philippines. Sample 1 (n = 223) and Sample 2 (n = 138) were collected 18 months and 30 months after the storm, respectively. Results from structural regression modeling indicated that insomnia was associated with both posttraumatic stress and general psychological distress. Poor sleep quality was associated with posttraumatic stress but not with general psychological distress. Findings underscore the longer-term relationship between sleep disturbances and overall sleep quality to posttraumatic stress in the context of a natural disaster. Implications for public mental health interventions in disaster settings are discussed.

Social Support, Dysfunctional Coping, and Community Reintegration as Predictors of PTSD Among Human Trafficking Survivors

Human trafficking exerts psychological effects on survivors that persist after intervention, and even after community reintegration. Effects include anxiety, depression, alienation, disorientation, aggression, suicidal ideation, attention deficit, and posttraumatic stress disorder (PTSD). Community supports and coping mechanisms may mitigate these effects. The report presented here is part of a long-term program of research to develop and test evidence-informed mental health and human capacity-building intervention programs for women and girls who are victims of trafficking. Structural equation modeling was used to assess a conditional process model (moderated mediation) of the effect of social support, coping, and community reintegration on PTSD among n = 144 girls and women. Participants received psychosocial intervention at a residential care facility for trafficking survivors. Results indicate model fit was excellent. Results indicate community reintegration indirectly influenced PTSD through its effect on perceived social support. Survivors who reported more difficulty reintegrating back into the community perceived less social support than those that reported easier community reintegration, and trafficking survivors who perceived less social support indicated more PTSD. Survivors with more PTSD symptoms tended to report using more dysfunctional coping mechanisms.

Sleep Disorders in Patients With Posttraumatic Stress Disorder

A growing body of evidence supports a bidirectional relationship between posttraumatic stress disorder (PTSD) and sleep disturbances. Fragmented sleep induced by sleep-related breathing disorders, insomnia, and nightmares impacts recovery and treatment outcomes and worsens PTSD symptoms. Despite recent attention, management of these disorders has been unrewarding in the setting of PTSD. This review summarizes the evidence for empirically supported treatments of these sleep ailments, including psychotherapeutic and pharmacologic interventions, as it relates to PTSD. Recent advances in positive airway pressure technology have made treatment of OSA more acceptable; however, adherence to CPAP therapy presents a substantial challenge. Concomitant insomnia, which engenders psychiatric and medical conditions, including depression, suicide, and alcohol and substance abuse, can be managed with cognitive behavioral therapy. Hypnotic agents are considered an alternative therapy, but concerns about adverse events and lack of high-level evidence supporting their efficacy in PTSD treatment have limited their use to resistant cases or as adjuncts to behavioral therapy when the response is less than desirable. Intrusion of nightmares can complicate PTSD treatment and exert serious strain on social, occupational, and marital relations. Imagery rehearsal therapy has shown significant reduction in nightmare intensity and frequency. The success of noradrenergic blocking agents has not been consistent among studies, with one-half reporting treatment failure. An integrated stepped care approach that includes components of both behavioral and pharmacologic interventions customized to patients' sleep-maladaptive behaviors may offer a solution to delivering accessible, effective, and efficient services for individuals with PTSD.

Efficacy of the Mantram Repetition Program for Insomnia in Veterans With Posttraumatic Stress Disorder: A Naturalistic Study

Statistics show that more than 80% of Veterans mention posttraumatic stress disorder (PTSD)-related symptoms when seeking treatment. Sleep disturbances and nightmares are among the top 3 presenting problems. Current PTSD trauma-focused therapies generally do not improve sleep disturbances. The mantram repetition program (MRP), a mind-body-spiritual intervention, teaches a portable set of cognitive-spiritual skills for symptom management. The aim of this study was to evaluate the efficacy of the MRP on insomnia in Veterans with PTSD in a naturalistic, clinical setting. Results show that participation in the MRP significantly reduced insomnia, as well as decreased self-reported and clinician-assessed PTSD symptom burden.

Comorbid insomnia and sleep apnea in Veterans with post-traumatic stress disorder

PURPOSE

The purpose of this study was to determine the impact of insomnia in Veterans with post-traumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) on health-related outcomes before and after 12 weeks of continuous positive airway pressure (CPAP) treatment.

METHODS

We conducted a prospective cohort study of Veterans with PTSD and documented apnea hypopnea index (AHI) ≥ 5 with and without clinically significant insomnia as determined by the Insomnia Severity Index (ISI). Health-related outcomes including PTSD checklist (PCL-M), SF-36, and Pittsburgh Sleep Quality Index (PSQI) were assessed at baseline and 12 weeks after initiation of OSA treatment. CPAP adherence was retrieved at each visit.

RESULTS

Seventy-two Veterans including 36 with comorbid insomnia and OSA (COMISA) and 36 OSA-only were enrolled. Veterans with COMISA were younger (p = 0.03), had lower BMI (p < 0.001), and were more likely to report depression than those with OSA-only (p = 0.004). Although AHI was higher in the COMISA (p = 0.01), both groups expressed comparable daytime sleepiness (p = 0.16). The COMISA group had no significant change in SF-36 and PSQI after 12 weeks of treatment and used CPAP much less frequently than OSA-only group (p = 0.001).

CONCLUSIONS

COMISA in Veterans with PTSD is associated with worse quality of life than those with OSA-only. Insomnia should be assessed in Veterans with PTSD who are not adherent to CPAP treatment.

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.

An examination of sleep quality in veterans with a dual diagnosis of PTSD and severe mental illness

Poor sleep quality is one of the most frequently reported symptoms by veterans with Posttraumatic Stress Disorder (PTSD) and by veterans with severe mental illness (SMI; i.e., schizophrenia spectrum disorders, bipolar disorder, major depression with or without psychotic features). However, little is known about the compounding effects of co-occurring PTSD/SMI on sleep quality in this population. Given the high rates of comorbidity and poor functional outcomes associated with sleep dysfunction, there is a need to better understand patterns of poor sleep quality in this population. The present study provides a description of sleep quality in veterans with a dual diagnosis of PTSD/SMI relative to veterans with PTSD only. Results indicated that, despite similar reports of PTSD symptom severity between the groups, veterans with PTSD/SMI reported higher levels of poor sleep quality than veterans only diagnosed with PTSD. Specifically, veterans with PTSD/SMI reported significantly greater difficulties with sleep onset and overall more sleep disturbance than their non-SMI counterparts. Implications of the findings are discussed within the context of an existing model of insomnia and suggest that more comprehensive sleep assessment and the provision of targeted sleep interventions may be helpful for those with a dual diagnosis of PTSD/SMI.

Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the future

Post-traumatic stress disorder (PTSD) is a serious psychiatric consequence of trauma that occurs in a proportion of individuals exposed to life-threatening events. Trauma-focused psychotherapy is often recommended as first choice for those who do not recover spontaneously. But many individuals require medications. In the US, only paroxetine (PRX) and sertraline (SRT) are FDA approved for PTSD. But response and remission rates with these medications are low, so numerous other pharmacologic interventions have been tried. To date, there has not been a systematic review of the data on what are the best next-step pharmacologic strategies for individuals who fail standard treatments. To that end, we review 168 published trials of medications other than PRX or SRT and provide a detailed analysis of the 88/168 studies that describe alternative pharmacologic interventions in patients refractory to other treatment. We also review clinical factors relevant to treatment-refractory PTSD; the neurobiology of extinction, as well as evidence-based psychotherapy and neuromodulation strategies for this condition.

Self-Reported Sleep Disturbance Mediates the Relationship Between PTSD and Cognitive Outcome in Blast-Exposed OEF/OIF Veterans

OBJECTIVES

To examine the contribution of sleep disturbance to cognitive performance following blast exposure.

DESIGN

Correlational research evaluating self-reported sleep disturbance as a mediator of the association between the primary blast-related comorbidities of mild traumatic brain injury (mTBI) and posttraumatic stress disorder and cognitive outcome.

PARTICIPANTS

One hundred sixty Operation Enduring Freedom/Operation Iraqi Freedom Veterans with a history of blast exposure assigned to 1 of 3 groups (no TBI, mTBI without loss of consciousness, and mTBI with loss of consciousness).

MAIN OUTCOME MEASURES

Neuropsychological measures and self-report of sleep disturbance.

RESULTS

Increased posttraumatic stress disorder symptomatology was associated with worse performance in multiple cognitive domains. This association was mediated in part by self-reported sleep disturbance. Traumatic brain injury with loss of consciousness was associated with lower manual dexterity, but this association was not mediated by sleep disturbance.

CONCLUSIONS

Our results highlight the importance of sleep disturbance as a factor contributing to cognitive outcome in individuals with posttraumatic stress disorder symptoms. They point to the importance of considering sleep problems in the diagnosis and treatment of cognitive deficits in veterans with blast exposure.

Potential pleiotropic beneficial effects of adjuvant melatonergic treatment in posttraumatic stress disorder

Loss of circadian rhythmicity fundamentally affects the neuroendocrine, immune, and autonomic system, similar to chronic stress and may play a central role in the development of stress-related disorders. Recent articles have focused on the role of sleep and circadian disruption in the pathophysiology of posttraumatic stress disorder (PTSD), suggesting that chronodisruption plays a causal role in PTSD development. Direct and indirect human and animal PTSD research suggests circadian system-linked neuroendocrine, immune, metabolic and autonomic dysregulation, linking circadian misalignment to PTSD pathophysiology. Recent experimental findings also support a specific role of the fundamental synchronizing pineal hormone melatonin in mechanisms of sleep, cognition and memory, metabolism, pain, neuroimmunomodulation, stress endocrinology and physiology, circadian gene expression, oxidative stress and epigenetics, all processes affected in PTSD. In the current paper, we review available literature underpinning a potentially beneficiary role of an add-on melatonergic treatment in PTSD pathophysiology and PTSD-related symptoms. The literature is presented as a narrative review, providing an overview on the most important and clinically relevant publications. We conclude that adjuvant melatonergic treatment could provide a potentially promising treatment strategy in the management of PTSD and especially PTSD-related syndromes and comorbidities. Rigorous preclinical and clinical studies are needed to validate this hypothesis.

Sleep-disordered breathing in patients with post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) and sleep-disordered breathing (SDB) are shared by many patients. They both affect sleep and the quality of life of affected subjects. A critical review of the literature supports an association between the two disorders in both combat-related and non-combat-related PTSD. The exact mechanism linking PTSD and SDB is not fully understood. A complex interplay between sleep fragmentation and neuroendocrine pathways is suggested. The overlap of symptoms between PTSD and SDB raises diagnostic challenges that may require a novel approach in the methods used to diagnose the coexisting disorders. Similar therapeutic challenges face patients and providers when treating concomitant PTSD and SDB. Although continuous positive airway pressure therapy imparts a mitigating effect on PTSD symptomatology, lack of both acceptance and adherence are common. Future research should focus on ways to improve adherence to continuous positive airway pressure therapy and on the use of alternative therapeutic methods for treating SDB in patients with PTSD.

The mediating role of sleep disturbances in the relationship between posttraumatic stress disorder and self-injurious behavior

Although posttraumatic stress disorder (PTSD) is associated with self-injurious behavior, it is currently unclear what mechanisms may account for this relationship. Sleep disturbances may be relevant as they are common among those with PTSD and are associated with emotion regulation difficulties, which may increase vulnerability to self-injurious behavior. As such, we investigated the relationship between PTSD and self-injurious behaviors, and the mediating roles of nightmares and insomnia. Hypotheses were tested cross-sectionally in a sample of psychology clinic outpatients (N=255). Participants completed a structured clinical interview assessing PTSD and self-report questionnaires measuring insomnia, nightmares, and self-injurious behaviors (i.e., Have you ever cut, burned, or scratched yourself on purpose?). PTSD was associated with self-injurious behavior after covarying for depression, and nightmare severity mediated the relationship between PTSD and self-injurious behavior. Findings are consistent with research indicating that sleep disturbances, specifically nightmares, are important predictors of poor outcomes among those with PTSD, and extend this research to suggest their role in self-injurious behaviors as well.

Cognitive-behavioral therapy for sleep disturbances in treating posttraumatic stress disorder symptoms: A meta-analysis of randomized controlled trials

Sleep disturbances are frequently reported in patients with posttraumatic stress disorder (PTSD). There is evidence that sleep disturbance is not only a secondary symptom but also a risk factor for PTSD. Sleep-specific psychological treatments provide an alternative to conventional trauma-focused psychological treatments. The current meta-analysis evaluated the efficacy of sleep-specific cognitive-behavioral therapy (CBT) in mitigating PTSD, sleep, and depressive symptoms. A total of 11 randomized controlled trials were included in the meta-analytic comparisons between sleep-specific CBT and waiting-list control groups at posttreatment. Random effects models showed significant reduction in self-report PTSD and depressive symptoms and insomnia severity in the sleep-specific CBT group. The corresponding effect sizes, measured in Hedges' g, were 0.58, 0.44, and 1.15, respectively. The effect sizes for sleep diary-derived sleep onset latency, wake after sleep onset, and sleep efficiency were 0.83, 1.02 and 1.15, respectively. The average study attrition rate of sleep-specific CBT was relatively low (12.8%), with no significant difference from the control group (9.4%). In conclusion, sleep-specific CBT appears to be efficacious and feasible in treating PTSD symptoms. Due to the relatively small number of randomized controlled trials available, further research is warranted to confirm its efficacy and acceptability, especially in comparison to trauma-specific psychological treatments.

Correlations Between Sexual Abuse Histories, Perceived Danger, and PTSD Among Intimate Partner Violence Victims

Intimate partner violence (IPV), childhood abuse, and sexual assault in adulthood are profound public health concerns, particularly for women. Exposure to trauma can contribute to long-standing health problems and escalated medical costs. Unfortunately, these experiences are often intertwined. Sexual assault often occurs in intimate relationships in which there is concurrent IPV; likewise, many victims of IPV have experienced childhood abuse. The prevalent intersections of these struggles can lead to posttraumatic stress disorder (PTSD) symptoms. This article examines the contributions of childhood abuse histories and sexual assault to PTSD symptoms among women experiencing IPV. Findings suggest childhood abuse experiences account for more variance in PTSD symptoms than adult sexual assault. Clinical implications are discussed.

Relationship between self-reported physical health problems and sleep disturbances among trauma survivors: a brief report

OBJECTIVES

History of trauma exposure is often associated with negative physical health outcomes. Better understanding of this association may have important implications for improved health and decreased health care-related costs. One possible link between trauma and poor health outcomes is the pernicious impact of sleep disturbances. In the present study, it was hypothesized that sleep quality would predict physical health symptoms above and beyond posttraumatic stress disorder (PTSD) and depression.

METHODS

Fifty-four trauma-exposed adults participated in a randomized controlled trial for treatment of trauma-related nightmares. Physical health symptoms, depression, PTSD symptoms, and sleep quality were assessed via self-report.

RESULTS

Consistent with expectations, analyses revealed sleep quality uniquely contributed to physical health symptoms above and beyond PTSD and depression symptoms. Moreover, sleep quality mediated the relationship between PTSD symptoms and physical health symptoms.

CONCLUSIONS

Findings suggest sleep disturbances may require specific interventions to maximize positive physical and mental health outcomes.

Sleep disturbances, TBI and PTSD: Implications for treatment and recovery

Post-Traumatic Stress Disorder (PTSD), traumatic brain injury (TBI), and sleep problems significantly affect recovery and functional status in military personnel and Veterans returning from combat. Despite recent attention, sleep is understudied in the Veteran population. Few treatments and rehabilitation protocols target sleep, although poor sleep remains at clinical levels and continues to adversely impact functioning even after the resolution of PTSD or mild TBI symptoms. Recent developments in non-pharmacologic sleep treatments have proven efficacious as stand-alone interventions and have potential to improve treatment outcomes by augmenting traditional behavioral and cognitive therapies. This review discusses the extensive scope of work in the area of sleep as it relates to TBI and PTSD, including pathophysiology and neurobiology of sleep; existing and emerging treatment options; as well as methodological issues in sleep measurements for TBI and PTSD. Understanding sleep problems and their role in the development and maintenance of PTSD and TBI symptoms may lead to improvement in overall treatment outcomes while offering a non-stigmatizing entry in mental health services and make current treatments more comprehensive by helping to address a broader spectrum of difficulties.

Treatment of Sleep Disturbances in Post-Traumatic Stress Disorder: A Review of the Literature

Sleep disturbances are among the most commonly endorsed symptoms of post-traumatic stress disorder (PTSD). Treatment modalities that are effective for the waking symptoms of PTSD may have limited efficacy for post-traumatic sleep problems. The aim of this review is to summarize the evidence for empirically supported and/or utilized psychotherapeutic and pharmacological treatments for post-traumatic nightmares and insomnia. While there are few controlled studies of the applicability of general sleep-focused interventions to the management of the sleep disturbances in PTSD, evidence is growing to support several psychotherapeutic and pharmacological treatments. Future investigations should include trials that combine treatments focused on sleep with treatments effective in managing the waking symptoms of PTSD.

Alterations in circadian/seasonal rhythms and vegetative functions are related to suicidality in DSM-5 PTSD

BACKGROUND

Alterations in rhythmicity and vegetative functions have been reported as correlates of suicidality, particularly in patients with mood disorders. No investigation has addressed their impact on patients with post-traumatic stress disorder (PTSD). Aim of the present study was to fulfill this gap.

METHODS

Sixty-five out- and inpatients with DSM-5 PTSD were assessed by using the Mood Spectrum-Self Report-Lifetime Version (MOODS-SR), a questionnaire for lifetime mood spectrum symptomatology including alterations in circadian/seasonal rhythms and vegetative functions. Six items of the MOODS-SR were combined and dichotomized to assess suicidal ideation and/or attempts.

RESULTS

Significant and positive associations were found between symptoms of lifetime dysregulations in rhythmicity and vegetative functions and suicidal ideation and/or attempts. All MOODS-SR sub-domains (rhythmicity, sleep, appetite/weight, sexual function, physical symptoms) were associated with an increased likelihood of suicidal ideation, but only changes in appetite/weight were associated with greater odd ratios of suicide attempts (OR = 2.099, 95% CI 1.148-3.841).

CONCLUSIONS

Our results suggest that lifetime dysregulations in rhythmicity and vegetative functions may represent correlates of suicidality in patients with DSM-5 PTSD.

Interactions between disordered sleep, post-traumatic stress disorder, and substance use disorders

Disordered sleep is associated with a number of adverse health consequences and is an integral component of many psychiatric disorders. Rates of substance use disorders (SUDs) are markedly higher among individuals with post-traumatic stress disorder (PTSD), and this relationship may be partly mediated by disturbed sleep. Sleep disturbances (e.g. insomnia, daytime sleepiness, vivid nightmares) are hallmark features of PTSD and there is evidence that individuals with PTSD engage in substance use as a means of coping with these symptoms. However, prolonged substance use can lead to more severe sleep disturbances due to the development of tolerance and withdrawal. Behavioural or pharmacological treatment of disordered sleep is associated with improved daytime symptoms and psychosocial functioning among individuals who have developed PTSD. Initial research also suggests that improving sleep could be similarly beneficial in reducing coping oriented substance use and preventing relapse among those seeking treatment for SUDs. Together, these findings suggest that ameliorating sleep disturbance among at-risk individuals would be a viable target for the prevention and treatment of PTSD and associated SUDs, but prospective research is needed to examine this hypothesis. Enhanced understanding of the interrelation between sleep, PTSD, and SUDs may yield novel prevention and intervention approaches for these costly, prevalent and frequently co-occurring disorders.

Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial

STUDY OBJECTIVES

Examine whether cognitive behavioral therapy for insomnia (CBT-I) improves sleep in posttraumatic stress disorder (PTSD) as well as nightmares, nonsleep PTSD symptoms, depression symptoms, and psychosocial functioning.

DESIGN

RANDOMIZED CONTROLLED TRIAL WITH TWO ARMS: CBT-I and monitor-only waitlist control.

SETTING

Department of Veterans Affairs (VA) Medical Center.

PARTICIPANTS

Forty-five adults (31 females: [mean age 37 y (22-59 y)] with PTSD meeting research diagnostic criteria for insomnia, randomly assigned to CBT-I (n = 29; 22 females) or monitor-only waitlist control (n = 16; nine females).

INTERVENTIONS

Eight-session weekly individual CBT-I delivered by a licensed clinical psychologist or a board-certified psychiatrist.

MEASUREMENTS AND RESULTS

Measures included continuous monitoring of sleep with diary and actigraphy; prepolysomnography and postpolysomnography and Clinician-Administered PTSD Scale (CAPS); and pre, mid, and post self-report questionnaires, with follow-up of CBT-I participants 6 mo later. CBT-I was superior to the waitlist control condition in all sleep diary outcomes and in polysomnography-measured total sleep time. Compared to waitlist participants, CBT-I participants reported improved subjective sleep (41% full remission versus 0%), disruptive nocturnal behaviors (based on the Pittsburgh Sleep Quality Index-Addendum), and overall work and interpersonal functioning. These effects were maintained at 6-mo follow-up. Both CBT-I and waitlist control participants reported reductions in PTSD symptoms and CAPS-measured nightmares.

CONCLUSIONS

Cognitive behavioral therapy for insomnia (CBT-I) improved sleep in individuals with posttraumatic stress disorder, with durable gains at 6 mo. Overall psychosocial functioning improved following CBT-I. The initial evidence regarding CBT-I and nightmares is promising but further research is needed. Results suggest that a comprehensive approach to treatment of posttraumatic stress disorder should include behavioral sleep medicine.

CLINICAL TRIAL INFORMATION

TRIAL NAME: Cognitive Behavioral Treatment Of Insomnia In Posttraumatic Stress Disorder. URL: http://clinicaltrials.gov/ct2/show/NCT00881647.

REGISTRATION NUMBER

NCT00881647.

Longitudinal relationships of insomnia, nightmares, and PTSD severity in recent combat veterans

OBJECTIVE

This observational, longitudinal study of veterans with recent combat exposure describes the prevalence, severity and associations of posttraumatic stress disorder (PTSD), insomnia, and nightmares over time.

METHODS

Eighty recent combat veterans recruited from Veterans Health Administration primary care settings met inclusion criteria including hazardous alcohol use and at least subthreshold PTSD. Insomnia status and nightmare status were assigned based on the Insomnia Severity Index total score and the PTSD Checklist nightmare item, respectively. Participants were re-assessed six months following their baseline assessment. Analyses of variance compared insomnia and nightmare groups on PTSD, depression, and alcohol use severity. Analyses of covariance (controlling for baseline differences) examined whether insomnia and/or nightmares were associated with the clinical course of PTSD. Persistence of conditions was also examined.

RESULTS

At baseline, 74% presented with insomnia and 61% endorsed distressing nightmares. Insomnia was associated with significantly higher PTSD and depression severity at both baseline and six months. The presence of nightmares was associated with significantly higher PTSD severity at both time points and with depression severity at baseline only. Despite decreases in PTSD and depression severity, insomnia severity was relatively unchanged after six months. The prevalence and severity of nightmare complaints diminished modestly over time.

CONCLUSION

Among this sample of recent combat veterans, insomnia and nightmares were each strongly associated with the severity of both PTSD and depressive symptoms. Over time, insomnia in particular did not appear to resolve spontaneously and was associated with ongoing PTSD. Addressing insomnia early, therefore, may be a strategy to alter the course of PTSD.