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

Treating sleep disturbances in refugees and asylum seekers: results from a randomized controlled pilot trial evaluating the STARS group intervention

Background: Sleep disturbances are highly prevalent in traumatized refugees and often persist despite treatment, and adapted scalable interventions are needed. The group intervention 'Sleep Training adapted for Refugees' (STARS) is a culturally- and context-sensitive approach based on evidence-based treatments for sleep disturbances (e.g. CBT-I, IRT). This study evaluated the feasibility, acceptability, and effectiveness of STARS.Method: A randomized-controlled trial (STARS vs. waitlist) with 47 young male Afghan refugees was conducted in a routine clinical setting (DRKS-ID: DRKS00024419) with pre-, post- and 3-month follow-up assessments. The primary outcome was insomnia severity (Insomnia Severity Index); secondary outcomes included PTSD, anxiety and depression symptoms, nightmares, coping with nightmares, fear of sleep, selected sleep diary measures, and quality of life. The data were analysed using mixed models.Results: Adherence to STARS was high (dropout = 17.4%, average attended sessions = 77%) as was client satisfaction (MCSQ-4 = 12.74, SDCSQ-4 = 2.08). A medium to large significant effect of time was observed for insomnia severity (d = 0.96) and most secondary measures (except nightmares and fear of sleep). However, there was no significant interaction with condition at post-treatment for the primary outcome (d = 0.29) and most secondary outcomes; the only exceptions were increased coping with nightmares, decreased daytime sleep, and time in bed.Conclusions: STARS appears feasible for treating sleep disturbances in traumatized refugees in a routine clinical setting, showing moderate to large within-group effects. However, it was not superior to the waitlist, likely due to unexpected improvements in the waitlist group. Adjustments to STARS may enhance its efficacy. Further research is needed to determine how STARS can be a scalable add-on treatment for sleep disturbances in traumatized refugees and asylum seekers.Trial registration: German Clinical Trials Register identifier: DRKS00024419..

Association between oral microbiome and sleep disorders in U.S. adults: analysis of NHANES database 2009-2012

BACKGROUND

The microbiome, especially the gut microbiome, contributes to the regulation, etiology, and pathogenesis of sleep disorder. However, limited evidence regarding the oral microbiome's role in sleep disorder. Therefore, this study aimed to investigate the association between sleep disorder and oral microbial diversity and whether oral microbiota is associated with all-cause mortality in people with sleep disorder.

METHODS

The study included 4,729 individuals in the National Health and Nutrition Examination Survey (NHANES) from 2009 to 2012 and mortality data until 2019. Sleep disorder was assessed by structured questionnaire. The oral microbiome was characterized by 16 S ribosomal RNA gene sequencing. Logistic regression models were conducted to quantify the association of α-diversity with different sleep status controlling for potential confounding variables, and principal coordinate analysis along with permutational multivariate analysis of variance for β-diversity. The association between the oral microbiome and all-cause mortality was assessed using Cox proportional hazard models.

RESULTS

The α-diversity showed that a lower number of operational taxonomic units (OTUs) (adjusted odds ratio [aOR] = 0.996; 95% confidence interval [CI] = 0.994-0.998), less Faith's phylogenetic diversity (aOR = 0.954, 95% CI = 0.934-0.975), and a lower Shannon-Weiner index (aOR = 0.854, 95% CI = 0.772-0.944) were associated with sleep disorder. β-diversity revealed different oral microbiome communities between the two groups, as measured by the Bray-Curtis dissimilarity (R2 = 0.358%, P = 0.001), unweighted UniFrac distance (R2 = 0.450%, P = 0.001) and weighted UniFrac distance (R2 = 0.709%, P = 0.001). Furthermore, the OTUs (odds ratio [OR] = 0.999; 95% CI = 0.998-0.999; P < 0.05), Faith's phylogenetic diversity (OR = 0.987; 95% CI = 0.975-0.998; P < 0.05), Shannon-Weiner index (OR = 0.924; 95% CI = 0.873-0.979; P < 0.05), and the inverse Simpson index (OR = 0.553; 95% CI = 0.306-0.997; P < 0.05) were all associated with a significant increase in the risk of all-cause death in participants with sleep disorder.

CONCLUSIONS

Intra-population richness, inter-population dispersion, and the phylogenetic diversity of the oral microbiome have all been linked to sleep disorder and all-cause mortality. Overall, these results will help to better understand the etiology and pathogenesis of sleep disorder. Further studies are required to determine the mechanisms underlying the role of microbiome in the pathogenesis of sleep disorder.

Insomnia in ambulatory care: A clinical review

PURPOSE

One-third to one-half of ambulatory care patients report insomnia. The objective of this clinical review is to detail the many causes and evidence-based treatment options for insomnia in outpatients and to recommend screening and summarize evidence for the place in therapy of prescription and nonprescription treatments.

SUMMARY

This work provides an overview of the literature on insomnia regarding causes, patient assessment, and nonpharmacological and pharmacological treatments. Patients who present with insomnia should be assessed for sleep apnea, restless legs syndrome, narcolepsy, and all contributing medications as well as medical, psychiatric, and substance use disorder diagnoses. The type of insomnia, namely difficulty falling asleep, difficulty maintaining sleep, and early morning awakening with resulting functional impairment, should be documented in addition to whether insomnia is short term or persistent. Cognitive behavioral therapy for insomnia (CBT-I) or digital CBT-I is first-line treatment for all patients with insomnia irrespective of the cause or type. Nonprescription treatments such as antihistamines or melatonin are for select populations. Prescription hypnotics are best utilized on an as-needed basis or for nightly use for less than 6 weeks. Z-hypnotics are safe and effective for insomnia in persons with depression or an anxiety disorder but should be avoided in older individuals or if there is respiratory or cognitive impairment. Orexin receptor antagonists are effective for sleep initiation and maintenance in healthy persons or if there is mild cognitive impairment, but they require further study in individuals with psychiatric and medical diagnoses. Trazodone is the most prescribed off-label treatment due to its efficacy for sleep initiation and maintenance and its lack of abuse potential.

CONCLUSION

Insomnia treatment should be guided by patient age, diagnoses, and type of insomnia. Pharmacological treatments should be used at the lowest effective dose for the shortest duration of time.

Fear of Death and Sleep Quality in the Aftermath of an Earthquake

PURPOSE

To examine fear of death and disruption in sleep patterns in individuals who have experienced an earthquake.

METHOD

A descriptive and relationship-oriented study was performed with 322 individuals who experienced the February 6, 2023, earthquake in Turkey. Data were collected between February 20 and May 15, 2023. A personal information form, the Pittsburgh Sleep Quality Index (PSQI), and Death Anxiety Scale (DAS) were used for data collection.

RESULTS

Participants' mean DAS score was 7.96 (SD = 1.05), and mean PSQI score was 8.74 (SD = 4.06). Statistically significant relationships were found between sex, marital status, and mean DAS score, and these variables accounted for 11.7% of the total variance. Similarly, statistically significant relationships were found among economic status, relationship to person trapped under the rubble, financial loss from the earthquake, and mean PSQI score, accounting for 11.3% of the total variance. Women and married people had greater fear of death, and those with good economic status, whose family members were buried under rubble, and who experienced financial loss as a result of the earthquake had lower sleep quality.

CONCLUSION

The earthquake led to moderate fear of death and poor sleep quality among participants. Findings highlight the need for targeted support for vulnerable groups following disasters. [Journal of Psychosocial Nursing and Mental Health Services, 63(2), 45-54.].

Insomnia and sleep apnea in the entire population of US Army soldiers: Associations with deployment and combat exposure 2010-2019, a retrospective cohort investigation

OBJECTIVES

This retrospective cohort study examined clinically diagnosed insomnia and sleep apnea and analyzed associations with deployment and combat exposure in active-duty soldiers (n=1,228,346) from 2010 to 2019.

METHODS

Retrospective data were obtained from the Soldier Performance, Health, and Readiness database.

RESULTS

Overseas soldier deployments peaked in 2010, decreasing thereafter as soldiers were withdrawn from Iraq and Afghanistan. From 2010 to 2012 insomnia incidence increased at a rate of 6.7 cases/1000 soldier-years, then decreased after 2012 at 5.3 cases/1000 soldier-years. Sleep apnea increased 2010-2016 at 1.9 cases/1000 soldier-years and generally declined thereafter. Risk of insomnia increased with deployment (hazard ratio=1.51; 95% confidence interval=1.49-1.52) and combat exposure (hazard ratio=1.15; 95% confidence interval=1.13-1.17). Risk of sleep apnea was increased by deployment (hazard ratio=1.89; 95% confidence interval, 1.86-1.92) and combat exposure (hazard ratio=1.09; 95% confidence interval, 1.07-1.11). Most relationships remained after accounting for other factors in multivariable analyses, except that the association between sleep apnea and combat exposure was reduced (hazard ratio=0.94; 95% confidence interval=0.92-0.97).

CONCLUSIONS

Insomnia risk decreased in the period nearly in parallel with a reduction in the number of deployments; nonetheless deployment and combat exposure increased insomnia risk in the period examined. Risk of sleep apnea increased in the period and was related to deployment but not combat exposure after accounting for demographics and comorbid conditions. Despite reductions in insomnia incidence and a slowing in sleep apnea incidence, sleep disorders remain highly prevalent, warranting continued emphasis on sleep-disorder screening and improving the soldier sleep habits.

Increase in short-term and long-term stress-associated mental illness after Jiji earthquake in Taiwan: A twenty-year longitudinal population-based cohort study (1999-2019)

BACKGROUND

Earthquakes have caused profound physical and mental health impacts in human history. The Jiji earthquake, which had a magnitude of 7.6 on the Richter scale, occurred on 21 September 1999 in Taiwan. A close follow-up on the mental health status of affected adults after major natural disasters to construct the short-term and long-term risk and prevalence of stress-associated mental illnesses has not been performed by using the nationwide health databases.

METHODS

This population-based cohort study included 468,804 adults affected by Jiji earthquake spanning from 2000 to 2019 who were matched at a 1:4 ratio with unaffected individuals based on age and sex (n = 1,875,216). Employing a subdistribution hazard regression analysis, we assessed the incidence of sleep, anxiety, and depressive disorders after Jiji earthquake. Corrections for multiple comparisons were carried out using the Benjamini-Hochberg procedure.

RESULTS

Affected adults experienced an increased incidence of short-term (approximately twice) stress-associated psychiatric disorders. The risk of the post-traumatic stress disorder (PTSD) is significantly higher in the affected adults (40-64 years: aSHR: 92.0; ≥65 years: aSHR: 96.7, p < 0.0001). Middle-aged (aged 40-64 years) male adults presented with significantly more short-term (< one year) and long-term (up to 20 years) stress-related mental illnesses, i.e., insomnia, anxiety, and depressive disorders, than individuals in the control group.

CONCLUSIONS

An earthquake has significant short and long-term effects on sleep quality, anxiety, and depressive disorders in affected adults. Optimal short and long-term close monitoring is needed to deploy medical resources and socioeconomic support to relieve mental stress burdens.

Results of two cross-sectional database analyses regarding nap-induced modulations of tinnitus

The influence of naps on tinnitus was systematically assessed by exploring the frequency, clinical and demographic characteristics of this phenomenon. 9,724 data from two different tinnitus databases (Tinnitus Hub: n = 6115; Tinnitus Research Initiative (TRI): n = 3627) were included. After separate analysis of the databases, these results were then compared with each other. In the Tinnitus Hub survey database, a total of 31.1% reported an influence on tinnitus by taking a nap (26.9% in the TRI database), with much more frequent worsening after a nap than improvement (23.0% a little or a lot worse; TRI: 17.7% worse; 8.1% a little or a lot better; TRI: 9.2% better). The influence of napping on tinnitus was associated in both databases with other clinical features, such as the dependence of tinnitus on night quality, stress and somatosensory maneuvers. The present study confirms the clinical observation that more tinnitus sufferers report worsening after a nap than tinnitus sufferers reporting an improvement. It was consistently shown that tinnitus sufferers reporting nap-induced modulation of tinnitus also report more frequently an influence of night sleep on their tinnitus. Further clinical and polysomnographic research is warranted to better understand the interaction between sleep and tinnitus.

Neurobiology and Treatment of Posttraumatic Stress Disorder

The recent worldwide surge of warfare and hostilities exposes increasingly large numbers of individuals to traumatic events, placing them at risk of developing posttraumatic stress disorder (PTSD) and challenging both clinicians and service delivery systems. This overview summarizes and updates the core knowledge of the genetic, molecular, and neural circuit features of the neurobiology of PTSD and advances in evidence-based psychotherapy, pharmacotherapy, neuromodulation, and digital treatments. While the complexity of the neurobiology and the biological and clinical heterogeneity of PTSD have challenged clinicians and researchers, there is an emerging consensus concerning the underlying mechanisms and approaches to diagnosis, treatment, and prevention of PTSD. This update addresses PTSD diagnosis, prevalence, course, risk factors, neurobiological mechanisms, current standard of care, and innovations in next-generation treatment and prevention strategies. It provides a comprehensive summary and concludes with areas of research for integrating advances in the neurobiology of the disorder with novel treatment and prevention targets.

Infralimbic activity during REM sleep facilitates fear extinction memory

Rapid eye movement (REM) sleep is known to facilitate fear extinction and play a protective role against fearful memories.1,2 Consequently, disruption of REM sleep after a traumatic event may increase the risk for developing PTSD.3,4 However, the underlying mechanisms by which REM sleep promotes extinction of aversive memories remain largely unknown. The infralimbic cortex (IL) is a key brain structure for the consolidation of extinction memory.5 Using calcium imaging, we found in mice that most IL pyramidal neurons are intensively activated during REM sleep. Optogenetically suppressing the IL specifically during REM sleep within a 4-h window after auditory-cued fear conditioning impaired extinction memory consolidation. In contrast, REM-specific IL inhibition after extinction learning did not affect the extinction memory. Whole-cell patch-clamp recordings demonstrated that inactivating IL neurons during REM sleep depresses their excitability. Together, our findings suggest that REM sleep after fear conditioning facilitates fear extinction by enhancing IL excitability and highlight the importance of REM sleep in the aftermath of traumatic events for protecting against traumatic memories.

Trauma Exposure in Migrant Children: Impact on Sleep and Acute Treatment Interventions

Trauma exposure significantly impacts sleep in children. Nightmares are common. Evidence-based therapies are superior to medications but may not always be available in acute settings. No FDA-approved medications exist for the treatment of trauma-related sleep disturbances in youth. The evidence-base for the use of medications is largely based on case reports, retrospective chart reviews, clinical opinion, and adult studies. This evidence is reviewed for a number of medications, including prazosin, trazodone, alpha-2 agonists, quetiapine, and others.

BNST GABAergic neurons modulate wakefulness over sleep and anesthesia

The neural circuits underlying sleep-wakefulness and general anesthesia have not been fully investigated. The GABAergic neurons in the bed nucleus of the stria terminalis (BNST) play a critical role in stress and fear that relied on heightened arousal. Nevertheless, it remains unclear whether BNST GABAergic neurons are involved in the regulation of sleep-wakefulness and anesthesia. Here, using in vivo fiber photometry combined with electroencephalography, electromyography, and video recordings, we found that BNST GABAergic neurons exhibited arousal-state-dependent alterations, with high activities in both wakefulness and rapid-eye movement sleep, but suppressed during anesthesia. Optogenetic activation of these neurons could initiate and maintain wakefulness, and even induce arousal from anesthesia. However, chronic lesion of BNST GABAergic neurons altered spontaneous sleep-wakefulness architecture during the dark phase, but not induction and emergence from anesthesia. Furthermore, we also discovered that the BNST-ventral tegmental area pathway might participate in promoting wakefulness and reanimation from steady-state anesthesia. Collectively, our study explores new elements in neural circuit mechanisms underlying sleep-wakefulness and anesthesia, which may contribute to a more comprehensive understanding of consciousness and the development of innovative anesthetics.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

A path model of associations between war-related exposure to trauma, nightmares, fear, insomnia, and posttraumatic stress among Ukrainian students during the Russian invasion

The present study examined the associations between war-related exposure, nightmares, fear, insomnia, and PTSD symptoms among university students from Western Ukraine. An online cross-sectional study was performed among 1,072 university students (80% of whom were women) during the war. Eight questions were developed to assess exposure to war, and seven items were designed regarding nightmares of war. War-related PTSD symptoms were assessed using an abbreviated six-item PTSD checklist (PCL-6), insomnia was measured using the Athens Insomnia Scale (AIS), and to examine fear of war, the Fear of COVID-19 Scale (FoCV-19S) was adopted. Positive correlations were found between exposure to war, nightmares of war, fear of war, insomnia, and war-related PTSD. The path model using structural equation modelling (SEM) analysis showed that the chain mediation partially explains the relationship between war exposure and war-related PTSD symptoms via nightmares of war, fear of war, and insomnia among university students during the Russian invasion of Ukraine. Women scored significantly higher than men in fear of war and symptoms of insomnia and PTSD, but the path model was invariant across genders. Young adults require treatment focused primarily on nightmares, insomnia, and fear of war to prevent PTSD symptoms.

From childhood adversity to latent stress vulnerability in adulthood: the mediating roles of sleep disturbances and HPA axis dysfunction

Childhood adversity is a prominent predisposing risk factor for latent stress vulnerability, expressed as an elevated likelihood of developing stress-related psychopathology upon subsequent exposure to trauma in adulthood. Sleep disturbances have emerged as one of the most pronounced maladaptive behavioral outcomes of childhood adversity and are also a highly prevalent core feature of stress-related psychopathology, including post-traumatic stress disorder (PTSD). After reviewing the extensive literature supporting these claims, the current review addresses the notion that childhood adversity-induced sleep disturbances may play a causal role in elevating individuals' stress vulnerability in adulthood. Corroborating this, sleep disturbances that predate adult trauma exposure have been associated with an increased likelihood of developing stress-related psychopathology post-exposure. Furthermore, novel empirical evidence suggests that sleep disturbances, including irregularity of the sleep-wake cycle, mediate the link between childhood adversity and stress vulnerability in adulthood. We also discuss cognitive and behavioral mechanisms through which such a cascade may evolve, highlighting the putative role of impaired memory consolidation and fear extinction. Next, we present evidence to support the contribution of the hypothalamic-pituitary-adrenal (HPA) axis to these associations, stemming from its critical role in stress and sleep regulatory pathways. Childhood adversity may yield bi-directional effects within the HPA stress and sleep axes in which sleep disturbances and HPA axis dysfunction reinforce each other, leading to elevated stress vulnerability. To conclude, we postulate a conceptual path model from childhood adversity to latent stress vulnerability in adulthood and discuss the potential clinical implications of these notions, while highlighting directions for future research.

Real-time sensing of war's effects on wellbeing with smartphones and smartwatches

BACKGROUND

Modern wars have a catastrophic effect on the wellbeing of civilians. However, the nature of this effect remains unclear, with most insights gleaned from subjective, retrospective studies.

METHODS

We prospectively monitored 954 Israelis (>40 years) from two weeks before the May 2021 Israel-Gaza war until four weeks after the ceasefire using smartwatches and a dedicated mobile application with daily questionnaires on wellbeing. This war severely affected civilians on both sides, where over 4300 rockets and missiles were launched towards Israeli cities, and 1500 aerial, land, and sea strikes were launched towards 16,500 targets in the Gaza Strip.

RESULTS

We identify considerable changes in all the examined wellbeing indicators during missile attacks and throughout the war, including spikes in heart rate levels, excessive screen-on time, and a reduction in sleep duration and quality. These changes, however, fade shortly after the war, with all affected measures returning to baseline in nearly all the participants. Greater changes are observed in individuals living closer to the battlefield, women, and younger individuals.

CONCLUSIONS

The demonstrated ability to monitor objective and subjective wellbeing indicators during crises in real-time is pivotal for the early detection of and prompt assistance to populations in need.

Treatment of insomnia based on the mechanism of pathophysiology by acupuncture combined with herbal medicine: A review

Insomnia is a sleep disorder which severely affects patients mood, quality of life and social functioning, serves as a trigger or risk factor to a variety of diseases such as depression, cardiovascular and cerebrovascular diseases, obesity and diabetes, and even increases the risk of suicide, and has become an increasingly widespread concern worldwide. Considerable research on insomnia has been conducted in modern medicine in recent years and encouraging results have been achieved in the fields of genetics and neurobiology. Unfortunately, however, the pathogenesis of insomnia remains elusive to modern medicine, and pharmacological treatment of insomnia has been regarded as conventional. However, in the course of treatment, pharmacological treatment itself is increasingly being questioned due to potential dependence and drug resistance and is now being replaced by cognitive behavior therapy as the first-line treatment. As an important component of complementary and alternative medicine, traditional Chinese medicine, especially non-pharmacological treatment methods such as acupuncture, is gaining increasing attention worldwide. In this article, we discuss the combination of traditional Chinese medicine, acupuncture, and medicine to treat insomnia based on neurobiology in the context of modern medicine.

Preventive and Therapeutic Mental Health Care after the Earthquake- Expert Opinion from the Psychiatric Association of Turkey

Two major earthquakes hit Turkey at the Kahramanmaraş region on February 6th 2023. The earthquakes affected almost 15 million individuals, resulting in more than forty thousand deaths, thousands of wounded and the destruction of ancient cities of humankind. Immediately after the earthquakes, the Psychiatric Association of Turkey organized an educational event to address the needs for a guidance on how to approach a trauma of such a big scale. The experts in this educational event summarized their presentations and prepared this review to guide the mental health professionals serving victims of this disaster. The review summarizes the early symptoms of trauma, and puts a framework on the principles of psychological first aid, the approach at the initial stages of the disaster, principles of planning, triage, and psychosocial support systems and the proper use of medications. The text covers the evaluation of the impact of trauma, aligning psychiatric practice with psychosocial interventions, the improvement of counseling skills and methods to better understand the mind during the acute post trauma phase. A set of presentations highlight the challenges in child psychiatry, brings a systematic overview to the earthquake and discuss the symptomatology, first aid and intervention principles in children and adolescents. Last, the forensic psychiatric perspective is presented, followed by a piece on the essentials of delivering bad news and the review is concluded with the emphasis on burnout, a syndrome to avoid particularly for field professionals, and possible preventive measures. Keywords: Disaster, trauma, psychosocial support, psychological first aid, acute stress disorder, post traumatic stress disorder.

Treatment with morning blue light increases left amygdala volume and sleep duration among individuals with posttraumatic stress disorder

Background

Posttraumatic stress disorder (PTSD) is associated with numerous cognitive, affective, and psychophysiological outcomes, including problems with sleep and circadian rhythms. We tested the effectiveness of a daily morning blue-light exposure treatment (BLT) versus a matched amber light treatment (ALT) to regulate sleep in individuals diagnosed with PTSD. Moreover, PTSD is also associated with reliable findings on structural neuroimaging scans, including reduced amygdala volumes and other differences in cortical gray matter volume (GMV) that may be indicative of underlying neurobehavioral dysfunctions. We examined the effect of BLT versus ALT on GMV and its association with sleep outcomes.

Methods

Seventy-six individuals (25 male; 51 female) meeting DSM-V criteria for PTSD (Age = 31.45 years, SD = 8.83) completed sleep assessments and structural neuroimaging scans, followed by random assignment one of two light groups, including BLT (469 nm; n = 39) or placebo ALT (578 nm; n = 37) light therapy daily for 30-min over 6-weeks. Participants wore a wrist actigraph for the duration of the study. After treatment, participants returned to complete sleep assessments and a structural neuroimaging scan. Neuroimaging data were analyzed using the Computational Anatomy Toolbox (CAT12) and Voxel-Based Morphometry (VBM) modules within the Statistical Parametric Mapping (SPM12) software.

Results

The BLT condition produced significant increases in total time in bed and total sleep time from actigraphy compared to the ALT condition, while ALT improved wake after sleep onset and sleep efficiency compared to BLT. Additionally, BLT led to an increase in left amygdala volume compared to ALT but did not affect hypothesized medial prefrontal regions. Finally, within group correlations showed that improvements in sleep quality and nightmare severity were correlated with increases in left amygdala volume over the course of treatment for the BLT group but not the ALT group.

Conclusion

In individuals with PTSD, daily exposure to morning blue light treatment was associated with improvements in objective sleep duration and increased volume of the left amygdala compared to amber placebo light treatment, and changes in amygdala volume correlated with subjective improvement in sleep. These findings suggest that daily morning BLT may provide an important non-pharmacologic adjunctive approach for facilitating sleep and neurobehavioral recovery from PTSD.

Low Sleep Satisfaction Is Related to High Disease Burden in Tinnitus

Previous studies have shown a high prevalence of sleep disturbances in tinnitus patients. However, no study has yet evaluated subjective sleep satisfaction. The present study aimed to investigate associations of self-reported sleep satisfaction with sociodemographic factors, tinnitus-related distress, depression, and self-reported quality of life. This is a retrospective analysis of 2344 outpatients with tinnitus presenting at a tertiary German tinnitus clinic from 2010 to 2020. Patients who filled in five questionnaires (Tinnitus Handicap Inventory (THI), Tinnitus Questionnaire (TQ), Major Depression Inventory (MDI), Tinnitus Sample Case History Questionnaire (TSCHQ), and the World Health Organization Quality of Life Brief Version (WHOQOL-Bref)) were included. Based on the question about sleep satisfaction in the WHOQOL-Bref, group classification into (I) sleep-satisfied, (II) neither satisfied or dissatisfied, and (III) sleep-dissatisfied patients was performed. Associations between sleep satisfaction and quality of life, depression, tinnitus distress, and tinnitus characteristics were analyzed by group differences and a multinomial regression model with elastic net penalization. A total of 42.38% of patients were satisfied or very satisfied with sleep, whereas 40.91% of patients were dissatisfied or very dissatisfied with sleep. The remaining patients reported being neither satisfied nor dissatisfied with sleep. Sleep-dissatisfied patients were significantly more burdened in questionnaires on depressive symptoms (MDI), tinnitus distress (TQ, THI), and quality of life (WHOQOL-Bref). In addition, they suffered significantly more often from comorbidities such as headache, neck pain, or temporomandibular joint disorder (TMJ). The elastic net regression based on sum scores of THI, TQ, MDI, the four domains of WHOQOL-Bref, as well as all individual questions from the TSCHQ was able to classify patients satisfied with their sleep with an accuracy of 79%, 87.8% sensitivity, and 70.4% specificity. The model could not identify patients indifferent with the quality of their sleep (neither satisfied nor dissatisfied) (sensitivity: 0%; specificity: 100%). The accuracy of the model to predict patients dissatisfied with their sleep was 80.7%, with 83% sensitivity and 78.4% specificity. Poor physical and mental health (Domain I/II WHOQOL-Bref) as well as tinnitus distress were the strongest predictors of sleep dissatisfaction. Conversely, for sleep satisfaction, good physical and mental health as well as low tinnitus distress were the strongest predictors. The division into sleep-satisfied and sleep-dissatisfied tinnitus patients allows a very good discrimination regarding disease burden as indicated by depression, tinnitus distress, quality of life, and pain-related comorbidities. Physical and mental health as well as tinnitus distress seem to be strongly related to sleep satisfaction underscoring the concept of "tinnitus" versus "tinnitus disorder", but also the importance of sleep satisfaction as a global health indicator. Moreover, these data indicate the relevance of addressing sleep disorders in the therapeutic management of chronic tinnitus patients.