Sleep Disturbances as the Hallmark of PTSD: Where Are We Now?

Germain, Anne

doi:10.1176/appi.ajp.2012.12040432

Cited by 508 publications

(428 citation statements)

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“…Although the present study focused on insomnia, the role of restless REM sleep in emotion regulation appears highly relevant to other realms of psychiatry. Restless REM sleep is present in MDD (18) and PTSD (19,20). Importantly, insomnia impedes the effectiveness of depression intervention (4), whereas treatment of insomnia improves remission from MDD (3).…”

Section: Discussionmentioning

confidence: 99%

“…We use the term "restless REM sleep" here to refer to REM sleep with a high number of phasic events, including arousals and eye movements. These phasic events commonly occur not only in insomnia (5) but also in depression (18) and posttraumatic stress disorder (PTSD) (19,20). If restless REM sleep interferes with the overnight resolution of emotional distress, it could contribute to its accumulation, appearing as a chronically hyperaroused state.…”

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confidence: 99%

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Slow dissolving of emotional distress contributes to hyperarousal

Wassing

Benjamins

Dekker

et al. 2016

Proc. Natl. Acad. Sci. U.S.A.

145

121

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The mechanisms underlying hyperarousal, the key symptom of insomnia, have remained elusive, hampering cause-targeted treatment. Recently, restless rapid-eye-movement (REM) sleep emerged as a robust signature of sleep in insomnia. Given the role of REM sleep in emotion regulation, we hypothesized that restless REM sleep could interfere with the overnight resolution of emotional distress, thus contributing to accumulation of arousal. Participants (n = 1,199) completed questionnaires on insomnia severity, hyperarousal, self-conscious emotional distress, and thought-like nocturnal mentation that was validated to be a specific proxy for restless REM sleep (selective fragmentation: R = 0.57, P < 0.001; eye movement density: R = 0.46, P < 0.01) in 32 polysomnographically assessed participants. The experience of distress lasting overnight increased with insomnia severity (β = 0.29, P < 10 −23 ), whereas shortlasting distress did not (β = −0.02, P = 0.41). Insomnia severity was associated with hyperarousal (β = 0.47, P < 10 −63 ) and with the thought-like nocturnal mentation that is specifically associated with restless REM sleep (β = 0.31, P < 10 −26 ). Structural equation modeling showed that 62.4% of the association between these key characteristics of insomnia was mediated specifically by reduced overnight resolution of emotional distress. The model outperformed all alternative mediation pathways. The findings suggest that restless REM sleep reflects a process that interferes with the overnight resolution of distress. Its accumulation may promote the development of chronic hyperarousal, giving clinical relevance to the role of REM sleep in emotion regulation in insomnia, depression, and posttraumatic stress disorder.B oth insomnia and affective disorders are among the most prevalent and burdening health concerns facing our society. Targeted prevention of affective disorders in people at risk, as well as identification of mechanisms of conversion, could be the most viable approach to mitigate their increasing global burden (1). For the prevention of new-onset or recurrent affective disorder, insomnia may be the major risk factor that can be targeted best (2, 3). About 13% of people with insomnia develop major depression disorder (MDD) within a year (2). Moreover, remission rates after cognitive behavioral therapy are 21% lower for depressed patients with abnormal sleep compared with patients with relatively intact sleep (4). It therefore appears highly relevant to understand the mechanisms involved in the role of insomnia in disturbed emotion regulation (2). The present study addresses the roles of restless rapid-eye-movement (REM) sleep (5) and chronic physiological arousal (6), which are characteristic of both insomnia and MDD.Although sleep contributes to the more robust consolidation of emotional memories, relative to neutral memories (7, 8), their later recall is not associated with anywhere near the same magnitude of subjective emotional distress, autonomic arousal, and amygdala activation (7, 9-11). REM sleep p...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Slow dissolving of emotional distress contributes to hyperarousal

Wassing

Benjamins

Dekker

et al. 2016

Proc. Natl. Acad. Sci. U.S.A.

145

121

View full text Add to dashboard Cite

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“…22,23 Addressing nightmares as a distinct sleep disorder following a traumatic experience is of clinical importance as patients with disturbed sleep have poor outcomes and sleep-focused therapy can lead to improvement in PTSD, anxiety, and depression. 24,25 Research on nightmares in military personnel is limited, though data suggest that veterans who have left military service have a higher prevalence than the general population. 10 The primary objective of this study was to characterize the prevalence of nightmares in United States military personnel with sleep disturbances.…”

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confidence: 99%

Nightmares in United States Military Personnel With Sleep Disturbances

Creamer

Brock

Matsangas

et al. 2018

Journal of Clinical Sleep Medicine

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Study Objectives: Sleep disturbances are common in United States military personnel. Despite their exposure to combat and trauma, little is known about nightmares in this population. The purpose of this study was to describe the prevalence and associated clinical and polysomnographic characteristics of nightmares in United States military personnel with sleep disturbances. Methods: Retrospective review of 500 active duty United States military personnel who underwent a sleep medicine evaluation and polysomnography at our sleep center. The Pittsburgh Sleep Quality Index and the Pittsburgh Sleep Quality Index-Addendum were used to characterize clinically significant nightmares. Subjective and objective sleep attributes were compared between groups. Results: At least weekly nightmares were present in 31.2%; yet, only 3.9% reported nightmares as a reason for evaluation. Trauma-related nightmares occurred in 60% of those patients with nightmares. Patients with nightmares had increased sleep onset latency (SOL) and rapid eye movement (REM) sleep latency (mean SOL/REM sleep latency 16.6/145 minutes, P = .02 and P = .01 respectively) compared to those without (mean SOL/REM sleep latency 12.5/126 minutes I NTRO DUCTI O NNightmares are defined by repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that cause clinically significant distress or impairment in social, occupational, or other areas of functioning. 1 Occasional nightmares are part of a normal adaptive response to life stressors and are not pathologic, with 85% of adults reporting at least one nightmare per year. 2 The prevalence of clinically significant nightmares, which occur at least once per week, is estimated between 0.9% and 6.8%. [3][4][5][6][7][8][9] In the largest study to date (69,813 adults), the prevalence of nightmares was 3.5% in men and 4.8% in women. 10 Participants from the World War II generation had a significantly higher prevalence of 7.2% in men and 7% in women. Nightmares are more common among patients with sleep disturbances, sleep disorders, depression, anxiety, and posttraumatic stress disorder However, most research evaluating sleep disorders in active duty military personnel has focused on insomnia, obstructive sleep apnea (OSA), and PTSD, noting that a recent study focusing on OSA and PTSD did not evaluate nightmares. [18][19][20] Following traumatic experiences, sleep disturbances are frequently reported, including trauma-related nightmares (TRN). 21 The nightmares of trauma survivors tend to be more severe and distressing than idiopathic nightmares. 1,3 Though not exclusive to PTSD, TRN have been referred to as the "hallmark" of this disorder, with rates as high as 90%. 22,23 Addressing nightmares as a distinct sleep disorder following a BRIEF SUMMARY Current Knowledge/Study Rationale: The spectrum of sleep disorders in military personnel is varied and complicated by the presence of comorbidities and psychological disorders. Currently, little is known regarding nightmares, especially trauma-related nig...

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“…Supporting the notion of inter-domain interactions, sleep problems are strongly linked to the maladaptive emotional and cognitive processing symptoms associated with PTSD [11]. Furthermore, recent research has demonstrated that sleep problems may play an etiological role in the development of PTSD [12,13].…”

Section: Introductionmentioning

confidence: 95%

“…Sleep-related behaviors are present in the loss construct under negative valence systems, but they are absent from biological drives (i.e., appetite, libido) in the construct of sustained threat within the same domain. Additionally, interactions are possible between various domains, as appears to be the case in arousal and negative valence in the context of sleep and trauma exposure [11].…”

Section: Introductionmentioning

confidence: 99%

Understanding Recent Insights in Sleep and Posttraumatic Stress Disorder from a Research Domain Criteria (RDoC) Framework

Kelly

Killgore

Haynes

2016

Curr Sleep Medicine Rep

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Posttraumatic stress disorder (PTSD) is associated with sleep disturbances, including insomnia, nightmares, sleep-disordered breathing, and REM abnormalities. Recent studies have expanded our knowledge of the neurobiology of trauma and sleep. In addition, intervention research has provided valuable information about how sleep treatments affect PTSD symptoms and how PTSD treatments affect sleep symptoms. This review of recent literature aims to move away from the categorical approach that currently dominates our conceptualization of trauma response and sleep disorders. Possible mechanisms of both trauma and sleep disturbance are posed within the framework put forth by the National Institute of Mental Health's (NIMH) Research Domain Criteria (RDoC) project. By examining domains of dysfunction that cut across disorders, RDoC may guide future research and treatment of the maladaptive neurobiological and behavioral correlates of both trauma and sleep disturbances.

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Sleep Disturbances as the Hallmark of PTSD: Where Are We Now?

Cited by 508 publications

References 92 publications

Slow dissolving of emotional distress contributes to hyperarousal

Slow dissolving of emotional distress contributes to hyperarousal

Nightmares in United States Military Personnel With Sleep Disturbances

Understanding Recent Insights in Sleep and Posttraumatic Stress Disorder from a Research Domain Criteria (RDoC) Framework

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