Pittsburgh Sleep Quality Index Addendum Research Articles

0671 Identifying Disruptive Nocturnal Behaviors in Trauma Associated Sleep Disorder with Video-Polysomnography on Consecutive Nights

Abstract Introduction Trauma associated sleep disorder (TSD) manifests with trauma-related nightmares, disruptive nocturnal behaviors (DNB), and autonomic hyperactivity. Although patients with TSD frequently report DNB, events are infrequently identified during in-lab polysomnography (PSG), possibly due to a sense of safety imparted by a monitored environment. It is unknown if patients with TSD acclimate to the lab environment if studied on consecutive nights. Given the infrequent and potentially subtle nature of DNB and REM sleep abnormalities, the objective of this study was to compare self-reported and PSG characteristics from two consecutive nights of PSG in patients with TSD. Methods Individuals were initially screened for TSD with the Pittsburgh Sleep Quality Index Addendum. Those reporting trauma-related nightmares and DNB underwent a structured clinical interview to confirm the diagnosis. Patients with TSD completed 2 consecutive nights of attended in-lab PSG with post-PSG dream/nightmare questionnaire. Video-PSG analysis was performed including detailed review of movements, excluding epochs with sleep disordered breathing. REM sleep analysis included quantifying “any” electromyographic (EMG) activity as an objective measurement for REM without atonia. ANOVA was used for statistical analysis. Results We diagnosed 15 individuals (11 males; 14 service members, 1 Veteran; average age 32.2 years) with TSD. Traumatic exposures were combat-related in 40% and physical or sexual assault related in 60%. There was a significant difference between proximal limb movements on night 1 vs night 2 (1.0 ± 1.73 vs 10.3 ± 4.04; p=0.02). There was a significant difference in the amount of increased EMG tone using 3 second REM mini epochs between the 2 nights (153 ± 147.8 mini epochs vs 417 ± 35.1; p=0.04). No difference was detected between nights for vocalizations or sleep parameters including total REM sleep time and percentage. Nightmares were reported by 33% during their first night PSG vs 66% during their second PSG. Conclusion In patients with TSD, there was an increase in the number of proximal limb movements, total mini epochs of “any” REM EMG activity, and nightmares during the second night of consecutive in-lab PSG testing. More than one night of in-lab PSG evaluation is likely required to best characterize the severe nocturnal disruptions of TSD. Support (if any)

Emotion dysregulation mediates the association between acute sleep disturbance and later posttraumatic stress symptoms in trauma exposed adults

ABSTRACT Background: Sleep disturbance is common within days to weeks following a traumatic event and has been associated with emotion dysregulation, a strong risk factor for PTSD development. This study aims to examine if emotion dysregulation mediates the relationship between early post-trauma sleep disturbance and subsequent PTSD symptom severity. Methods: Adult participants (n = 125) completed questionnaires regarding sleep disturbance (via Pittsburgh Sleep Quality Index Addendum; PSQI-A) and emotion dysregulation (via Difficulties in Emotion Regulation Scale; DERS) within 2 weeks after exposure to traumatic events. Results: PTSD symptom severity was assessed with PTSD Checklist for DSM-5 (PCL-5) at 3-month follow-up. There were strong correlations between PSQI-A, DERS, and PCL-5 (r ranges between .38 and .45). Mediation analysis further revealed significant indirect effects of overall emotion regulation difficulties in the relationship between sleep disturbance at 2 weeks and PTSD symptom severity at 3 months (B = .372, SE = .136, 95% CI: [.128, .655]). Importantly, limited access to emotion regulation strategies emerged as the single, significant indirect effect in this relationship (B = .465, SE = .204, 95% CI [.127, .910]) while modelling DERS subscales as multiple parallel mediators. Conclusions: Early post-trauma sleep disturbance is associated with PTSD symptoms over months, and acute emotion dysregulation explains part of this association. Those with limited emotion regulation strategies are at particular risk of developing PTSD symptoms. Early interventions focusing on the appropriate strategies for emotion regulation may be crucial for trauma-exposed individuals.

Relationship between Posttraumatic Stress Disorder and Sleep Disturbances in Syrian Refugees in the United States.

Background Posttraumatic stress disorder (PTSD) is associated with disturbed sleep. However, the impact of sleep disturbances and PTSD symptomology in refugee populations is not well known. This study examined how PTSD-related sleep symptoms and overall sleep quality were impacted by previous and current traumatic and stressful experiences. Methods Adult Syrian refugees living in Southeast Michigan were assessed via scheduled in-home interviews. Overall sleep quality was measured using the Pittsburgh Sleep Quality Index. PTSD-related sleep disturbances were measured using the Pittsburgh Sleep Quality Index Addendum. The presence of PTSD symptomatology was assessed via self-report using the Posttraumatic Stress Disorder Checklist. The Life Events Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-5 screened for prior traumatic events experienced and the Postmigration Living Difficulties Questionnaire was assessed for postmigration stressors. Correlational analysis was conducted between overall sleep quality, PTSD symptom severity, and previous trauma experienced. A stepwise linear regression analysis was conducted to examine the role of overall sleep quality, PTSD-specific sleep disturbances, current living difficulties, and the number of preimmigration traumatic events directly experienced or witnessed due to the presence of overall PTSD symptomology. Results A total of 53 adults completed the study. PTSD-disturbed sleep was found to be positively associated with overall poor sleep quality ( r = 0.42, p < 0.01), PTSD symptomology ( r = 0.65, p < 0.01), and current living difficulties ( r = 0.37, p < 0.05). The PTSD-related sleep disturbances (B = 0.66, p < 0.01) and postmigration living difficulties (B = 0.44, p < 0.01) were found to be the strongest predictors of PTSD symptoms. Conclusion Disturbed sleep is strongly associated with current stressful experiences and PTSD symptomology among Syrian refugees.

Re‐experiencing Symptoms and Sleep Disturbances in Women with PTSD

Individuals with post-traumatic stress disorder (PTSD) are at significantly higher risk of developing cardiovascular disease. While there is accumulating evidence that insufficient sleep independently contributes to adverse cardiovascular conditions, the specific associations between PTSD symptoms, cardiovascular variables and sleep disturbances (i.e. disruptive nighttime behaviors) are still unclear. In a group of trauma-exposed civilian women, we assessed the predictive value of the PTSD diagnostic clusters of re-experiencing, arousal and avoidance/numbing on blood pressure (BP), heart rate (HR) and sleep disturbances. We hypothesized that BP, HR and sleep will be differentially linked to specific diagnostic clusters. PTSD status was assessed using the gold-standard clinician administered PTSD scale (CAPS) and PTSD symptom severity via the PTSD Symptom Scale (PSS). We measured baseline BP, HR and quantified sleep disturbances via the Pittsburgh Sleep Quality Index Addendum for PTSD (PSQI-A). Of the 49 women included in the analysis, a subset of 43 (age, 49±12 years old; body mass index (BMI), 37±7 kg/m2) also presented with comorbid depression as per Beck Depression Inventory (BDI). Our analysis yielded no significant correlations between resting BP and CAPS or PSS scores. However, we found a modest correlation between HR and CAPS score (r=.210, p=.074), solely driven by avoidance symptoms (r=.344, p=.009). PSQI-A was correlated with CAPS (r=.536, P<.001) and PSS total scores (r=.685, P<.001). Interestingly, the correlation with PSS appeared to be mainly driven by hyperarousal (r=.621, p<.001) and re-experiencing (r=.704, p<.001) symptoms than avoidance/numbing symptoms (r=.442, p=.001). PSQI-A was also correlated with depression (r=.589, P<.001). To further determine the predictive value of the PTSD diagnostic clusters, we conducted two hierarchical linear regression models predicting HR and PSQI-A by relevant covariates of age, BMI, and BDI total score in step 1, and re-experiencing, hyperarousal, and avoidance symptoms scores in step 2. The final model with age, BMI, depression, and all three PTSD symptom clusters was significant (R2=.607, p=.016), and those clusters explained 21.3% of the variance beyond other predictors in PSQI-A score; the re-experiencing cluster was the strongest predictor (b =.535, p<.001). On the other hand, the final model predicting HR (R2=.205, p=.035) included age, BMI, and avoidance symptoms as significant predictors (p<.05). In summary, the current results show that while avoidance/numbing symptoms might partly contribute to resting HR in PTSD, the disruptive nighttime behaviors described in PTSD are strongly predicted by symptoms of re-experiencing (i.e. intrusive thoughts, flashbacks), even when controlling for the common comorbid depression. This suggests that the level of sleep dysfunction reported in PTSD could depend on the presence of specific symptoms which can serve to identify at-risk individuals who may benefit from targeted sleep interventions.

Cognitive Behavioral Therapy for Insomnia Reduces Fear of Sleep in Individuals With Posttraumatic Stress Disorder.

Our study aims were to examine (1) the association between fear of sleep and posttraumatic stress disorder (PTSD) symptoms, (2) the association between fear of sleep and subjective and objective insomnia symptoms and disruptive behaviors during sleep, and (3) whether fear of sleep decreases following cognitive behavioral therapy for insomnia (CBT-I). Forty-five adults with PTSD and insomnia participated in the study. Fear of sleep was assessed using the Fear of Sleep Inventory; PTSD symptoms were assessed using the Clinician Administered PTSD Scale; and sleep disturbance symptoms were assessed using the Insomnia Severity Index, polysomnography, sleep diaries, and the Pittsburgh Sleep Quality Index Addendum for PTSD. Participants were randomly assigned to 8 weeks of CBT-I (n = 29) or a waitlist control condition (n = 16). Greater fear of sleep was associated with greater PTSD symptom severity, greater nightmare frequency, and greater hypervigilance intensity. Greater fear of sleep was associated with decreased wake after sleep onset (WASO), reduced total sleep time, and greater disruptive nocturnal behaviors. Following CBT-I, there was a significant reduction in fear of sleep compared to the waitlist condition. These improvements persisted 6 months later. Fear of sleep was related to sleep disturbances specific to trauma rather than "classic" insomnia symptoms. Unexpectedly, greater fear of sleep was associated with reduced WASO. These results may be related to having a truncated sleep period and thus more consolidated sleep. Fear of sleep deceased following CBT-I despite not being a permissible target for this research protocol and not being related to insomnia symptoms. Registry: CinicalTrials.gov; Name: Treating People with Post-traumatic Stress Disorder with Cognitive Behavioral Therapy for Insomnia; Identifier: NCT00881647; URL: https://clinicaltrials.gov/ct2/show/NCT00881647.

Nightmares in United States Military Personnel With Sleep Disturbances

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. 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. 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). The comorbid disorders of depression (P ≤ .01, relative risk [RR] 3.55 [95% CI, 2.52-4.98]), anxiety (P ≤ .01, RR 2.57 [95% CI, 1.93-3.44]), posttraumatic stress disorder (P ≤ .01, RR 5.11 [95% CI, 3.43-7.62]), and insomnia (P ≤ .01, RR 1.59 [95% CI, 1.42-1.79]) were all associated with nightmares. Clinically significant nightmares are highly prevalent in United States military personnel with sleep disturbances. Nightmares are associated with both subjective and objective sleep disturbances and are frequently comorbid with other sleep and mental health disorders. A commentary on this article appears in this issue on page 303.

Doxazosin, an α-1-adrenergic-receptor Antagonist, for Nightmares in Patients with Posttraumatic Stress Disorder and/or Borderline Personality Disorder: a Chart Review.

Objective: Centrally active α-1-adrenergic-receptor antagonists such as prazosin are effective in the treatment of nightmares in patients with posttraumatic stress disorder (PTSD). A pharmacological alternative is doxazosin, which has a longer half-life and fewer side effects. However, doxazosin is currently being used without solid empirical evidence. Furthermore, no study so far has assessed the effects of α-1-antagonists on nightmares in patients with borderline personality disorder (BPD). We retrospectively assessed the effectiveness of doxazosin on nightmares in PTSD and BPD. Method: A retrospective chart review of patients treated with doxazosin for trauma-associated nightmares in our clinic was performed. As in previous prazosin studies, the B2 score of the Clinician-Administered PTSD Scale (CAPS) was used as the primary outcome measure. Furthermore, the Pittsburgh Sleep Quality Index-Addendum for PTSD (PSQI-A) and sleep logs were analyzed. Results: We identified 51 patients with PTSD and/or BPD (mean age 35.7 years, 92.3% women) who received doxazosin for nightmares. Of these, 46 patients continued doxazosin over a 4-week period and 31 patients over a 12-week period. Within the 12-week period, doxazosin treatment significantly reduced nightmares regardless of PTSD/BPD. 25 percent of patients treated for 12 weeks had full remission of nightmares. PSQI-A scores indicated that additional trauma-associated sleep symptoms improved over 12 weeks. Furthermore, recuperation of sleep improved with doxazosin within the first 4 weeks of treatment. Conclusion: Doxazosin might improve trauma associated nightmares and more general sleep parameters in patients with PTSD and BPD. Randomized controlled trials are warranted.

Cognitive Behavioral Therapy for Insomnia in Posttraumatic Stress Disorder: A Randomized Controlled Trial

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. RANDOMIZED CONTROLLED TRIAL WITH TWO ARMS: CBT-I and monitor-only waitlist control. Department of Veterans Affairs (VA) Medical Center. 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). Eight-session weekly individual CBT-I delivered by a licensed clinical psychologist or a board-certified psychiatrist. 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. 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. TRIAL NAME: Cognitive Behavioral Treatment Of Insomnia In Posttraumatic Stress Disorder. URL: http://clinicaltrials.gov/ct2/show/NCT00881647. NCT00881647.

Validation of the French version of the Pittsburgh Sleep Quality Index Addendum for posttraumatic stress disorder

BackgroundSleep disturbances are one of the main complaints of patients with trauma-related disorders. The original Pittsburgh Sleep Quality Index Addendum for PTSD (PSQI-A) is self-report instrument developed to evaluate posttraumatic stress disorder (PTSD)-specific sleep disturbances in trauma-exposed individuals. However, to date, the PSQI-A has not yet been translated nor validated in French.ObjectiveThe present study aims to: a) translate the PSQI-A into French, and b) examine its psychometric properties.MethodSeventy-three adult patients (mean age=40.3 [SD=15.0], 75% females) evaluated in a specialized psychotraumatology unit completed the French versions of the PSQI-A, Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale (HADS), and Impact Event Scale-Revised (IES-R).ResultsThe French version of the PSQI-A showed satisfactory internal consistency, inter-item correlations, item correlations with the total score, convergent validity with PTSD and anxiety measures, and divergent validity with a depression measure.ConclusionOur findings support the use of the French version of the PSQI-A for both clinical care and research. The French version of the PSQI-A is an important addition to the currently available instruments that can be used to examine trauma-related sleep disturbances among French-speaking individuals.

Validation of the Pittsburgh Sleep Quality Index Addendum for Posttraumatic Stress Disorder (PSQI‐A) in U.S. Male Military Veterans

Sleep disturbances are core symptoms of posttraumatic-stress disorder (PTSD), yet they bear less stigma than other PTSD symptoms. Given the growing number of returning military veterans, brief, valid assessments that identify PTSD in a minimally stigmatizing way may be useful in research and clinical practice. The study purpose was to evaluate the psychometric properties of the Pittsburgh Sleep Quality Index Addendum for PTSD (PSQI-A), and to examine its ability to identify PTSD cases among U.S. male military veterans. Male military veterans (N = 119) completed the PSQI-A, as well as measures of sleep quality, combat exposure, posttraumatic stress, depression, and anxiety. Veterans with PTSD had higher PSQI-A identified disruptive nocturnal behaviors than veterans without PTSD. The PSQI-A had good internal consistency and convergent validity with sleep quality, combat exposure, PTSD symptoms, depression, and anxiety. A cutoff score ≥ 4 provided an area under the curve = .81, with 71% sensitivity, 82% specificity, and 60% positive and 83% negative predictive value for a clinical diagnosis of PTSD; correct classification was 74%. The PSQI-A is a valid measure to possibly detect PTSD among male military veterans. Assessment of disruptive nocturnal behaviors may provide a cost-effective, nonstigmatizing approach to PTSD screening without directly probing for trauma exposure(s).

Long-term impact of earthquakes on sleep quality.

PurposeWe investigated the impact of the 6.3 magnitude 2009 L’Aquila (Italy) earthquake on standardized self-report measures of sleep quality (Pittsburgh Sleep Quality Index, PSQI) and frequency of disruptive nocturnal behaviours (Pittsburgh Sleep Quality Index-Addendum, PSQI-A) two years after the natural disaster.MethodsSelf-reported sleep quality was assessed in 665 L’Aquila citizens exposed to the earthquake compared with a different sample (n = 754) of L'Aquila citizens tested 24 months before the earthquake. In addition, sleep quality and disruptive nocturnal behaviours (DNB) of people exposed to the traumatic experience were compared with people that in the same period lived in different areas ranging between 40 and 115 km from the earthquake epicenter (n = 3574).ResultsThe comparison between L’Aquila citizens before and after the earthquake showed a significant deterioration of sleep quality after the exposure to the trauma. In addition, two years after the earthquake L'Aquila citizens showed the highest PSQI scores and the highest incidence of DNB compared to subjects living in the surroundings. Interestingly, above-the-threshold PSQI scores were found in the participants living within 70 km from the epicenter, while trauma-related DNBs were found in people living in a range of 40 km. Multiple regressions confirmed that proximity to the epicenter is predictive of sleep disturbances and DNB, also suggesting a possible mediating effect of depression on PSQI scores.ConclusionsThe psychological effects of an earthquake may be much more pervasive and long-lasting of its building destruction, lasting for years and involving a much larger population. A reduced sleep quality and an increased frequency of DNB after two years may be a risk factor for the development of depression and posttraumatic stress disorder.

Psychometric properties of the Persian version of the Pittsburgh Sleep Quality Index addendum for PTSD (PSQI-A)

Considering the frequent occurrence of natural disasters in Iran, the need for an inventory assessing the quality of sleep in the posttraumatic stress disorder (PTSD) patients is clearly evident. The Pittsburgh Sleep Quality Index addendum for PTSD (PSQI-A) has been recently developed to assess the disruptive nocturnal behaviors in the PTSD patients. This study was aimed to explore the reliability and validity of the Persian version of the PSQI-A. Eighty-five PTSD patients related to the two recent major earthquakes of Kerman Province were enrolled in the study, and 133 healthy subjects were conveniently selected as the control group. The inventory was translated and then back-translated according to standard methods. The reliability was checked by computing the Cronbach;s alpha coefficient and corrected item-total correlation. The sensitivity and specificity were assessed by comparing the PSQI-A score with the DSM-IV-TR diagnosis. Convergent validity was checked against the General Health Questionnaire 12 (GHQ-12). The mean (+/-SD) of the two groups were 42.1(+/-13.8) and 34.2 (+/-9.8), respectively. The sex distribution was comparable in the two groups (females consisted 55% and 58% of the PTSD and control groups, respectively). There were significant differences between the items comparing the two groups except for the "acting out dreams". Overall the Cronbach;s alpha coefficient was 0.89, and the item-total correlation of all the seven items were over 0.4 except for the acting out dreams. At cut-off of 7/8, the sensitivity and specificity were 100% and 93%, respectively. The sum score showed a correlation of 0.66 with the GHQ-12. Although the psychometric properties of one of the seven items of the inventory were to some extent unsatisfactory, the overall reliability and validity of the questionnaire were acceptable.

A brief Sleep Scale for Posttraumatic Stress Disorder: Pittsburgh Sleep Quality Index Addendum for PTSD

Sleep disturbances reflect a core dysfunction underlying Posttraumatic Stress Disorder (PTSD). Specifically, disruptive nocturnal behaviors (DNB) may represent PTSD-specific sleep disturbances. The Pittsburgh Sleep Quality Index Addendum for PTSD (PSQI-A) is self-report instrument designed to assess the frequency of seven DNB. The goal of this study was to examine the psychometric properties of the PSQI-A to characterize DNB in a group of participants with and without PTSD. Results indicate that the PSQI-A has satisfactory internal consistency and good convergent validity with two standard PTSD measures even when excluding their sleep-related items. A global PSQI score of 4 yielded a sensitivity of 94%, a specificity of 82%, and a positive predictive value of 93% for discriminating participants with PTSD from those without PTSD. The PSQI-A is a valid instrument for PTSD applicable to both clinical and research settings.