Sleep Disturbances In Posttraumatic Stress Disorder Research Articles

Sleep spindle dynamics suggest over-consolidation in post-traumatic stress disorder.

Devastating and persisting traumatic memories are a central symptom of post-traumatic stress disorder (PTSD). Sleep problems are highly co-occurrent with PTSD and intertwined with its etiology. Notably, sleep hosts memory consolidation processes, supported by sleep spindles (11–16 Hz). Here we assess the hypothesis that intrusive memory symptoms in PTSD may arise from excessive memory consolidation, reflected in exaggerated spindling. We use a newly developed spindle detection method, entailing minimal assumptions regarding spindle phenotype, to assess spindle activity in PTSD patients and traumatized controls. Our results show increased spindle activity in PTSD, which positively correlates with daytime intrusive memory symptoms. Together, these findings provide a putative mechanism through which the profound sleep disturbance in PTSD may contribute to memory problems. Due to its uniform and unbiased approach, the new, minimal assumption spindle analysis seems a promising tool to detect aberrant spindling in psychiatric disorders.

Disturbed Sleep in PTSD: Thinking Beyond Nightmares.

Sleep disturbances frequently co-occur with posttraumatic stress disorder (PTSD). Insomnia and nightmares are viewed as core symptoms of PTSD. Yet, relations between disturbed sleep and PTSD are far more complex: PTSD is linked to a broad range of sleep disorders and disturbed sleep markedly affects PTSD-outcome. This article provides a concise overview of the literature on prevalent comorbid sleep disorders, their reciprocal relation with PTSD and possible underlying neurophysiological mechanisms. Furthermore, diagnostic procedures, standard interventions—particularly first choice non-pharmacological therapies—and practical problems that often arise in the assessment and treatment of sleep disturbances in PTSD are described. Finally, we will present some perspectives on future multidisciplinary clinical and experimental research to develop new, more effective sleep therapies to improve both sleep and PTSD.

Treatment of Sleep Comorbidities in Posttraumatic Stress Disorder.

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. 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. 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.

1078 Sleep Problems In Posttraumatic Stress Disorder (PTSD) In A Nationally Representative Us Sample Before And After Controlling For Comorbid Depression: Results From A Nationally Representative US Sample

Abstract Introduction The impact of psychiatric comorbidities on sleep disturbances in PTSD have been studied in the National Comorbidity Survey (NCS)(Leskin GA, 2002) and the NCS-replication (Lauterbach D, 2011) studies. We examined sleep problems in PTSD before and after controlling for comorbid depressive disease, in the National Ambulatory Medical Care Survey(NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) which use a multi-stage probability design to collect nationally representative data on health care visits. Methods We examined patient visits(1995-2015) from NAMCS/NHAMCS with a PTSD diagnosis (ICD-9-CM 309.81). Both NAMCS/NHAMCS allow ≥3 reasons for visit(RFV) and ≥3 physician-assigned diagnoses (using ICD9-CM codes). The following variables were created: ‘Insomnia’: ICD9-CM codes 307.41,307.42,780.51,RFV 11351; ‘Sleep Disturbance’(SD): ICD-9CM codes 780.5, 780.50, 780.59; ‘Nightmares’: ICD9-CM code 307.4, RFV 11353; Obstructive sleep apnea (OSA): ICD-CM codes 327.23,780.57, RFV 11355, checklist; and ‘Depression’: ICD9-CM codes 296.2, 296.3, 296.82, 311, 296.20-296.36, 300.4. Results There were an estimated 37,262,245±3,203,047 (unweighted count or UWC=3,995; 66.4%±1.8% female;.mean±age: 40.39 ± 0.56 years; ‘Depression’ was comorbid with 37.7%±1.5% cases) PTSD patients visits. All sleep variables accounted for 11.2%±1.2% (UWC=303) of PTSD visits with their individual frequencies as follows: ‘Insomnia’6.5%±1.1%(UWC=153); ‘Nightmares’: 1.9%±0.4%(UWC=74); ‘SD’: 2.0%±0.3%(UWC=67); OSA: 1.3%±0.3%(UWC=27). Logistic regression analysis using PTSD versus all other patient visits as dependent variable revealed the following sleep predictors of PTSD after controlling for age and sex and: (i) before controlling for ‘Depression’: ‘Insomnia’: OR=7.16, (95%CI 4.78-10.73); ‘SD’: OR=4.43(95%CI 2.55-7.71); ‘Nightmares’:OR=104.29 (95%CI56.65-192.02); ‘OSA’: OR=1.71(95%CI 0.94-3.12); and (ii) after controlling for ‘Depression’: ‘Insomnia’: OR=2.88 (95%CI 1.87-4.42); ‘SD’: OR=2.84 (95%CI 1.73-4.67); and ‘Nightmares’: OR=58.33(95%CI 26.39-128.94); and ‘OSA’: OR=2.02(95%CI 1.14-3.57). Conclusion In a nationally representative sample, the association of PTSD with insomnia, sleep disturbance and nightmares remained significant, albeit decreased, after controlling for the confounding effect of comorbid depression; however the association of PTSD with OSA emerged only after the effect of depression was controlled for. Support None

1079 Is PTSD In Young Women Associated With Rem Sleep Abnormalities?

Abstract Introduction The increase in violence against young women has a high impact on the prevalence of Posttraumatic stress disorder (PTSD). The lifetime prevalence of PTSD is twice as high in women. However, most studies assessing sleep disturbances in PTSD were conducted predominantly in male samples and combat veterans. Objective: To analyze the sleep of young women with and without PTSD. Hypothesis: Women with PTSD have worse sleep quality, higher arousability, and higher muscle activity during REM sleep. Methods Case-controlled study with young women. Seventy-four women who suffered sexual assault and developed PTSD (DSM-5); and 64 women from the community without PTSD. Women were recruited from the PTSD outpatient clinic (Universidade Federal de São Paulo, Brazil).Clinician-Administered Posttraumatic Stress Scale (CAPS 5), Beck Depression and Anxiety Inventories (BDI) (BAI), full in-lab Polysomnography (PSG), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Índex (PSQI), Fatigue Impact Scale (FIS), and Insomnia Severity Índex (ISI) were applied to all participants. Analysis of variance, regression models, and general linear modeling were used. Results Patients mean age was 28 vs 24 for the control group (p=0.004). CAPS mean score in PTSD-group was 42.5±9.1. BDI, BAI, FIS, PSQI, ISI scores were worse in PTSD-group (p<0.05, all). Pittsburgh Sleep Quality Index (PSQI) score was significantly associated with CAPS 5 independently of depression, fatigue, and sleep fragmentation. The PTSD women had lower total sleep time (p= 0.01) and lower REM sleep percentage (p=0.04). However, the control group had higher arousal index (p=.0.01) and had higher muscle activity during REM sleep (p=0.03) than PTSD. Conclusion Women with PTSD had significantly worse score in PSQI, FIS, and ISI. PSQI score was associated with PTSD severity. However, when PSG results are concerned, we found higher sleep fragmentation in the control group. We speculate that women with PTSD may have felt safer and taken care of in the lab, which might explain the difference between objective and subjective measures of sleep quality in PTSD. Support Acknowledgments: FAPESP: Fundação de Apoio à pesquisa de São Paulo, AFIP: Associação Incentivo a Pesquisa

Differences in rapid eye movement (REM) sleep abnormalities between posttraumatic stress disorder (PTSD) and major depressive disorder patients: REM interruption correlated with nightmare complaints in PTSD

ObjectiveThe presence of repeated nightmares in posttraumatic stress disorder (PTSD) has been hypothesized as a dysfunction of rapid eye movement (REM) sleep, but there has been remarkably little agreement about the pathophysiology. This presents a deterrent to more effective treatments. REM sleep abnormalities including elevated REM density also have been replicated in major depressive disorder (MDD). The purpose of this study was to clarify the difference of REM sleep abnormalities between the two disorders for understanding the pathophysiology of sleep disturbances in PTSD. MethodsPolysomnographic measures were compared among 14 PTSD patients (aged 23.7 ± 5.5 years) and 14 MDD patients (aged 27.9 ± 10.1 years) under drug-naive or drug-free conditions. We defined REM interruption by summing the intrusive wake times during the REM period and adding the subsequent wake times to the last epoch of REM period. The significant polysomnographic measures were correlated with PTSD symptoms within the PTSD group. ResultsREM interruption was significantly increased in the PTSD group compared with the MDD group (12.2 vs 2.1 min, p = 0.001). REM density was also significantly increased in the PTSD group compared with the MDD group (30.5 vs 23.1%, p = 0.019). Within the PTSD group, we found significant correlations between the severity of trauma-related nightmare complaints and the percentage of REM interruption (R = 0.62, p = 0.017), but not REM density. ConclusionsREM sleep abnormalities are different between PTSD and MDD. Increased REM interruption may be a biological marker correlated with nightmare complaints in PTSD patients. Treatments including pharmacotherapy that reduces REM interruption might ameliorate nightmares in PTSD.

P.2.d.015 - Is cognitive dysfunction in bipolar disorder related to sleep abnormalities?

Sleep disturbance is common in chronic post-traumatic stress disorder (PTSD). However, prior work has demonstrated that there are inconsistencies between subjective and objective assessments of sleep disturbance in PTSD. Therefore, we investigated whether subjective or objective sleep assessment has greater clinical utility to differentiate PTSD patients from healthy subjects. Further, we evaluated whether the combination of subjective and objective methods improves the accuracy of classification into patient versus healthy groups, which has important diagnostic implications. We recruited 32 chronic war-induced PTSD patients and 32 age- and gender-matched healthy subjects to participate in this study. Subjective (i.e. from three self-reported sleep questionnaires) and objective sleep-related data (i.e. from actigraphy scores) were collected from each participant. Subjective, objective, and combined (subjective and objective) sleep data were then analyzed using support vector machine classification. The classification accuracy, sensitivity, and specificity for subjective variables were 89.2%, 89.3%, and 89%, respectively. The classification accuracy, sensitivity, and specificity for objective variables were 65%, 62.3%, and 67.8%, respectively. The classification accuracy, sensitivity, and specificity for the aggregate variables (combination of subjective and objective variables) were 91.6%, 93.0%, and 90.3%, respectively. Our findings indicate that classification accuracy using subjective measurements is superior to objective measurements and the combination of both assessments appears to improve the classification accuracy for differentiating PTSD patients from healthy individuals.

Differentiation chronic post traumatic stress disorder patients from healthy subjects using objective and subjective sleep-related parameters

Sleep disturbance is common in chronic post-traumatic stress disorder (PTSD). However, prior work has demonstrated that there are inconsistencies between subjective and objective assessments of sleep disturbance in PTSD. Therefore, we investigated whether subjective or objective sleep assessment has greater clinical utility to differentiate PTSD patients from healthy subjects. Further, we evaluated whether the combination of subjective and objective methods improves the accuracy of classification into patient versus healthy groups, which has important diagnostic implications. We recruited 32 chronic war-induced PTSD patients and 32 age- and gender-matched healthy subjects to participate in this study. Subjective (i.e. from three self-reported sleep questionnaires) and objective sleep-related data (i.e. from actigraphy scores) were collected from each participant. Subjective, objective, and combined (subjective and objective) sleep data were then analyzed using support vector machine classification. The classification accuracy, sensitivity, and specificity for subjective variables were 89.2%, 89.3%, and 89%, respectively. The classification accuracy, sensitivity, and specificity for objective variables were 65%, 62.3%, and 67.8%, respectively. The classification accuracy, sensitivity, and specificity for the aggregate variables (combination of subjective and objective variables) were 91.6%, 93.0%, and 90.3%, respectively. Our findings indicate that classification accuracy using subjective measurements is superior to objective measurements and the combination of both assessments appears to improve the classification accuracy for differentiating PTSD patients from healthy individuals.

Influence of Sleep Disturbance on Global Functioning After Posttraumatic Stress Disorder Treatment.

Chronic insomnia and recurrent nightmares are prominent features of posttraumatic stress disorder (PTSD). Evidence from adult research indicates that these sleep disturbances do not respond as well to cognitive-behavioral therapies for PTSD and are associated with poorer functional outcomes. This study examined the effect of prolonged exposure therapy for adolescents versus client-centered therapy on posttraumatic sleep disturbance, and the extent to which sleep symptoms impacted global functioning among adolescents with sexual abuse-related PTSD. Participants included 61 adolescent girls seeking treatment at a rape crisis center. The Child PTSD Symptom Scale-Interview (Foa, Johnson, Feeny, & Treadwell, 2001) was used to assess PTSD diagnosis and severity of symptoms, including insomnia and nightmares. The Children's Global Assessment Scale (Shaffer etal., 1983) was used to assess global functioning. There were significant main effects of time and treatment on insomnia symptoms. Additionally, there was a main effect of time on nightmares. Results also showed that insomnia and nightmares significantly predicted poorer global functioning posttreatment (R2 = .21). Despite significant improvements in posttraumatic sleep disturbance, there were still clinically significant insomnia symptoms after treatment, suggesting that additional interventions may be warranted to address residual sleep disturbance in PTSD.

Pharmacology for sleep disturbance in PTSD.

Symptoms of sleep disturbance, particularly nightmares and insomnia, are a central feature of post-traumatic stress disorder (PTSD). Emerging evidence suggests that specific treatment of PTSD-related sleep disturbance improves other symptoms of the disorder, which in turn suggests that such disturbance may be fundamental to development and maintenance of the disorder. This mini-review focuses on pharmacological treatment of sleep disturbance in adult PTSD (specifically, studies testing the efficacy of antidepressants, adrenergic inhibiting agents, antipsychotics and benzodiazepine and non-benzodiazepine hypnotics). We conclude that only prazosin, an adrenergic inhibiting agent, has had its efficacy established by multiple randomised controlled trials. There is also high-level evidence supporting use of eszopiclone, as well as risperidone and olanzapine as adjunct therapy. Antidepressants such as sertraline, venlafaxine and mirtazapine, benzodiazepines such as alprazolam and clonazepam and non-benzodiazepine hypnotics such as zolpidem appear ineffective in treating PTSD-related sleep disturbance. Most studies that report reduced frequency of nightmares and insomnia also report decreases in overall symptom severity. Such findings suggest that (i) sleep disruption is central to PTSD; (ii) treating sleep disruption may be an effective way to address other symptoms of the disorder and (iii) PTSD symptoms tend to cluster together in predictable ways.

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.

Sleep disturbances and PTSD: a perpetual circle?

Background: Sleep facilitates the consolidation of fear extinction memory. Nightmares and insomnia are hallmark symptoms of posttraumatic stress disorder (PTSD), possibly interfering with fear extinction and compromising recovery. A perpetual circle may develop when sleep disturbances increase the risk for PTSD and vice versa. To date, therapeutic options for alleviating sleep disturbances in PTSD are limited.Methods: We conducted three studies to examine the relationship between sleep and posttraumatic symptoms: (1) a prospective longitudinal cohort study examining the impact of pre-deployment insomnia symptoms and nightmares on the development of PTSD; (2) a cross-sectional study examining subjective sleep measures, polysomnography, endocrinological parameters, and memory in veterans with PTSD, veterans without PTSD, and healthy controls (HCs); (3) a randomized controlled trial (RCT) (n=14) comparing the effect of prazosin and placebo on sleep disturbances in veterans with PTSD. In addition to these studies, we systematically reviewed the literature on treatment options for sleep disturbances in PTSD.Results: Pre-deployment nightmares predicted PTSD symptoms at 6 months post-deployment; however, insomnia symptoms did not. Furthermore, in patients with PTSD, a correlation between the apnea index and PTSD severity was observed, while obstructive sleep apnea syndrome was not more prevalent. We observed a significant increase in awakenings during sleep in patients with PTSD, which were positively correlated with adrenocorticotropic hormone (ACTH) levels, negatively correlated with growth hormone (GH) secretion, and the subjective perception of sleep depth. Also, heart rate was significantly increased in PTSD patients. Interestingly, plasma levels of GH during the night were decreased in PTSD. Furthermore, GH secretion and awakenings were independent predictors for delayed recall, which was lower in PTSD. In our RCT, prazosin was not associated with improvement of any subjective and objective sleep parameters. Only a few RCTs have been published. They show promising results for atypical antipsychotics and prazosin, the latter especially on nightmare reduction.Conclusions: Disturbed sleep due to nightmares increases the risk for PTSD. PTSD in turn leads to increased sleep fragmentation, decreased GH secretion, and frequent nightmares, which may again compromise fear extinction, synaptic plasticity, and recovery. This suggests that disturbed sleep is a precipitating and perpetuating factor in PTSD symptomatology, creating a perpetual circle. This dissertation suggests that activity of the hypothalamic–pituitary–adrenal axis and the sympathetic nervous system (SNS) is involved in disturbed sleep in patients with PTSD.Mentors: Prof. Dr. R.S. Kahn (University Medical Centre, Department of Psychiatry, the Netherlands), Prof. Dr. J.B.A.M. Arends (Technical University Eindhoven, the Netherlands) and Dr. E. Vermetten (Military Mental Health, the Netherlands). Theses defended in Utrecht, June 21, 2012. For the abstract or full text in other languages, please see Supplementary files under Reading Tools online.

REM Sleep Bout Duration and Frequency in PTSD

The few pharmacological treatments shown to be effective in reducing sleep disturbance in posttraumatic stress disorder (PTSD) might work through normalization of rapid eye movement (REM). However, evidence of REM sleep disturbance in PTSD has been inconsistent and the definition of REM bout has varied as well. In this study, we compared polysomnographic findings in adults with PTSD to both normal sleepers and insomniacs. We found no differences between those with and without PTSD on REM bout frequency or duration. We did, however, find gender differences within our PTSD sample as consistent with a previous review suggesting that males with PTSD are more likely to demonstrate REM sleep disturbance. Consensus on REM bout definition is needed, in addition to studies powered to detect gender differences.

Treatment of sleep disturbances in posttraumatic stress disorder: A review

Sleep disturbances are among the most commonly reported posttraumatic stress disorder (PTSD) symptoms. It is essential to conduct a careful assessment of the presenting sleep disturbance to select the optimal available treatment. Cognitive-behavioral therapies (CBTs) are at least as effective as pharmacologic treatment in the short-term and more enduring in their beneficial effects. Cognitive-behavioral treatment for insomnia and imagery rehearsal therapy have been developed to specifically treat insomnia and nightmares and offer promise for more effective relief of these very distressing symptoms. Pharmacotherapy continues to be an important treatment choice for PTSD sleep disturbances as an adjunct to CBT, when CBT is ineffective or not available, or when the patient declines CBT. Great need exists for more investigation into the effectiveness of specific pharmacologic agents for PTSD sleep disturbances and the dissemination of the findings to prescribers. The studies of prazosin and the findings of its effectiveness for PTSD sleep disturbance are examples of studies of pharmacologic agents needed in this area. Despite the progress made in developing more specific treatments for sleep disturbances in PTSD, insomnia and nightmares may not fully resolve.

Sleep problems among persons with a lifetime history of posttraumatic stress disorder alone and in combination with a lifetime history of other psychiatric disorders: a replication and extension

Objective Sleep problems are a clinical and/or diagnostic feature for a broad array of mood, substance use, and anxiety disorders, including posttraumatic stress disorder (PTSD). Previous research by Leskin et al (Leskin GA, Woodward SH, Young HE, Sheikh J. Effects of comorbid diagnoses on sleep disturbance in PTSD. J Psychiat Res 2002;36:449-452) using the baseline National Comorbidity Survey (NCS) data found that persons with PTSD and panic disorder had a greater proportion of sleep problems than persons with other comorbid disorders. The current study extends Leskin et al's findings using the replication of the NCS. It compared persons with a lifetime history of PTSD (either alone or in combination) with 6 comparison disorders (adult separation anxiety, alcohol dependence, generalized anxiety, dysthymia, major depression, and panic) on severity of sleep disorder symptoms. Method The NCS Replication was a national probability survey of 9282 individuals that examined the prevalence and correlates of mental disorders. Subjects were chosen through a multistage probability sample of US households and interviewed using a computer-aided version of the Composite International Diagnostic Interview. Results The PTSD (alone) group did not differ from the comparison disorders on difficulties of falling/staying asleep but did report more weeks per year when they had sleep difficulties than persons with adult separation anxiety, alcohol dependence, and major depression. Conclusion Unlike Leskin et al, the additive effects of a second disorder on sleep difficulties are not unique to panic disorder. However, when sleep difficulties were indexed by the number of weeks per year, differences between diagnostic groups emerged. If the goal of a diagnostic system is to carve nature at its joints, a sleep disturbance symptom reflecting frequency of difficulties in this way is clearly superior to less precise alternatives.

The relationship between sleep disturbance and the course of anxiety disorders in primary care patients

This study examined the relationship between sleep disturbance and the course of anxiety disorders in primary care patients. Participants were part of the Primary Care Anxiety Project (PCAP), a naturalistic, longitudinal study of anxiety disorders in primary care. Participants completed an intake evaluation and follow-up assessments at 6 months, 12 months, and annually thereafter. Only participants with sleep data at intake were included in the current study ( n = 533). The majority (74%) reported experiencing sleep disturbance at intake. Those with a diagnosis of generalized anxiety disorder (GAD) or post-traumatic stress disorder (PTSD) were over 2 times more likely to have sleep problems. Sleep disturbance at intake did not relate to the longitudinal course of GAD, social phobia, panic disorder, or obsessive–compulsive disorder. However, it did predict the course of PTSD, controlling for comorbid major depressive disorder (MDD) and having more than one anxiety disorder diagnosis intake, those with sleep disturbance at intake being less likely to remit from PTSD in the 5 years of follow-up. By year 5, only 34% of those with sleep problems at intake remitted from PTSD whereas 56% of those without sleep disturbance remitted from the disorder. The findings suggest that sleep disturbance in PTSD may have prognostic significance and may be important to address in clinical interventions.

Post-Traumatic Stress Disorder: Basic Science and Clinical Practice

Post-Traumatic Stress Disorder: Basic Science and Clinical Practice

A combined group treatment for nightmares and insomnia in combat veterans: A pilot study

Insomnia and nightmares are hallmarks of posttraumatic stress disorder (PTSD). Sleep disturbances in PTSD negatively impact clinical course and functioning. In this open clinical trial, the preliminary effects of a combined treatment for insomnia and nightmares in combat veterans with PTSD were assessed. Ten combat veterans participated in a 10-session group treatment combining cognitive-behavioral therapy for insomnia with exposure, rescripting, and relaxation therapy. Participants maintained daily sleep and dream diaries and completed self-report measures of sleep quality and PTSD symptoms pre- and posttreatment. Participants reported improvements in sleep and nightmares following treatment. Future research using controlled designs to evaluate this treatment is warranted.

Sleep Disturbances in Posttraumatic Stress Disorder

<p>Sleep disturbances are a prominent feature of trauma reactions and posttraumatic stress disorder (PTSD) across the lifespan. However, the literature on the prevalence, specific nature, time course, clinical and psychophysiological correlates, and effects of sleep-focused treatment in children and adolescents exposed to traumatic events is limited. Therefore, this article focuses on the nature, evaluation, and treatment of sleep disturbances in adults with PTSD.</p> <h4>ABOUT THE AUTHOR</H4> <P>Anne Germain, PhD, is with the Department of Psychiatry, University of Pittsburgh School of Medicine.</P> <P>Address correspondence to: Anne Germain, PhD, Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O’Hara Street, Room E-1124, Pittsburgh, PA 15213; fax 412-246-5300; or e-mail <A HREF="mailto:germaina@upmc.edu">germaina@upmc.edu</A>.</P> <P>Dr. Germain has disclosed no relevant financial relationships.</P> <P>doi: 10.3928/00485713-20090514-02</P> <H4>EDUCATIONAL OBJECTIVES</H4><OL> <P><LI>Classify sleep disturbances as an important treatment target in adults with PTSD.</P></LI> <P><LI>Identify frequent sleep disturbances associated with PTSD.</P></LI> <P><LI>Recognize effective pharmacological and behavioral treatments of sleep disturbances in PTSD.</P></LI></OL>

Sleep-specific mechanisms underlying posttraumatic stress disorder: Integrative review and neurobiological hypotheses

Posttraumatic stress disorder (PTSD) is a prevalent disorder that is associated with poor clinical and health outcomes, and considerable health care utilization and costs. Recent estimates suggest that 5-20% of military personnel who serve in current conflicts in Iraq and Afghanistan meet diagnostic criteria for PTSD. Clinically, sleep disturbances are core features of PTSD that are often resistant to first-line treatments, independently contribute to poor daytime functioning, and often require sleep-focused treatments. Physiologically, these observations suggest that PTSD is partially mediated by sleep disruption and its neurobiological correlates that are not adequately addressed by first-line treatments. However, polysomnographic studies have provided limited insights into the neurobiological underpinnings of PTSD during sleep. There is an urgent need to apply state-of-the-science sleep measurement methods to bridge the apparent gap between the clinical significance of sleep disturbances in PTSD and the limited understanding of their neurobiological underpinnings. Here, we propose an integrative review of findings derived from neurobiological models of fear conditioning and fear extinction, PTSD, and sleep-wake regulation, suggesting that the amygdala and medial prefrontal cortex can directly contribute to sleep disturbances in PTSD. Testable hypotheses regarding the neurobiological underpinnings of PTSD across the sleep-wake cycle are offered.