Sleep Disturbance In Veterans Research Articles

Preliminary evidence of transcutaneous vagus nerve stimulation effects on sleep in veterans with post-traumatic stress disorder.

Sleep problems are common among veterans with post-traumatic stress disorder and closely associated with hyperarousal symptoms. Transcutaneous vagus nerve stimulation (tVNS) may have potential to improve sleep quality in veterans with PTSD through effects on brain systems relevant to hyperarousal and sleep-wake regulation. The current pilot study examines the effect of 1 h of tVNS administered at "lights out" on sleep architecture, microstructure, and autonomic activity. Thirteen veterans with PTSD completed two nights of laboratory-based polysomnography during which they received 1 h of either active tVNS (tragus) or sham stimulation (earlobe) at "lights out" with randomised order. Sleep staging and stability metrics were derived from polysomnography data. Autonomic activity during sleep was assessed using the Porges-Bohrer method for calculating respiratory sinus arrhythmia (RSAP-B ). Paired t-tests revealed a small decrease in the total sleep time (d=-0.31), increase in N3 sleep (d=0.23), and a small-to-moderate decrease in REM sleep (d=-0.48) on nights of active tVNS relative to sham stimulation. tVNS was also associated with a moderate reduction in cyclic alternating pattern (CAP) rate (d=-0.65) and small-to-moderate increase in RSAP-B during NREM sleep. Greater NREM RSAP-B was associated with a reduced CAP rate and NREM alpha power. This pilot study provides preliminary evidence that tVNS may improve sleep depth and stability in veterans with PTSD, as well as increase parasympathetically mediated nocturnal autonomic activity. These results warrant continued investigation into tVNS as a potential tool for treating sleep disturbance in veterans with PTSD.

Veteran Acceptance of Sleep Health Information Technology: a Mixed-Method Study.

Sleep disturbances, including chronic insomnia and sleep apnea, are major concerns for US veterans, with rising rates and detrimental effects on physical, mental, and social well-being. Sleep disturbances in veterans are also underdiagnosed and undertreated for reasons that include limited sleep clinician availability, long wait times, and the time commitment for treatment. Greater use of sleep health information technologies could improve access to assessment and treatment of sleep disturbances. However, the assessment of acceptance of these technologies among veterans is still ongoing. This mixed-method study combines data from two separate but similar randomized controlled trials to assess acceptance of sleep health information technologies for veterans with chronic insomnia. Sleep health information technologies included in these trials were the following: (1) a WatchPAT sleep monitor for home-based sleep assessment, including detection of sleep apnea, and (2) the VA mobile app Cognitive Behavioral Therapy for Insomnia (CBT-i Coach), which supports self-management of insomnia. The combined sample of 37 veterans receiving care within one New England VA medical center completed a six-week trial using both health information technology tools. Participants completed a survey and interview at the end of the 6weeks. Overall, participants found the tools acceptable, easy to use, and useful and reported they would use them in the future. Thus, these sleep health information technologies appear to provide an acceptable remote option for assessing and managing sleep issues for veterans. ClinicalTrials.gov NCT02392000; http://clinicaltrials.gov/ct2/show/NCT02392000 and ClinicalTrials.gov NCT03305354; https://clinicaltrials.gov/ct2/show/NCT03305354.

0642 Characterizing Actigraphy-Measured Sleep Disturbance in Veterans and Service Members with Post-traumatic Headache following Mild Traumatic Brain Injury

Abstract Introduction Post-traumatic headache (PTH) frequently occur following traumatic brain injury (TBI) is particularly prevalent in Veterans with deployment-related TBI. PTH is associated with a range of physical and mental health symptoms, including post-traumatic stress disorder (PTSD), depression, anxiety, post-concussive symptoms, and subjective sleep complaints. Subjective sleep disturbance is associated with greater pain severity, and headaches (HA) are associated with poorer sleep. Poor sleep may be a mechanism by which PTH exerts both direct and indirect effects on health outcomes Despite the high prevalence of sleep problems in individuals with PTH, we know little about sleep disturbance in Veterans and military personnel with PTH. This study sought to characterize the relationship between objective sleep disturbance and HA in Veterans and military personnel with chronic PTH following mild TBI. Methods Veterans and active-duty service members (N=39, Mage= 49.4, 89.7% male) were included from a larger study evaluating prazosin as prophylactic treatment for persistent PTH. Participants completed baseline measures of PTSD symptoms, insomnia, sleep quality, HA frequency and impairment, as well as 7-day actigraphy, sleep diary, and HA logs. Actigraphy-derived sleep parameters include sleep onset latency (SOL), total sleep time (TST), sleep efficiency (SE), and wake after sleep onset (WASO). Daily HA logs were used to assess HA severity and duration. Analyses were conducted in SPSS 26.0 using multilevel modeling, controlling for the effects of time. Results Preliminary results suggest number of HA days at baseline was significantly associated with self-reported sleep quality (r=-.398, p= .016), but not with subjective SOL, TST, or WASO. Number of HA days was significantly correlated with actigraphy-measured WASO (r=.178, p=.003). Actigraphy-measured SOL, SE, WASO, and TST were not significantly associated with same-day HA severity and duration. Conclusion This preliminary data suggest examination of sleep fragmentation may be important in enhancing our understanding of PTH and related impairment. Findings support the importance of using both subjective and objective measures in the assessment of sleep in Veterans and service members with PTH. Support (If Any) This project was supported by a VA Career Development Award 5IK2RX001136 from the United States Department of Veterans Affairs Rehabilitation Research and Development Service. The contents of this work do not represent the views of the Department of Veterans Affairs or the United States government.

How effectively does CBT-I address the traumatic and functional causes of insomnia and sleep disturbance in Veterans?

LAY SUMMARY Cognitive-behavioural therapy for insomnia (CBT-I) continues to be recommended as the first-line treatment for an increasing number of Veterans seeking help for insomnia. Unfortunately, these recommendations are made on the basis of evidence from the general public, who do not experience the same predisposing, activating, and maintaining causes of insomnia as Veterans. This review considers whether CBT-I really addresses the causes of insomnia among Veterans, which can be labelled as functional (e.g., caffeine use) and traumatic (e.g., nightmares). Nine randomized controlled trials of CBT-I delivered to Veterans having trouble falling or staying asleep were reviewed. Evidence was not consistent enough to support the continued recommendation of CBT-I as a first-line treatment for insomnia among Veterans. On a wider level, the authors question whether psychological causes of a mental health problem are always, or should be, fully considered in the process of creating clinical guidelines for treatment.

Correlates of sleep disturbance in Veterans with traumatic brain injury and chronic pain: A cross-sectional study.

Few studies have investigated sleep in Veterans with comorbid traumatic brain injury (TBI) and chronic pain. To describe mood and cognitive correlates with sleep disturbance in a sample of Veterans with both TBI and chronic pain. Cross-sectional, correlational analyses were completed using baseline data from a randomized controlled trial comparing psychosocial treatments for pain in Veterans with TBI. Enrollment occurred between July 2015 and January 2017. Self-report measures of hours slept, insomnia severity, depression and PTSD symptoms were collected along with a brief neuropsychological assessment. Participants (n=221) were an average age of 37.2 years (SD=8.2) and mostly male (89%). Participants reported sleeping an average of 4.9h a night (SD=1.4) with an average Insomnia Severity Index (ISI) score of 17.4 (SD=5.4) suggesting moderate insomnia symptoms. Fewer hours slept was associated with higher depression scores (r=-0.28, p<0.001) and slower processing speed (r=0.23, p<0.001). Increasing insomnia severity was associated with greater depression (r=0.57, p<0.001) and PTSD symptoms (r=0.44, p<0.001), and slower processing speed (r=-0.22, p<0.001). The average ISI score was above the clinical cut off for insomnia diagnosis. Results suggest that those with more severe insomnia symptoms report higher depression and PTSD symptoms as well as exhibit slower processing speed. Improving sleep in this population may be important for improving outcome following TBI.

Complementary and Integrative Health Interventions for Insomnia in Veterans and Military Populations.

Insomnia can be a serious problem diminishing quality of life for Veterans and military populations with and without posttraumatic stress disorder (PTSD). Sleep disturbances are one of the symptoms of PTSD but even after evidence-based PTSD treatments, insomnia symptoms often remain. The primary approaches for treating insomnia are cognitive behavioral therapy for insomnia (CBT-I) and pharmacotherapy. However, each of these treatments has drawbacks. Complementary and Integrative Health (CIH) approaches such as mindfulness meditation, mantram meditation, yoga, and tai chi may provide alternative treatments for insomnia in military populations. This paper provides a brief review of studies on CIH interventions for sleep disturbances in Veterans. It also proposes possible mechanisms by which CIH practices may be effective, including increasing hippocampal volume and gamma-aminobutyric acid acid (GABA). Finally, the acceptability of CIH approaches among Veterans is discussed.

Pain, Activation and Sleep Skills (PASS): An Integrated Behavioral Intervention for Addressing Sleep Disturbance in Veterans Living with Chronic Pain

To describe characteristics and outcomes of Veterans completing the Pain, Activation and Sleep Skills (PASS) program, an integrated behavioral group intervention to address comorbid chronic pain and insomnia.

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

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

Anxiety Symptoms and Sleep Disturbance in Veterans with Posttraumatic Stress Disorder: The Impact of Receiving and Training a Service Dog

The impact of posttraumatic stress disorder (PTSD) on our combat veterans and their families is extensive. Symptoms of anxiety and the effects of sleep disturbance have a negative impact on daily functioning (Wright et al., 2011). The presence of a dog has demonstrated a reduction in anxiety symptoms, which may have a positive influence on improved sleep (Shearer, Hunt, Chowdhury, &amp; Nicol, 2016). The Veterans Administration (VA) has been using canines to assist combat veterans in reintegrating into civilian life, and most currently, as a part of psychological therapy (Rubenstein, 2012). This research examined the impact on combat veterans with PTSD of receiving and training a service dog using Stake’s (2006) collective case study model. Interviews were conducted with fifteen combat veterans diagnosed with PTSD participating in a 14-week program for receiving and training their own service dog. The goal of the study was to explore the veterans’ experience of the training program, as well as determine any effect on their PTSD symptoms. Symptom severity decreases were reported, which had the residual effects of decreased anxiety symptoms, sleep disturbance, and nightmares.

Acupuncture for Treatment of Persistent Disturbed Sleep

To evaluate real, as compared with sham, acupuncture in improving persistent sleep disturbance in veterans with mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD). This sham-controlled randomized clinical trial at a US Department of Veterans Affairs Medical Center (2010-2015) included 60 veterans aged 24-55 years (mean of 40 years) with history of mTBI of at least 3 months and refractory sleep disturbance. Most of these participants (66.7%) carried a concurrent DSM-IV clinical diagnosis of PTSD. For the present study, they were randomized into 2 groups and stratified by PTSD status using the PTSD Checklist-Military Version. Each participant received up to 10 treatment sessions. The primary outcome measure was change in baseline-adjusted global Pittsburgh Sleep Quality Index (PSQI) score following intervention. Secondary outcomes were wrist-actigraphy-assessed objective sleep measurements. Comorbid PTSD was analyzed as a covariate. Mean (SD) preintervention global PSQI score was 14.3 (3.2). Those receiving real acupuncture had a global PSQI score improvement of 4.4 points (relative to 2.4 points in sham, P = .04) and actigraphically measured sleep efficiency (absolute) improvement of 2.7% (relative to a decrement of 5.3% in sham, P = .0016). Effective blinding for active treatment was maintained in the study. PTSD participants presented with more clinically significant sleep difficulties at baseline; acupuncture was effective for both those with and without PTSD. Real acupuncture, compared with a sham needling procedure, resulted in a significant improvement in sleep measures for veterans with mTBI and disturbed sleep, even in the presence of PTSD. These results indicate that an alternative-medicine treatment modality like acupuncture can provide clinically significant relief for a particularly recalcitrant problem affecting large segments of the veteran population. ClinicalTrials.gov identifier: NCT01162317.

Sleep Disturbances in Traumatic Brain Injury: Associations With Sensory Sensitivity.

Sleep disturbances following traumatic brain injury (TBI) in Veterans are very common and often persist as chronic sequelae. In addition, sensory sensitivity, ie, discomfort upon exposure to light and noise, is common after TBI. However, the relationship between sleep disturbances and sensory sensitivity in Veterans following TBI has not yet been examined, yet both are established early markers of neurodegeneration. Veterans (n = 95) in the chronic phase of recovery from TBI at the VA Portland Health Care System completed an overnight polysomnography and provided self-report data on sensory (eg, light and noise) sensitivity, and sleep disturbances. Participants were categorized into four sensory sensitivity groups: (1) "neither," neither light nor noise sensitivity (n = 36); (2) "light," only light sensitivity (n = 12); (3) "noise," only noise sensitivity (n = 24); and (4) "both," light and noise sensitivity (n = 23). Veterans with TBI reported sleep disturbances that were significantly correlated with the severity of their sensory sensitivity and associated with posttraumatic stress disorder (PTSD). Multiple linear regression revealed insomnia severity to be the strongest predictor of the relationship between sleep disturbances and sensory sensitivity. Furthermore, sensory sensitivity was associated with a higher mean heart rate during sleep, even after controlling for PTSD status. These data are the first to report the prevalence and association between sensory sensitivity and sleep disturbances in Veterans with TBI. These data also suggest that the underlying mechanism of the sleep-sensory relationship could be due in part to comorbid PTSD and autonomic nervous system hyperarousal.

Acupuncture for treatment of persistent disturbed sleep: A randomized clinical trial in veterans with mild traumatic brain injury and post-traumatic stress disorder

Persistent sleep disturbance is one of the most highly prevalent symptoms after mild traumatic brain injury (mTBI) and is often refractory to conventional therapies. In the presence of co-existing post-traumatic stress disorder (PTSD), it is especially hard to treat. This randomized clinical trial (RCT) is to evaluate real acupuncture, as compared to sham, in improving persistent sleep disturbance in veterans with mTBI and PTSD. This RCT was conducted at a US Department of Veterans Affairs Medical Center and included sixty veterans aged 24–55 (mean 40) with history of mTBI of at least 3-months and refractory sleep disturbance. They were randomized into 2 groups and stratified by PTSD status. Each received up to 10 treatment sessions. The primary outcome measure was change in baseline-adjusted global Pittsburgh Sleep Quality Index (PSQI) score following intervention. Secondary outcomes were wrist-actigraphy assessed objective sleep measurements. Comorbid PTSD was analyzed as a covariate. Mean [SD] pre-intervention global PSQI score was 14.3 [3.2]. Those receiving real acupuncture had a global PSQI score improvement of 4.4 points (relative to 2.4 points in sham, P = 0.04), and actigraphically measured sleep efficiency (absolute) improvement of 2.7% (relative to a decrement of 5.3% in sham, P = 0.0016). Effective blinding for active treatment was maintained throughout the study. PTSD participants presented with more significant sleep difficulties at baseline; acupuncture was effective for those both with and without PTSD. Real acupuncture, compared to a sham needling procedure, resulted in a significant improvement in subjective and objective sleep measures for veterans with mTBI and disturbed sleep, even in the presence of PTSD. These results indicate that an alternative medicine treatment modality like acupuncture provides meaningful relief for a particularly recalcitrant problem affecting large segments of the veteran population.

Sleep disturbances in veterans with chronic war-induced PTSD.

:Post-traumatic stress disorder is related to a wide range of medical problems, with a majority of neurological, psychological, cardiovascular, respiratory, gastrointestinal disorders, diabetes, as well as sleep disorders. Although the majority of studies reveal the association between PTSD and sleep disturbances, there are few studies on the assessment of sleep disruption among veterans with PTSD. In this review, we attempt to study the sleep disorders including insomnia, nightmare, sleep-related breathing disorders, sleep-related movement disorders and parasomnias among veterans with chronic war-induced PTSD. It is an important area for further research among veterans with PTSD.

Auricular Acupuncture for Sleep Disturbance in Veterans With Post-Traumatic Stress Disorder: A Feasibility Study

The purpose of this study was to examine the feasibility and acceptability of an auricular acupuncture (AA) insomnia regimen among Operation Iraqi Freedom and Operation Enduring Freedom veterans with post-traumatic stress disorder and sleep disturbance. Secondarily, this study examined the effect of an AA insomnia regimen on objective sleep times by wrist actigraphy, subjective sleep times by sleep diary, and sleep quality ratings utilizing the Pittsburg Sleep Quality Index. Veterans (n = 30) were randomized to receive a 3-week AA insomnia regimen. Veterans receiving the AA insomnia regimen reported it as a more acceptable treatment for sleep disturbance than subjects in the control group (AA group median = 5 vs. control group median = 3, p = 0.004). Significant differences between groups were found on the sleep quality and daytime dysfunction components of the Pittsburgh Sleep Quality Index (p = 0.003, p = 0.004). No other significant differences between groups were found for objective and subjective sleep measures. These results suggest that an AA insomnia regimen may improve sleep quality and daytime dysfunction among veterans with post-traumatic stress disorder. Future, large-scale, prospective clinical trials are needed to examine AA effects on sleep.

The epworth sleepiness scale in the assessment of sleep disturbance in veterans with tinnitus.

Purpose. Tinnitus and sleep disturbance are prevalent in veterans, and a better understanding of their relationship can help with tinnitus treatment. Materials and Methods. Retrospective chart review of 94 veterans seen in audiology clinic between 2010 and 2013 is presented. Results. The mean age was 62 years, and 93 of 94 veterans were males. The majority (96%) had hearing loss. The positive predictive value of the ESS for sleep disorder was 97% and the negative predictive value was 100%. Veterans with a Tinnitus Handicap Inventory (THI) score ≥38 had significantly higher Epworth Sleepiness Scale (ESS) scores compared to those with THI score <38 (P = 0.006). The former had a significantly higher incidence of PTSD, anxiety, and sleep disorder. A subgroup of patients had normal sleep despite rising THI scores. Bilateral tinnitus, vertigo, and anxiety were found to be predictors of sleep disturbance. Conclusions. The ESS can be used as a tool in the initial assessment of sleep disorders in veterans with tinnitus. Higher tinnitus handicap severity is significantly associated with greater sleep disturbance. Optimal management of tinnitus may require concomitant treatment of sleep disorder, PTSD, anxiety, and depression.

Subjective Sleep Disturbance in Veterans Receiving Care in the Veterans Affairs Polytrauma System Following Blast-Related Mild Traumatic Brain Injury

This investigation sought to characterize prevalence and factors associated with subjective sleep disturbance (SSD) in a clinical sample of veterans with blast-related mild traumatic brain injury (mTBI). Adult veterans with history of blast-related mTBI were enrolled in a cross-sectional study. Data on demographics, injury, and current symptoms, including SSD, were obtained. Descriptive and univariate analyses investigated prevalence of SSD and associated factors. Participants were 114 veterans with blast-related mTBI (96% male; mean age = 31 years, SD = 8; mean number of days since injury =1,044, SD = 538). 78% screened positive for post-traumatic stress disorder and 77% reported SSD. Loss of consciousness at time of injury, current nightmares, depression, headache, fatigue, and positive screen for post-traumatic stress disorder were significantly associated with SSD (p < 0.05). SSD was pervasive in this clinical sample and was significantly associated with multiple modifiable emotional symptoms as well as headache and fatigue; this is consistent with previous literature including samples with history of nonblast-related mTBI. Future research incorporating objective measurement of SSD and associated symptoms is needed to inform evidence-based screening, assessment, and treatment efforts for veterans with history of mTBI.

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.

A Multi-Component Cognitive-Behavioral Intervention for Sleep Disturbance in Veterans with PTSD: A Pilot Study

A significant portion of US military personnel are returning from deployment with trauma-related sleep disturbance, and disrupted sleep has been proposed as a mechanism for the development of medical conditions in those with posttraumatic stress disorder (PTSD). Although individuals with PTSD may realize improved sleep with either PTSD treatment or CBT for insomnia, many continue to experience residual sleep difficulties. Newly developed interventions designed to address nightmares are effective to this end, but often do not fully remove all aspects of PTSD-related sleep difficulties when used in isolation. A combined intervention involving both a nightmare-specific intervention and CBT for insomnia may lead to more marked reductions in PTSD-related sleep disturbances. Twenty-two veterans meeting criteria for PTSD were enrolled in the study. A combined intervention comprised of CBT for insomnia and imagery rehearsal therapy was evaluated against a usual care comparison group. Intent-to-treat analyses revealed medium to large treatment effect sizes for all sleep diary outcomes, and very large treatment effects for insomnia severity, sleep quality, and PTSD symptoms. Findings demonstrate that an intervention targeting trauma-specific sleep disturbance produces large short-term effects, including substantial reductions in PTSD symptoms and insomnia severity. Future research should focus on the optimal approach to the treatment of comorbid PTSD and sleep disturbance in terms of sequencing, and should assure that sleep-focused interventions are available and acceptable to our younger veterans, who were more likely to drop out of treatment.