Trauma-associated Sleep Disorder Research Articles

Features of Nightmare Disorder and Trauma-associated Sleep Disorder Among U.S. Military Personnel (S36.007)

Features of Nightmare Disorder and Trauma-associated Sleep Disorder Among U.S. Military Personnel (S36.007)

Consecutive Video Polysomnography Increases Detection of Movements and REM Without Atonia in Trauma-associated Sleep Disorder in Military Service Members and Veterans (P8-9.010)

Consecutive Video Polysomnography Increases Detection of Movements and REM Without Atonia in Trauma-associated Sleep Disorder in Military Service Members and Veterans (P8-9.010)

0657 Incidence and Features of Nightmares and Trauma Associated Sleep Disorder in U.S. Military Personnel with Sleep Disturbances

Abstract Introduction The incidence and clinical significance of nightmares is difficult to estimate due to varying criteria across studies. The Nightmare Disorder Index (NDI) is a validated measure to evaluate nightmare disorder. However, there is no measure to differentiate trauma-related nightmares compared to trauma associated sleep disorder (TSD), a unique REM parasomnia. The objectives of this study were to (1) determine the incidence of nightmare disorder and TSD in patients referred for a clinically indicated sleep evaluation, and (2) further characterize TSD. Methods All initial sleep referrals completed intake questionnaires including validated measures such as the NDI, Epworth Sleepiness Scale (ESS) and Insomnia Severity Index (ISI). Patients who endorsed at least weekly nightmares related to trauma, with vocalizations or disruptive nocturnal behaviors, and autonomic surges additionally received a structured clinical interview focusing on thematic content of dreams, dream enactment behavior, self-reported symptoms of autonomic hyperactivity, and, if previously treated, nightmare severity before and after therapy. Results 102 new patients completed the NDI and 56.9% (58) met criteria for probable nightmare disorder (ND). Of the 58 patients with probable ND, 13.8% (8) had symptoms consistent with TSD (7.8% of new referrals). Compared to ND patients, TSD patients were more likely to have higher ISI (24.0 ± 3.0 vs. 18.6 ± 5.6) (p=0.023) and total NDI score (15.8 ± 3.5 vs. 10.0 ± 3.7) (p< 0.001), but not ESS (p=0.158). Structured interview revealed all TSD patients had significant daytime distress or impairment. The nature of trauma was combat for 3 individuals, physical assault for 1, and sexual assault for 4 (one occurring while deployed). All individuals reported tachycardia secondary to nightmares and tachypnea and diaphoresis were each reported in 75% of patients. Regarding dream content, 25% endorsed accurate replay of trauma, 25% related to trauma but non-replay, and 50% mixed. For DNB, 87.5% of patients endorsed vocalization (moaning, screaming, or yelling), 87.5% endorsed movements (tossing, turning, or thrashing), and 37.5% endorsed combative behaviors (striking of bed partner). Conclusion This study reports a surprisingly high incidence of probable ND among all new sleep medicine patients. TSD appears to be a clinically distinct, more severe parasomnia compared to ND. Support (if any)

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)

0669 Disruptive Nocturnal Behaviors in PTSD Patients are Associated with More Severe Psychiatric Pathology

Abstract Introduction The similarities and differences between trauma associated sleep disorder (TASD) and REM sleep behavior disorder (RBD) are unclear. However, both REM sleep parasomnias are associated with disruptive nocturnal behaviors (DNB) that manifest as episodes of sleep-related vocalizations, and/or complex motor behaviors. Patients who have more DNB are more likely to have a higher prevalence of PTSD. Methods In a cross-sectional study, we examined the relationship between DNB severity and the severity of psychiatric symptoms in PTSD patients. 73 civilian patients with histories of complex developmental trauma (age 47.0 ±13.3 years; 89.6% female) met the DSM-5 criteria for moderate-to-severe PTSD. PTSD Checklist for DSM-5 (PCL-5) was used to obtain an index of current PTSD severity (37.41 ± 19.84; PCL-5 >30 cutoff for PTSD). DNB was defined as the sum of the two items 1f and 1g in the Pittsburgh Sleep Quality Index PTSD Addendum (PTSD-A). The participants rated how often during the past 1 month they had trouble sleeping because of the following: (PTSD-A Item1f) “Had episodes of terror or screaming during sleep without fully awakening” and (PTSD-A Item1g) “Had episodes of ‘acting out’ their dreams, such as kicking, punching, running or screaming”. We used a stepwise multiple regression analysis with DNB as the dependent variable and the variables described below as independent variables. Results We determined the following relationships: 1. PCL-5 (r=0.359, p=0.002); 2. Brief Symptom Inventory which includes Somatization (r=0.476,p< 0.001);Obsessive-compulsiveness (r=0.429, p< 0.001); Interpersonal Sensitivity (r=0.337, p=0.004); Depression (r=0.398, p< 0.001); Anxiety (r=0.449,p< 0.001); Hostility (r=0.577, p< 0.001); Phobic Anxiety (r=0.353, p=0.002); Paranoid Ideation (r=0.412, p< 0.001); and Psychoticism (r=0.414, p< 0.001); 3. Insomnia Severity Index (r=0.363, p=0.002); 4. Beck Suicide Scale or BSS (r=0.268, p=0.025); 5.Beck Anxiety Inventory (r=0.472, p< 0.001); and 6. Fear of Sleep(r=0.493,p< 0.001). Fear of Sleep Inventory (FOS) (Beta=0.442, t=4.258, p< 0.001) and Beck Scale for Suicidal Ideation (BSS) (Beta=0.300, t=2.887, p=0.005) emerged as the significant predictors of DNB. Conclusion DNB was correlated with a wide range of psychiatric pathology in PTSD. This suggests that DNB could be an integral feature of severe PTSD. To our knowledge, this has not been previously reported. Support (if any) None

Probable trauma associated sleep disorder in post-9/11 US Veterans.

The purpose of this study was to (1) estimate trauma associated sleep disorder (TASD) prevalence among post-9/11 era veterans and to describe differences in service and comorbid mental health clinical characteristics among individuals with and without probable TASD, and (2) estimate TASD prevalence and characteristics of reported traumatic experiences stratified by sex. We used cross-sectional data from the post-deployment mental health study of post-9/11 veterans, which enrolled and collected baseline data from 2005 to 2018. We classified veterans as having probable TASD using self-reported measures: traumatic experiences from the traumatic life events questionnaire (TLEQ) and items from the Pittsburgh sleep quality index with Addendum for posttraumatic stress disorder (PTSD) mapped to TASD diagnostic criteria and ascertained mental health diagnoses (PTSD, major depressive disorder [MDD]) via Structured Clinical Interview for DSM-IV. We calculated effect sizes as prevalence ratios (PR) for categorical variables and Hedges' g for continuous variables. Our final sample included 3618 veterans (22.7% female). TASD prevalence was 12.1% (95% CI: 11.1% to 13.2%) and sex-stratified prevalence was similar for female and male veterans. Veterans with TASD had a much higher comorbid prevalence of PTSD (PR: 3.72, 95% CI: 3.41 to 4.06) and MDD (PR: 3.93, 95% CI: 3.48 to 4.43). Combat was the highest reported most distressing traumatic experience among veterans with TASD (62.6%). When stratifying by sex, female veterans with TASD had a wider variety of traumatic experiences. Our results support the need for improved screening and evaluation for TASD in veterans, which is currently not performed in routine clinical practice.

Dream Enactment Behavior: A Documented Case Presenation with a Transition from Post Traumatic Stress Disorder to REM Behavior Disorder

Dream enactment behavior (DEB) contains the hallmark criteria for the diagnosis of REM behavior disorder (RBD) and it is attributed as the underlying mechanism with its distinct pathology and presentation. The recently described condition, trauma associated sleep disorder (TSD), is closely related to posttraumatic stress disorder (PTSD), and shares the same diagnostic criteria for RBD but they differ significantly in their underlying pathophysiology. The transition from one to another has not been described well (and only self-reported) in the medical literature. This article describes a case study of a patient with a history of PTSD in remission, who developed symptoms documented by polysomnography that are typical of idiopathic RBD that are not connected to the patient's previous trauma

Trauma Immediately Preceding REM-Behavior Disorder: A Valuable Prognostic Marker?

Background: The definition of rapid eye movement (REM) sleep behavior disorder (RBD) has varied over the years. Rapid eye movement sleep behavior disorder can be considered isolated or idiopathic or can occur in the context of other disorders, including trauma-associated sleep disorder (TSD) and overlap parasomnia. However, whether trauma in RBD carries any prognostic specificity is currently unknown.Study Objectives: To test the hypothesis that RBD secondary to trauma is less likely to result in the development of neurodegeneration compared to idiopathic RBD (iRBD) without trauma in the general population.Methods: A retrospective cohort study of 122 consecutive RBD patients (103 males) at two tertiary sleep clinics in Europe between 2005 and 2020 was studied. Patients were diagnosed as having iRBD by video polysomnography (vPSG) and had a semi-structured interview at presentation, including specifically eliciting any history of trauma. Patients with secondary RBD to recognized causes were excluded from the study. Patients with iRBD were categorized into three groups according to reported trauma history: (1) No history of trauma, (2) traumatic experience at least 12 months prior to RBD symptom onset, and (3) traumatic experience within 12 months of RBD symptom onset. Idiopathic RBD duration was defined as the interval between estimated onset of RBD symptoms and last hospital visit or death. Follow-up duration was defined as the interval between iRBD diagnosis and last hospital visit or death.Results: In a follow-up period of up to 18 years, no patient who experienced trauma within 12 months preceding their iRBD diagnosis received a diagnosis of a neurodegenerative disorder (n = 35), whereas 38% of patients without trauma within the 12 months of symptom onset developed a neurodegenerative illness. These patients were also significantly more likely to have a family history of α-synucleinopathy or tauopathy.Conclusions: The development of RBD within 12 months of experiencing a traumatic life event, indistinguishable clinically from iRBD, did not lead to phenoconversion to a neurodegenerative disorder even after 18 years (mean follow up 6 years). We suggest that a sub-type of RBD be established and classified as secondary RBD due to trauma. Additionally, we advocate that a thorough psychological and trauma history be undertaken in all patients presenting with dream enactment behaviors (DEB).

Dream Enactment Behaviors Associated With Posttraumatic Stress Disorder.

The investigators aimed to draw attention to current debates surrounding the etiologies of dream enactment behaviors in patients with posttraumatic stress disorder (PTSD). The phenomenological overlap between PTSD-related nocturnal symptoms, rapid eye movement sleep behavior disorder (RBD), and trauma-associated sleep disorder (TASD) is discussed. Strategies used to diagnose and manage dream enactment behaviors, whether due to RBD or another confounding sleep disorder, are considered. Finally, the need for further research on the pathophysiological overlap and integrated treatment of PTSD, RBD, and, possibly, TASD is highlighted.

Dream enactment behavior-a real nightmare: a review of post-traumatic stress disorder, REM sleep behavior disorder, and trauma-associated sleep disorder.

Dream enactment behavior is a phenomenon demonstrated in patients with post-traumatic stress disorder, rapid eye movement sleep behavior disorder, as well as with a more recently described condition entitled trauma-associated sleep disorder, which shares diagnostic criteria for rapid eye movement sleep behavior disorder. While these conditions share some commonalities, namely dream enactment behavior, they are quite different in pathophysiology and underlying mechanisms. This review will focus on these 3 conditions, with the purpose of increasing awareness for trauma-associated sleep disorder in particular.

0803 Clinical and Polysomnographic Features of Trauma Associated Sleep Disorder (TASD)

Abstract Introduction Trauma associated sleep disorder (TASD) is an emerging parasomnia that develops after trauma with clinical features of trauma related nightmares (TRN), disruptive nocturnal behaviors (DNB), and autonomic disturbances. The purpose of this study is to characterize the clinical and polysomnographic (PSG) features of TASD. Methods Clinical history and detailed video-PSG review, to include post-PSG nightmare reports, of a cohort of patients with TASD. Results Patients (n=40, 32 men, 8 women) were active duty service members with a median age of 38.9 yrs (range 24-57 yrs). Dream content typically related to combat (n=37, 92.5%), with 75% (n=30) reporting TRN and 60% (n=24) reporting dream enactment at least weekly. Self-reported DNB included vocalizations, violent limb movements, thrashing, defensive posturing, and jumping from bed. There was a high rate of comorbid insomnia (n=35, 87.5%), PTSD (n=23, 63.9%), anxiety (n=25, 62.5%), depression (n=20, 50%), OSA (n=19, 47.5%), chronic pain (n=12, 30%), and TBI (n=13, 32.5%). Most patients had REM sleep without atonia (RSWA) (n=33, 82.5%), though a minority had purposeful DNB (n=11, 27.5%). Vocalizations were present in seven (17.5%) patients. Patients with PTSD were more likely to have purposeful DNB (n=9, 100%) than those without PTSD (n=13, 50%; p=0.013), whereas patients with purposeful DNB had markedly less N3 sleep (1.0±11.4%) than those without purposeful DNB (13.8±16.2%; p=0.002). There was no significant difference in medications between DNB groups. Conclusion TASD is frequently comorbid with other sleep and behavioral health disorders. Characteristics of TASD are often captured on video-PSG during REM sleep, though DNB may be less pronounced than what patients report in their habitual sleeping environment. Clinical and video-PSG correlations are invaluable in assessing patients with TASD. This study, which is the largest cohort to date, provides a further basis for establishing TASD as a unique REM-related parasomnia. Support N/A

Is trauma-associated sleep disorder a sub-form REM sleep behavior disorder? a Canadian longitudinal study on aging cohort study

Is trauma-associated sleep disorder a sub-form REM sleep behavior disorder? a Canadian longitudinal study on aging cohort study

Posttraumatic stress disorder increases the odds of REM sleep behavior disorder and other parasomnias in Veterans with and without comorbid traumatic brain injury.

To describe the crude prevalence of rapid eye movement (REM) sleep behavior disorder (RBD) following traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) in Veterans, given potential relationships between TBI, PTSD, RBD, and neurodegeneration. Veterans (n = 394; 94% male; 54.4 ± 15.5 years of age) were prospectively/cross-sectionally recruited from the VA Portland Health Care System and completed in-lab video-polysomnography and questionnaires. TBI and PTSD were assessed via diagnostic screening and medical record review. Subjects were categorized into four groups after assessment of REM sleep without atonia (RSWA) and self-reported dream enactment: (1) "Normal," neither RSWA nor dream enactment, (2) "Other Parasomnia," dream enactment without RSWA, (3) "RSWA," isolated-RSWA without dream enactment, and (4) "RBD," RSWA with dream enactment. Crude prevalence, prevalence odds ratio, and prevalence rate for parasomnias across subjects with TBI and/or PTSD were assessed. Overall prevalence rates were 31%, 7%, and 9% for Other Parasomnia, RSWA, and RBD, respectively. The prevalence rate of RBD increased to 15% in PTSD subjects [age adjusted POR: 2.81 (1.17-4.66)] and to 21% in TBI + PTSD subjects [age adjusted POR: 3.43 (1.20-9.35)]. No subjects met all diagnostic criteria for trauma-associated sleep disorder (TASD), and no overt dream enactment was captured on video. The prevalence of RBD and related parasomnias is significantly higher in Veterans compared with the general population and is associated with PTSD and TBI + PTSD. Considering the association between idiopathic-RBD and synucleinopathy, it remains unclear whether RBD (and potentially TASD) associated with PTSD or TBI + PTSD similarly increases risk for long-term neurologic sequelae.

Trauma Associated Sleep Disorder: Clinical Developments 5Years After Discovery.

We review recent and growing evidence that provides support for a novel parasomnia, trauma associated sleep disorder (TASD). Based on these findings, we further develop the clinical and polysomnographic (PSG) characteristics of TASD. We also address factors that precipitate TASD, develop a differential diagnosis, discuss therapy, and propose future directions for research. Nightmares, classically a REM phenomenon, are prevalent and underreported, even in individuals with trauma exposure. When specifically queried, trauma-related nightmares (TRN) are frequently associated with disruptive nocturnal behaviors (DNB), consistent with TASD. Capture of DNB in the lab is rare but ambulatory monitoring reveals dynamic autonomic concomitants associated with disturbed dreaming. TRN may be reported in NREM as well as REM sleep, though associated respiratory events may confound this finding. Further, dream content is more distressing in REM. Therapy for this complex disorder likely requires addressing not only the specific TASD components of TRN and DNB but comorbid sleep disorders. TASD is a unique parasomnia developing after trauma. Trauma-exposed individuals should be specifically asked about their sleep and if they have nightmares with or without DNB. Patients who report TRN warrant in-lab PSG as part of their evaluation.

Trauma-Associated Sleep Disorder: A Posttraumatic Stress/REM Sleep Behavior Disorder Mash-Up?

Trauma-associated sleep disorder (TASD) is a parasomnia sharing characteristics of post-traumatic stress disorder (PTSD) and REM sleep behavior disorder (RBD) including dream-enactment behavior (DEB). Here we report REM sleep without atonia (RSWA) and other neurological features in a patient with complex vocal and motor DEB following traumatic combat military exposure. Post-discharge, his wife observed frequent yelling and jerking during sleep with dream mentation reminiscent of traumatic military experiences. He was initially diagnosed with PTSD. Polysomnography demonstrated RSWA and severe obstructive sleep apnea treated with nasal continuous positive airway pressure (CPAP). Dream-enactment behavior severity and frequency was reduced, but still persisted despite nasal CPAP and sequential fluoxetine, escitalopram, prazosin, and melatonin trials. Our case demonstrated overlapping clinical features of PTSD and RBD with polysomnography features of RSWA supportive of idiopathic RBD but no "soft signs" suggesting underlying synucleinopathy. Longitudinal follow-up of larger case series must clarify whether TASD consistently manifests REM sleep atonia loss and determine the phenoconversion risk for synucleinopathy neurodegeneration. A commentary on this article appears in this issue on page 181.

1096 Trauma Associated Sleep Disorder Unmasked by Treatment of OSA: A Case Report

1096 Trauma Associated Sleep Disorder Unmasked by Treatment of OSA: A Case Report

Trauma-Associated Sleep Disturbances: a Distinct Sleep Disorder?

This paper describes a newly proposed sleep disorder, trauma-associated sleep disorder (TSD). Whether or not this represents a truly unique condition is controversial. In this paper, we describe the overlapping features and differences between TSD, post-traumatic stress disorder (PTSD) and Rapid Eye Movement (REM) sleep behavior disorder (RBD). While REM sleep without atonia (RWA) and dream enactment are part of the diagnostic criteria for both RBD and TSD, only TSD features nightmares that occur both in non-REM and REM. A key difference between TSD and PTSD is the presence of symptoms during wakefulness in the latter, though the relationship between the two disorders is, as of yet, unclear. It is unknown whether or not a relationship exists between TSD and neurodegeneration, thus this needs to be explored further. Additional research, such as application of TSD diagnostic criteria to more diverse population, would help to determine whether or not TSD is a distinct clinical entity, its relationships to PTSD, as well as the association of this condition with the development of neurodegeneration.

The Prevalence and Characteristics of REM Sleep without Atonia (RSWA) in Patients Taking Antidepressants.

The association of REM sleep without atonia (RSWA) as well as REM sleep behavior disorder (RBD) with the intake of selective serotonin reuptake inhibitors (SSRI) and selective norepinephrine reuptake inhibitors (SNRI) is well established. Our study objective was to determine the prevalence of RSWA and RBD among a group of sleep center patients taking SSRI and SNRI. A retrospective chart review was done at our tertiary sleep center, and 10,746 consecutive records from October 1, 2007, through October 31, 2013, were searched for SSRI and SNRI names using the Sleep Cataloguer Software. The search resulted in 1,444 records, which were then reviewed for keywords of RSWA and RBD. The AASM scoring criteria were used to determine RSWA. Reports of 41 patients with known narcolepsy or α-synucleinopathies were excluded. The remaining records were mined for age, sex, presence of obstructive sleep apnea (OSA), type of antidepressant (SSRI or SNRI), and diagnosis for which antidepressant was prescribed. We used logistic regression analysis to adjust for age, OSA, and sex. Of the 1,444 participants on antidepressants, 176 (12.2%) had RSWA (all confirmed by the investigators) compared to 226 of the entire sleep lab population of 10,746 (2.1%), risk ratio (95% CI) 9.978 (8.149, 12.22). Seven of the 176 patients on antidepressants had RBD (0.48%) compared to 108 of 10,746 (1%), p = 0.005. SSRI and SNRI are associated with a higher prevalence of RSWA but not of RBD. This is independent of medication type.