Veterans who focus on sexual assault trauma show slower between-session habituation and symptom reduction during prolonged exposure treatment for posttraumatic stress disorder.

OBJECTIVE: Prolonged exposure (PE) is an effective treatment for posttraumatic stress disorder (PTSD), but veterans with sexual assault (SA) trauma often discontinue it prematurely. Elevated dropout rates may be due to SA triggering more intense and complex emotions that are more difficult to habituate during imaginal exposures; SA during PE has yet to be examined as a moderator of distress habituation or symptom reduction. METHOD: Participants were N = 65 veterans (n = 12 SA treatment focus; n = 10 SA history but not treatment focus; n = 43 no SA history) enrolled in a clinical trial of a preparatory sleep intervention followed by PE. The sample was representative of the veteran population. Growth curve modeling was used to examine differences in peak subjective units of distress scale (SUDS) ratings across imaginal exposures and changes in biweekly PTSD symptom assessments between veterans who did versus did not focus on SA during PE and between veterans who did versus did not endorse a history of SA. RESULTS: Peak SUDS ratings and PTSD symptoms declined slower among veterans who focused on an SA trauma relative to those who did not. In contrast, participants who endorsed SA history showed similar declines in distress and PTSD symptoms relative to veterans with no SA history. CONCLUSIONS: Veterans who focus on SA during PE may take longer to habituate to trauma content and experience resolution of PTSD symptoms. Awareness of this pattern could allow clinicians to deliver PE more effectively to veterans focusing on an SA trauma. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Sleep efficiency predicts improvements in fear extinction and PTSD symptoms during prolonged exposure for veterans with comorbid insomnia.

Prolonged exposure (PE) is an evidenced-based psychotherapy for PTSD, but many Veterans fail to achieve a clinically meaningful response. Sleep issues are prevalent in Veterans and may interfere with PE by disrupting the learning and consolidation of fear extinction memories during PE exposures. Here, we examined whether changes in fear extinction across imaginal exposures and PTSD symptoms during PE were predicted by diary-assessed levels of nightly sleep efficiency (SE; i.e., percent of time in bed spent sleeping), which may indirectly index sleep fragmentation and sleep-facilitated memory processes. Participants were Veterans with PTSD and comorbid insomnia (N = 40) participating in a clinical trial of cognitive-behavioral therapy for insomnia plus PE. SE was measured via nightly sleep diaries, fear extinction was operationalized as a reduction in peak distress between weekly imaginal exposures, and PTSD symptoms were assessed bi-weekly. Cross-lagged panel models revealed that higher sleep efficiency during the week predicted lower peak distress at the subsequent imaginal exposure and lower PTSD symptoms at the subsequent assessment, whereas PTSD symptoms and peak distress did not predict subsequent sleep efficiency. Efficient sleep may facilitate fear extinction and PTSD reduction during PE. Targeting sleep efficiency could improve PE effectiveness for Veterans with comorbid insomnia.

Examining the bidirectional relationship between posttraumatic stress disorder symptom clusters and PAP adherence.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is a common sleep disturbance in individuals with posttraumatic stress disorder (PTSD), with an emerging literature showing that treating OSA with positive airway pressure (PAP) therapy has a moderate effect on decreasing PTSD severity. Unfortunately, PAP adherence among individuals with PTSD is low. Our study examined how baseline PTSD cluster subscores predict 6-month PAP adherence and how PAP adherence predicts change in PTSD cluster subscores over time. METHODS: We examined PTSD and PAP adherence in 41 veterans with PTSD newly diagnosed with OSA over 6 months of PAP use (mean age = 50.27 years; 73.7% White; 13.6% female). The Posttraumatic Stress Disorder Checklist-Specific (PCL-S) was used to examine PTSD and subscales (re-experiencing, avoidance, and hyperarousal). We used longitudinal analyses to examine PTSD subscores on PAP adherence and PAP adherence predicting changes in PTSD subscores at 6-month follow-up. RESULTS: Among veterans with PTSD, higher levels of re-experiencing and hyperarousal, but not avoidance, predicted lower PAP use. Overall, the high-adherent group showed a 14.36-point decrease on the PCL-S, while the low-adherent group averaged just a 3.66-point decrease. More days of PAP use were associated with greater improvement in hyperarousal and avoidance subscores but not re-experiencing. CONCLUSIONS: Our findings reaffirm the importance of PAP use among patients with comorbid PTSD and sleep apnea, as well as the difficulty in achieving adherent PAP use in this population. Directly addressing heightened re-experiencing and hyperarousal in PTSD may increase PAP adherence among veterans with PTSD and requires future research. CITATION: Colvonen PJ, Goldstein LA, Sarmiento KF. Examining the bidirectional relationship between posttraumatic stress disorder symptom clusters and PAP adherence. J Clin Sleep Med. 2023;19(5):857-863.

Pre-deployment threat learning predicts increased risk for post-deployment insomnia: Evidence from the Marine Resiliency Study.

Insomnia is a common and impairing consequence of military deployment, but little is known about pre-deployment risk factors for post-deployment insomnia. Abnormal threat learning tendencies are commonly observed in individuals with insomnia and maladaptive responses to stress have been implicated in the development of insomnia, suggesting that threat learning could be an important risk factor for post-deployment insomnia. Here, we examined pre-deployment threat learning as a predictor of post-deployment insomnia and the potential mechanisms underlying this effect. Male servicemembers (N = 814) completed measures of insomnia, psychiatric symptoms, and a threat learning task before and after military deployment. Threat learning indices that differentiated participants with versus withoutinsomnia at post-deployment were tested as pre-deployment predictors of post-deployment insomnia. Post-deployment insomnia was linked to elevations on several threat learning indices at post-deployment, but only higher threat conditioning, as indexed by higher threat expectancy ratings to the danger cue, emerged as a pre-deployment predictor of post-deployment insomnia. This effect was independent of combat exposure levels and partially mediated by greater post-deployment nightmares. The tendency to acquire stronger expectations of aversive events following encounters with danger cues may increase risk for post-deployment insomnia, in part due to the development of more severe nightmares.

Diagnosing obstructive sleep apnea in a residential treatment program for veterans with substance use disorder and PTSD.

BACKGROUND: Obstructive sleep apnea (OSA) is often comorbid with both substance use disorders (SUD) and posttraumatic stress disorder (PTSD), yet frequently goes undiagnosed and untreated. We present data on the feasibility and acceptability of objective OSA diagnosis procedures, findings on OSA prevalence, and the relationship between OSA and baseline SUD/PTSD symptoms among veterans in residential treatment for comorbid PTSD/SUD. METHODS: Participants were 47 veterans admitted to residential PTSD/SUD treatment. Participants completed questionnaires assessing PTSD and sleep symptoms, and filled out a sleep diary for seven days. Apnea-hypopnea index (AHI) was recorded using the overnight Home Sleep Apnea test (HSAT; OSA was diagnosed with AHI ≥ 5). RESULTS: Objective OSA diagnostic testing was successfully completed in 95.7% of participants. Of the 45 veterans who went through HSAT, 46.7% had no OSA, 35.6% received a new OSA diagnosis, and 8.9% were previously diagnosed with OSA and were using positive airway pressure treatment (PAP); an additional 8.9% were previously diagnosed with OSA, reconfirmed with the HSAT, but were not using PAP. One hundred percent of respondents during follow-up deemed the testing protocol's usefulness as "Good" or "Excellent." CONCLUSION: OSA diagnostic testing on the residential unit was feasible and acceptable by participants and was effective in diagnosing OSA. OSA testing should be considered for everyone entering a SUD and PTSD residential unit. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

STOP-BANG screener vs objective obstructive sleep apnea testing among younger veterans with PTSD and insomnia: STOP-BANG does not sufficiently detect risk.

STUDY OBJECTIVES: Posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) cooccur even in veterans who are younger with lower body mass index. The STOP-BANG screener for OSA relies heavily on high blood pressure, age, and body mass index and may not generalize to veterans with PTSD. The inability to effectively screen veterans for OSA is problematic given negative outcomes of untreated OSA. METHODS: Our study compared the STOP-BANG to objective OSA diagnostic testing in 48 younger veterans (mean age 43.7 years; 43.8% Caucasian; 20.8% female) seeking treatment for PTSD and insomnia. Apnea-hypopnea events per hour (apnea-hypopnea index), recorded by NOX T3 sleep monitors, were used to diagnose OSA (apnea-hypopnea index ≥ 5 events/h). Logistic regressions examined how STOP-BANG cut-off scores (≥ 3 and ≥ 5) classified OSA status (apnea-hypopnea index ≥ 5 events/h). Follow-up chi-square goodness-of-fit tests examined single-item STOP-BANG performance in the OSA-positive subsample (n = 28). RESULTS: The STOP-BANG (≥ 3) had good sensitivity (92.6%) but poor specificity (47.6%) and negative (0.16) and positive (1.77) likelihood ratios. The STOP-BANG (≥ 5) led to improved specificity (76.19%), but sensitivity (37.04%) and positive (1.56)/negative likelihood ratios (0.83) were poor. Single-item OSA subgroup analyses revealed that body mass index, age, and neck circumference performed poorly, while tiredness and sex performed well. CONCLUSIONS: Findings suggest that the STOP-BANG correctly diagnosed OSA in some veterans but missed OSA in large number of younger veterans with PTSD. This suggests objective diagnostic OSA testing is needed in veterans with PTSD. Future research is needed to develop more accurate OSA screening measures in this population. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Integrated CBT-I on PE and PTSD Outcomes (Impact Study); URL: https://www.clinicaltrials.gov/ct2/show/NCT02774642; Identifier: NCT02774642. CITATION: Lyons R, Barbir LA, Owens R, Colvonen PJ. STOP-BANG screener vs objective obstructive sleep apnea testing among younger veterans with PTSD and insomnia: STOP-BANG does not sufficiently detect risk. J Clin Sleep Med. 2022;18(1):67-73.

Prevalence rates and correlates of insomnia disorder in post-9/11 veterans enrolling in VA healthcare.

STUDY OBJECTIVES: Post-9/11 veterans are particularly vulnerable to insomnia disorder. Having accurate prevalence rates of insomnia disorder in this relatively young, diverse population, is vital to determine the resources needed to identify and treat insomnia disorder. However, there are no accurate prevalence rates for insomnia disorder in post-9/11 veterans enrolling in the VA Healthcare System (VHA). We present accurate prevalence of insomnia disorder, and correlates, in a large sample of post-9/11 veterans enrolling in a VHA. METHODS: This was an observational study of 5,552 post-9/11 veterans newly enrolling for health care in a VHA. Data were collected using VA eScreening. Insomnia diagnosis was determined using a clinical cutoff score of ≥ 11 on the Insomnia Severity Index. Measures also included sociodemographic, service history, posttraumatic stress disorder (PTSD), depression, suicidal ideation, alcohol misuse, military sexual trauma, traumatic brain injury (TBI), and pain intensity. RESULTS: About 57.2% of the sample population had insomnia disorder. Our sample was nationally representative for age, sex, ethnicity, branch of the military, and race. The sample also was at high-risk for a host of clinical disorders, including PTSD, TBI, and pain; all of which showed higher rates of insomnia disorder (93.3%, 77.7%, and 69.6%, respectively). CONCLUSIONS: The findings suggest alarmingly high rates of insomnia disorder in this population. Examining and treating insomnia disorder, especially in the context of co-occurring disorders (e.g. PTSD), will be a necessity in the future.

Examining sleep over time in a randomized control trial comparing two integrated PTSD and alcohol use disorder treatments.

STUDY OBJECTIVES: Insomnia is highly co-occurring with both posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). This is concerning since insomnia contributes to worse substance abuse and PTSD, and a host of negative health consequences. No study has tracked how sleep indices and insomnia change related to integrated PTSD and AUD treatment using evidence-based exposure therapy. This study examined how insomnia changes over time in a randomized control trial of two integrated PTSD and AUD treatments. METHODS: Participants were 119 adult veterans (90 % male) seeking treatment for AUD and PTSD at a large urban VA. Participants were randomized to either COPE (integrated treatment using prolonged exposure) or Seeking Safety (integrated therapy using cognitive behavioral, interpersonal techniques and case management). Assessments were done at pre- and post-treatment and include: Clinician Administered PTSD Scale, Timeline Follow-back calendar-assisted interview for AU, insomnia severity index (ISI), sleep diary and actigraphy for 7 days. RESULTS: ISI showed significant decreases, but a majority remained above the clinical cutoff at post-treatment. Wake after sleep onset decreased, but only by 8 min, remaining above clinical thresholds. Decreases in PTSD, but not in heavy drinking, predicted change in ISI. No significant changes were observed in other sleep variables measured. CONCLUSIONS: Findings suggested some statistical improvements in sleep quality, but sleep indices remained above clinical cut-offs. This study provides evidence that insomnia is an independent disorder and not responsive to PTSD or AUD treatments alone. Sleep symptoms should be assessed and treated in patients with comorbid mental health conditions.

Efficacy of Integrated Exposure Therapy vs Integrated Coping Skills Therapy for Comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A Randomized Clinical Trial.

Importance: Co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common and associated with psychiatric and functional problems. Understanding whether exposure therapy is tolerable and efficacious for treating PTSD and AUD is critical to ensure that best practice treatments are available. Objective: To compare the efficacy of integrated (ie, targeting both PTSD and alcohol use) prolonged exposure (I-PE) therapy with present-centered integrated coping skills (I-CS) therapy, a more commonly available treatment, in reducing PTSD symptoms and alcohol use. Design, Setting, and Participants: This prospective randomized clinical trial with masked assessments considered 186 veterans seeking Veterans Affairs mental health services. A total of 119 veterans with PTSD and AUD were randomized. Data were collected from February 1, 2013, to May 31, 2017, before treatment, after treatment, and at 3- and 6-month follow-ups. Intention-to-treat analyses were performed. Interventions: Veterans underwent I-PE (Concurrent Treatment of PTSD and Substance Use Disorder Using Prolonged Exposure) or I-CS (Seeking Safety) therapy. Main Outcomes and Measures: A priori planned outcomes were PTSD symptoms (Clinician Administered PTSD Scale for DSM-5) and percentage of heavy drinking days (Timeline Follow-Back) before treatment, after treatment, and at 3- and 6-month follow-ups. Results: A total of 119 veterans (mean [SD] age, 41.6 [12.6] years; 107 [89.9%] male) were randomized. Linear mixture models found that PTSD symptoms decreased in both conditions, with a significantly greater decrease for I-PE treatment compared with I-CS treatment (treatment × time interaction, -2.83; F3,233.1 = 4.92; Cohen d = 0.41; P = .002). The percentage of heavy drinking days improved in both conditions but was not statistically different between I-PE and I-CS treatment (treatment × time interaction, 1.8%; F3,209.9 = 0.18; Cohen d = 0.04; P = .91). Conclusions and Relevance: The I-PE arm had a greater reduction in PTSD symptoms than the I-CS arm and comparable drinking decreases. The study provides evidence that exposure therapy is more efficacious in treating PTSD than a more commonly available integrated treatment without exposure for comorbid PTSD and AUD. Trial Registration: ClinicalTrials.gov identifier: NCT01601067.

A Review of the Relationship Between Emotional Learning and Memory, Sleep, and PTSD.

PURPOSE OF REVIEW: The emotional memory and learning model of PTSD posits maladaptive fear conditioning, extinction learning, extinction recall, and safety learning as central mechanisms to PTSD. There is increasingly convincing support that sleep disturbance plays a mechanistic role in these processes. The current review consolidates the evidence on the relationships between emotional memory and learning, disturbed sleep, and PTSD acquisition, maintenance, and treatment. RECENT FINDINGS: While disrupted sleep prior to trauma predicts PTSD onset, maladaptive fear acquisition does not seem to be the mechanism through which PTSD is acquired. Rather, poor extinction learning/recall and safety learning seem to better account for who maintains acute stress responses from trauma versus who naturally recovers; there is convincing evidence that this process is, at least in part, mediated by REM fragmentation. Individuals with PTSD had higher "fear load" during extinction, worse extinction learning, poorer extinction recall, and worse safety learning. Evidence suggests that these processes are also mediated by fragmented REM. Finally, PTSD treatments that require extinction and safety learning may also be affected by REM fragmentation. Addressing fragmented sleep or sleep architecture could be used to increase emotional memory and learning processes and thus ameliorate responses to trauma exposure, reduce PTSD severity, and improve treatment. Future studies should examine relationships between emotional memory and learning and disturbed sleep in clinical PTSD patients.

Examining Insomnia and PTSD Over Time in Veterans in Residential Treatment for Substance Use Disorders and PTSD.

Objective/Background: Insomnia occurs in 66-90% of individuals with posttraumatic stress disorder (PTSD) and 36-72% of individuals with substance use disorder (SUD). Individuals with both PTSD and SUD are more likely to have insomnia than individuals with only one disorder. Insomnia is associated with poorer treatment outcomes for both PTSD and SUD, increased daytime symptomology for PTSD, and increased relapse for SUDs. As such, it is important to understand how sleep affects PTSD treatment among patients dually diagnosed with SUD and how sleep changes over time in a residential unit for SUDs. Participants: Participants were 40 veterans with comorbid PTSD and SUD in a 28-day Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) PTSD track. Methods: Analyses used mixed models with Time (baseline, posttreatment, 3-month follow-up) to examine PTSD and insomnia severity over time. Results: Results of the longitudinal mixed model showed that PTSD symptoms improved over time but that insomnia symptoms did not. Although baseline insomnia did not affect follow-up PTSD symptoms, individuals with greater insomnia severity at the start of treatment had more severe baseline PTSD symptomatology. However, there was not an interaction of insomnia and PTSD severity over time such that baseline insomnia did not affect PTSD trajectories. Conclusions: These findings are consistent with the PTSD outpatient treatment findings and further adds evidence that insomnia is unremitting without direct intervention. Given the relationship insomnia has with PTSD severity, SUD, and relapse, directly targeting insomnia may further help improve both PTSD and SUD treatment outcomes.

Piloting cognitive-behavioral therapy for insomnia integrated with prolonged exposure.

OBJECTIVE: Approximately 35-61% of individuals with posttraumatic stress disorder (PTSD) report insomnia. Further, upward of 70% report clinically significant insomnia following PTSD treatment. There are converging lines of evidence suggesting that insomnia not only independently affects daytime functioning and worsens PTSD symptoms but also may compromise response to PTSD treatment, such as prolonged exposure (PE). Taken together, integrated insomnia and PTSD treatment may increase client-centered care and treatment outcomes. METHOD: This article reviews the theory and evidence for treating sleep prior to PTSD treatment, describes the key elements of integrated cognitive-behavioral treatment for insomnia (CBT-I) and PE (2NITE protocol), and presents pilot data from a sample of 12 treatment-seeking veterans with PTSD and insomnia who completed the 2NITE protocol. Sleep data were collected with sleep diaries and actigraphy watches. RESULTS: The Client Satisfaction Questionnaire indicated high satisfaction with the 2NITE protocol (mean score 29.66 out of 32 points). On average, there were statistical and clinically significant changes in all measures, including a 20.17-point decrease in the PTSD Checklist DSM-5, a 11.75-point decrease in the insomnia severity index, an 18.58-point increase in the World Health Organization Quality of Life index, a 11% increase in sleep efficiency, and a 51-min increase in total sleep time from the actigraphy data. CONCLUSIONS: Among individuals with insomnia and PTSD, integrating CBT-I and PE with the 2NITE protocol represents a logical, innovative, and empirically informed method for augmenting existing treatments and optimizing outcomes that justifies further investigation. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Differential relationships of guilt and shame on posttraumatic stress disorder among veterans.

OBJECTIVE: Despite important conceptual differences between shame and guilt, literature distinguishing these emotions in relation to posttrauma functioning for veterans has been largely theoretical. This is the first study to concurrently examine trauma-related guilt and internalized shame in relation to PTSD severity as the dependent variable. Our primary aim was to examine guilt and shame on PTSD symptom severity within the same model. A secondary aim was to evaluate whether trauma-related guilt can occur independent of shame. METHOD: Participants were 144 veterans seeking PTSD treatment. Regression analysis was used for our primary aim. Chi-square was used for our secondary aim to examine the percentage of participants categorized one standard deviation above (high) and below (low) the mean for shame and guilt. RESULTS: Entered together, internalized shame (ß = .44, p < .001) and guilt-related distress (ß = .32, p < .001) were related to PTSD severity. Guilt cognitions and global guilt were unrelated to PTSD. Analyses showed significant differences in participants categorized as low/high shame and low/high global guilt (χ² = 14.22, p < .001), guilt-related distress (χ² = 15.09, p < .001), and guilt cognitions (χ² = 13.16, p < .001). Across guilt subscales, "shame-free" trauma-related guilt did not exist (0%). Conclusions Internalized shame and guilt distress were both related to PTSD severity; however, shame added variance not already accounted for by guilt. Tangney, Stuewig, and Mashek (2007) stipulate that guilt becomes maladaptive when fused with shame; however, our results indicate trauma-related guilt is possibly always fused with shame. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Recent Advancements in Treating Sleep Disorders in Co-Occurring PTSD.

PURPOSE OF REVIEW: Comorbidity of posttraumatic stress disorder (PTSD) and insomnia, nightmares, and obstructive sleep apnea (OSA) is high. We review recent research on psychotherapeutic and pharmacological interventions for sleep disorders in PTSD. RECENT FINDINGS: PTSD treatments decrease PTSD severity and nightmare frequency, but do not resolve OSA or insomnia. Research on whether insomnia hinders PTSD treatment shows mixed results; untreated OSA does interfere with PTSD treatment. Cognitive behavioral therapy for insomnia is the recommended treatment for insomnia; however, optimal ordering with PTSD treatment is unclear. PTSD treatment may be most useful for PTSD-related nightmares. CPAP therapy is recommended for OSA but adherence can be low. Targeted treatment of sleep disorders in the context of PTSD offers a unique and underutilized opportunity to advance clinical care and research. Research is needed to create screening protocols, determine optimal order of treatment, and elucidate mechanisms between sleep and PTSD treatments.

Anxiety sensitivity in the association between posttraumatic stress and substance use disorders: A systematic review.

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are complex psychiatric conditions that commonly co-occur. No evidence-based, "gold standard" treatments for PTSD/SUD comorbidity are currently available. Thus, it is imperative to better understand cognitive-affective mechanisms, targetable via cognitive-behavioral intervention (i.e., malleable), that may be related to both disorders in order to improve the theory and treatment of PTSD/SUD. Anxiety sensitivity is a malleable cognitive-affective factor with relevance to both PTSD and SUD. This systematic review focused on the published literature on anxiety sensitivity and trauma/PTSD and substance use/SUD from 1966 - May 1, 2018, and includes a total of 35 manuscripts. The state of the literature, limitations, and future research directions are discussed.

Pretreatment biomarkers predicting PTSD psychotherapy outcomes: A systematic review.

Although our understanding of the relationship between posttraumatic stress disorder (PTSD), brain structure and function, neural networks, stress-related systems, and genetics is growing, there is considerably less attention given to which biological markers predict evidence-based PTSD psychotherapy outcomes. Our systematic PRISMA-informed review of 20 studies examined biomarkers as predictors of evidence-based PTSD psychotherapy outcomes. Results provide preliminary evidence that specific structural and functional neural systems (involved in information processing), glucocorticoid sensitivity and metabolism (part of the hypothalamic-pituitary-adrenal axis and the response to stress), heart rate (involved with fear habituation), gene methylation, and certain genotypes (associated with serotonin and glucocorticoids) predicted positive response to PTSD treatment. These pre-treatment biomarkers are associated with processes integral to PTSD treatment, such as those affecting fear learning and extinction, cognitive restructuring, information processing, emotional processing, and interoceptive monitoring. Identifying pre-treatment biomarkers that predict treatment response may offer insight into the mechanisms of psychological treatment, provide a foundation for improving the pharmaceutical augmentation of treatment, and inform treatment matching.