Sleep disturbance as a predictor of affective functioning and symptom severity among individuals with PTSD: An ecological momentary assessment study

doi:10.1016/j.brat.2017.07.014

Behaviour Research and Therapy

Volume 97, October 2017, Pages 146-153

https://doi.org/10.1016/j.brat.2017.07.014 Get rights and content

Highlights

•
Poor sleep quality and efficiency predicted increased daytime PTSD symptoms.
•
Poor sleep quality and efficiency predicted increased daytime negative affect.
•
Poor sleep quality predicted decreased daytime positive affect.
•
The effect of sleep quality on PTSD symptoms was mediated by negative affect.
•
Daytime PTSD symptoms only predicted nightmares.

Abstract

Recent research has highlighted the etiological role of sleep disturbance in posttraumatic stress disorder (PTSD); however it is currently unknown how daily changes in sleep are associated with next-day PTSD symptoms. Furthermore, sleep is critical for maintaining appropriate affect, leading some to hypothesize that affective dysfunction may account for the link between sleep disturbances and PTSD symptoms. Thus, the current study tested the relationship between sleep disturbances, affective valence, and PTSD symptoms utilizing an ecological momentary assessment (EMA) design among individuals with PTSD (n=30) who participated in 4 EMA-based assessments daily over 8 days. Multilevel modeling indicated that, after accounting for prior evening's PTSD symptoms, poor sleep quality and reduced sleep efficiency were associated with increased PTSD symptoms and negative affect. Furthermore, results supported the indirect effect of poor sleep quality on elevated PTSD symptoms through increased negative affect in the morning. Findings add to the body of research demonstrating the negative impact of poor sleep for individuals with PTSD by indicating that daily variations in sleep can affect next-day PTSD symptoms, and identifying negative affect as a mechanism of this relationship.

Section snippets

Participants

We recruited 30 participants diagnosed with PTSD according to the Structured Clinical Interview for DSM-V (SCID; First, Williams, Karg, & Spitzer, 2015). Participants were at least 18 years of age and were recruited from the local community (n=24, 80.0%) and the university's undergraduate student research pool (n=6, 20.0%). Participants were screened via phone or the university's research pool using the PTSD Checklist (Weathers, Litz, Herman, Huska, & Keane, 1993), and then scheduled for a

Data analytic plan

Multilevel modeling was used due to its ability to take into account nested data and missing data better than classical analyses used to analyze EMA studies (Schwartz & Stone, 1998). Analyses were conducted using MPlus Version 7.4 with full information maximum likelihood estimation using the robust estimator (Muthén & Muthén, 1998–2012). The models consisted of 3 levels with random effects: sessions nested within days nested within individuals. The models were estimated using an unstructured

Results

First, data were screened to confirm accurate data entry, assess for outliers, and evaluate skewness and kurtosis. Evaluation of ranges confirmed that the majority of responses were entered correctly. In three cases, participants entered numbers that were logically impossible (e.g., sleeping over 300 h in one night). Consistent with recommendations of Bell and Malacova (2004), these responses were omitted. No outliers were indicated that could potentially influence the models. Regarding missing

Discussion

The current study utilized EMA to evaluate relationships between sleep disturbance, PTSD symptoms, affect, and whether the relationships between sleep and PTSD symptoms can be accounted for by negative affect. Consistent with hypothesis, after accounting for prior evening's PTSD symptoms, poor sleep quality and efficiency were significantly associated with increased daytime PTSD symptoms. This is consistent with prior research (Short et al., 2014b, Wright et al., 2011), but we expand upon it by

Funding

This work was in part supported by the Military Suicide Research Consortium (MSRC), Department of Defense, and VISN 19 Mental Illness Research, Education, and Clinical Center (MIRECC) (Grant number is W81XWH-10-2-0181), but does not necessarily represent the views of the Department of Defense, Department of Veterans Affairs, or the United States Government. Support from the MSRC does not necessarily constitute or imply endorsement, sponsorship, or favoring of the study design, analysis, or

References (60)

G. Belleville et al.
Meta-analytic review of the impact of cognitive-behavior therapy for insomnia on concomitant anxiety
Clinical Psychology Review
(2011)
N. Breslau et al.
Sleep disturbance and psychiatric disorders: A longitudinal epidemiological study of young adults
Biological Psychiatry
(1996)
D.J. Buysse et al.
The pittsburgh sleep quality Index: A new instrument for psychiatric practice and research
Psychiatry Research
(1989)
Y. Dagan et al.
Actigraphic sleep monitoring in posttraumatic stress disorder (PTSD) patients
Journal of Psychosomatic Research
(1997)
A. Ehlers et al.
A cognitive model of posttraumatic stress disorder
Behavior Research and Therapy
(2000)
A. Germain et al.
A brief sleep scale for posttraumatic stress disorder: Pittsburgh sleep quality index addendum for PTSD
Journal of Anxiety Disorders
(2005)
A.G. Harvey
Insomnia: Symptom or diagnosis?
Clinical Psychology Review
(2001)
E.O. Johnson et al.
The association of insomnia with anxiety disorders and depression: Exploration of the direction of risk
Journal of Psychiatric Research
(2006)
J.L. Paterson et al.
Changes in structural aspects of mood during 39–66h of sleep loss using matched controls
Applied Ergonomics
(2011)
J.L. Peugh
A practical guide to multilevel modeling
Journal of School Psychology
(2010)

P. Sagaspe et al.

Effects of sleep deprivation on Color-Word, Emotional, and Specific Stroop interference and on self-reported anxiety

Brain and Cognition

(2006)

N.A. Short et al.

Sleep and affective functioning: Examining the association between sleep quality and distress tolerance among veterans

Personality and Individual Differences

(2016)

N.A. Short et al.

The mediating role of sleep disturbances in the relationship between posttraumatic stress disorder and self-injurious behavior

Journal of Anxiety Disorders

(2015)

N.A. Short et al.

Insomnia and emotion dysregulation: Independent and interactive associations with posttraumatic stress symptoms among trauma-exposed smokers

Journal of Affective Disorders

(2014)

J. Westermeyer et al.

Reliability of sleep log data versus actigraphy in veterans with sleep disturbance and PTSD

Journal of Anxiety Disorders

(2007)

P.K. Alvaro et al.

A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression

Sleep

(2013)

American Psychiatric Association

Diagnostic and statistical manual of mental disorders

(2013)

J.F. Bell et al.

R.A. Bryant et al.

Sleep disturbance immediately prior to trauma predicts subsequent psychiatric disorder

Sleep

(2010)

J.A. Caldwell et al.

The effects of 37 hours of continuous wakefulness on the physiological arousal, cognitive performance, self-reported mood, and simulator flight performance of F-117A pilots

Military Psychology

(2004)

C.E. Carney et al.

Wrist actigraph versus self-report in normal sleepers: Sleep schedule adherence and self-report validity

Behavioral Sleep Medicine

(2004)

A.L. Chesson et al.

The indications for polysomnography and related procedures

Sleep

(1997)

J.C. DeViva et al.

Factors associated with insomnia among civilians seeking treatment for PTSD: An exploratory study

Behavioral Sleep Medicine

(2004)

U.W. Ebner-Priemer et al.

Ecological momentary assessment of mood disorders and mood dysregulation

Psychological Assessment

(2009)

J.D. Edinger et al.

Cognitive behavioral therapy for treatment of chronic primary insomnia: A randomized controlled trial

JAMA

(2001)

M.B. First et al.

Structured clinical interview for DSM-5—research version (SCID-5 for DSM-5, research version; SCID-5-RV)

(2015)

K. Fredriksen et al.

Sleepless in Chicago: Tracking the effects of adolescent sleep loss during the middle school years

Child Development

(2004)

A. Germain

Sleep disturbances as the hallmark of PTSD: Where are we now?

American Journal of Psychiatry

(2013)

A.N. Goldstein et al.

The role of sleep in emotional brain function

Annual Reviews of Clinical Psychology

(2014)

A.G. Harvey

Insomnia, psychiatric disorders, and the transdiagnostic perspective

Current Directions in Psychological Science

(2008)

Cited by (54)

Using experience sampling methodology (ESM) to improve our understanding of day-to-day intrusion frequency and related distress in survivors of trauma
2024, Journal of Behavior Therapy and Experimental Psychiatry
Cognitive models of posttraumatic stress disorder (PTSD) suggest that appraisals of traumatic sequelae and subsequent distress drive the development and maintenance of PTSD. Posttraumatic research has relied heavily on macro-longitudinal designs, with weeks or months between assessments of trauma-related cognitions and symptoms. The present study uses experience sampling methodology (ESM) better understand the day-to-day experiences of trauma exposed individuals.
One-hundred trauma exposed adults reported their posttraumatic symptoms, interpretations, and behaviours four times a day over a 10-day ESM period.
As anticipated, within-person fluctuations in negative appraisals of intrusions and maladaptive coping strategies (e.g., thought suppression) were significantly positively associated with intrusion frequency and related distress. In all cases, the associations for negative appraisals and maladaptive coping were stronger with intrusion related distress than intrusion frequency.
The observed contemporaneous associations only demonstrate that variables reliably fluctuated together and cannot indicate causality.
The findings demonstrate that day-to-day fluctuations in trauma related perceptions and sequelae are significant and should be explored alongside broader individual differences to advance our understanding of the development, maintenance, and treatment of PTSD.
The role of affect in associations between sleep disturbances and posttraumatic stress disorder symptoms: A systematic review
2023, Sleep Medicine
Strong evidence supports a bidirectional association between sleep disturbances and posttraumatic stress disorder (PTSD). Affect – temporary internal states experienced as feeling good or bad, energized or enervated – may play a central role in explaining this link. The current systematic review summarizes the literature on associations between sleep, PTSD, and affect among trauma-exposed adults. We systematically searched five electronic databases (PubMed, PsycInfo, PTSDpubs, Web of Science, CINAHL) using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Of 2656 screened articles, 6 studies met inclusion criteria. Four findings emerged: (1) greater insomnia symptom severity predicted greater PTSD symptom severity above the influence of negative affect, (2) negative affect mediated the effect of sleep quality on next-day PTSD symptom severity, (3) positive affect mediated the effect of PTSD symptom severity on insomnia symptom severity and sleep disturbances, and (4) greater negative affect (specifically, greater anger) was associated with greater severity of PTSD and sleep disturbances. Findings highlight areas for future research, such as the need to investigate more dimensions, timescales, and methods of studies simultaneously assessing affect, sleep, and PTSD, as well as the need for more longitudinal and experimental work to determine causality across these constructs.
The role of positive affect processes in the association between posttraumatic stress disorder symptoms and sleep: A multi-study design
2023, Journal of Affective Disorders
Posttraumatic stress disorder (PTSD) symptoms have been linked to sleep disturbances. Limited work has explored how positive affect processes may account for this relationship. Advancing research in this area, we utilized a multi-study design to investigate the role of positive affect processes (levels of positive affect, positive emotionality, hedonic deficits, negative affect interference) in the PTSD-sleep association.
Data from 149 trauma-exposed firefighters (M_age = 38.93 ± 9.65, 5.40 % women) were collected between September 2021 and November 2021, and data from 119 trauma-exposed community members (M_age = 29.60 ± 8.67, 68.10 % women) were collected between February 2021 and December 2021. Participants completed an online survey on PTSD symptoms, sleep disturbances, and positive affect processes.
Positive affect levels (b = 0.03, 95 % confidence interval [CI] [0.01, 0.06]; firefighter sample), positive emotionality (b = 0.07, CI [0.03, 0.13]; community sample), and negative affect interference (b = 0.06, CI [0.01, 0.14]; community sample) significantly accounted for the associations between PTSD symptom severity and sleep disturbances controlling for the effects of gender and age.
Findings highlight the role of positive affect processes in the link between PTSD and sleep, and support addressing positive affect processes as potential targets in clinical interventions for co-occurring PTSD-sleep problems.
Anxiety sensitivity as a transdiagnostic risk factor for trajectories of adverse posttraumatic neuropsychiatric sequelae in the AURORA study
2022, Journal of Psychiatric Research
Anxiety sensitivity, or fear of anxious arousal, is cross-sectionally associated with a wide array of adverse posttraumatic neuropsychiatric sequelae, including symptoms of posttraumatic stress disorder, depression, anxiety, sleep disturbance, pain, and somatization. The current study utilizes a large-scale, multi-site, prospective study of trauma survivors presenting to emergency departments. Hypotheses tested whether elevated anxiety sensitivity in the immediate posttrauma period is associated with more severe and persistent trajectories of common adverse posttraumatic neuropsychiatric sequelae in the eight weeks posttrauma. Participants from the AURORA study (n = 2,269 recruited from 23 emergency departments) completed self-report assessments over eight weeks posttrauma. Associations between heightened anxiety sensitivity and more severe and/or persistent trajectories of trauma-related symptoms identified by growth mixture modeling were analyzed. Anxiety sensitivity assessed two weeks posttrauma was associated with severe and/or persistent posttraumatic stress, depression, anxiety, sleep disturbance, pain, and somatic symptoms in the eight weeks posttrauma. Effect sizes were in the small to medium range in multivariate models accounting for various demographic, trauma-related, pre-trauma mental health-related, and personality-related factors. Anxiety sensitivity may be a useful transdiagnostic risk factor in the immediate posttraumatic period identifying individuals at risk for the development of adverse posttraumatic neuropsychiatric sequelae. Further, considering anxiety sensitivity is malleable via brief intervention, it could be a useful secondary prevention target. Future research should continue to evaluate associations between anxiety sensitivity and trauma-related pathology.
Posttraumatic stress disorder, sleep and medical cannabis treatment: A daily diary study
2022, Journal of Anxiety Disorders
Despite increasing use of Medical Cannabis (MC) among posttraumatic stress disorder (PTSD) patients, research is lacking on how MC treatment relates to PTSD symptomatology, in particular sleep disturbances. This study examines the time gap between MC use and sleep onset and its association with (1) number of awakenings throughout the night, (2) early awakenings, (3) nightmares. Each morning over a two week period, 77 licensed MC patients suffering from PTSD reported on the timing of previous night MC use and sleep disturbances. Within-person analyses found that shorter time gaps between previous night MC use and sleep start time was associated with lower likelihood of experiencing nightmares throughout the night, but it was not associated with nightly awakenings or waking up too early. Between-person analyses showed that individuals who used MC products with higher CBD concentrations reported fewer early awakenings. These preliminary results indicate that future research should test causal relations between MC use and sleep problems in PTSD patients. Future research is warranted in order to explore causal relationships between MC use, nightmares and insomnia in PTSD patients.
Bidirectional associations between daily PTSD symptoms and sleep disturbances: A systematic review
2022, Sleep Medicine Reviews
Citation Excerpt :
See Table 2 for a summary of results on bidirectional associations between daily PTSD symptoms and nightly sleep. Across four studies [39,40,42,43], eight effects of PTSD symptoms predicting that night's sleep were examined; five of these effects (63%) were statistically significant (p < .05). Specifically, three studies examined effects of PTSD symptoms on sleep duration; three studies examined effects of PTSD symptoms on sleep quality; two studies examined effects of PTSD symptoms on sleep efficiency; and two studies examined effects of PTSD symptoms on nightmares.
Sleep disturbances are a core feature of posttraumatic stress disorder (PTSD) and can affect PTSD onset, maintenance, and recovery. However, there is conflicting evidence about the directionality of sleep and PTSD symptoms, particularly at the daily level. The current systematic review summarizes the literature on within-person associations between daily PTSD symptoms and sleep among trauma-exposed adults. We searched four databases using PRISMA 2020 guidelines. Of 2006 screened articles, six met inclusion criteria. Study sample sizes ranged from 30 to 202 participants, and studies assessed PTSD symptoms and sleep for 7–28 days. Two relatively consistent findings emerged: (1) shorter sleep and poorer quality sleep predicted greater next-day PTSD symptoms, and (2) greater PTSD symptoms predicted nightmares and poorer sleep quality that night. Individual study risk of bias was low to moderate. The current review provides initial support for a bidirectional association between daily self-reported sleep and PTSD symptoms. Potential clinical implications include targeting sleep via evidence-based PTSD interventions and using just-in-time adaptive interventions to disrupt the daily PTSD-sleep cycle. Findings also highlight areas for future research, such as the need to incorporate more objective sleep measures, examine PTSD symptom clusters, justify sample sizes and number of daily observations, and recruit more diverse samples.

View all citing articles on Scopus

View full text

Sleep disturbance as a predictor of affective functioning and symptom severity among individuals with PTSD: An ecological momentary assessment study

Highlights

Abstract

Section snippets

Participants

Data analytic plan

Results

Discussion

Funding

Clinical Psychology Review

Biological Psychiatry

Psychiatry Research

Journal of Psychosomatic Research

Behavior Research and Therapy

Journal of Anxiety Disorders

Clinical Psychology Review

Journal of Psychiatric Research

Applied Ergonomics

Journal of School Psychology

Brain and Cognition

Personality and Individual Differences

Journal of Anxiety Disorders

Journal of Affective Disorders

Journal of Anxiety Disorders

A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression

Sleep

Diagnostic and statistical manual of mental disorders

Sleep disturbance immediately prior to trauma predicts subsequent psychiatric disorder

Sleep

The effects of 37 hours of continuous wakefulness on the physiological arousal, cognitive performance, self-reported mood, and simulator flight performance of F-117A pilots

Military Psychology

Wrist actigraph versus self-report in normal sleepers: Sleep schedule adherence and self-report validity

Behavioral Sleep Medicine

The indications for polysomnography and related procedures

Sleep

Factors associated with insomnia among civilians seeking treatment for PTSD: An exploratory study

Behavioral Sleep Medicine

Ecological momentary assessment of mood disorders and mood dysregulation

Psychological Assessment

Cognitive behavioral therapy for treatment of chronic primary insomnia: A randomized controlled trial

JAMA

Structured clinical interview for DSM-5—research version (SCID-5 for DSM-5, research version; SCID-5-RV)

Sleepless in Chicago: Tracking the effects of adolescent sleep loss during the middle school years

Child Development

Sleep disturbances as the hallmark of PTSD: Where are we now?

American Journal of Psychiatry

The role of sleep in emotional brain function

Annual Reviews of Clinical Psychology

Insomnia, psychiatric disorders, and the transdiagnostic perspective

Current Directions in Psychological Science