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Persons with posttraumatic stress disorder (PTSD) frequently experience relationship failures in family and occupational domains resulting in loss of social supports. Prior research has implicated impairments in social cognition. The Reading the Mind in the Eyes Test (RMET) measures a key component of social cognition, the ability to infer the internal states of other persons based on features of the eyes region of the face; however, studies administering this popular test to persons with PTSD have yielded mixed results. This study assessed RMET performance in 47 male U.S. military Veterans with chronic, severe PTSD. Employing a within-subjects design that avoided selection biases, it aimed specifically to determine whether components of RMET performance, including accuracy, response latency, and stimulus dwell time, were improved by the company of a service dog, an intervention that has improved social function in other populations. RMET accuracies and response latencies in this PTSD sample were in the normal range. The presence of a familiar service dog did not improve RMET accuracy, reduce response latencies, or increase dwell times. Dog presence increased the speed of visual scanning perhaps consistent with reduced social fear.

Introduction The nature of sleep can leave sleepers vulnerable to environmental threats, requiring a balance between the demands for vigilance and the physiological requirement for sleep. Understanding the sleeping context is particularly relevant to understanding the dynamics of sleep disturbance observed in individuals with posttraumatic stress symptoms (PTSS) because of subsequent increased vigilance to threats. This study examined the associations between neighborhood disadvantage, sleep respiratory sinus arrhythmia (RSA), fear of sleep, and nightmare frequency in a sample of trauma-exposed Veterans. Methods Baseline data from an ongoing study examining sleep with trauma nightmares using ambulatory sleep measurement in a sample of U.S. military Veterans were analyzed. Participants completed assessments of nightmare frequency and fear of sleep, and slept on a mattress actigraphy system for at least seven nights, which captured sleep-period RSA as an index of autonomic activation. Neighborhood disadvantage was assessed with the Area Deprivation Index (ADI), a census-based socioeconomic index. For this study, participants’ zip codes were linked to 2020 ADI scores using the Neighborhood Atlas, and the census-block groups were ranked into state-level 1 to 10 deciles (split into halves- low and high). Higher ADI scores indicate greater disadvantage. The differences between the least and most disadvantaged groups were analyzed with binary logistic regression models. Results Data were available from 33 Veterans. The mean state-level ADI was 6.2 (SD = 2.7). Low and high state-level ADI scores were 4.3 (SD = 2, n = 19) and 8.7 (SD = 0.8, n = 14), respectively. Residing in zip codes with greater neighborhood disadvantage was associated with elevated fear of sleep (OR = 1.2, p = 0.04), and a trend for reduced sleep-period RSA (OR = 0.4, p = 0.05). No differences were observed for past week nightmare frequency. Conclusion In this sample of Veterans, living in the most disadvantaged neighborhoods was significantly associated with greater fear of sleep, and may be associated with reduced RSA. Sleep context may increase hypervigilance in turn serving as a mechanism by which trauma-induced sleep disruptions are maintained. Support (if any) Funded by the U.S. Department of Veterans Affairs, Veterans Health Administration Clinical Science Research and Development Service - IK2 CX001874.

Introduction Observational research demonstrates a strong association between nightmares, insomnia, and sleep apnea in veterans with posttraumatic stress disorder (PTSD), supportive of the notion of a “complex sleep disturbance”. Relations between sleep disturbances and PTSD are often bi-directional and disturbed sleep affects non-sleep PTSD outcomes. We aimed to examine relationships between nightmares, respiratory events, CPAP use, and insomnia in trauma-exposed veterans with frequent nightmares. Methods Three weeks of app-based daily sleep diaries and weekly insomnia severity index (ISI) reports were collected from 41 veterans with a history of trauma and frequent nightmares. Relationships between weekly nightmares (total number), CPAP use, sleep efficiency, and ISI scores were analyzed using linear regression with standard errors adjusted for clustering of weeks within participants. Of the 41 participants, a subset of 15 participants completed 6-9 nights of at-home objective sleep measurements (Sleep Profiler) to examine the relationship between apnea events and nightmare awakenings. Measurements involved EEG integrated with airflow, respiratory effort, oxygen saturation, and actigraphy with event marker for real-time reporting of nightmares preceding awakenings. Results 41 veterans (mean age 48 (SD=16), 30% female) participated. Higher prior week ISI score predicted reduced CPAP adherence (β=-.53, p=.005). In turn, increased frequency and duration of CPAP use was associated with a significant increase in sleep efficiency the same week (β=.53, p=.018 and β=.56, p=.026, respectively). Analysis of respiratory events indicates that 20 of the 64 nightmare awakenings (31%) were preceded (i.e., within seconds of awakening) by apnea or hypopnea events. Of these 20, 11 events were reported by participants with a diagnosis of OSA and a CPAP device. Amongst these 11 events, 7 (64%) occurred on nights during which the participant reported use of their CPAP. Conclusion Analyses demonstrated statistically significant and clinically meaningful relationships among insomnia, nightmares, respiratory events and CPAP adherence in our sample, highlighting their interrelationships in trauma subjects. These data support the hypothesis that OSA contributes to nightmare experiences by demonstrating an immediate temporal relationship between apnea/hypopnea events and nightmare awakenings, and they underscore the importance of detecting and adequately treating sleep apnea for the treatment of nightmares in veterans. Support (if any)

Dog ownership has been associated with reduced cardiovascular and all-cause mortality in epidemiological samples. U.S. miliary Veterans exhibit elevated rates of cardiovascular disease. Associations between dog ownership and cardiovascular disease were examined in the National Health and Resilience in Veterans Study (NHRVS) which surveys nationally representative samples of U.S. military Veterans. Dog ownership data were obtained from 3078 Veterans and cross-tabulated with self-reported cardiovascular disease and risk factors. Adjustments were made for age, gender, trauma load, posttraumatic stress disorder (PTSD), major depressive disorder (MDD), alcohol/substance use, and exercise. Relative to non-owners, dog owners (39.2% of sample) were younger, more likely to meet criteria for PTSD and/or MDD, and to report more exercise. Dog ownership was associated with lower adjusted odds of hypertension and dyslipidemia. Dog ownership interacted with exercise to lower odds of self-reported heart disease by 33% and mitigated an effect of trauma load on hypertension. Conversely, the lowering of odds for diabetes and stroke in young and middle-aged Veterans reversed sign in older Veterans. Finally, dog ownership doubled the risk for stroke in Veterans who smoked. Increased physical activity remains the most likely factor accounting for these results, though potentially adverse interactions with aging and concurrent medical conditions call for additional investigation.

Nightmares are a core feature of posttraumatic stress disorder, are poorly understood, and are associated with serious negative outcomes. Their biology has been difficult to study, and the feasibility of capturing them in the naturalistic home environment has been poor. This said, the published research and dominant scientific model has focused on nightmares as a manifestation of noradrenergic hyperarousal during rapid eye movement sleep. The current study used at-home, participant-applied devices to measure nightmare physiology in posttraumatic stress disorder treatment-seeking veterans, by examining heartrate measures as indicators of noradrenergic tone, and sleep-stage characteristics and stability in the sleep preceding time-stamped nightmare awakenings. Our data indicate the high feasibility of participant-administered, at-home measurement, and showed an unexpected stability of -rapid eye movement sleep along with no evidence of heartrate elevations in sleep preceding nightmare awakenings. Altogether, these data highlight new opportunities for the study of nightmares while questioning the sufficiency of dominant models, which to date are largely theoretically based.

Though popular across many audiences, engagement with a service dog has undergone limited empirical evaluation as a complementary or alternative treatment for posttraumatic stress disorder (PTSD). The present study took advantage of a service dog training intervention underway in a Department of Veterans Affairs residential PTSD treatment program to perform a within-subjects comparison of a range of phenotypic markers. The present report considers negative and positive affect, assessed throughout the day, contrasting weeks when participants were or were not accompanied by their service dog. Fifty-four veterans were studied for 2-6 weeks. Negative and positive affect were sampled five times per day using items from the Positive and Negative Affect Schedule. Participants also wore a single-patch ECG/activity recorder and slept on beds recording sleep actigraphically. Linear mixed effects regression was employed to estimate the effect of the presence of service dog on momentary affect in the context of other presumable influences. Missing data were managed using methods applicable to random and nonrandom missingness. In this sample, the presence of a service dog was associated with reduced negative and increased positive affect, with both effects diminishing over time. Only negative affect was associated with time in residential treatment, and only positive affect was associated with concurrent heart rate, activity, and the interaction of activity and prior-night actigraphic sleep efficiency. These results concur with prior reports of reduced PTSD symptomology in association with the presence of a service dog, and with the distinct neurocircuitries underlying defensive and appetitive emotion and motivation. Limitations derive from the artificial environment and brief duration of study. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background Individual reactions to traumatic stress vary dramatically, yet the biological basis of this variation remains poorly understood. Recent studies have demonstrated surprising plasticity of oligodendrocytes and myelin in the adult brain, providing a potential mechanism by which aberrant structural and functional changes arise in the brain following trauma exposure. Methods We tested the hypothesis that gray matter myelin contributes to traumatic stress-induced behavioral variation. We exposed adult rats to a single, severe stressor and used a multimodal approach to characterize avoidance, startle, and fear-learning behavior. We quantified oligodendrocyte and myelin content in multiple brain areas and compared these measures to behavioral metrics. We then induced overexpression of the oligodendrogenic transcription factor Olig1 in the adult rat dentate gyrus (DG) to test the potential, causal role of oligodendrogenesis in behavioral variation. Lastly, T1-/T2-weighted estimates of myelin were compared to trauma-induced symptom profiles in humans. Results Oligodendrocytes and myelin in the DG of the hippocampus positively correlated with stress-induced avoidance behaviors in male rats. In contrast, myelin levels in the amygdala positively correlated with contextual fear learning. Olig1 overexpression increased place avoidance compared to control virus animals, indicating that increased oligodendrocyte drive in the DG is sufficient to induce an avoidance behavioral phenotype. Finally, variation in myelin correlated with trauma-induced symptom profiles in humans in a region-specific manner that mirrored our rodent findings. Conclusions These results demonstrate a species-independent relationship between region-specific, gray matter oligodendrocytes and myelin and differential behavioral phenotypes following traumatic stress exposure. This study provides a novel biological framework for understanding the mechanisms that underlie individual variance in sensitivity to traumatic stress.

Study Objectives Published research indicates that sleep is involved in emotional information processing. Using a fear-potentiated startle (FPS) and nap sleep protocol, we examined the relationship of emotional learning with REM sleep (REMS) in trauma-exposed participants. We also explored the roles of posttraumatic stress disorder (PTSD) symptoms, biological sex, and an integrative measure of polysomnography-measured (PSG) sleep in the learning-sleep relationship. Methods After an adaptation nap, participants (N = 46) completed two more visits (counterbalanced): a stress-condition visit, which included FPS conditioning procedures prior to a nap and assessment of learning retention and fear extinction training after the nap, and a control visit, which included a nap opportunity without stressful procedures. FPS conditioning included a “fear” visual stimulus paired with an air blast to the neck and a “safety” visual stimulus never paired with an air blast. Retention and extinction involved presentation of the visual stimuli without the air blast. Primary analyses examined the relationship between FPS responses pre- and post-sleep with stress-condition REMS duration, controlling for control-nap REMS duration. Results Higher safety learning predicted increased REMS and increased REMS predicted more rapid extinction learning. Similar relationships were observed with an integrative PSG sleep measure. They also showed unexpected effects of PTSD symptoms on learning and showed biological sex effects on learning-sleep relationships. Conclusions Findings support evidence of a relationship between adaptive emotional learning and REMS. They underscore the importance of examining sex effects in sleep-learning relationships. They introduce an integrative PSG sleep measure with potential relevance to studies of sleep and subjective and biological outcomes.

Citation:Miller KE, Woodward SH. Wakemeter relies on changing perception thresholds across sleep stages. J Clin Sleep Med. 2020;16(5):825.

STUDY OBJECTIVES: Understanding nightmares (NM) and disturbing dreams (DD) in posttraumatic stress disorder (PTSD) has been limited by the unpredictability of these events and their nonappearance in the sleep laboratory. This study used intensive, longitudinal, ambulatory methods to predict morning reports of NM/DD in veterans in whom chronic, severe PTSD was diagnosed. METHODS: Participants were 31 male United States military veterans engaged in residential treatment for PTSD and participating in a service animal training intervention. Participants slept on mattress actigraphs and provided reports of momentary mood, as well as morning NM/DD reports, for up to 6 weeks. Mattress actigraphy provided sleep-period heart rate and respiratory sinus arrhythmia (RSA), and an actigraphic estimate of sleep efficiency. On one night, a respiratory event index (REI) was obtained using an ambulatory system. RESULTS: A total of 468 morning reports were obtained, of which 282 endorsed NM/DD during the prior night, and 186 did not. After accounting for multiple predictors, only elevated REI and lower prior-night sleep RSA predicted morning endorsement of NM/DD. These two predictors did not interact. CONCLUSIONS: Elevated REI and lower sleep period RSA were independently predictive of NM/DD. The former result is consistent with studies showing that sleep-disordered breathing (SDB) is a factor in NM/DD, and that continuous positive airway pressure (CPAP) can reduce these symptoms in patients with comorbid PTSD and SDB. The latter result implicates dysregulated arousal modulation during sleep in trauma-related NM/DD. It is consistent with findings that NM/DD are reported in patients without SDB and can persist in patients with comorbid PTSD and SDB even when CPAP successfully remediates SDB. CITATION: Miller KE, Jamison AL, Gala S, Woodward SH. Two independent predictors of nightmares in posttraumatic stress disorder. J Clin Sleep Med. 2018;14(11):1921–1927.

STUDY OBJECTIVES: Actigraphy, the tool of choice for assessment of sleep phase disorders, is insensitive to movement-free waking. This study aimed to determine whether the detection of waking could be performed by recording instrumental responses to haptic stimuli delivered by a low-cost device. METHODS: Twenty adults underwent 2 nights of laboratory polysomnography (PSG) while wearing a fingerless glove under which a stimulating actigraph (“Wakemeter”) was apposed to the palm. The Wakemeter, controlled by a tablet computer, delivered gentle, haptic stimuli every 10 minutes during the sleep period. If a stimulus was detected, the participant squeezed the Wakemeter. Stimulus times, response times and movements were streamed to the tablet. Concurrent PSG data were scored blind to stimuli and responses. Self-reported sleep quality ratings were collected each morning. RESULTS: The Wakemeter was acceptable to 19 of 20 participants, and effects on self-reported and objective sleep were small. The probability of a response to the stimulus during a wake epoch was high regardless of movement. In contrast, actigraphy magnitude distributions were indistinguishable across epochs scored wake without movement versus sleep, confirming a known limitation of actigraphy. A simple method for calculating sleep efficiency from responses to the stimuli yielded estimates that were highly correlated with PSG-derived estimates (rho = .69, P < .001). CONCLUSIONS: Behavioral responses to haptic stimuli detected epochs of movement-free wake during the sleep period and may augment actigraphy in the low-burden estimation of sleep efficiency. Acceptability of the method over longer recording periods remains to be established. CITATION: Miller KE, Bäbler L, Maillart T, Faerman A, Woodward SH. Sleep/wake detection by behavioral response to haptic stimuli. J Clin Sleep Med. 2019;15(11):1675–1681.

Introduction Posttraumatic Stress Disorder (PTSD) is prevalent among military veterans and is associated with a number of negative outcomes. Despite available treatments, rates of recovery are poor and many symptoms persist post-treatment. Previous research suggests that exercise functions to reduce symptoms of anxiety and improve sleep quality, though its effects are understudied among those with PTSD. Method We sought to assess the extent to which exercise and sleep interactively impact changes in PTSD severity. Participants were 217 veterans in residential PTSD treatment who were offered the opportunity to participate in a bike-exercise program. Data were collected at treatment intake and discharge. Results Exercise (defined as total volume of cycling completed over the course of treatment) was associated with greater reductions in PTSD hyperarousal symptoms at discharge only among veterans with poor intake sleep quality. Conclusions Overall, exercise may be a beneficial adjunctive treatment for reducing hyperarousal symptoms among individuals with PTSD and poor sleep.

Trauma-related nightmares distinguish posttraumatic stress disorder from related mood and anxiety disorders and promise a privileged view into its pathophysiology. This promise has been unkept, in part, because nightmares are rarely observed in the sleep laboratory and represent, at best, a free-recall exercise in which the original stimulus is unknown to the experimenter. We discuss below our efforts to learn more about trauma-related nightmares using laboratory and ambulatory polysomnography. These and other results are next integrated into a broader perspective on the possible interaction of sleep and fear systems. Finally, we consider the important findings of Cano, Mochizuki, and Saper and their implications for future work in this area.

There have been few direct examinations of the volitional control of emotional responses to provocative stimuli in PTSD. To address this gap, an emotion regulation task was administered to 27 Operation Enduring Freedom/Operation Iraqi Freedom combat veterans and 23 healthy controls. Neutral and aversive photographs were presented to participants who did or did not employ emotion regulation strategies. Objective indices included corrugator electromyogram, the late positive potential, and the electrocardiogram. On uninstructed trials, participants with PTSD exhibited blunted cardiac reactivity rather than the exaggerated cardioacceleratory responses seen in trauma cue reactivity studies. On interleaved regulation trials, no measure evidenced group differences in voluntary emotion regulation. Persons with PTSD may not differ from normals in their capacity to voluntarily regulate normative emotional responses to provocative stimuli in the laboratory, though they may nevertheless respond differentially on uninstructed trials and endorse symptoms of dyscontrol pathognomonic of the disorder outside of the laboratory.

This paper reports the results of a study that administered an emotion regulation task to Operation Enduring Freedom/Operation Iraqi Freedom veterans diagnosed with posttraumatic stress disorder (27) and to healthy controls (23). Seated movement and postural responses were transduced with a sensitive accelerometer attached to the underside of a low-mass cantilevered chair. Consistent with prior studies in which subjects stood on force plates, aversive photographs induced attenuation of nondirectional movement in patients and controls. Regarding seated postural responses, controls leaned towards neutral photographs and away from aversive ones, while participants with PTSD did the opposite. Regulation had no impact on seated movement but was associated with a seated postural withdrawal from the computer screen.

Background Research on the link between respiratory sinus arrhythmia (RSA) and posttraumatic stress disorder (PTSD) has largely focused on average levels of RSA. However, given that rapid shifts in parasympathetic tone are necessary to maintain adaptive cardiac variability, the exclusive focus on these tonic estimates provides an incomplete quantification of parasympathetic cardiac regulation. Method The present study is a secondary analysis of previously published data. This analysis aimed to address this limitation by examining the dynamic regulatory effect of the parasympathetic nervous system on heart rate. As such, we examined epoch-to-epoch parasympathetic cardiac regulation – operationalized as the lagged relationship between RSA and heart rate (HR) across consecutive 30-s epochs – across a single night in participants with PTSD, panic disorder (PD), comorbid PTSD and PD (PTSD + PD), and healthy controls. Electrocardiogram and respiratory signals were continuously recorded from 23 participants with PTSD, 14 with PD, 16 with PTSD + PD, and 16 control participants over a single night of sleep in a laboratory setting. Results No group differences in tonic RSA were observed; however, participants with PTSD only and PTSD + PD exhibited significantly greater epoch-to-epoch parasympathetic cardiac regulation over the night than those with PD only and control participants. Moreover, greater severity of hyperarousal symptoms was significantly associated with increased epoch-to-epoch parasympathetic cardiac regulation among participants with PTSD only and PTSD + PD. Discussion These data provide preliminary evidence for an upregulatory parasympathetic response to self-reported hyperarousal in participants with PTSD only and PTSD + PD reflected by increased epoch-to-epoch parasympathetic cardiac regulation.

Attentional bias towards aversive stimuli has been demonstrated in the anxiety disorders and in posttraumatic stress disorder, and attentional bias modification has been proposed as a candidate treatment. This study rigorously assessed attentional bias towards aversive and pleasant visual imagery associated with the presence or absence of a familiar service canine in 23 veterans with chronic military-related posttraumatic stress disorder. Participants were repeatedly tested with and without their service canines present on two tasks designed to elicit spontaneous visual attention to facial and scenic image pairs, respectively. Each stimulus contrasted an emotive image with a neutral image. Via eye-tracking, the difference in visual attention directed to each image was analyzed as a function of the valence contrast and presence/absence of the canine. Across both tasks, the presence of a familiar service canine attenuated the normative attentional bias towards aversive image content. In the facial task, presence of the service canine specifically reduced attention toward angry faces. In that task, as well, accumulated days with the service canine similarly modulated attention toward facial emotion. The results suggest that the presence of a familiar service canine is associated with attenuation of attentional bias to aversive stimuli in chronic military-service-related posttraumatic stress disorder. Questions remain regarding the generalization of such effects to other populations, their dependence on the familiarity, breed, and training of the canine, and on social context.

Objective Childhood and combat trauma have been observed to interact to influence amygdala volume in a sample of U.S. military veterans with and without PTSD. This interaction was assessed in a second, functionally-related fear system component, the pregenual and dorsal anterior cingulate cortex, using the same sample and modeling approach. Method Anterior cingulate cortical tissues (gray + white matter) were manually-delineated in 1.5 T MR images in 87 U.S. military veterans of the Vietnam and Persian Gulf wars. Hierarchical multiple regression modeling was used to assess associations between anterior cingulate volume and the following predictors, trauma prior to age 13, combat exposure, the interaction of early trauma and combat exposure, and PTSD diagnosis. Results As previously observed in the amygdala, unique variance in anterior cingulate cortical volume was associated with both the diagnosis of PTSD and with the interaction of childhood and combat trauma. The pattern of the latter interaction indicated that veterans with childhood trauma exhibited a significant inverse linear relationship between combat trauma and anterior cingulate volume while those without childhood trauma did not. Such associations were not observed in hippocampal or total cerebral tissue volumes. Conclusions In the dorsal anterior cingulate cortex, as in the amygdala, early trauma may confer excess sensitivity to later combat trauma., Highlights • Childhood and combat trauma may interact to influence anterior cingulate cortex. • These findings partially replicate findings in amygdala. • Formally similar relations are found in endocrinological and psychometric data.

A cardinal feature of posttraumatic stress disorder (PTSD) is decreased sleep quality. Anxiety sensitivity (AS) is one factor that has shown early theoretical and empirical promise in better understanding the relation between sleep quality and PTSD outcomes. The current study is the first to test the independent and interactive effects of sleep quality and AS on PTSD symptoms. Consistent with hypotheses, AS and sleep quality were found to be independent and interactive predictors of PTSD symptom severity in our sample of male military veterans seeking treatment for PTSD. Slope analyses revealed that AS was differentially related to PTSD symptom severity as a function of quality of sleep. The veterans with good sleep quality and relatively lower levels of AS had the lowest level of PTSD symptoms, whereas the veterans with poor sleep quality and low AS evidenced severity of PTSD symptoms similar to those with high AS.

Background Human studies have often found that brain regions rich in glucocorticoid receptors exhibit smaller volume in samples with past trauma and ongoing stress; however, relatively little research has addressed the hypothesis that such smaller volumes can be traced to elevated circulating glucocorticoid hormones (GCs). This issue takes on renewed interest in light of recent proposals to treat symptoms of stress disorders such as posttraumatic stress disorder (PTSD) with exogenous synthetic GCs. We sought to examine the relation of circulating GCs to brain macrostructure among veterans with and without PTSD. Methods Participants ( n = 90) included combat veterans with and without PTSD. Veterans completed self-report surveys, home-based cortisol samples, reactive cortisol samples over the course of two serial Trier Social Stress Tests, a low-dose dexamethasone suppression test, and structural magnetic resonance brain imaging over the course of 3 to 5 days. Results No associations were observed between any salivary cortisol index and the volumes of the hippocampus or amygdala. A negative association was observed between evening basal cortisol and both FreeSurfer global volume and BrainImage supratentorial tissue volume. This effect was moderated by PTSD. Also observed was a positive association between reactive cortisol and these same brain volumes. Conclusions Estimates of cortical but not hippocampal or amygdala volume were moderately associated with evening basal salivary cortisol and cortisol reactivity to a social stressor. Existing models relating GC receptor density, circulating cortisol levels, and regional brain volumes received little support.

The primary objective was to compare the evoked K-complex response to salient versus non-salient auditory stimuli in combat-exposed Vietnam veterans with and without post-traumatic stress disorder (PTSD). Three categories of auditory stimuli (standard 1000 Hz tones, trauma-related combat sounds, and affectively neutral environmental sounds) were presented during stage 2 sleep utilizing an oddball paradigm with probabilities of occurrence of 60%, 20% and 20% respectively. Twenty-four combat-exposed Vietnam veterans, 14 with PTSD and 10 without PTSD were studied in a sleep laboratory at the National Center for PTSD in Menlo Park, CA. While significantly fewer K-complexes overall were elicited in patients, there were no differences in the proportion of K-complexes elicited by tones and combat stimuli within either group. Patients produced significantly more K-complexes to neutral stimuli than to tone or combat stimuli. Examination of the N550 component of the evoked K-complex revealed significantly longer latencies in the patient group. Across the entire sample, N550 latencies were longer for combat stimuli relative to tone neutral stimuli. There were no group or stimulus category differences for N550 amplitude. The results suggest that salient information, as defined by trauma-related combat sounds, did not preferentially elicit K-complexes in either the PTSD group or the control group, suggesting that K-complexes function to protect sleep more than to endogenously process meaningful stimuli.

The startle response, a simple defensive response to a sudden stimulus signaling proximal threat, has been well studied in rodents and humans, but has been rarely examined in monkeys. The first goal of the present studies was to develop a minimally immobilizing startle measurement paradigm and validate its usefulness by testing two core features of the startle response (habituation and graded responsivity) in squirrel monkey subjects. Two different types of startle stimuli were used: standard broad-band noise bursts, and species-specific alarm vocalizations ("yaps") which are elicited in response to threat in both wild and captive animals. The second goal of the present studies was to test whether yaps produce enhanced startle responsivity due to their increased biological salience compared to simple, non-biologically relevant noise bursts. The third goal of the present studies was to evaluate the hypothalamic-pituitary-adrenal (HPA) axis response to startle stimuli, as little is known about the stress-activating role of startle stimuli in any species. These experiments determined that the whole-body startle response in relatively unrestrained squirrel monkeys habituates across repeated stimulus presentations and is proportional to stimulus intensity. In addition, differential habituation was observed across biologically salient vs. standard acoustic startle stimuli. Responses to "yaps" were larger initially but attenuated more rapidly over trials. Responses to "yaps" were also larger in the early subepochs of the response window but then achieved a lower level than responses to noise bursts in the later subepochs. Finally, adrenocorticotropic hormone and cortisol concentrations were significantly elevated above baseline after startle stimuli presentation, though monkeys did not exhibit differential HPA axis responses to the two types of startle stimuli. The development of monkey startle methodology may further enhance the utility of this paradigm in translational studies of human stress-related psychiatric disorders.

The proposition that declarative memory deficits are systematically related to smaller hippocampal volume was tested in a relatively large sample (n = 95) of U.S. military veterans with and without combat-related posttraumatic stress disorder. This correlative analysis was extended by including multiple measures of verbal and visual declarative memory and multiple memory-relevant regional brain volumes that had been shown to exhibit main effects of PTSD in prior work. Small-to-moderate effects were observed on verbal declarative memory in line with a recent meta-analysis; nevertheless, little or no evidence of systematic linear covariation between memory measures and brain volumes was observed. (JINS, 2009, 15, 830–839.)

Background While it has been reported that persons with posttraumatic stress disorder (PTSD) manifest tonic autonomic activation, the literature contains numerous counterexamples. In revisiting the question, this study employed a novel method of mattress actigraphy to unobtrusively estimate heart rate and respiratory sinus arrhythmia over multiple nights of sleep in the home. Methods Sleep cardiac autonomic status was estimated in four diagnostic groups, posttraumatic stress disorder, panic disorder, persons comorbid for both conditions, and control subjects. All 59 participants were community-residing nonveterans screened for sleep apnea and periodic leg movement disorder with polysomnography. Heart rate and respiratory sinus arrhythmia were calculated from the kinetocardiogram signal measured via accelerometers embedded in a mattress topper. Times in bed and asleep were also estimated. Per participant data were obtained from a median of 12 nights. Results Both posttraumatic stress disorder and posttraumatic stress disorder/panic disorder comorbid groups exhibited significantly higher heart rates and lower respiratory sinus arrhythmia magnitudes than panic disorder participants and control subjects. Panic disorder participants were indistinguishable from control subjects. The PTSD-only group exhibited longer times in bed and longer times presumably asleep than the other three groups. Conclusions In this study, posttraumatic stress disorder, but not panic disorder, was associated with altered cardiac autonomic status during sleep. Among participants meeting criteria for PTSD alone, autonomic activation co-occurred with prolongation of actigraphic sleep.

This exploratory study compared objective sleep patterns and sleep-related factors between caregiving and non-caregiving women with sleep impairments, and compared the sleep patterns of the caregivers with their care recipients. Nine women caring for adults with dementia and a comparison sample of 34 non-caregiving women provided three nights of in-home polysomnography (PSG) and self-report questionnaires of sleep quality and physical and emotional well-being. Care recipients' sleep was monitored with actigraphy on the same nights of the caregivers' PSG. Caregivers and non-caregivers' sleep patterns were similar across most PSG-measured parameters. Caregivers perceived more sleep disturbances, but PSG showed minimal differences compared to non-caregivers. Caregivers reported more depressive symptoms, and depression was strongly correlated with longer sleep latency. Caregiver's sleep quantity was highly correlated with the sleep quantity of their care recipient. The results suggest that, in this sample, caregivers' sleep was not significantly different from the non-caregiving women, despite differences in perceptions. Although the sample is small, this exploratory study supports the use of multiple nights of in-home PSG to assess caregiver sleep and provides more data on sleep patterns of female dementia caregivers and their relatives.

Existing data suggest anterior cingulate cortex plays a role in autonomic regulation. In persons with posttraumatic stress disorder, autonomic regulation appears impaired, and smaller mean anterior cingulate cortex volume has been reported. This study examined relationships between anterior cingulate cortical volume and the magnitude of respiratory sinus arrhythmia at rest in seventy-seven U.S. military survivors of combat, forty of whom met criteria for posttraumatic stress disorder. RSA magnitude did not differ in combat survivors with and without PTSD, contradicting studies comparing civilian PTSD to non-traumatized controls. RSA magnitude was positively correlated with right but not left anterior cingulate volume, a finding statistically independent of the presence or absence of PTSD.

BACKGROUND: This study sought to determine the 12-month effects of exercise increases on objective and subjective sleep quality in initially inactive older persons with mild to moderate sleep complaints. METHODS: A nonclinical sample of underactive adults 55 years old or older (n = 66) with mild to moderate chronic sleep complaints were randomly assigned to a 12-month program of primarily moderate-intensity endurance exercise (n = 36) or a health education control program (n = 30). The main outcome measure was polysomnographic sleep recordings, with additional measures of subjective sleep quality, physical activity, and physical fitness. Directional hypotheses were tested. RESULTS: Using intent-to-treat methods, at 12 months exercisers, relative to controls, spent significantly less time in polysomnographically measured Stage 1 sleep (between-arm difference = 2.3, 95% confidence interval [CI], 0.7–4.0; p = .003), spent more time in Stage 2 sleep (between-arm difference = 3.2, 95% CI, 0.6–5.7; p = .04), and had fewer awakenings during the first third of the sleep period (between-arm difference = 1.0, 95% CI, 0.39–1.55; p = .03). Exercisers also reported greater 12-month improvements relative to controls in Pittsburgh Sleep Quality Index (PSQI) sleep disturbance subscale score (p = .009), sleep diary–based minutes to fall asleep (p = .01), and feeling more rested in the morning (p = .02). CONCLUSIONS: Compared with general health education, a 12-month moderate-intensity exercise program that met current physical activity recommendations for older adults improved some objective and subjective dimensions of sleep to a modest degree. The results suggest additional areas for investigation in this understudied area.

Psychobiological studies of posttraumatic stress disorder (PTSD) often challenge participants to assess the dynamics of systems evolved to organize responses to extreme events. Informed consent insures that volunteers have every opportunity to preevaluate the conditions of the research experience and decline if made uncomfortable by them. Notwithstanding their necessity, these protections set the stage for self-selection phenomena that may bias study outcomes. This study compared prospectively obtained psychometric data from 196 participants and 1229 nonparticipants in sleep and psychophysiological studies of PTSD. Lower subjective nightmare severity was endorsed by persons who later agreed to participate in a study of baseline sleep, an observation consistent with the low nightmare frequencies observed in most laboratories studies of sleep in PTSD.

Children and adolescents with maltreatment-related posttraumatic stress disorder (PTSD) exhibit smaller intracranial tissue volume than controls. Linear relationships have also been observed between intracranial tissue volume and the age of maltreatment onset. The authors explored associations among adult PTSD, early trauma, and cerebral volumes in 99 combat veterans. A bone-based estimate of cranial volume was developed to adjust for variation in body size. Posttraumatic stress disorder was not associated with smaller cerebral tissue volume, but rather with smaller cerebrospinal fluid (CSF) and cranial volumes. These findings co-occurred with expected effects of alcoholism and aging on cerebral tissue and CSF volumes. The results point to early developmental divergences between groups with and without PTSD following adult trauma.

Posttraumatic stress disorder (PTSD) patients with comorbid panic disorder (PD) may express additive symptoms of central fear system disturbance. They endorse elevated levels of sleep and nightmare disturbance [Leskin GA, et al., J Psychiatr Res 2002;36:449-452], and demonstrate movement suppression during laboratory sleep [Woodward SH, et al., Sleep 2002;25:681-688]. We estimated respiratory rate and rate variability separately for rapid-eye movement (REM) and non-rapid-eye movement (NREM) sleep. Subjects were 49 Vietnam combat-related PTSD inpatients (11 with comorbid PD and 38 without) and 15 controls. Computer-based estimates of respiratory rate and variability were derived from 10 to 18 hr of baseline sleep collected over two or three nights. Neither rate nor rate variability distinguished PTSD patients with comorbid PD from those without, or PTSD patients from controls; however, PTSD patients failed to exhibit the expected differences between REM and NREM respiratory rates. Moreover, the difference between REM and NREM respiratory rate was inversely related to a continuous measure of PTSD severity. PTSD patients with trauma-related nightmare complaint exhibited higher sleep respiration rates over both REM and NREM sleep. Conversely, in addition to slowed respiration, nightmare-free patients exhibited reduced respiratory rate variability in REM relative to NREM sleep, which was a reversal of the normal pattern. These finding are discussed in light of known telencephalic regulatory influences upon respiration rate.

Study Objectives: To corroborate findings from the National Comorbidy study with objective sleep data. Design: Retrospective data review. Setting: Sleep Laboratory, National Center for Posttraumatic Stress Disorder Participants: Male Vietnam combat veteran. Interventions: N/A Measurements and Results: We reanalyzed laboratory sleep data obtained from subjects undergoing inpatient treatment for posttraumatic stress disorder. Comorbid panic disorder was not associated with a significant worsening of objective sleep in this sample. Posttraumatic stress disorder, comorbid panic disorder, and trauma-related nightmare complaint were all associated with significant and systematic reductions of sleep movement time. Analyses of potential rescoring artifacts provided further support for this effect. Conclusions: A curvilinear function may describe the relationship between anxiety symptom severity and sleep-movement time in both posttraumatic stress disorder and panic disorder. Evidence for movement suppression in association with pathologic levels of human anxiety is consistent with the suppression of movement (freezing) exhibited by animals under conditions of perceived threat.

Background: Nightmares are rare in the sleep laboratory, even in patients with posttraumatic stress disorder for whom nightmare complaints are diagnostic. Nevertheless, it is possible that laboratory conditions do not preclude the observation of telltales—nightmare-related modifications of tonic sleep—given sufficiently large samples. Methods: Sixty-three unmedicated, nonapneic Vietnam combat veterans undergoing inpatient treatment for posttraumatic stress disorder underwent polysomnographic testing and assessment of nightmare complaint. Results: Trauma-related nightmare complaint, but not non–trauma-related complaint, was associated with increased wake-after-sleep-onset in the sleep laboratory. No relationships between nightmare complaint and rapid eye movement sleep architecture were observed. Conclusions: Increased wake-after-sleep-onset was specifically associated with trauma-related nightmare complaint, confirming data from other quarters suggesting they are both phenomenologically and functionally distinct from normal dreaming.

Posttraumatic stress disorder is widely understood to include "persistent symptoms of increased arousal." This presumption has rarely been tested under conditions in which effects of anticipatory anxiety could be ruled out. In this study, heart rate and electroencephalogram spectral power were assessed during sleep, a state free of most sources of artifact contaminating indices of tonic arousal. Fifty-six unmedicated nonapneic Vietnam combat-related inpatients with posttraumatic stress disorder (PTSD) and 14 controls spent 3 or more nights in the sleep laboratory during which their electrocardiograms and electroencephalograms were continuously recorded. Heart rate and electroencephalogram spectral power were quantified continuously off-line and averaged by sleep stage over all postadaptational nights. Sleep heart rate exhibited no group differences and no covariation with the severity of subjective hyperarousal reported by PTSD patients. PTSD patients exhibited a trend toward reduced low-frequency electroencephalogram spectral power during nonrapid-eye-movement (NREM) sleep. This reduction was significant during slow-wave sleep in those subjects producing scoreable slow-wave sleep. The relationship of rapid-eye-movement (REM) beta-band power to NREM beta-band power was different in PTSD patients and controls, with the patients exhibiting more beta in REM versus NREM sleep than controls. In patients, NREM sleep sigma-band electroencephalogram spectral power exhibited a positive correlation with subjective hyperarousal. Finally, a novel and surprisingly strong inverse correlation between REM-NREM sleep heart rate difference and REM percent of sleep was observed in PTSD patients only. In summary, peripheral and central measures of tonic arousal during sleep demonstrated contrastive relations to PTSD diagnostic and symptom status. The data suggest that more consideration should be directed to mechanisms of central arousal in PTSD.

To determine the relations between obstructive sleep apnea (OSA) diagnosis, the likelihood of being diagnosed with a psychological condition, among obese veterans, after accounting for severity of obesity and the correlated nature of patients within facility. We hypothesized that (1) individuals with a diagnosis of OSA would be more likely to receive a diagnosis of a (a) mood disorder and (b) anxiety disorder, but not (c) substance use disorder.Cross-sectional retrospective database review of outpatient medical records between October 2009 and September 2010, conducted across all 140 Veterans Health Administration (VHA) facilities.The entire VA Health Care System.Population-based sample of veterans with obesity (N = 2,485,658).Physician- or psychologist-determined diagnosis of psychological conditions including mood, anxiety, and substance use disorders.Using generalized linear mixed modeling, after accounting for the correlated nature of patients within facility and the severity of obesity, individuals with a diagnosis of sleep apnea had increased odds of receiving a mood disorder diagnosis (OR = 1.85; CI = 1.71-1.72; p0.001), anxiety disorder diagnosis (OR = 1.82; CI = 1.77-1.84; p0.001), but not a diagnosis of substance use disorder.Among obese veterans within VA, OSA is associated with increased risk for having a mood and anxiety disorder, but not substance use disorder, with the strongest associations observed for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). In addition, this relation remained after accounting for severity of BMI.

Recent data have suggested that first night effects are attenuated in inpatient depressive subjects. We examined first night effects in 80 inpatients hospitalized for post-traumatic stress disorder (PTSD) as well as non-hospitalized PTSD sufferers and non-ill control subjects. PTSD inpatients exhibited attenuated first night effects compared to non-hospitalized PTSD sufferers and non-trauma-exposed controls. Non-ill combat-exposed subjects also exhibited small first night effects. Within the inpatient sample, severity indices of PTSD, depression and anxiety failed to account for variance in first night effects. These data demonstrate attenuation of first night effects in a new inpatient population and suggest their statistical independence vis-a-vis a range of relevant symptoms. Both the attenuation of first night effects in PTSD inpatients and their accentuation in PTSD outpatients may be indicative of enhanced sensitivity to the sleep environment. Conversely, the trend to small first night effects in non-ill combat-exposed subjects may reflect a dimension of their apparent resistance to traumatic stress.

The sleep of 27 unmedicated Vietnam combat-related posttraumatic stress disorder (PTSD) inpatients was monitored for 3 nights. Depressive comorbidity was considered both as a diagnostic category using DMS-III-R criteria, and as a continuous variable using the Beck Depression Inventory (BDI). Data collected included sleep architecture features that have discriminated unipolar depressives from controls in many prior studies, rapid eye movement (REM) sleep latency, and slow-wave sleep time, as well as two additional indices that have sometimes discriminated depressives from controls in waking studies—baseline heart rate and facial electromyography. Structured Clinical Interview for the DSM-III-R (SCID)-diagnosed PTSD + major depressive disorder (MDD) patients failed to exhibit shorter REM latencies, greater REM percents of sleep, or greater REM densities than PTSD − MDD patients, but did exhibit less slow wave sleep. PTSD + MDD patients also exhibited less facial (mentalis) electromyographic activity. REM densities and baseline heart rates were equivocal. REM density, baseline heart rate, and mentalis electromyography all correlated with the BDI, the former two positively, the last, negatively. In summary, SCID-diagnosed PTSD + MDD patients failed to exhibit the classic REM sleep architectural modifications associated with unipolar depression, despite the fact that several other psychophysiologic indices of dysphoria were detectable in their sleep.