The Relationship of Sleep Quality and Posttraumatic Stress to Potential Sleep Disorders in Sexual Assault Survivors with Nightmares, Insomnia, and PTSD

Journal of Traumatic Stress volume 14, pages647–665(2001)Cite this article

Abstract

Sleep quality and posttraumatic stress disorder (PTSD) were examined in 151 sexual assault survivors, 77% of whom had previously reported symptoms of sleep-disordered breathing (SDB) or sleep movement disorders (SMD) or both. Participants completed the Pittsburgh Sleep Quality Index (PSQI) and the Posttraumatic Stress Scale (PSS). High PSQI scores reflected extremely poor sleep quality and correlated with PSS scores. PSQI scores were greater in participants with potential SDB or SMD or both. PSQI or PSS scores coupled with body-mass index and use of antidepressants or anxiolytics predicted potential sleep disorders. The relationship between sleep and posttraumatic stress appears to be more complex than can be explained by the current PTSD paradigm; and, sleep breathing and sleep movement disorders may be associated with this complexity.

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References

  1. American Academy of Sleep Medicine. (1997). The international classification of sleep disorders (pp. 28–31). Allen Press: Author.

  2. American Academy of Sleep Medicine. (1999). Sleep-related breathing disorders in adults: Recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep, 22, 667–689.

    Google Scholar 

  3. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM-IV) (4th ed., pp. 580–583). Washington, DC: Author.

    Google Scholar 

  4. American Sleep Disorders Association. (1997). Practice parameters for the indications for polysomnography and related procedures. Sleep, 20, 406–422.

    Google Scholar 

  5. Benca, R. M. (1996). Sleep in psychiatric disorders. Neurologic Clinics, 14, 739–764.

    Google Scholar 

  6. Black, J. E., Guilleminault, C., Colrain, I. M., & Carrillo, O. (2000). Upper airway resistance syndrome. Central electroencephalographic power and changes in breathing effort. American Journal of Respiratory and Critical Care Medicine, 162, 406–411.

    Google Scholar 

  7. Blake, D., Weathers, F., Nagy, L., Kaloupek, G., Klauminzer, D., Charney, D., & Keane, T. (1990). Clinician-Administered PTSD Scale (CAPS). Unpublished interview, National Center for Posttraumatic Stress Disorder.

  8. Buysse, D., Reynolds, C., Monk, T., Berman, S., & Kupfer, D. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, 193–213.

    Google Scholar 

  9. Buysse, D. J., Reynolds, C. F., III, Hauri, P. J., Roth, T., Stepanski, E. J., Thorpy, M. J., Bixler, E. O., Kales, A., Manfredi, R. L., Vgontzas, A. N., Stapt, D. M., Houck, P. R., & Kupfer D. J. (1994). Diagnostic concordance for DSM-IV sleep disorders, a report from the APA/NIMH DSM-IV Field Trial. American Journal of Psychiatry, 151, 1351–1360.

    Google Scholar 

  10. Chesson, A., Jr., Hartse, K., Anderson, W. M., Davila, D., Johnson, S., Littner, M., Wise, M., & Rafecas, J. (2000). Practice parameters for the evaluation of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep, 23, 237–241.

    Google Scholar 

  11. Decary, A., Rouleau, I., & Montplaisir, J. (2000). Cognitive deficits associated with sleep apnea syndrome: A proposed neuro-psychological test battery. Sleep, 23, 369–381.

    Google Scholar 

  12. Derderian, S. S., Bridenbaugh, R. H., & Rajagopal, K. R. (1988). Neuropsychologic symptoms in obstructive sleep apnea improve after treatment with nasal continuous positive airway pressure. Chest, 94, 1023–1027.

    Google Scholar 

  13. Engdahl, B. E., Eberly, R. E., Hurwitz, T. D., Mahowald, M. W., & Blake, J. (2000). Sleep in a community sample of elderly war veterans with and without posttraumatic stress disorder. Biological Psychiatry, 47, 520–525.

    Google Scholar 

  14. Exar, E. N., & Collop, N. A. (1999). The upper airway resistance syndrome. Chest, 115, 1127–1139.

    Google Scholar 

  15. Foa, E. B., & Meadows, E. A. (1997). Psychosocial treatments for posttraumatic stress disorder: Critical review. Annual Review of Psychology, 48, 449–480.

    Google Scholar 

  16. Foa, E., Riggs, D., Dancu, C., & Rothbaum, B. (1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459–473.

    Google Scholar 

  17. Ford, D. E., & Kamerow, D. B. (1989). Epidemiologic study of sleep disturbances and psychiatric disorders. JAMA, 262, 1479–1484.

    Google Scholar 

  18. Frederickson, P. A., & Krueger, B. R. (1994). Insomnia associated with specific polysomnographic findings. In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (2nd ed., pp. 523–534) London: W. B. Saunders.

    Google Scholar 

  19. Glaubman, H. M., Miculincer, M., Porat, A., Wasserman, O., & Birger, M. (1990). Sleep of chronic post traumatic patients. Journal of Traumatic Stress, 3, 255–263.

    Google Scholar 

  20. Guilleminault, C. (1989). Clinical features and evaluation of obstructive sleep apnea. In M. H. Kryger, T. Roth & W. C. Dement (Eds.), Principles and practice of sleep medicine (1st ed., pp. 552–558). London: W. B. Saunders.

    Google Scholar 

  21. Guilleminault, C., Stoohs, R., Kim, Y. D., Chervin, R., Black, J., & Clerk, A. (1995). Upper airway sleep disordered breathing in women. Annals of Internal Medicine, 122, 493–501.

    Google Scholar 

  22. Hosselet, J. J., Norman, R. G., Ayappa, I., & Rapoport, D. M. (1998). Detection of flow limitation with a nasal cannula/pressure transducer system. American Journal of Respiratory and Critical Care Medicine, 157, 1461–1467.

    Google Scholar 

  23. Hurwitz, T., Mahowald, M., Kuskowski, M., & Engdahl, B. (1998). Polysomnographic sleep is not clinically impaired in Vietnam combat veterans with chronic posttraumatic stress disorder. Biological Psychiatry, 44, 1066–1073.

    Google Scholar 

  24. Inman, D. J., Silver, S. M., & Doghramji, K. (1990). Sleep disturbances in posttraumatic stress disorder: A comparison with non-PTSD insomnia. Journal of Traumatic Stress, 3, 429–437.

    Google Scholar 

  25. Kalina, M., Jurek-Pelczarska, J., Koslacz, E., Farnik-Brodzinska, M., & Tazbirek, M. (1999). [The depression level in patients with obstructive sleep apnea syndrome]. Wiadomosci Lekarskie, 52, 134–143.

    Google Scholar 

  26. Katz, L., Fleisher, W., Kjernisted, K., & Milanese, P. (1996). A review of the psychobiology and pharmacotherapy of posttraumatic stress disorder. Canadian Journal of Psychiatry, 41, 233–238.

    Google Scholar 

  27. Kilpatrick, D. G., Resnick, H. S., Freedy, J. R., Pelcovitz, D., Resick, P., Roth, S., & van der Kolk, B. (1998). Posttraumatic stress disorder field trial: evaluation of the PTSD construct-criteria A through E. In T. A. Widiger, A. J. Frances, H. A. Pincus, R. Ross, M. B. First, W. Davis, & M. Kline (Eds.), DSM-IV Sourcebook (Vol. 4, pp. 803–846). Washington, DC: American Psychiatric Press.

    Google Scholar 

  28. Krakow, B., Germain, A., Tandberg, D., Koss, M., Schrader, R., Hollifield, M., Cheng, D., & Edmond, T. (2000). Sleep breathing and sleep movement disorders masquerading as insomnia in sexual assault survivors. Comprehensive Psychiatry, 41, 49–56.

    Google Scholar 

  29. Krakow, B., Hollifield, M., Schrader, R., Koss, M., Tandberg, D., Lauriello, J., McBride, L., Cheng, D., Edmond, T., & Kellner, R. (2000). A controlled study of imagery rehearsal for chronic nightmares in sexual assault survivors with PTSD: A preliminary report. Journal of Traumatic Stress, 13, 589–609.

    Google Scholar 

  30. Krakow, B., Lowry, C., Germain, A., Gaddy, L., Hollifield, M., Koss, M., Tandberg, D., & Johnston, L. (2000). A retrospective study on improvements in nightmares and posttraumatic stress disorder following treatment for co-morbid sleep-disordered breathing. Journal of Psychosomatic Research, 49, 291–298.

    Google Scholar 

  31. Krakow, B., Melendrez, D., Pedersen, B., Johnston, L., Hollifield, M., Germain, A., Koss, M., Warner, T. D., & Schrader, R. (2001). Complex insomnia: Insomnia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD. Biological Psychiatry, 49, 948–953.

    Google Scholar 

  32. Krakow, B., Melendrez, D., Santana, E., Johnston, L., Sisley, B., & Hollifield, M. (2001). Prevalence and timing of sleep disturbance in Cerro Grande Firestorm victims. Sleep, 24(Suppl.): A394.

    Google Scholar 

  33. Krakow, B., Tandberg, D., Scriggins, L., & Barey, M. (1995). A controlled comparison of self-rated sleep complaints in acute and chronic nightmare sufferers. Journal of Nervous and Mental Disease, 183, 623–627.

    Google Scholar 

  34. Kupfer, D. J. (1999). Pathophysiology and management of insomnia during depression. Annals of Clinical Psychiatry, 11, 267–276.

    Google Scholar 

  35. Lavie, P., Katz, N., Pillar, G., & Zinger, Y. (1998). Elevated awaking thresholds during sleep: Characteristics of chronic war-related posttraumatic stress disorder patients. Biological Psychiatry, 44, 1060–1065.

    Google Scholar 

  36. Martin, S. E., Wraith, P. K., Deary, I. J., & Douglas, N. J. (1997). The effect of nonvisible sleep fragmentation on daytime function. American Journal of Respiratory and Critical Care Medicine, 155, 1596–1601.

    Google Scholar 

  37. Melendrez, D., Krakow, B., Pedersen, B., Hollifield, M., Johnston, L., Germain, A., & Koss, M. (2000). Sleep disordered breathing in twenty consecutive crime victims presenting for nightmare and insomnia treatment: A preliminary report. Sleep, 23(Suppl. 2): A257–A258.

    Google Scholar 

  38. Mellman, T. A. (1997). Psychobiology of sleep disturbances in posttraumatic stress disorder. Annals of the New York Academy of Sciences, 821, 142–149.

    Google Scholar 

  39. Mellman, T. A., David, D., Kulick-Bell, R., Hebding, J., & Nolan, B. (1995). Sleep disturbance and its relationship to psychiatric morbidity after Hurricane Andrew. American Journal of Psychiatry, 152, 1659–1663.

    Google Scholar 

  40. Millman, R. P., Fogel, B. S., McNamara, M. E., & Carlisle, C. C. (1989). Depression as a manifestation of obstructive sleep apnea: Reversal with nasal continuous positive airway pressure. Journal of Clinical Psychiatry, 50, 348–351.

    Google Scholar 

  41. Montserrat, J. M., & Badia, J. R. (1999). Upper airway resistance syndrome. Sleep Medicine Reviews, 3, 5–21.

    Google Scholar 

  42. Morin, C. M. (1993). Insomnia: Psychological assessment and management. New York: Guilford Press.

    Google Scholar 

  43. Mosko, S., Zetin, M., Glen, S., Garber, D., DeAntonio, M., Sassin, J., McAnich, J., & Warren, S. (1989). Self reported depressive symptomatology, mood ratings, and treatment outcome in sleep disorders patients. Journal of Clinical Psychology, 45, 51–60.

    Google Scholar 

  44. National Institutes of Health, U.S. Department of Health and Human Services. (1992). Wake up America: A national sleep alert, Vol. 1: Executive summary and executive report, report of the National Commission on Sleep Disorders Research (pp. 1–76). Washington, DC: Dement, W. C.

    Google Scholar 

  45. Neylan, T. C., Marmar, C. R., Metzler, T. J., Weiss, D. S., Zatzick, D. F., Delucchi, K. L., Wu, R. M., & Schoenfeld, F. B. (1998). Sleep disturbances in theVietnam generation: Findings from a nationally representative sample of male Vietnam veterans. American Journal of Psychiatry, 155, 929–933.

    Google Scholar 

  46. Nofzinger, E. A., Buysse, D. J., Reynolds, C. F., III, & Kupfer, D. J. (1993). Sleep disorders related to another mental disorder (nonsubstance/primary): A DSM-IV literature review. Journal of Clinical Psychiatry, 54, 244–255.

    Google Scholar 

  47. Palombini, L., Colrain, I., Black, J., Gastal, O. L., & Guilleminault, C. (1999). Clinical findings in UARS patients. Sleep, 22(Suppl. 1): S277.

    Google Scholar 

  48. Pillar, G., Malhotra, A., & Lavie, P. (2000). Post-traumatic stress disorder and sleep—what a nightmare! Sleep Medicine Reviews, 4, 183–200.

    Google Scholar 

  49. Ramos Platon, M. J., & Espinar Sierra, J. (1992). Changes in psychopathological symptoms in sleep apnea patients after treatment with nasal continuous positive airway pressure. International Journal of Neuroscience, 62, 173–195.

    Google Scholar 

  50. Reite, M. (1998). Sleep disorders presenting as psychiatric disorders. Psychiatric Clinics of North America, 21, 591–607.

    Google Scholar 

  51. Reite, M., Buysse, D., Reynolds, C., & Mendelsohn, W. (1995). The use of polysomnography in the evaluation of insomnia. Sleep, 18, 58–70.

    Google Scholar 

  52. Ross, R. J., Ball, W. A., Sullivan, K. A., & Caroff, S. N. (1989). Sleep disturbance as the hallmark of posttraumatic stress disorder. American Journal of Psychiatry, 146, 697–707.

    Google Scholar 

  53. Shalev, A., Bonne, O., & Eth, S. (1996). Treatment of posttraumatic stress disorder: A review. Psychosomatic Medicine, 58, 165–182.

    Google Scholar 

  54. Solomon, S., Gerrity, E., & Muff, A. (1992). Efficacy of treatments for posttraumatic stress disorder: An empirical review. JAMA, 268, 633–638.

    Google Scholar 

  55. Woodward, S. H., Friedman, M. J., & Bliwise, D. L. (1996). Sleep and depression in combat-related PTSD in patients. Biological Psychiatry, 39, 182–192.

    Google Scholar 

  56. Youakim, J. M., Doghramji, K., & Schutte, S. L. (1998). Posttraumatic stress disorder and obstructive sleep apnea. Psychosomatics, 39, 168–171.

    Google Scholar 

  57. Young, T., Palta, M., Dempsey, J., Skatrud, J., Weber, S., & Badr, S. (1993). The occurrence of sleep disordered breathing among middle-aged adults. New England Journal of Medicine, 328, 1230–1235.

    Google Scholar 

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Author information

Affiliations

  1. Sleep & Human Health Institute, Albuquerque, New Mexico

    Barry Krakow, Teddy D. Warner, Michael Hollifield, Dan Tandberg & Lisa Johnston

  2. University of New Mexico Health Sciences Center, Albuquerque, New Mexico

    Barry Krakow

  3. Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico

    Barry Krakow & Dan Tandberg

  4. Department of Psychiatry, University of New Mexico Health Sciences Center, Albuquerque, New Mexico

    Barry Krakow, Teddy D. Warner, Michael Hollifield & Lisa Johnston

  5. Department of Psychology, University of Montreal & Laboratoire des rêves et des cauchemars, Hôpital Sacré-Coeur, Montréal, Québec, Canada

    Anne Germain

  6. Department of Mathematics and Statistics, University of New Mexico, Albuquerque, New Mexico

    Ron Schrader

  7. University of Arizona Health Science Center, Tucson, Arizona

    Mary Koss

  8. Department of Family and Community Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico

    Michael Hollifield

  9. Sleep & Human Health Institute, Albuquerque, New, Mexico

    Dominic Melendrez & Lisa Johnston

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Krakow, B., Germain, A., Warner, T.D. et al. The Relationship of Sleep Quality and Posttraumatic Stress to Potential Sleep Disorders in Sexual Assault Survivors with Nightmares, Insomnia, and PTSD. J Trauma Stress 14, 647–665 (2001). https://doi.org/10.1023/A:1013029819358

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  • PTSD
  • insomnia
  • nightmares
  • sleep-disordered breathing
  • restless legs
  • periodic limb movements