Clarifying Heterogeneity of Daytime and Nighttime Symptoms of Posttraumatic Stress in Combat Veterans With Insomnia

Daytime and nighttime symptoms of posttraumatic stress disorder (PTSD) are common among combat veterans and military service members. However, there is a great deal of heterogeneity in how symptoms are expressed. Clarifying the heterogeneity of daytime and nighttime PTSD symptoms through exploratory clustering may generate hypotheses regarding ways to optimally match evidence-based treatments to PTSD symptom profiles. We used mixture modeling to reveal clusters based on 6 daytime and nighttime symptoms of 154 combat veterans with insomnia and varying levels of PTSD symptoms. Three clusters with increasing symptom severity were identified (n1 = 50, n2 = 70, n3 = 34). These results suggest that, among veterans with insomnia, PTSD symptoms tend to exist on a continuum of severity, rather than as a categorical PTSD diagnosis. Hypotheses regarding possible targeted treatment strategies for veterans within each identified cluster, as well as ways to generalize these methods to other groups within the military, are discussed.

[1]  V. Mysliwiec,et al.  Trauma associated sleep disorder: A proposed parasomnia encompassing disruptive nocturnal behaviors, nightmares and REM without atonia in trauma survivors , 2015 .

[2]  C. Nievergelt,et al.  Genomic predictors of combat stress vulnerability and resilience in U.S. Marines: A genome-wide association study across multiple ancestries implicates PRTFDC1 as a potential PTSD gene , 2015, Psychoneuroendocrinology.

[3]  C. Nievergelt,et al.  Blood-based gene-expression biomarkers of post-traumatic stress disorder among deployed marines: A pilot study , 2015, Psychoneuroendocrinology.

[4]  V. Mysliwiec,et al.  Trauma associated sleep disorder: a proposed parasomnia encompassing disruptive nocturnal behaviors, nightmares, and REM without atonia in trauma survivors. , 2014, Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine.

[5]  J. Flory,et al.  Glucocorticoid-related predictors and correlates of post-traumatic stress disorder treatment response in combat veterans , 2014, Interface Focus.

[6]  Moors Pieter,et al.  Test-retest reliability. , 2014 .

[7]  C. Nievergelt,et al.  Assessment of plasma C-reactive protein as a biomarker of posttraumatic stress disorder risk. , 2014, JAMA psychiatry.

[8]  Shira Maguen,et al.  Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial. , 2014, Sleep.

[9]  P. Ouimette,et al.  Longitudinal relationships of insomnia, nightmares, and PTSD severity in recent combat veterans. , 2013, Journal of psychosomatic research.

[10]  P. Resick,et al.  Change in sleep symptoms across Cognitive Processing Therapy and Prolonged Exposure: a longitudinal perspective. , 2013, Behaviour research and therapy.

[11]  Isaac R Galatzer-Levy,et al.  636,120 Ways to Have Posttraumatic Stress Disorder , 2013, Perspectives on psychological science : a journal of the Association for Psychological Science.

[12]  Adam D Bramoweth,et al.  Deployment-Related Insomnia in Military Personnel and Veterans , 2013, Current Psychiatry Reports.

[13]  Janine D. Flory,et al.  The use of biomarkers in the military: From theory to practice , 2013, Psychoneuroendocrinology.

[14]  E. Peskind,et al.  A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan. , 2013, The American journal of psychiatry.

[15]  B. Green Post-traumatic stress disorder: new directions in pharmacotherapy , 2013 .

[16]  Anne Germain,et al.  Validation of the Pittsburgh Sleep Quality Index Addendum for posttraumatic stress disorder (PSQI-A) in U.S. male military veterans. , 2013, Journal of traumatic stress.

[17]  P. Mommersteeg,et al.  Placebo-controlled comparison of prazosin and cognitive-behavioral treatments for sleep disturbances in US Military Veterans. , 2012, Journal of psychosomatic research.

[18]  D. Picchioni,et al.  Insomnia as predictor versus outcome of PTSD and depression among Iraq combat veterans. , 2011, Journal of clinical psychology.

[19]  E. Walker,et al.  Diagnostic and Statistical Manual of Mental Disorders , 2013 .

[20]  S. Guay,et al.  Persistence of sleep disturbances following cognitive-behavior therapy for posttraumatic stress disorder. , 2011, Journal of psychosomatic research.

[21]  P. Calhoun,et al.  A multi-component cognitive-behavioral intervention for sleep disturbance in veterans with PTSD: a pilot study. , 2011, Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine.

[22]  C. Macera,et al.  Sleep patterns before, during, and after deployment to Iraq and Afghanistan. , 2010, Sleep.

[23]  R. McLay,et al.  Insomnia is the most commonly reported symptom and predicts other symptoms of post-traumatic stress disorder in U.S. service members returning from military deployments. , 2010, Military medicine.

[24]  T. Insel,et al.  Wesleyan University From the SelectedWorks of Charles A . Sanislow , Ph . D . 2010 Research Domain Criteria ( RDoC ) : Toward a New Classification Framework for Research on Mental Disorders , 2018 .

[25]  Charles W Hoge,et al.  Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. , 2010, Archives of general psychiatry.

[26]  Anne Germain,et al.  Sleep-specific mechanisms underlying posttraumatic stress disorder: integrative review and neurobiological hypotheses. , 2008, Sleep medicine reviews.

[27]  Ran Tao,et al.  Cognitive-Behavioral Therapy. , 2008, Advances in experimental medicine and biology.

[28]  R. Ruff,et al.  Mild traumatic brain injury in U.S. soldiers returning from Iraq. , 2008, The New England journal of medicine.

[29]  B. Rothbaum,et al.  Prolonged Exposure Therapy for PTSD : Emotional Processing of Traumatic Experiences Therapist Guide , 2007 .

[30]  B. Rothbaum,et al.  Venlafaxine Extended Release in Posttraumatic Stress Disorder: A Sertraline- and Placebo-controlled Study , 2006, Journal of clinical psychopharmacology.

[31]  Ann Hackmann,et al.  Cognitive therapy for post-traumatic stress disorder: development and evaluation. , 2005, Behaviour research and therapy.

[32]  C. Hoge,et al.  Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. , 2004, U.S. Army Medical Department journal.

[33]  C. Zayfert,et al.  Residual Insomnia Following Cognitive Behavioral Therapy for PTSD , 2004, Journal of traumatic stress.

[34]  E. Peskind,et al.  Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: a placebo-controlled study. , 2003, The American journal of psychiatry.

[35]  B. Doebbeling,et al.  Confirmatory factor analyses of posttraumatic stress symptoms in deployed and nondeployed veterans of the Gulf War. , 2002, Journal of abnormal psychology.

[36]  K. Junghanns,et al.  Test-retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia. , 2002, Journal of psychosomatic research.

[37]  P. Nishith,et al.  A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. , 2002, Journal of consulting and clinical psychology.

[38]  L. Johnston,et al.  An open-label trial of evidence-based cognitive behavior therapy for nightmares and insomnia in crime victims with PTSD. , 2001, The American journal of psychiatry.

[39]  A. Husain,et al.  REM Sleep Behavior Disorder: Potential Relationship to Post-traumatic Stress Disorder , 2001, Journal of clinical neurophysiology : official publication of the American Electroencephalographic Society.

[40]  M M Ohayon,et al.  Sleep disturbances and psychiatric disorders associated with posttraumatic stress disorder in the general population. , 2000, Comprehensive psychiatry.

[41]  J. Lauriello,et al.  A Controlled Study of Imagery Rehearsal for Chronic Nightmares in Sexual Assault Survivors With PTSD: A Preliminary Report , 2000, Journal of traumatic stress.

[42]  B. Rothbaum,et al.  Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial. , 2000, JAMA.

[43]  P. Resick,et al.  Cognitive Processing Therapy for Rape Victims: A Treatment Manual , 1993 .

[44]  D. Weiss,et al.  The prevalence of lifetime and partial post-traumatic stress disorder in Vietnam theater veterans , 1992 .

[45]  Daniel J Buysse,et al.  The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research , 1989, Psychiatry Research.

[46]  Kathryn L. Taylor,et al.  Clinical evaluation of a measure to assess combat exposure. , 1989 .

[47]  A. Beck,et al.  An inventory for measuring clinical anxiety: psychometric properties. , 1988, Journal of consulting and clinical psychology.

[48]  A. Beck,et al.  An inventory for measuring depression. , 1961, Archives of general psychiatry.

[49]  Treatment for posttraumatic stress disorder in military and veteran populations: final assessment. , 2014, Military medicine.

[50]  R Core Team,et al.  R: A language and environment for statistical computing. , 2014 .

[51]  M. Carter Diagnostic and Statistical Manual of Mental Disorders, 5th ed. , 2014 .

[52]  E. Deblinger,et al.  PTSD symptom cluster profiles of youth who have experienced sexual or physical abuse. , 2014, International Journal of Child Abuse & Neglect.

[53]  Adrian E. Raftery,et al.  mclust Version 4 for R : Normal Mixture Modeling for Model-Based Clustering , Classification , and Density Estimation , 2012 .

[54]  Anne Germain,et al.  A brief sleep scale for Posttraumatic Stress Disorder: Pittsburgh Sleep Quality Index Addendum for PTSD. , 2005, Journal of anxiety disorders.

[55]  J. Davidson,et al.  Clinician‐administered PTSD scale: A review of the first ten years of research , 2001, Depression and anxiety.

[56]  F. Weathers Psychometric Properties of Nine Scoring Rules for the Clinician Administered Posttraumatic Stress Disorder Scale , 2001 .

[57]  Adrian E. Raftery,et al.  How Many Clusters? Which Clustering Method? Answers Via Model-Based Cluster Analysis , 1998, Comput. J..

[58]  V. Follette,et al.  Cognitive-behavioral therapies for trauma , 1998 .

[59]  D. Charney,et al.  The development of a Clinician-Administered PTSD Scale , 1995, Journal of traumatic stress.