Grief-enhanced Trauma-informed Care process(GTC)Grief-enhanced Trauma-informed Care process(GTC)

Other Markers For Traumatic Stress And Grief- Sleep Disturbances

Traumatic stress disorder (e.g., PTSD) is often characterized by sleep disturbances, including

insomnia, nightmares, and fragmented sleep. Actigraphy, polysomnography (PSG),

Electroencephalography (EEG) and event-related potentials (ERPs) are critical tools for

identifying neurophysiological alterations underlying these disturbances.

Main Key Points

Insomnia:

Difficulty falling or staying asleep due to hyperarousal and intrusive thoughts.

Nightmares:

Distressing, vivid dreams replaying traumatic events disrupt sleep and increase nighttime awakenings.

Fragmented Sleep:

Frequent awakenings lead to non-restorative sleep and daytime fatigue.

Hyperarousal:

Persistent physiological alertness prevents deep, restorative sleep.

Disrupted REM Sleep:

Impaired emotional processing and memory consolidation due to interruptions in this critical sleep stage.

PTSD profoundly impacts both health and sleep, creating a cycle where sleep disturbances exacerbate physical and mental health issues, and these health problems, in turn, worsen PTSD symptoms. Sleep plays a critical role in emotional regulation, memory consolidation, and physical recovery. When sleep is disrupted, as often occurs in PTSD, these essential processes are compromised, amplifying the negative effects on overall well-being.

Sleep problems are among the most persistent and debilitating symptoms of PTSD. These include insomnia, where individuals have difficulty falling or staying asleep, and nightmares, which often involve distressing, vivid replays of traumatic events. PTSD is also characterized by fragmented sleep, where individuals wake frequently throughout the night, disrupting the normal architecture of sleep. These disturbances lead to non-restorative sleep, leaving individuals feeling physically and mentally fatigued, which can impair daily functioning and worsen emotional dysregulation.

Additionally, individuals with PTSD often experience hyperarousal, a state of heightened physiological and emotional alertness, even during sleep. This hyperarousal is driven by overactivation of the stress-response system, including the hypothalamic-pituitary-adrenal (HPA) axis. It prevents the body from fully relaxing, contributing to difficulties in achieving deep, restorative sleep. Over time, chronic sleep deprivation from PTSD can impair memory, concentration, and problem-solving abilities while increasing irritability and emotional instability.

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1. Actigraphy

Actigraphy is a non-invasive method for monitoring sleep-wake patterns using wearable devices. It measures movement to determine periods of sleep and wakefulness, can detect insomnia, sleep fragmentation, sleep latency, total sleep time and efficiency. Veterans with PTSD showed lower sleep efficiency and longer sleep onset latency compared to controls, as measured by actigraphy. Nightly variability in activity levels correlated with subjective reports of nightmares and hyperarousal.

2. Polysomnography (PSG)

Polysomnography is the gold standard for sleep analysis, involving multi-channel recording of physiological signals. It uses Electroencephalography (EEG), Electrooculography (EOG), Electromyography (EMG), and Respiratory Monitoring.

EEG findings in PTSD are: Decreased delta (0.5–4 Hz) power during SWS, and Increased beta(13–30 Hz) power during non-REM (NREM) sleep, reflecting hyperarousal.
EOG findings of PTSD are: Shortened REM latency and Increased REM density (frequency of eye movements), correlating with nightmares.
EMG findings of PTSD are: Increased phasic muscle activity during REM sleep, indicative of heightened autonomic arousal.
Respiratory findings of PTSD are: Higher prevalence of sleep-disordered breathing (e.g., apnea-hypopnea index > 5 events/hour).

Polysomnographic recordings in PTSD patients revealed reduced delta power and increased REM fragmentation, particularly in combat veterans. The degree of REM fragmentation correlated with nightmare frequency and emotional reactivity.

3. Electroencephalogram (EEG)

Altered Sleep Architecture
- Slow-Wave Sleep (SWS) Reduction is a decreased restorative deep sleep (stages 3 and 4). Hyperarousal inhibits transition to delta-wave activity. PTSD patients exhibit lower delta power during SWS, which is associated with memory impairments.
- REM Sleep Dysregulation is a shortened REM latency and increased REM fragmentation. Amygdala hyperactivity disrupts REM-related emotional processing. PTSD patients demonstrate elevated theta activity (4–8 Hz) during REM sleep, which is linked to recurring nightmares.
Heightened Beta Activity
- increased beta (13–30 Hz) power, associated with hypervigilance and wakefulness. Persistent sympathetic nervous system activation prevents sleep-state transitions. Elevated beta power is observed in PTSD patients during non-REM (NREM) sleep.
3. Alpha-Delta Sleep Anomaly
- Co-occurrence of alpha (8–13 Hz) and delta waves during SWS, reducing restorative sleep. Fragmented arousal interrupts sleep continuity. PTSD patients show alpha intrusions in SWS, is associated with fatigue and non-restorative sleep.
  
  Three main manifestations of PTSD in sleep are:
  
  1- Hyperarousal: Elevated beta activity and alpha-delta intrusions during sleep.
  
  2- Impaired Emotional Regulation: Reduced REM sleep and theta dysregulation.
  
  3- Memory Consolidation Deficits: Decreased SWS and delta power.