International Society for Traumatic Stress Studies

Sleep Disturbances in Adolescent Girls with Posttraumatic Stress Disorder

Posted 9 December 2016 in JOTS Highlights by Janeese Brownlow, PhD & Richard Ross, MD, PhD

Disturbed sleep is a core feature of posttraumatic stress disorder (PTSD). Sleep disturbances, in the form of chronic insomnia and recurrent nightmares, are a frequent residual complaint after successful PTSD treatment. There is substantial evidence to support the effectiveness of cognitive behavioral therapies for the treatment of PTSD. However, treatment modalities that are efficacious for the waking symptoms of PTSD may have limited utility for PTSD sleep disturbances (Brownlow, Harb, & Ross, 2015), and very few PTSD treatment studies specifically examine sleep problems as an outcome measure. Further, the few studies that have examined the efficacy of evidence-based treatments for PTSD sleep disturbances have been in adult populations primarily. Adolescents who are in a developmental period marked by dramatic neurobiological and behavioral changes (Colrain & Baker, 2011; Roberts, Roberts, & Chen, 2001) may respond differently to treatment. It is particularly important to study PTSD sleep disturbances in adolescents because this age group has an increased risk for trauma exposure and subsequent PTSD (Hanson et al., 2008); furthermore, adolescence is marked by considerable variability in sleep patterns, which increases the risk for physiological, cognitive, and psychological changes, and adverse functional outcomes in the aftermath of trauma (Belleville, Guay, & Marchand, 2009; Roberts, et al., 2008).  The public health implications of recognizing and treating sleep disturbances in adolescents with PTSD are great.
 
In a new study published in the Journal of Traumatic Stress, Brownlow and colleagues examined the effects on insomnia and nightmare symptoms of treatment with prolonged exposure-adolescents (PE-A) versus client-centered therapy (CCT) over time, in 61 adolescent girls (mean age 15.34 years, SD = 1.54) with sexual abuse-related PTSD. Measurements were made pre-treatment, post-treatment, 6 months after treatment, and again 12 months after treatment. The degree to which residual PTSD sleep disturbances influenced global functioning following successful PTSD treatment was examined. Insomnia and nightmare symptoms were assessed using the Child PTSD Symptom Scale (CPSS; Foa, Johnson, Feeny & Treadwell, 2001). The Children’s Global Assessment Scale (CGAS; Schaffer et al., 1983) was used to assess global functioning. The investigators found that, post-treatment, 20% of adolescent girls continued to endorse nightmare symptoms and 55% continued to report insomnia symptoms. There were significant main effects of treatment and time on insomnia and nightmares, suggesting that both treatments improved PTSD sleep disturbances over time (although PE-A was superior to CCT). Findings also revealed that residual insomnia and nightmare symptoms predicted poorer global functioning in these adolescent girls. These findings are consistent with the adult literature in two regards: 1) PTSD sleep disturbances are frequent residual complaints despite successful PTSD treatment; and 2) Residual PTSD sleep disturbances are associated with poorer functioning following otherwise successful PTSD treatment. These findings highlight the importance of early detection and treatment of sleep problems in adolescents with PTSD. This can be accomplished by initial screening for sleep problems, and the inclusion of sleep measurements over the course of PTSD treatment.

Reference Article

Brownlow, J. A., McLean, C. P., Gehrman, P. R., Harb, G. C., Ross, R., & Foa, E. B. (In Press). Influence of Sleep Disturbance on Global Functioning after Posttraumatic Stress Disorder Treatment. Journal of Traumatic Stress.

Discussion Questions

  • Would addressing the PTSD sleep disturbances, specifically, prior to PTSD treatment or during the course of PTSD treatment, have greater success in reducing these disturbances?
  • This study focused on adolescent girls. Would the same findings be expected in adolescent boys?

Author Biographies 

Janeese A. Brownlow, PhD is a National Research Service Award (NRSA) Fellow at the Center for Sleep and Circadian Neurobiology and the Behavioral Sleep Medicine Program at the Perelman School of Medicine at the University of Pennsylvania. Her research focuses on the application of neurofunctional probes in the pathophysiology and treatment of insomnia in relation to posttraumatic stress disorder.
 
Richard J. Ross, MD, PhD is a Professor of Psychiatry at the Corporal Michael J. Crescenz Veterans Affairs Medical Center and the Perelman School of Medicine at the University of Pennsylvania. His research focuses on the pathophysiology and treatment of posttraumatic stress disorder, particularly its very prominent sleep disturbances.

References 

Belleville, G., Guay, S., & Marchand, A. (2011). Persistence of sleep disturbance following cognitive-behavior therapy for posttraumatic stress disorder. Journal of Psychosomatic Research, 70, 318-327. doi:10.1016/j.jpsychores.2010.09.022
 
Brownlow, J. A., Harb, G. C., & Ross, R. J. (2015). Treatment of sleep disturbances in post-traumatic stress disorder: a review of the literature. Current Psychiatry Reports, 17, 41. doi 10.1007/s11920-015-0587-8
 
Colrain, I. M., & Baker, F. C. (2011). Changes in sleep as a function of adolescent development. Neuropsychology Review, 21, 5-21. doi:10.1007/s11065-010-9155-5
 
Foa, E. B., Johnson, K. M., Feeny, N. C., & Treadwell, K. R. (2001). The child PTSD symptom scale: A preliminary examination of its psychometric properties. Journal of Clinical Child & Adolescent Psychology, 30, 376-384. doi:10.1207/S15374424JCCP3003_9
 
Hanson, R. F., Borntrager, C., Self-Brown, S., Kilpatrick, D. G., Saunders, B. E., Resnick, H. S., & Amstadter, A. (2008). Relations among gender, violence expsoure, and mental health: The national survey of adolescents. American Journal of Orthopsychiatry, 78, 313-321. doi: 10.1037/a0014056
 
Roberts, R. E., Roberts, C. R., & Duong, H. T. (2008). Chronic insomnia and its negative consequences for health and functioning of adolescents: A 12-month prospective study. Journal of Adolescent Health, 42, 294-302. doi: 10.1016/j.jadohealth.2007.09.016
 
Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H., & Aluwahlia, S. (1983). A Children's Global Assessment Scale (CGAS). Archives of General Psychiatry, 40, 1228-1231. doi:10.1001/archpsyc.1983.01790100074010