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• W2799672711 abstract "Free AccessSleep QualityMore Than Just a Good Night's Sleep Scott G. Williams, MD, FAASM, Jacob F. Collen, MD, FAASM, Christopher J. Lettieri, MD, FAASM Scott G. Williams, MD, FAASM Address correspondence to: Scott G Williams, MD, Director for Medicine, River Pavilion, Second Floor, Fort Belvoir Community Hospital, 9300 DeWitt Loop, Ft. Belvoir, VA 22060(571) 231-1363 E-mail Address: [email protected] Directorate for Medicine, Fort Belvoir Community Hospital, Fort Belvoir, Virginia Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland Search for more papers by this author , Jacob F. Collen, MD, FAASM Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland Search for more papers by this author , Christopher J. Lettieri, MD, FAASM Directorate for Medicine, Fort Belvoir Community Hospital, Fort Belvoir, Virginia Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland Search for more papers by this author Published Online:May 15, 2018https://doi.org/10.5664/jcsm.7084Cited by:2SectionsPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutINTRODUCTIONPsychological stress and sleep influence each other in a complex and bidirectional manner.1 It is well-recognized that behavioral health disorders impair sleep, sleep quality, and associated features such as cognition.2 A complaint of poor sleep, particularly insomnia, is an essential criterion for many psychiatric illnesses. In short, these conditions are thought to cause insomnia. What is less well established is how poor sleep can cause, or at least contribute to, the development of behavioral health disorders. Acute and chronic life stressors commonly diminish sleep quality and impair sleep onset. In turn, a lack of restorative sleep (insufficient quality or quantity) can reduce physical and emotional resiliency, leading to a maladaptive stress response, putatively increasing the chance of developing anxiety or depression.In this issue of the Journal of Clinical Sleep Medicine, Palagini and colleagues provide an important addition to the literature, demonstrating that resilience is negatively correlated with insomnia.3 In their study, the authors refer to the stress diathesis model and the stress-risk-vulnerability dimension. According to the diathesis-stress model of insomnia, patients with insomnia experience high stress-related sleep reactivity and greater emotional dysregulation. The stress-risk-vulnerability dimension describes an individual's dynamic capacity to process and adapt to stressors while maintaining normal psychological and physical functioning. In short, this process describes an individual's resilience. Those with less resilience have a diminished capacity to successfully adapt to stressful events and have an increased vulnerability for developing insomnia (and by extension, mental health disorders). In the study by Palagini et al., because individuals with insomnia had heightened stress-related sleep reactivity, more emotional dys-regulation, and hyperarousal, they also had reduced measures of resilience.The concept that sleep disturbances may not be merely a product of an individual's ability to tolerate stress and anxiety, but may actually cause or contribute to maladaptive coping and dysfunctional processing, has been previously hypothesized. Data supporting the argument for sleep as a determinant of psychological resiliency include studies assessing the impact of sleep quality immediately preceding trauma,4 as well as studies demonstrating the role of sleep as a function of suicide risk in vulnerable patients.5,6 A study exploring the relationship between perceived sleep quality and resilience found those reporting poor sleep quality (Pittsburgh Sleep Quality Index scores > 5) obtained lower resilience scores compared with those reporting good sleep quality (P = .025).7 In this study, those with poorer sleep quality (odds ratio = 3.3) and those sleeping < 7 h/night (odds ratio = 3.3), were at greater risk of low resilience. In a study determining the relationships between sleep, indices of resilience, and behavior among children, investigators found sleep disturbances reduced resilience and consequently increased problematic behavior, potentially predisposing individuals to psychopathology.8 Similarly, Wong and colleagues observed that sleep rhythmicity during early childhood predicted behavioral control in adolescence and resilience as young adults.9Much of the work exploring preexisting sleep disorders and susceptibility to future psychiatric conditions has been done in posttraumatic stress disorder (PTSD). An evolving body of literature supports the view that sleep disorders may be implicated in the underlying pathophysiology of PTSD and not simply a consequence or manifestation of the disease.10,11 In our practice, we have seen many Military service members returning from combat with sleep complaints and sleep disorders, particularly insufficient sleep syndrome, obstructive sleep apnea, and insomnia. We have observed those with sleep complaints or diagnosed sleep disorders have substantially higher rates of PTSD compared to those without sleep issues.12,13 This is especially true of those who did not sustain physical combat injuries. After excluding individuals with traumatic injuries, premorbid sleep complaints were significantly higher among those who developed PTSD compared with controls. We hypothesized that patients with existing disrupted sleep may have diminished resiliency making them more vulnerable to developing behavioral health issues and increasing their risk of subsequent PTSD.In the study by Palagini et al., it should be noted that the authors are largely working within the construct that resilience capacity is more of a static trait. Similar to work by Tkachenko and Dinges, there may be distinct cognitive profiles modulating the stress response, leading to a differential vulnerability to effects of sleep loss.14 The impact that sleep debt has on resiliency, the stress response and an individual's ability to appropriately process stress, therefore, may be at least partially genetically predisposed. To state that resilience capacity is unchangeable, though, may be an oversimplification. More likely, there is a dynamic and interdependent relationship where resiliency has a biologic tendency but is modulated by environmental factors to include sleep. Regardless, their work gives further evidence that sleep quality and resiliency are linked. Given that resilience is a critical process for processing events and adaptively overcoming stress, it seems clear that poor sleep would predis-pose to conditions arising from maladaptive stress processing. The authors accurately acknowledge that the data are limited to subjective reports, and the cross-sectional design provides little information regarding the natural history of the insomnia.Because this was only one snapshot in time, it is unclear how resiliency was affected by the presence or severity of insomnia, or whether treatment of insomnia would improve resiliency. Despite these limitations, the impact of lowered resilience is supportive of the hypothesis that preexisting insomnia might increase the risk of disorders such as PTSD. We concur that the evaluation and treatment of emotional dysregulation should be a routine component of sleep medicine practice, but clearly more work is indicated in order to definitively prove causation. Regardless, this manuscript sets the stage for a longitudinal study to determine whether diminished resiliency is a trait that lowers the threshold to develop insomnia, whether insomnia is a condition that can itself diminish resiliency, or whether there is a true bidirectional relationship that perpetuates the vicious cycle of worsening symptoms.DISCLOSURE STATEMENTThe authors report no conflicts of interest. The views in this commentary reflect those of the authors, and do not constitute official policy of the United States Army or Department of Defense.CITATIONWilliams SG, Collen JF, Lettieri CJ. More than just a good night's sleep. J Clin Sleep Med. 2018;14(5):709–710.REFERENCES1 Alvaro PK, Roberts RM, Harris JKA Systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression. Sleep; 2013;367:1059-1068, 23814343. CrossrefGoogle Scholar2 Brownlow JA, Klingman EA, Boland EM, Brewster GS, Gehrman PRPsychiatric disorders moderate the relationship between insomnia and cognitive problems in military Soldiers. J Affect Disord; 2017;221:25-30, 28628764. CrossrefGoogle Scholar3 Palagini L, Moretto U, Novi Met al.Lack of resilience is related to stress-related sleep reactivity, hyperarousal and emotion dysregulation in insomnia disorder. J Clin Sleep Med; 2018;145:759-766. LinkGoogle Scholar4 Bryant RA, Creamer M, O'Donnell M, Silove D, McFarlane ACSleep disturbance immediately prior to trauma predicts subsequent psychiatric disorder. Sleep; 2010;331:69-74, 20120622. CrossrefGoogle Scholar5 Drapeau CW, Nadorff MRSuicidality in sleep disorders: prevalence, impact and management strategies. Nat Sci Sleep; 2017;9:213-226, 29075143. CrossrefGoogle Scholar6 Bryan CJ, Gonzales J, Rudd MDet al.Depression mediates the relation of insomnia severity with suicide risk in three clinical samples of U.S. military personnel. Depress Anxiety; 2015;329:647-655, 26047362. CrossrefGoogle Scholar7 Arbinaga FSelf-reported perceptions of sleep quality and resilience among dance students. Percept Mot Skills; 2018;1252:351-368, 29436981. CrossrefGoogle Scholar8 Chatburn A, Coussens S, Kohler MJResiliency as a mediator of the impact of sleep on child and adolescent behavior. Nat Sci Sleep; 2013;6:1-9, 24379734. Google Scholar9 Wong MM, Puttler LI, Nigg JT, Zucker RASleep and behavioral control in earlier life predicted resilience in young adulthood: A prospective study of children of alcoholics and controls. Addict Behav; 2018;82:65-71, 29494860. CrossrefGoogle Scholar10 van Liempt S, van Zuiden M, Westenberg H, Super A, Vermetten EImpact of impaired sleep on the development of PTSD symptoms in combat veterans: a prospective longitudinal cohort study. Depress Anxiety; 2013;305:469-474, 23389990. CrossrefGoogle Scholar11 Gehrman P, Seelig AD, Jacobson IGet al.Predeployment sleep duration and insomnia symptoms as risk factors for new-onset mental health disorders following military deployment. Sleep; 2013;367:1009-1018, 23814337. CrossrefGoogle Scholar12 Lettieri CJ, Collen JC, Williams SGObstructive sleep apnea syndrome and post-traumatic stress disorder: Clinical outcomes and impact of PAP therapy. Chest; 2016;1492:483-490, 26291560. CrossrefGoogle Scholar13 Williams SG, Collen JC, Orr N, Holley AB, Lettieri CJSleep disorders in combat-related post traumatic stress disorder. Sleep Breath; 2015;191:175-182, 24752303. CrossrefGoogle Scholar14 Tkachenko O, Dinges DFInterindividual variability in neurobehavioral response to sleep loss: a comprehensive review. Neurosci Biobehav Rev; 2018;89:29-48, 29563066. CrossrefGoogle Scholar Next article FiguresReferencesRelatedDetailsCited by Lopez-Castroman J and Jaussent I Sleep Disturbances and Suicidal Behavior , 10.1007/7854_2020_166, . Do subjective and objective resilience measures assess unique aspects and what is their relationship to adolescent well‐being?Sigley‐Taylor P, Chin T and Vella‐Brodrick D Psychology in the Schools, 10.1002/pits.22517 Volume 14 • Issue 05 • May 15, 2018ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationApril 17, 2018Submitted in final revised formApril 17, 2018Accepted for publicationApril 17, 2018Published onlineMay 15, 2018 Information© 2018 American Academy of Sleep MedicinePDF download" @default.
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