​1. Title: 

Sleep Structure in Refugees Diagnosed With PTSD 

2. Project period: 

31.01.2018 – 31.06.2019 

3. Investigator(s): 

Mia Beicher Ansbjerg, Pre-graduate Researcher and Medical Student 

4. Supervisors and collaborative partners: 

• Principal supervisor: Associate Professor Jessica Carlsson Lohmann, CTP 
• Co-supervisor: MD Hinuga Sandal, CTP 
• Co-supervisor: Professor Poul Jennum, Danish Center for Sleep Medicine 
• Co-supervisor: Lone Baandrup, Mental Health Center Glostrup 

5. Background: 

Post-Traumatic Stress Disorder (PTSD) is the clinical manifestation of traumatic events and is often associated with flash backs, avoidance behaviour, hyperarousal and sleep disturbances, the latter being highly prevalent and causing many obstacles for patients in their everyday life. Sleep disturbances, if left untreated, may persist or even worsen symptoms of PTSD despite a multidisciplinary treatment effort, constituting a risk for poor outcome of psychiatric treatment. It has been argued that effective treatment of sleep disturbances may accelerate recovery in PTSD. 

6. Aim/s: 

The aim of this study is to examine sleep structure in refugees with PTSD enrolled in treatment programs at the Competence Centre for Transcultural Psychiatry (CTP). By using polysomnographic measurements, the following hypotheses are tested: 

• Sleep structure and sleep architecture in refugees diagnosed with PTSD differ from healthy controls. 
  
• Refugees diagnosed with PTSD has increased dream activity compared to healthy controls, which may be associated to increased incidence of REM Sleep Without Atonia (RSWA) and REM Sleep Behavior Disorder (RBD). 
• Refugees diagnosed with PTSD has increased incidence of Sleep Apnea and Periodic Limp Movements (PLMs) compared to healthy controls. 

7. Methods 

The study is a cross-sectional study performed at CTP in collaboration with Danish Center for Sleep Medicine. 

7.1 Number of participants (N): 

20 refugees diagnosed with PTSD and 20 healthy controls. 

7.2 Population: 

Trauma-affected refugees or family reunited with a refugee fulfilling the criteria for Posttraumatic Stress Disorder and referred for treatment at CTP. 

7.3 Description of data and data collection: 

The study will include patients from May 2018 to February 2019. All patients referred to CTP will be invited to an initial consultation with a doctor. During this consultation a diagnostic assessment will be performed and the clinical history will be obtained. Patients who give informed consent will be invited to participate in the sleep project and have sleep measurements performed by polysomnography. Furthermore self-administered questionnaires and semi-structured interviews will be used to collect information on mental health, sleep quality, sleep length and nightmares. Each patient will be equipped with PSG equipment to do measurements at home for one night (12 hours). Healthy control subjects will fill out the same CTP standard ratings and have the same diagnostic assessment and PSG measurement. 

7.4 Application/acceptance from the Danish Data Protection Agency, the National Committee on Health Research Ethics: 

Approved. 

7.5 Analysis 

The differences between the two groups will be analyzed using parametric or non-parametric statistical tests. The study is a proof-of-concept study and therefore a power calculation has not been performed. Due to the small sample size the data obtained might not be statistically significant which will be taken into consideration when analyzing the data. 

8. Expected results: 

This study will be the first to record the biophysiological changes that occur during sleep in refugees with PTSD. This will contribute with new and potentially crucial knowledge of sleep disturbances in these patients. The study is expected to be hypothesis generating in relation to what future studies should focus on. 

9. Dissemination of results 

The results will be presented at national and international conferences, in other settings relevant to professionals working with trauma-affected refugees and in peer-reviewed scientific journals. 

10. References 

1. Kobayashi I, Boarts JM, Delahanty DL. Polysomnographically measured sleep abnormalities in PTSD: a meta-analytic review. Psychophysiology. 2007 Jul;44(4):660-9. Epub 2007 May 22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17521374 

2. Baglioni C, Nanovska S, Regen W, Spiegelhalder K, Feige B, Nissen C, Reynolds CF, Riemann D. Sleep and mental disorders: A meta-analysis of polysomnographic research. Psychol Bull. 2016 Sep;142(9):969- 990. Epub 2016 Jul 14. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27416139 

3. Germain A. Sleep disturbances as the hallmark of PTSD: where are we now? Am J Psychiatry. 2013 Apr 1;170(4):372–82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23223954 

4. Jennum P, Bonke J, Clark AJ, Flyvbjerg A, Garde AH, Hermansen K, et al. Søvn og sundhed. Videnråd for forebyggelse. 2015. Available from: http://www.vidensraad.dk/sites/default/files/vidensraad_soevn-ogsundhed_digital.pdf 

5. Sandahl H, Vindbjerg E, Carlsson J. Treatment of Sleep Disturbances in Refugees Suffering from Posttraumatic Stress Disorder. Transcult Psychiatry. 2016; Available from: https://www.ncbi.nlm.nih.gov/pubmed/29226795

6. Schoenfeld FB, Deviva JC, Manber R. Treatment of sleep disturbances in posttraumatic stress disorder: a review. J Rehabil Res Dev [Internet]. 2012 Jan;49(5):729–52. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23015583 

7. Spoormaker VI, Montgomery P. Disturbed sleep in post-traumatic stress disorder: secondary symptom or core feature? Sleep Med Rev [Internet]. 2008 Jun;12(3):169–84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18424196