Intrusions are core symptoms of PTSD, with at least one intrusion symptom being required for a diagnosis. Intrusion symptoms include unwanted and upsetting memories, nightmares, flashbacks, and emotional distress and/or physical reactivity after exposure to reminders.

What is the evidence for intrusions in people with PTSD?

Moderate to low quality evidence finds five clusters of intrusion symptoms; distressing memories, distressing dreams, flashbacks, emotional cue distress, and physiological cue reactivity.

Items relating to distressing memories

Disturbing memories kept coming into my mind. I found myself remembering bad things that happened to me. Upsetting thoughts kept coming back to me over and over again. Memories of the trauma kept entering my mind. Upsetting thoughts or memories came into my mind against my will.

Items relating to distressing dreams

I had bad dreams about terrible things that have happened to me. My dreams were so real that I woke up and forced myself to stay awake. I had dreams about the trauma. I had bad dreams or nightmares about the trauma. I had disturbing dreams of a traumatic experience from the past.

Items relating to flashbacks

Being in certain situations made me feel as if I am back when the trauma occurred. I acted as if the trauma were happening again. I acted as though the event were happening again. I had flashbacks (sudden, vivid, distracting memories) of the trauma. I felt as though the trauma was happening again. I felt I was reliving the traumatic event.

Items relating to emotional cue distress

I felt upset when I was reminded of the trauma. Reminders of the trauma made me feel nervous. I became distressed and upset when something reminded me of the event. Any reminder brought back feelings about the trauma. I felt scared when something reminded me of the trauma. I felt upset by reminders of the event. I felt nervous when something reminded me of the trauma.

Items relating to physiological cue reactivity

I had sweating or dizziness when something reminded me of my experiences. I got an upset stomach when reminded of bad things that happened to me. When something reminded me of something bad that happened to me, I felt shaky. I had trouble breathing when something reminded me of a stressful experience from the past. Reminders of the trauma made me shake. Reminders of the trauma made my heart beat really fast.

August 2021

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Hyperarousal is a core symptom of PTSD, with at least two hyperarousal symptoms being required for a diagnosis. Hyperarousal symptoms include irritability or aggression, risky or destructive behaviour, hypervigilance, heightened startle reaction, difficulty concentrating, and difficulty sleeping.

What is the evidence regarding hyperarousal in people with PTSD?

Moderate to high quality evidence finds small effects of less sleep efficiency, less total sleep time, less slow wave sleep, and more wake time after sleep onset in people with PTSD. Moderate to low quality evidence finds a medium-sized effect that people with PTSD and sleep disturbances were more likely to report suicidal behaviours.

Moderate to low quality evidence finds five clusters of hyperarousal symptoms. These are irritability and anger, difficulty concentrating, hypervigilance, startle, and sleep difficulty.

Items relating to irritability/anger

I lost my cool and exploded over minor everyday things. I lost my temper. Little things made me angry. I felt irritable. I had angry outbursts. I felt that if someone pushed me too far, I would become angry.

Items relating to difficulty concentrating

I had difficulty paying attention. I was unusually forgetful. I had difficulty concentrating. I had trouble concentrating. I had trouble keeping my mind on what I was doing. I had more trouble than usual remembering things.

Items relating to hypervigilance

I watched out for danger since the trauma. I was overly alert (for example, checking to see who was around me). I was very aware of my surroundings and nervous about what’s going on around me. I felt on guard.

Items relating to startle

Unexpected noises made me jump. I was jumpy or easily startled by ordinary noises or movements. I was watchful or on guard. I got startled when there was a sudden noise or movement. Unexpected noises startled me more than usual. I was jumpy or startled at something unexpected. I felt jumpy or easily startled.

Items relating to sleep difficulty

My sleep was restless. I had trouble falling asleep. I had sleep problems. I had trouble staying asleep.

August 2021

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A PTSD diagnosis requires exposure to at least one trauma. Traumas include being exposed to threatened death, actual or threatened serious injury, or actual or threatened sexual violence. Examples are direct exposure, witnessing a trauma, or learning that a relative or close friend was exposed.

At least one “intrusion” symptom is required for a PTSD diagnosis. These symptoms include unwanted and upsetting memories, nightmares, flashbacks, and emotional distress or physical reactions following reminders. At least one “avoidance” symptom is also required for a PTSD diagnosis. These symptoms include avoidance of trauma-related thoughts or feelings, and/or avoidance of trauma-related reminders. At least two “negative alterations in cognitions and mood” are required. These include negative thoughts or feelings that began or worsened after the trauma, an inability to recall key features of the trauma, overly negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others for causing the trauma, negative mood, decreased interest in activities, feeling isolated, and difficulty experiencing positive mood. Finally, there needs to be at least two “hyperarousal” symptoms, such as irritability or aggression, risky or destructive behaviour, hypervigilance, heightened startle reaction, difficulty concentrating, and difficulty sleeping.

Symptoms must last for more than one month and cause significant distress or problems to the individual’s daily functioning. Symptoms must not be due to medication, substance use, or other illness. The latest World Health Organization’s International Classification of Diseases (ICD-11) also includes complex PTSD, which involves the core symptoms of PTSD plus disturbances in self organisation, mood dysregulation, negative self-concept, and disturbances in relationships.

A variety of tools have been developed to screen for or diagnose PTSD. The gold standards for diagnosis are the Clinician-Administered PTSD Scale (CAPS) and the Structured Clinical Interview for DSM-V (SCID-5), PTSD module. There are also a wide range of self-report PTSD measures, including the Primary Care PTSD Screen (PC-PTSD) and the PTSD Checklist (PCL), which are mostly used to monitor PTSD symptom severity, but can also be used for screening and diagnosing PTSD in people who have been exposed to trauma.

What is the evidence regarding diagnosis and detection of PTSD?

Moderate to high quality evidence finds a small increase in the severity of PTSD symptoms in people exposed to DSM-5 nominated traumas of actual or threatened death or serious injury or of threat to the physical integrity of self or others compared to people exposed to other traumas such as divorce, financial stress, or minor car accidents.

Around 24.5% of people diagnosed with PTSD have a delayed onset (>6 months post trauma), with most of these people experiencing earlier and milder subclinical symptoms. Delayed-onset PTSD is highest in professional groups and in those who experienced combat trauma (prevalence in both is around 40%).

There is reasonable sensitivity and good specificity of the PC-PTSD and the PCL for predicting a diagnosis of PTSD. There is good diagnostic validity and internal consistency, and reasonable test-retest and external (convergent) validity of the PCL. For children, the average T score on the Trauma Symptom Checklist for Children is around 50 in those exposed to traumatic events, which is 15 points less than the clinical cut-off for PTSD on this scale. Factors associated with increased scores on the Trauma Symptom Checklist for Children include international (vs. U.S.) samples, sexual abuse (vs. neglect, community violence, or complex trauma), female sex, and older age in sexual abuse samples.

Moderate to low quality evidence finds machine learning techniques (mostly support vector machine learning) using neuroimaging, neuropsychological, or audio data can reasonably predict PTSD in people previously diagnosed with PTSD using traditional means (mostly the CAPS or PCL).

August 2021

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Typically, sleep follows a characteristic pattern of four stages, where stage 1 is a state of drowsiness and early sleep, stage 2 comprises the largest component of the sleep cycle and is the first complete loss of awareness of the external environment, stage 3 is a deep slow-wave sleep, and the fourth stage is rapid eye movement (REM) sleep where muscle paralysis and memorable dreaming occurs. Sleep disturbances include changes in sleep time, sleep latency (the length of time it takes from full wakefulness to sleep) and sleep efficiency (the amount of time spent asleep while in bed).

What is the evidence for medications for sleep disturbance?

Moderate to low quality evidence finds no benefit of the nonbenzodiazepine eszopiclone over placebo for sleep efficacy and no differences in adverse effects.

October 2020

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People with bipolar disorder may show disturbances in the amount or quality of sleep they receive. Typically sleep follows a characteristic pattern of four stages, where stage 1 is a state of drowsiness and early sleep; stage 2 comprises the largest component of the sleep cycle and is the first complete loss of awareness of the external environment; stage 3 is a deep, slow-wave sleep; and the fourth stage is rapid eye movement (REM) sleep where memorable dreaming and muscle paralysis occurs.

Sleep disturbance can be measured in many ways, including the total sleep time, the sleep latency (the length of time it takes from full wakefulness to sleep), and the sleep efficiency index (the amount of time spent asleep while in bed). Sleep latency can have varying definitions, particularly regarding the definition of “asleep” – some studies define this more strictly as the time from lights out until 10 consecutive minutes of stages 2, 3 or 4, while other studies define the latency more leniently as the time from lights out until the first signs of stage 2 sleep.

What is the evidence for sleep disturbance in people with bipolar disorder?

Moderate to high quality evidence suggests around 30% of people with bipolar disorder have hypersomnia. There were large effects of more time in bed and poorer sleep quality; medium-sized effects of less sleep efficacy, more sleep time (particularly stage 1, and more awakenings; and small effects of more sleep latency and wakefulness in people with bipolar disorder than in people without a mental disorder. Sleep disturbances were greater in people with bipolar disorder than in people with schizophrenia.

Sleep disturbances may be apparent prior to the onset of bipolar disorder, including during childhood and adolescence. A decreased need for sleep may precede a manic episode, while hypersomnia may precede a depressive episode. Insomnia can precede either a manic or a depressive episode.

Moderate quality evidence finds a medium-sized effect of lower relative amplitude of the sleep-wake cycle in people with bipolar disorder than people at familial or clinical risk of bipolar disorder.

September 2021

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Typically, sleep follows a characteristic pattern of four stages, where stage 1 is a state of drowsiness and early sleep, stage 2 comprises the largest component of the sleep cycle and is the first complete loss of awareness of the external environment, stage 3 is a deep slow-wave sleep, and the fourth stage is rapid eye movement (REM) sleep where muscle paralysis and memorable dreaming occurs.

Sleep disturbances include changes in sleep time, sleep latency (the length of time it takes from full wakefulness to sleep) and sleep efficiency (the amount of time spent asleep while in bed). Parasomnias include sleep walking, night terrors, nightmares, sleep paralysis, and dream enactment behaviours. Chronotype describes sleep-wake and activity timing, involving a preference for either evening hours, intermediate (neither) hours, or morning hours. These preferences can change over time and differ in the peaks of circadian rhythms and the secretion of hormones.

What is the evidence for sleep disturbance in people with schizophrenia?

Moderate quality evidence found medium-sized effects of more total sleep time, more time in bed, more evening chronotype, and more motor activity in people with schizophrenia than in controls. There were also small effects of more sleep latency, less sleep efficacy, and more time awake after sleep onset in people with schizophrenia. There were medium-sized effects of increased stage 1 sleep, decreased stage 4 sleep, decreased slow wave sleep, and decreased REM latency. There were small effects of decreased stage 3 sleep and increased REM duration. Sleep disturbances were also found in people at-risk of psychosis compared to controls.

People recently withdrawn from antipsychotics had shorter total sleep time, longer sleep onset latency, decreased sleep efficacy, longer awake time, increased stage 1 sleep, decreased stage 2, 3, and 4 sleep, decreased slow wave sleep and shorter REM latency than controls. People on antipsychotics had significantly longer sleep onset latency, increased stage 2 sleep, and decreased total REM sleep than controls.

Moderate to low quality evidence finds frequent (weekly) nightmares were reported in 9% to 55% of people with schizophrenia. Around 15% reported sleep paralysis and 17% reported sleep-related eating disorders.

February 2022

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