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Published in final edited form as: J Affect Disord. 2022 Apr 9;308:65–70. doi: 10.1016/j.jad.2022.04.018

Trauma type as a risk factor for insomnia in a military population

Janeese A Brownlow a,b,*, Elizabeth A Klingaman c,d, Katherine E Miller e, Philip R Gehrman b,e
PMCID: PMC11444673  NIHMSID: NIHMS2021794  PMID: 35413357

Abstract

Background:

This study evaluated whether lifetime traumatic stress compared to deployment-related traumatic stress differentially affected the likelihood of insomnia in military personnel.

Methods:

Data were obtained from the Army Study to Assess Risk and Resilience in Servicemembers (unweighted N = 21,499; weighted N = 670,335; 18–61 years; 13.5% Female). DSM-5 criteria were applied to the Brief Insomnia Questionnaire to determine past month insomnia diagnostic status. A lifetime stress survey was used to assess traumatic stress encountered outside of the military, and a deployment-related stress survey assessed for various types of deployment-related traumatic stress.

Results:

Adjusting for sex and psychiatric disorders, lifetime traumatic stress increased the prevalence for insomnia among those who endorsed combat death of close friend or relative, 1.021 (95% CI, 1.02–1.02), followed by those who reported other experiences that put them at risk of death or serious injury, 1.013 (95% CI, 1.01–1.01), whereas deployment-related traumatic stress showed that the prevalence for insomnia was highest for those who reported being sexually assaulted or raped, 1.059 (95% CI, 1.04–1.08), followed by those who endorsed being hazed or bullied by one or more members of their unit 1.042 (95% CI, 1.04–1.05).

Limitations:

The cross-sectional nature of the assessment limits causal inferences and there was no clinician determined diagnosis for insomnia.

Conclusion:

Findings suggest that traumas over both one’s lifetime and during deployment are associated with a higher prevalence for insomnia among Army soldiers. Results highlight the importance of considering both lifetime and deployment traumas into mental health assessment and treatment for active-duty soldiers.

Keywords: Traumatic stress, Sleep disturbance, Soldiers

1. Introduction

Traumatic stress has been increasingly recognized as an important antecedent to clinically significant insomnia and may interfere with the normal sleep-wake regulatory processes by sensitizing the central nervous system’s arousal centers, resulting in physiological hyperarousal (Sinha, 2016). Further, studies conducted among military populations have shown that exposure to traumas (i.e., prior to and after service connection) such as sexual and physical abuse/assaults are associated with increased vulnerability to combat-related posttraumatic stress disorder (PTSD) severity and increased risk for psychiatric disorders (Clancy et al., 2006; Millegan et al., 2016; Mondragon et al., 2015; Murdoch et al., 2007). Recent data suggest that the cumulative burden of multiple traumas, as well as the diversity of traumatic events, also predicts PTSD. For example, Brownlow et al. (2018) found that number of types of traumatic stress (i.e., diversity) and well as the number of traumatic events (i.e., cumulative) significantly predicted the likelihood of developing PTSD in young adult military soldiers. Studies have found high prevalence of multiple traumas prior to (60%) and during (6.3%–75.9%) deployment, as well as in newly enlisted military soldiers (5.8%–34.2%) (Bolton et al., 2001; Brownlow et al., 2018; Seedat et al., 2003). Similar to the high prevalence of multiple traumas in military populations, high prevalence of traumatic stress has also been reported in young adults within the community. For instance, Hall Brown et al. (2015) found that 97% of young adult African Americans endorsed at least one traumatic event during their lifetime, with high prevalence of multiple traumas [i.e., sexual (40.9%), physical assault (71.8%), accident (82.8%), natural disaster (50.5%)].

The prevalence of insomnia and/or sleep disturbances is common in military populations ranging from 22%–74% (Hoge et al., 2008; Klingaman et al., 2018; Mysliwiec et al., 2013). Difficulty initiating and maintaining sleep are common features following exposure to traumatic events and PTSD (Babson and Feldner, 2010; Caldwell and Redeker, 2005; Lavie, 2001; Ohayon and Shapiro, 2000). However, limited data exist regarding the relationship between different types of traumatic stress and disturbed sleep. Only a few studies have examined aspects of traumatic events and their effect(s) on sleep (Hefez et al., 1987; Kaminer and Lavie, 1991; Rosen et al., 1991). Specifically, Hefez et al. (1987) found that situational stressors (e.g., “combat neurosis”, “sea disaster”) were associated with decreased sleep efficiency indices, shorter REM sleep time, and increased REM sleep latencies compared to healthy controls. More recently, in both military (Conway et al., 2020) and civilian (Brindle et al., 2018) populations, data have emerged regarding adversities during childhood and their relation to sleep disturbance. Specifically, Conway et al. (2020) found that sleep disturbances mediated the relationship between adverse childhood experiences and mental/functional impairments. Similarly, Brindle et al. (2018) found that childhood traumas were significantly associated with poor sleep health. Although these studies provide evidence regarding trauma history and sleep disturbance, few studies have considered how different aspects of traumatic stress impacts disturbed sleep.

Multiple features of traumatic stress (e.g., prior trauma exposure, type of trauma, frequency of traumatic events, mental health) are thought to significantly influence the intensity and characteristics of disturbed sleep following a traumatic event (Caldwell and Redeker, 2005). To date, one study has examined the direct effect of multiple traumatic events on disturbed sleep. Controlling for sex, Hall Brown et al. (2015) found that sexual traumas, physical assaults, and exposure to sudden violent deaths were stronger predictors of moderate to severe insomnia compared to other types of traumas.

Military personnel, particularly those engaged in combat, are at increased risk for trauma exposure, PTSD, and sleep problems (Gehrman et al., 2013; Wright et al., 2011). Further, lifetime traumatic stress encountered outside of the military compared to deployment-related traumatic stress may differentially affect the development of sleep problems. Deployment itself presents significant challenges that interfere with healthy sleep. Deployment-related traumatic stress and the threat of injury to self and others may directly contribute to sustained increases in vigilance and arousal during wakefulness and sleep (Bramoweth and Germain, 2013). Given the dire consequences of disturbed sleep in military personnel (e.g., poor work performance and physical and mental health (Klingaman et al., 2018)), an understanding of lifetime traumatic stress versus deployment-related traumatic stress and their relation to sleep problems is relevant to the overall health and functioning of this population.

The goal of the present study was to determine which specific types of traumas (i.e., lifetime traumatic stress encountered outside of the military versus deployment-related traumatic stress) were most strongly associated with insomnia in active-duty Army soldiers. Given the exploratory nature of the study, no specific hypotheses regarding how different trauma types would affect sleep disturbance were made.

2. Methods

2.1. Participants

The data source for the present study was the All Army Study (AAS), a sub-study of the Army Study to Assess Risk and Resilience in Servicemembers (STARRS). The AAS is a cross-sectional self-administered questionnaire administered between 2011 and 2013. For the current study, participants were a representative sample (unweighted N = 21,499; weighted N = 670,335) of U.S. Army soldiers recruited in quarterly samples from active-duty Army personnel. Each quarterly AAS replicate consisted of a stratified (by Army Command and location) probability sample of Army units (or, for large units, subunits), selected without replacement with sample sizes proportional to unit strength (Ursano et al., 2014; Ursano et al., 2015).

All study procedures were approved by the Human Subjects Committees of the Uniformed Services University of the Health Sciences for the Henry M. Jackson Foundation (the primary grantee), the Institute for Social Research at the University of Michigan (the organization collecting the data), and all other collaborating organizations. Data analysis was determined by the local institution to be exempt from review (see Heeringa et al., 2013; Kessler et al., 2013 for complete description on the methodology of data collection). All participants provided written informed consent.

2.2. Measures

2.2.1. Insomnia status

Insomnia status was measured with the Brief Insomnia Questionnaire (BIQ (Kessler et al., 2010; Roth et al., 2011) which assesses frequency (number of nights per week) of insomnia symptoms in the past 30 days (i.e., taking more than 30 min to fall asleep, waking three or more times during a single night, waking at night and taking more than 30 min to get back to sleep, waking more than 30 min too early in the morning, and feeling tired or unrested in the morning even after a full night of sleep). The measure also assesses the degree to which daytime functioning was impacted in the past 30 days by these sleep problems in the areas of daytime fatigue, somatic problems, moodiness, reduced performance at work/school, and accident-proneness on a five-point Likert scale (1 = extremely, 2 = a lot, 3 = some, 4 = a little, 5 = not at all). Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria were used in conjunction with this measure to determine probable current insomnia (past 30 days) disorder (American Psychiatric Association, 2013). To be categorized as having current insomnia, soldiers had to meet the following criteria: 1) insomnia symptoms 3 or more nights per week; 2) sleep problems that interfered with overall functioning at least “a lot”; and 3) sleep problems that occurred at least 3 months out of the past year. The BIQ is a standardized measure and psychometric properties have been reported (see Kessler et al., 2010).

2.2.2. Lifetime and deployment-related traumatic events

Data used to obtain lifetime and deployment-related traumatic events were derived from the Office of the Surgeon General United States Army Medical Command, Office of the Command Surgeon HQ USCETCOM, and the Office of Command Surgeon US forces Afghanistan (2011), and the deployment risk and resilience inventory (King et al., 2006; Vogt et al., 2008).

2.2.3. Lifetime traumatic events

Lifetime traumatic stress was assessed using a 15-item lifetime stress survey that evaluated the different types of lifetime traumatic stress that were encountered outside of the military, such as “You had a life-threatening illness or injury,” “serious physical assault (e.g., mugging)” or “sexual assault or rape.” The number of times a respondent experienced each lifetime stress item was rated on a Likert scale (0 = 0, 1 = 1, 2 = 2–4, 3 = 5–9, or 4 = 10 or more). A cumulative lifetime traumatic stress total score was also generated by summing each item. Scores ranged from 0 to 60, with higher scores indicating a greater range of lifetime traumatic stress exposures. Cronbach’s alpha for the lifetime traumatic stress survey in the current sample was 0.80.

2.2.4. Deployment-related traumatic events

Deployment-related traumatic stress was assessed using a 15-item deployment-related stress survey which evaluated various types of deployment-related traumatic stress, such as “Get wounded by the enemy”, “Fire rounds at the enemy or take enemy fire (either direct or indirect fire)”, or “Have member(s) of your unit who were seriously wounded or killed.” The number of times a respondent experienced each deployment-related stress item was rated on a Likert scale (0 = 0, 1 = 1, 2 = 2–4, 3 = 5–9, 4 = 10 or more). A cumulative deployment-related traumatic stress total score was created by summing each item. Scores ranged from 0 to 60, with higher scores indicating greater diversity of deployment-related traumatic stress. Cronbach’s alpha for the deployment-related traumatic stress survey in the current sample was 0.88.

2.2.5. Mental health comorbidities

Soldiers were asked about several domains of mental health functioning based on items adapted from the Composite International Diagnostic Interview Screening Scales (CIDI-SC (Kessler and Ustiin, 2004)) and a 6-item screening version of the PTSD Checklist (PCL (Weathers et al., 1993)). The CIDI-SC/PCL current diagnoses included in the present study were major depressive disorder (MDD), generalized anxiety disorder (GAD), and PTSD.

2.3. Data analysis

IBM SPSS version 24 was used for data analysis. A weighted system derived from the administrative data (Ursano et al., 2015) was used for statistical analyses; all analyses were based on the weighted sample. Prior to any inferential statistics, the dependent variable was assessed to determine deviations from the required assumptions (e.g., normality). Descriptive statistics were conducted to determine the prevalence of insomnia, traumatic stress, and deployment-related traumatic stress. Pearson’s Chi-square test and Student’s t-test were used to assess for group differences (insomnia vs no insomnia) on demographics, and lifetime and deployment-related traumatic stress, while the phi coefficient was used to quantify the strength of the relationship between variables.

Four separate multivariate modified Poisson Regression models were employed: two models were generated to examine prevalence of insomnia status on lifetime traumatic stress total score and the deployment-related traumatic stress total score and two similar models were generated that adjusted for potential confounds [sex, major depressive episode (MDE), PTSD, generalized anxiety disorder (GAD)]. Coefficients and standard errors were used to create prevalence ratios (PRs) with 95% confidence intervals. Multivariate significance was assessed using a Wald Chi-squared test. P values < .05 (two-tailed) were considered statistically significant.

3. Results

The prevalence of insomnia for this sample was 22%. Participants were military soldiers between the ages of 18 and 61 years (M = 29.49, SD = 7.9, 13.5% female). Approximately, 66.3% were White, 84.5% were non-Hispanic, 14.5% had a four-year degree, and 57.1% were married. There were significant differences on demographic, deployment status, and psychiatric variables between those soldiers with insomnia versus those soldiers without insomnia (see Table 1).

Table 1.

Sample demographics by insomnia status.

Total sample No insomnia Insomnia X2 or t-test p-Value Phi or [CI]
N M (SD) or % n % n %
Age (M, SD) 670,335 29.49 (7.9) 29.57 8.04 29.18 7.35 16.79 <.001 [0.35, 0.44]
Sex 670,447 1.13 (0.3) 1918.96 <.001 0.053
 Female 90,424 13.5 65,502 72.44 24,922 27.56
 Male 580,023 86.5 457,764 78.92 122,259 21.09
Education 2.29 (1.3) 10,403.79 <.001 0.125
 GED/H.S.b 203,323 34.5 172,125 74.73 58,198 25.27
 Post H.S., technical study or certificate 217,421 32.5 163,327 75.12 54,094 24.88
 Associate degree 71,259 10.7 55,526 77.92 15,733 22.08
 Four-year degree 97,085 14.5 84,060 86.58 13,026 13.42
 Graduate/professional 52,287 7.8 46,575 89.08 5712 10.92
Race 2.14 (1.8) 1560.13 <.001 0.049
 White 438,196 66.3 345,673 78.89 92,524 21.11
 Black 107,634 16.3 82,414 76.57 25,220 23.43
 American Indian/Alaskan Native 8399 1.3 6008 71.53 2391 28.47
 Asian 23,483 3.6 19,511 83.09 3972 16.91
 Pacific Islander 6505 1.0 4837 74.36 1668 25.64
 Multicultural 27,040 4.1 19,737 72.99 7303 27.01
 Other 49,618 7.5 37,311 75.20 12,307 24.80
Ethnicity 1.15 (0.3) 10.09 .002 0.004
 Non-Hispanic 559,953 84.5 437,530 78.14 122,423 21.86
 Hispanic 102,337 15.5 79,505 77.69 22,831 22.31
Marital status 1.61 (0.8) 5224.25 <.001 0.095
 Married 333,086 57.1 263,621 79.15 69,465 20.85
 Never Married 174,913 30.0 148,008 84.62 26,906 15.38
 Divorced 48,052 8.2 36,298 75.54 11,753 24.46
 Separated 26,626 4.6 18,328 68.83 8299 31.17
 Widowed 788 0.1 538 68.27 250 31.73
Deployment status
 Total months deployed-humanitarian 501,954 0.23 (0.8) 385,724 76.84 116,230 23.16 5.63 <.001 [0.01, 0.02]
 Total months deployed-combat zone 505,405 3.85(2.2) 387,866 76.74 117,539 23.26 −32.09 <.001 [−0.25, −0.22]
 Total months deployed-peacekeeping 514,550 3.79 (2.3) 395,495 76.86 119,055 23.14 −26.64 <.001 [−0.22, −0.19]
 Total times deployed humanitarian 581,853 0.16 (0.6) 456,027 78.37 125,826 21.63 −5.93 <.001 [−0.14, −0.01]
 Total times deployed-combat zone 580,725 1.48 (1.4) 455,067 78.36 125,658 21.64 −40.38 .000 [−0.19, −0.17]
 Total times deployed-peacekeeping 588,471 1.44 (1.4) 460,715 78.29 127,755 21.71 −37.40 <.001 [−0.17, −0.15]
Psychiatric disorders
 Major Depressive Episode 43,600 6.5 6557 15.04 37,043 84.96 107,916.08 <.001 0.400 a
 Posttraumatic Stress Disorder 44,398 6.6 13,471 30.34 30,927 69.66 63,066.76 <.001 0.306 a
 Generalized Anxiety Disorder 36,904 5.5 6434 17.43 30,470 82.57 83,640.57 <.001 0.352 a
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Bold text indicates both a statistically significant difference between groups after Bonferroni collection and an effect size of at least a medium magnitude.

a

Effect size (Phi): 0.10 = small effect; 0.30 = medium effect; 0.50 = large effect.

b

GED = general education development test recognized as earning high school equivalency credential.

There were significant insomnia diagnostic status group differences on lifetime traumatic stress items. The largest differences were on the items: a combat death of a close friend or relative (t = −123.45, p < .001), you had any other experience that put you at risk of death or serious injury (t = −114.07, p < .001), you witnessed someone being seriously injured or killed (t = −108.49, p < .001), and you were bullied (on going comments or behaviors) during your childhood or adolescence (t = −105.27, p < .001). There were also group differences for deployment-related traumatic stress; specifically, the largest differences were on: you were hazed or bullied by one or more members of your unit (t = −34.25, p < .001), witnessed violence within the local population or mistreatment toward non-combatants (t = —28.22, p < .001), have close call (that is, equipment shot off body, IED exploded near you (t = −23.66, p < .001), and save the life of a soldier or civilian (t = −21.22, p < .001).

Lifetime traumatic stress items encountered outside of the military versus deployment-related were further analyzed controlling for sex and frequently comorbid psychiatric disorders (i.e., MDE, PTSD, GAD; see Table 2). Adjusting for covariates, increased lifetime traumatic stress items were associated with an increased prevalence for insomnia. Specifically, the prevalence of having insomnia was the highest for: combat death of a close friend or relative, showing that there was a 2.1% increase in the prevalence of insomnia for those who endorsed combat death of a close friend of relative, 1.021 (95% CI, 1.02–1.02); experiences that put them at risk of death or serious injury, indicating a 1.3% increase in the prevalence of insomnia for those who endorsed experiences that put them at risk of death or serious injury, 1.013 (95% CI, 1.01–1.01); and life-threatening illness or injury, suggesting a 1.8% increase in the prevalence of insomnia for those who endorsed life-threatening illness or injury, 1.018 (95% CI, 1.02–1.02).

Table 2.

Unadjusted and adjusted prevalence ratios for lifetime traumatic stress on insomnia.

Unadjusted Adjusted
PR 95% CI X2 P PR 95% CI X2 P
Sexual assault or rape 1.041 1.04–1.04a 1450.68 <.001 1.002 1.00–1.00a 2.65 .104
You had a life-threatening illness or injury 1.047 1.04–1.05 1301.87 <.001 1.018 1.02–1.02a 255.48 <.001
Combat death of a close friend or relative 1.043 1.04–1.05 5719.14 <.001 1.021 1.02–1.02 1560.13 <.001
You were bullied (ongoing comments or behaviors) during your childhood or adolescence 1.025 1.02–1.03 4450.63 <.001 1.005 1.01–1.01a 232.04 <.001
You had any other experience that put you at risk of death or serious injury 1.022 1.02–1.02a 2352.41 <.001 1.013 1.01–1.01 973.45 <.001
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a

Due to rounding.

Increased deployment-related traumatic stress items were also associated with an increased prevalence of insomnia after adjusting for covariates (see Table 3). The prevalence of having insomnia was the highest for the following items: being hazed or bullied by one or more members of their unit, showing that there was a 4.2% increase in the prevalence of insomnia for those who endorsed being hazed or bullied by one or more members of their unit, 1.042 (95% CI, 1.04–1.05); being sexually assaulted or raped, indicating a 5.9% increase in the prevalence of insomnia for those who endorsed being assaulted or raped, 1.059 (95% CI, 1.04–1.08); having a close call (with equipment shot off body, near IED explosion), suggesting a 0.5% increase in the prevalence of insomnia for those who endorsed having a close call, 1.005 (95% CI, 1.00–1.01).

Table 3.

Unadjusted and adjusted prevalence ratios for deployment-related traumatic stress on insomnia.

Unadjusted Adjusted
PR 95% CI X2 P PR 95% CI X2 P
You were hazed or bullied by one or more members of your unit 1.071 1.07–1.08 710.98 <.001 1.042 1.04–1.05 258.90 <.001
You were sexually assaulted or raped 0.971 0.95–0.1.00 5.77 .016 1.059 1.04–1.08 32.00 <.001
Have a close call (that is, equipment shot off body, IED exploded near you) 1.015 1.01–1.02 183.17 <.001 1.005 1.00–1.01 28.72 <.001
Have direct responsibility for the death of U.S. or ally personnel 1.043 1.03–1.06 26.13 <.001 0.995 0.98–1.01 0.59 .443
Save the life of a Soldier or civilian 1.017 1.01–1.02 103.44 <.001 1.001 1.00–1.01 0.78 .376
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4. Discussion

The present study explored the relationships between specific traumatic events (i.e., lifetime traumatic stress encountered outside of the military and deployment-related traumatic stress) and insomnia. We found that lifetime and deployment-related traumatic stress both increased the prevalence of having insomnia even when adjusting for sex and psychiatric disorders. This study adds to a growing body of literature on traumatic stress and sleep disturbance which has suggested that traumatic situational events led to lower sleep efficiency (Kaminer and Lavie, 1991; Rosen et al., 1991), shorter rapid-eye movement sleep time, and longer REM sleep latencies (Hefez et al., 1987), and more disturbed sleep due to bad dreams (Rosen et al., 1991) in patients who survived traumatic events compared to controls. Specifically, since the impact of trauma exposure on sleep is dependent on the nature of the trauma, this work highlights the importance of differentiating among specific traumas encountered outside of the military versus deployment-related traumas. Lifetime traumatic stress as a result of combat death of a close friend or relative, experiences that put them at risk of death or serious injury, and life-threatening illness or injury were significant predictors of insomnia. These findings support previous literature particularly in regard to the association with risk of death or serious injury and life-threatening injury. Recent work by Devine et al. (2020) found that soldiers with sleep-related e-Profiles (i.e., a temporary or permanent medical condition that may render the soldier medically not ready to deploy) were more likely to experience motor vehicle accidents and work/duty-related injuries as soldiers. While causation cannot be determined, impaired sleep could contribute to an increased risk of experiencing injuries, including those accrued outside of the military setting, stressing the importance of sleep for duty readiness and reducing potential trauma-related symptoms.

Deployment-related traumatic stress as a result of being sexually assaulted or raped, having a close call (equipment shot off body, near IED explosion), and being hazed or bullied by one or more members of their unit were significant predictors of insomnia. Our findings support previous literature particularly in regard to sexual assault or rape and prominent sleep disturbances in civilian (Hall Brown et al., 2015; Krakow et al., 2001) and military (Jenkins et al., 2015) populations. In civilians, Krakow et al. (2001) found that poor sleep quality was associated with posttraumatic stress scores in sexual assault survivors, and this relationship increased the potential for other sleep disorders such as sleep breathing and movement disorders. In a military sample, 60.8% of veterans with military sexual traumas reported clinically significant insomnia symptoms (Jenkins et al., 2015). Regarding having a close call (equipment shot off body, near IED explosion), there are data to suggest that blast injuries result in mTBI, and about 97% of military personnel with chronic mTBI report sleep complaints to include hypersomnia (85%), insomnia (55%), sleep fragmentation (54%), and obstructive sleep apnea syndrome (35%.) (Bramoweth and Germain, 2013). Further, there is preliminary evidence to suggest that blast versus blunted related TBI may be accompanied by distinct sleep disturbance profiles (Bramoweth and Germain, 2013).

The present study also reported an interesting finding associated with both lifetime traumatic stress and deployment-related traumatic stress. Specifically, the results indicated that being bullied during childhood or adolescence and being hazed or bullied by one or more members of a unit significantly increased the prevalence for insomnia. There are some growing data to support these findings, suggesting that bullying has a significant impact on sleep disturbance, albeit in adolescents (Zhou et al., 2015; Donoghue and Meltzer, 2018) and particularly bullying in the workplace (Niedhanimer et al., 2009). For instance, Donoghue and Meltzer (2018) found that both “victims” and “bully victims” reported increased bedtime fears, insomnia, and parasomnias compared to bullies and non-bullies. This finding also aligns with data from military samples, in that soldiers with insomnia perceived less support from other unit members and leaders compared to their counterparts without insomnia (Klingaman et al., 2018). Given that military hazing also has been indicated as a risk factor for suicidal ideation among soldiers (Kim et al., 2019), increased unit morale can serve an important buffer against these poor mental health outcomes.

Overall, our findings suggest that lifetime and deployment-related traumatic stress increased the prevalence for the development of insomnia disorder.

4.1. Limitations

This study had several important strengths, including a large, representative sample and the ability to control for psychiatric disorders that are frequently implicated in military personnel. However, the conclusions drawn from this study, and the generalizability of our findings are tempered by some limitations. First, the cross-sectional nature of this study limited the ability to make causal inferences among traumatic stress items and insomnia. Future studies should include longitudinal designs in order to elucidate the nature and significance of the relationship between insomnia and traumatic stress in this population. Related, the measures of traumatic stress were administered at the same time point, and the timing of the experiences of the events (outside of the military versus during deployment) could not be verified. Therefore, it may be important for future work to inquire about additional trauma-related details, such as the age of when the experiences occurred. Third, insomnia status was based on self-report questionnaires, and while the determination of insomnia was based on an approximation of DSM criteria, this is not an ideal substitute for a clinician-determined diagnosis. Fourth, although our study did take into account psychiatric disorders given this population, they were also based on self-report scales rather than clinical interview. Finally, it would be beneficial to evaluate other sleep disturbances that are commonly implicated in this population (i.e., nightmares, obstructive sleep apnea, short sleep duration) to further elucidate the relationship between trauma and disturbed sleep.

5. Conclusion

The present study extends previous literature by demonstrating that specific types of traumas encountered outside of the military and during deployment are associated with insomnia in currently serving U.S. Army personnel. It is well established that psychiatric disorders and insomnia are mutually exacerbating, and insomnia significantly detracts from Soldiers’ military readiness (Brownlow et al., 2017; Klingaman et al., 2018). Because multiple dimensions of trauma even prior to deployment increase the risk for insomnia in military personnel, these must be integrated into mental health assessment and treatment for currently serving soldiers.

Acknowledgements

JAB’s time was supported by a center grant from the National Institute of General Medical Sciences (Grant # 5P20GM103653). KEM’s time was supported by Career Development Award Number IK2 CX001874 from the United States Department of Veterans Affairs Clinical Sciences R&D (CSRD) Service. The views expressed here are the authors’ and do not necessarily represent the views of the Department of Veterans Affairs or the United States government.

Abbreviations

AAS

All Army Study

BIQ

Brief Insomnia Questionnaire

DSM

Diagnostic Statistical Manual

GAD

Generalized Anxiety Disorder

IBM

International Business Machines

IED

Improvised Explosive Device

mTBI

mild Traumatic Brain Injury

MDE

Major Depressive Episode

PR

Prevalence Ratio

PSQI

Pittsburgh Sleep Quality Index

PTSD

Posttraumatic Stress Disorder

REM

Rapid Eye Movement

SPSS

Statistical Manual for the Social Sciences

STARRS

Study to Assess Risk and Resilience in Servicemembers

US

United States

Footnotes

CRediT authorship contribution statement

The following authors contributed to the study design and data analyses: Janeese A. Brownlow, PhD and Philip R. Gehrman, PhD, CBSM. All authors (Janeese A. Brownlow, PhD, Elizabeth A. Klingaman, PhD, Katherine E. Miller, PhD, and Philip R. Gehrman, PhD, CBSM) contributed to manuscript preparation and review, and all authors approved the submitted manuscript.

Declaration of competing interest

All authors declare that they have no conflicts of interest to disclose.

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