Daily Variation in Posttraumatic Stress Disorder Symptom Clusters in Individuals with and without Posttraumatic Stress Disorder

doi:10.21203/rs.3.rs-5248602/v1

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Daily Variation in Posttraumatic Stress Disorder Symptom Clusters in Individuals with and without Posttraumatic Stress Disorder

https://doi.org/10.21203/rs.3.rs-5248602/v1

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Background: Posttraumatic stress disorder (PTSD) has four symptom clusters: intrusion, avoidance, negative cognitions/mood, and hyperarousal. Little is known about day-to-day variation in the four PTSD symptom clusters. This study examined the day of the week and weekday versus weekend variation in PTSD symptom clusters in individuals with and without PTSD.

Methods: Using an ecological momentary assessment methodology, participants (N = 159; 80 with PTSD, 79 without PTSD) completed self-report assessments of posttraumatic stress symptoms (PTSS) four times daily for 15 days. Linear mixed models were used to examine the associations between the seven days of the week and weekday versus weekend variation in PTSD symptom clusters and PTSD.

Results: All four symptom clusters varied across the seven days of the week among participants with PTSD (intrusion: p = .038, avoidance: p < .001, negative cognitions/mood: p = .007, hyperarousal: p < .001), but not among those without PTSD. Among those with PTSD, thefour symptom clusters were higher on weekdays than weekends (intrusion: p = .008, avoidance: p = .002, negative cognitions/mood: p < .001, and hyperarousal: p < .001). However, among those without PTSD, weekdays were higher than weekends only for the intrusion (p = .042) and hyperarousal (p = .017) clusters. Differences in when symptom clusters peaked were also noted.

Conclusions: Among individuals with PTSD, the four symptom clusters vary by the day of the week with more symptoms on weekdays compared to weekends. Identification of the factors associated with day-to-day variation in PTSD symptom clusters may be important for understanding the neurobiology of PTSD and for diagnosis, assessment, interventions, and treatments of those with PTSD.

Trial registration: Clinical trial number: not applicable.

posttraumatic stress disorder

symptom clusters

ecological momentary assessment

military personnel

Posttraumatic stress disorder (PTSD) is associated with multiple negative outcomes including detrimental effects on mental and physical health and quality of life [1, 2]. In the general U.S. population, PTSD has an estimated lifetime prevalence of 6.4–6.8% [3, 4] and a 12-month prevalence of 3.5% [5]. Among combat veterans, the prevalence is higher with the most commonly cited estimate of current PTSD being 15% [6, 7]. The Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) identifies 20 posttraumatic stress symptoms (PTSS), which are grouped into four symptom clusters: intrusion, avoidance, negative cognitions/mood, and hyperarousal [8].

PTSS are not static. PTSS fluctuate across time [9] and have been specifically shown to vary across the days of the week and differ between weekdays and weekends [10]. However, it is not known to what extent the four DSM-5 PTSD symptom clusters vary from day-to-day. The presence of daily variation in the PTSD symptom clusters may have broad implication for understanding the neurobiology of PTSD and for the diagnosis, assessment, intervention, and treatment of those with PTSD [11].

Prior studies suggest that the symptom clusters may differ in their contribution to the development and maintenance of PTSD [12]. For example, hyperarousal has been shown to predict PTSD severity and changes in other symptom clusters [13–15]. However, most prior studies examining PTSS have used retrospective assessments, which ask respondents to recall symptoms over the past month. Retrospective assessments are subject to recall bias and do not capture potential moment-to-moment symptom variation nor the temporal relationships between symptoms that may be important for understanding PTSD [16, 17]. In contrast, ecological momentary assessment (EMA) approaches, which involve repeated real-time sampling of respondent experiences in their natural environment, minimize recall bias, maximize ecological validity, and allow for the examination of contextual influences on behavior and temporal relationships of interest [18–20].

The purpose of the present study is to determine whether PTSD symptom clusters (intrusion, avoidance, negative cognitions/mood, hyperarousal) vary by the day of the week, and whether there is a relationship between symptom clusters and the day of the week. We used an EMA methodology to determine the day-to-day and weekday versus weekend difference in PTSD symptom clusters in U.S. military Service Members with and without PTSD during their typical daily routines. PTSS were assessed four times a day for 15 consecutive days, which allowed us to examine the temporal patterns of PTSD symptom clusters and the extent to which symptom clusters differ between weekdays, when most individuals are in their work environments and work demands are present, and weekends, when the demands of the work week are usually lessened. We hypothesized that because daily work demands would be higher and being in a military work environment may increase exposure to trauma reminders that may trigger symptoms, PTSD symptom cluster scores would be higher on weekdays versus weekends in those with PTSD but not among those without PTSD. We elected to include those without PTSD as their symptom scores may reflect the daily variation in stress symptoms associated with normal life stressors. To our knowledge, this is the first study to examine the day of the week variation in PTSD symptom clusters.

Participants

A total of N = 309 current and former U.S. Service members were screened for eligibility to enroll; n = 219 screened in. Of those, n = 183 enrolled, n = 8 declined enrollment, and n = 28 did not return for the enrollment appointment. Of the N = 183 who enrolled, n = 159 were included in data analyses, n = 14 did not return the daily assessments, n = 8 did not provide three or more daily assessments, n = 1 did not complete the assessment of PTSD in the baseline questionnaire, and n = 1 was removed as an outlier. This study was part of a larger data collection project examining posttraumatic stress in U.S. Service members. Methods common to the larger project (e.g., recruitment and screening) have been reported in prior publications [10, 21, 22]. The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Boards of Walter Reed National Military Medical Center and the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Written informed consent was obtained after the procedures were explained. Participation was voluntary.

Procedure and measures

Recruitment and enrollment screening

Recruitment was conducted at a military treatment facility. Service members self-referred from advertisements or approach to a recruiting table and completed a 26-item screening questionnaire [10].

Demographics

After enrollment, participants completed a baseline assessment, which included demographic characteristics: gender, age, race (White versus Non-White), and education level (some college or lower versus bachelor’s or higher).

Assessment of PTSD

At baseline, participants completed an assessment of exposure to traumatic events and the 20-item Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) [23]. A probable PTSD diagnosis required one or more cluster A traumatic exposures (all participants had at least one qualifying exposure), one or more items from clusters B and C, two or more items from clusters D and E, and a symptom severity score of 38 or higher [23]. For details of the traumatic exposure measures and criteria for PTSD, see prior publication [21]. Of the N = 159 participants, n = 80 met criteria for probable PTSD (hereafter referred to as those with PTSD) and n = 79 did not meet criteria for PTSD. The PCL-5 is a psychometrically sound instrument with good internal consistency (α = .96), test–retest reliability (r = .84), and convergent and discriminant validity [24].

Daily assessments

In the 15 days that followed, participants completed four assessments per day using an EMA methodology [10]. Of the 9,540 assessments possible during the acquisition period, N = 7,761 assessments were collected, and of those N = 7,591 assessments were included in the data analyses (n = 170 [2.2%] were dropped because they were completed too early [n = 41], too late [n = 47], were missing the completion date or time [n = 81], or due to an error in electronic data [n = 1]; the overall assessment adherence rate was 79.6%). Of the N = 7,591 assessments included in the analyses, n = 5,776 (76.1%) were completed within 0–2 hours, n = 1,313 (17.3%) within 2–4 hours, and n = 502 (6.6%) within 4–6 hours of the 6-hour assessment completion window. Participants were not compensated for completing assessments.

PTSS

Daily PTSS were assessed using 18 non-sleep PCL-5 items [23], which were included on all four of the daily assessments. The PCL-5’s two sleep-related items, Repeated, disturbing dreams of the stressful experience and Trouble falling or staying asleep, were not appropriate for use on all four daily assessments. The response format of the PCL-5 items was modified to an 11-point scale, 0 (Not at all) to 10 (Extremely), with a 0-180 symptom severity score range. The change from a 5-point scale to an 11-point scale was recommended to produce data with more variance [25]. Instructions were also modified to be relevant to the timing of the assessments; instructions in the first daily assessment contained the timing phrase “…since you awakened” and instructions in the second, third, and fourth daily assessment contained the phrase “…in the last couple of hours.” Item means were calculated for each of the four PTSD symptom clusters with a range of 0–10 (see Figure S1).

Day of week and weekday/weekend variables

To test if the outcome differed by day of the week, a 7-day and a dichotomous weekday (Monday through Friday) / weekend (Saturday and Sunday) variable were created. A general variable for time was not included in the analyses because we did not find a developmental trend by time in the PTSD symptoms clusters.

Data analyses

Linear mixed models were used to examine the day of week variation in the four PTSD symptom clusters (intrusion, avoidance, negative cognitions/mood, hyperarousal), with daily assessments (level-1) nested within subjects (level-2). To account for unequal time intervals, a spatial power covariance structure was specified. For all four clusters, the first-order autoregression assumption, AR(1), was used as it improved model fit compared to compound symmetry. Both the seven days of the week and between weekdays and weekends were examined.

As we were particularly interested in examining the day of week variation among participants with and without PTSD, stratified analyses were conducted by PTSD group. Gender, age, race, and education were included as covariates. The Tukey-Kramer method was used to adjust for multiple pairwise comparisons. All analyses were conducted in PC SAS version 9.3 (SAS Institute, Cary, North Carolina).

Sample characteristics

Sample characteristics and descriptive statistics are shown in Table 1. Mean age of participants in the analytic sample (n = 159) was 41.5 (range 19–69). The majority (59.8%, n = 95) were male, White (64.8%, n = 103), and 55.3% (n = 35) had a bachelors or graduate degree or higher. The majority (65.4%, n = 104) were married with 76.6% (n = 82) currently living with their spouse. In total, 80 (50.3%) had PTSD and 79 (49.7%) did not have PTSD. There was no difference between those with and without PTSD in demographic characteristics.

Table 1

Demographic Characteristics and Descriptive Statistics of Participants with and without PTSD
	Total (N = 159)	PTSD (N = 80)	Without PTSD (N = 79)
Categorical	n (%)	n (%)	n (%)
Gender
Male	95 (59.8)	44 (55.0)	51 (64.6)
Female	64 (40.3)	36 (45.0)	28 (35.4)
Race
White	103 (64.8)	52 (65.0)	51 (64.6)
Non-white	56 (35.2)	28 (35.0)	28 (35.4)
Education
High school or G.E.D.	7 (4.4)	5 (6.3)	2 (2.5)
Some college/technical school	64 (40.3)	34 (42.5)	30 (38.0)
Bachelor’s degree	29 (18.2)	16 (20.0)	13 (16.5)
Graduate degree	59 (37.1)	25 (31.3)	34 (43.0)
Marital Status
Currently married	104 (65.4)	51 (63.8)	53 (67.1)
Not currently married	55 (34.6)	29 (36.3)	26 (32.9)
Living with spouse (among married)
Yes	82 (76.6)	38 (71.7)	44 (81.5)
No	25 (23.4)	15 (28.3)	10 (18.5)
Continuous	M (SD)	M (SD)	M (SD)
Age	41.5 (13.7)	38.8 (11.8)	44.2 (15.0)
Intrusion (range 0–40)	8.5 (8.5)	13.1 (8.3)	3.9 (5.8)
Avoidance (range 0–20)	5.9 (5.1)	8.7 (4.7)	3.1 (3.9)
Negative cogn./mood (range 0–70)	18.7 (16.2)	28.6 (15.2)	8.7 (9.8)
Hyperarousal (range 0–50)	11.8 (9.6)	17.3 (1.4)	6.2 (6.2)
Note. PTSD = posttraumatic stress disorder. There was no difference between those with PTSD and without PTSD in demographic characteristics.

Autocorrelation and intraclass correlations

The autocorrelation, the correlation between two successive assessments collected 4 hours apart, ranged from .29 to .43 among participants with PTSD, and from .40 to .48 among those without PTSD. The ICC (the proportion of variance associated with between-person differences) among participants with and without PTSD consisted of 67.1% and 55.2% of the total variance in intrusion, 59.4% and 68.5% in avoidance, 67.8% and 71.8% in negative cognitions/mood, and 64.0% and 71.5% in the hyperarousal symptom cluster. The remaining proportion of the variances (28.2%-44.8%) were due to the within-person variance in each symptom cluster.

7-day day of week variation

For each cluster, we first examined the 7-day day of week variation among participants with and without PTSD (Fig. 1). All four symptom clusters varied across the seven days among participants with PTSD with a generally declining level from Monday to Saturday/Sunday (intrusion: p = .038, avoidance: p < .001, negative cognitions/mood: p = .007, and hyperarousal: p < .001), but did not vary among those without PTSD (see Table 2 and Supplementary Tables S1-S3). Further pairwise comparisons with Tukey-Kramer method showed similar results after controlling for multiple tests among those with PTSD.

Table 2

Day of Week Differences in the Intrusion Symptom Cluster: Mixed Models
	PTSD (n = 80)		Without PTSD (n = 79)
Parameter	Coefficient [95% CI]	p	Coefficient [95% CI]	p
Fixed effects
Intercept	11.15 [7.70-14.59]	< .001	3.11 [0.53–5.68]	.019
Female vs. male	-0.70 [-4.37-2.97]	.705	0.07 [-2.77-2.92]	.959
Age (centered at 41.5)	0.08 [-0.11-0.27]	.409	0.03 [-0.07-0.14]	.566
Non-white vs. White	0.61 [-3.37-4.58]	.762	2.03 [-0.82-4.89]	.160
Some college or lower vs. bachelor’s or higher ^a	1.32 [-3.27-5.92]	.568	-1.56 [-4.68-1.56]	.324
Day of week ^b
Monday	1.60 [0.47–2.74]	.006	0.35 [-0.25-0.95]	.257
Tuesday	1.80 [0.66–2.94]	.002	0.21 [-0.39-0.81]	.486
Wednesday	1.07 [-0.05-2.20]	.061	0.35 [-0.25-0.95]	.255
Thursday	1.00 [-0.11-2.12]	.078	0.46 [-0.14-1.05]	.131
Friday	0.64 [-0.45-1.74]	.250	0.07 [-0.51-0.65]	.810
Sunday	0.54 [-0.59-1.67]	.349	-0.21 [-0.80-0.39]	.499
Random effects
Between-person variance	31.18	< .001	64.53	.001
Autocorrelation	0.41	< .001	0.40	< .001
Within-person variance	15.31	< .001	52.36	< .001
Intraclass correlation ^c	0.67		0.55
Note. PTSD = posttraumatic stress disorder.
^a Bachelor’s degree or higher was set as the reference. ^b Saturday was set as the reference. The intrusion symptom cluster varied across the seven days among participants with PTSD, F(6, 451) = 2.24, p = .038, but not among those without PTSD, F(6, 459) = 1.13, p = .343. ^c Intraclass Correlation was calculated by the ratio of between-person variance and the total variance.

Weekday versus weekend differences

We then examined weekday versus weekend differences in the four symptom clusters among participants with and without PTSD (Fig. 2). Among participants with PTSD, all four symptom clusters were higher on weekdays than weekends (intrusion: p = .008, avoidance: p = .002, negative cognitions/mood: p < .001, and hyperarousal: p < .001); among those without PTSD, there was a weekday versus weekend difference only on intrusion (p = .042) and hyperarousal (p = .017) symptom clusters.

Using an EMA approach, this study examined the day of the week variation in each of the DSM-5 PTSD symptom clusters (intrusion, avoidance, negative cognitions/mood, and hyperarousal) across 15 days in individuals with and without PTSD. All four symptom clusters varied across the seven days of the week among individuals with PTSD, but not among individuals without PTSD (see Fig. 1). The symptom clusters all showed a similar pattern; symptoms were highest on weekdays and declined to the lowest point on Saturday/Sunday. These results are consistent with our previous findings that showed the same pattern in overall PTSS [10] and suggest there are at least some common drivers for the four symptom clusters since they all changed in a similar way.

We also compared weekdays (Monday through Friday) versus weekends (Saturday and Sunday) to focus on potential differences between traditional work and non-work days. Among those with PTSD, all four PTSD symptom clusters were higher on weekdays than weekends. In this analysis, of interest is that among those without PTSD the intrusion and hyperarousal clusters were higher on weekdays than weekends, but there was no weekday-weekend difference in the avoidance and negative cognitions/mood clusters (see Fig. 2). These differences in the non-PTSD group may reflect that these symptom clusters capture daily stress experiences as well as traumatic stress responses. Whether the daily stress and traumatic stress are the same neurobiological mechanisms or how they are similar and different (e.g., overlapping) would be important to consider. The absence of weekday versus weekend differences in avoidance and negative cognitions/mood may similarly reflect that these clusters are not a significant part of normal daily stressor responses but reflect more pathological/disorder-based symptoms with unique neurobiology associated with PTSD only.

Daily variation in PTSD symptom clusters may be related to a number of factors. Sleep disturbances have been shown to affect PTSS [22, 26, 27]. Sleep duration varies across the days of the week for individuals with and without PTSD, and those with PTSD have more trouble falling asleep and lower sleep quality on weekdays compared to weekends [22]. Having a shorter sleep duration and more trouble falling asleep the previous night predicts higher PTSS the following day among individuals with PTSD [21]. In addition, nightmares predict each of the four PTSD symptom clusters [28] and short sleep duration is associated with a subsequent increase in intrusion symptoms [29, 30]. Lifestyle and psychosocial factors such as exercise [31], leisure activities [32], and social interactions [33] would be expected to differ between weekdays and weekends. There may also be day-to-day differences in factors that trigger PTSD symptoms. In a military population, exposures to uniforms, equipment, weapons, training exercises, injured soldiers, or combat-related stimuli, which may be present in the work day environment but not in the non-work day environment, may trigger PTSD symptoms. Further research is needed with studies that capture daily activities and evaluate their temporal association to variation in PTSD symptom clusters. Identifying precipitating and potentially protective factors may suggest environmental and lifestyle interventions to reduce PTSD symptoms. Future studies may wish to explore traumatic event reminders, interpersonal conflicts, and stressful events in both the work and home environments.

The present study has several limitations. Measures of PTSS, trauma exposure, and PTSD were obtained by self-report. For PTSS, this limitation is partially mitigated by collection of daily symptom assessments at the time of the behavior of interest or within hours afterwards. The measures for trauma exposure and PTSD had the potential for retrospective recall bias and may be less accurate compared to a clinical psychiatric assessment. Although, all our assessments included well-validated self-assessment measures. Subjects were recruited from a military medical center, which may limit the generalizability of our findings. Since we did not track participants’ daily activities, such as work schedules, we do not know to what extent the PTSD symptom clusters vary with daily activities.

This study provides further evidence that PTSD symptom clusters are not static; among individuals with PTSD, all four symptom clusters vary across the seven days of the week and differ between weekdays and weekends. Individuals without PTSD also showed weekday-weekend differences but only in intrusion and hyperarousal suggesting these symptoms are partly related to every day versus traumatic stress. Further study of PTSD symptom cluster variation may lead to a better understanding of how symptoms change over time and the neurobiological, psychological, behavioral, and/or lifestyle factors associated with change. Identifying factors that precede symptom change may aid the development of effective interventions and identify treatments to reduce PTSD.

Among individuals with PTSD, the four symptom clusters vary by the day of the week with more symptoms on weekdays compared to weekends. Identification of the factors associated with day-to-day variation in PTSD symptom clusters may be important for understanding the neurobiology of PTSD and for diagnosis, assessment, interventions, and treatments of those with PTSD.

AR(1)

first-order autoregression assumption

DSM-5

Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition

EMA

ecological momentary assessment

ICC

intraclass correlation coefficient

PCL-5

Posttraumatic Stress Disorder Checklist for DSM-5

PTSD

posttraumatic stress disorder

PTSS

posttraumatic stress symptoms.

Ethics approval and consent to participate

This research was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Walter Reed National Military Medical Center and the Uniformed Services University of the Health Sciences Institutional Review Boards. Participation was voluntary and all participants provided written informed consent. Clinical trial number: not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Funding

This research study is supported by a program grant from the Uniformed Services University of the Health Sciences (USUHS) to the Center for the Study of Traumatic Stress (CSTS) Program (HU00012320029). The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense. The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government. The views expressed in this manuscript are those of the author(s) and do not necessarily reflect the official policy of the Department of Defense or the U.S. Government.

Author Contribution

Q.B. contributed to design and development of the study and project materials, managed subject recruitment and retention, data acquisition and curation, and drafting and revision of the manuscript. R.J.U. conceptualized the study, obtained funding, provided oversight and direction, contributed to data analysis and interpretation, and drafting and revision of the manuscript. J.W. performed data analysis and contributed to drafting and revision of the manuscript. J.A.H. and N.D. contributed to subject recruitment and retention and data acquisition and curation. R.A., a principal investigator, contributed to the oversight of the data collection site, institutional collaboration, and regulatory compliance. C.S.F., a principal investigator, contributed to the design of the study, performed oversight of scientific and budgetary aspects of the study, and manuscript revision. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

Data Availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Daily Variation in Posttraumatic Stress Disorder Symptom Clusters in Individuals with and without Posttraumatic Stress Disorder

Status:

Version 1

Abstract

Figures

Background

Methods

Participants

Procedure and measures

Recruitment and enrollment screening

Demographics

Assessment of PTSD

Daily assessments

PTSS

Day of week and weekday/weekend variables

Data analyses

Results

Sample characteristics

Autocorrelation and intraclass correlations

7-day day of week variation

Weekday versus weekend differences

Discussion

Conclusions

Abbreviations

Declarations

Competing interests

Funding

Author Contribution

Acknowledgements

Data Availability

References

Additional Declarations

Supplementary Files

Status:

Version 1