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Volume 14 No. 11
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Accepted Papers

Scientific Investigations

Increased Sleep Disturbances and Pain in Veterans With Comorbid Traumatic Brain Injury and Posttraumatic Stress Disorder

Nadir M. Balba, MA1,2; Jonathan E. Elliott, PhD1,3; Kris B. Weymann, PhD, RN1,4; Ryan A. Opel, BSc1; Joseph W. Duke, PhD5; Barry S. Oken, MD, PhD2,3; Benjamin J. Morasco, PhD6,7; Mary M. Heinricher, PhD1,2,8; Miranda M. Lim, MD, PhD1,2,3,9,10
1VA Portland Health Care System, Portland, Oregon; 2Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon; 3Department of Neurology, Oregon Health and Science University, Portland, Oregon; 4School of Nursing, Oregon Health and Science University, Portland, Oregon; 5Department of Biological Sciences, Northern Arizona University, Flagstaff, Arizona; 6Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon; 7Department of Psychiatry, Oregon Health and Sciences University, Portland, Oregon; 8Department of Neurological Surgery; Oregon Health and Science University, Portland, Oregon; 9Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon; 10Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, Oregon

Study Objectives:

Veterans are at an increased risk for traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), both of which are associated with sleep disturbances and increased pain. Furthermore, sleep disturbances and pain are reciprocally related such that each can exacerbate the other. Although both TBI and PTSD are independently linked to sleep disturbances and pain, it remains unclear whether Veterans with comorbid TBI+PTSD show worse sleep disturbances and pain compared to those with only TBI or PTSD. We hypothesized that sleep and pain would be worse in Veterans with comorbid TBI+PTSD compared to Veterans with only TBI or PTSD.


Veterans (n = 639) from the VA Portland Health Care System completed overnight polysomnography and self-report questionnaires. Primary outcome variables were self-reported sleep disturbances and current pain intensity. Participants were categorized into four trauma-exposure groups: (1) neither: without TBI or PTSD (n = 383); (2) TBI: only TBI (n = 67); (3) PTSD: only PTSD (n = 126); and (4) TBI+PTSD: TBI and PTSD (n = 63).


The PTSD and TBI+PTSD groups reported worse sleep compared to the TBI and neither groups. The TBI+PTSD group reported the greatest pain intensity compared to the other groups.


These data suggest sleep and pain are worst in Veterans with TBI and PTSD, and that sleep is similarly impaired in Veterans with PTSD despite not having as much pain. Thus, although this is a complex relationship, these data suggest PTSD may be driving sleep disturbances, and the added effect of TBI in the comorbid group may be driving pain in this population.


Balba NM, Elliott JE, Weymann KB, Opel RA, Duke JW, Oken BS, Morasco BJ, Heinricher MM, Lim MM. Increased sleep disturbances and pain in Veterans with comorbid traumatic brain injury and posttraumatic stress disorder. J Clin Sleep Med. 2018;14(11):1865–1878.

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