Clinical ReviewSleep disturbances in sexual abuse victims: A systematic review
Introduction
Sleep disturbances and traumatic symptomatology have long been associated with the diagnostic and statistical manual of mental disorders. 4th edition (DSM-IV-TR) criteria for acute and posttraumatic stress disorder, which lists insomnia and nightmares as core symptoms.1 Moreover, several studies have documented an association between various sleep disturbances and traumatized individuals, with differences emerging as a result of specific trauma types.2 Over the past decade an impressive body of literature has emerged investigating the extent and nature of sleep disturbance associated with sexual abuse. This is an important field of study given the known prevalence of sexual abuse3 as well as the adverse impact of sleep disturbance on health and emotional functioning.*4, *5, *6, *7, 8, 9, 10, 11
Sexual abuse is defined as any sexual act to which the victim did not consent, could not consent, or was pressured or manipulated into consenting. The sexual acts in question may comprise a wide range of behaviors, such as touching and fondling, indecent exposure, intercourse, and attempted or completed rape. When the victims’ age is below the legal age of consent, the term “child sexual abuse” is commonly used. The term “incest” refers to illegal sexual activity occurring between people who are closely related, often within immediate family.
Sexual abuse is quite prevalent in most countries, with an international review reporting prevalence rates of 7–36% for women, and 3–29% for men.3 Several methodological factors contribute to the large variability in prevalence estimates, such as sample characteristics, different definitions of sexual abuse, methods of data collection, and response rates.*3, *12, 13
Hauri and Fisher14 proposed a theoretical framework of how stressful events may lead to enduring sleep disturbances. According to their learning perspective, a stressful event may cause insomnia which subsequently leads to associations of the sleep environment with frustration and arousal, which then becomes a maintaining factor of the insomnia after the termination of the stressful event. A similar explanatory model has been proposed regarding the relationship between sexual abuse and sleep disturbances. Here, Noll and colleagues15 emphasize that sleep is naturally restricted to times and places of safety, while feelings of threat and stress inhibit sleep. Since sexual abuse often occurs in a place where the individual has to continue sleeping after the abuse, sleep safety may be compromised for many victims of sexual abuse. Consequently, the bed may become associated with sexual abuse and danger, which again may contribute to the persistence of sleep disturbance even after the termination of abuse. In accordance with the abovementioned models, studies have found an increased prevalence of sleep disturbances in sexually abused persons compared to non-abused samples.16, 17, 18, 19 Although the mechanisms proposed by these theoretical models seem plausible, no studies to date have addressed them empirically, which leaves no empirical data substantiating the models.
Understanding the prevalence and nature of sleep disturbances in sexual abuse victims is important in order to ensure correct diagnostic and treatment decisions given that sleep disturbances are associated with multiple disorders and has significant and wide-reaching adverse consequences. More specifically, sleep disturbance is associated with poorer job performance and increased use of alcohol,20, 21 a decline in multiple measures of cognitive performance22, 23 as well as a higher rate of automobile accidents.*5, 24 Moreover, there are well documented adverse effects of sleep disturbance on mood11 and general health.*5, 24
A comprehensive understanding and overview of the relationship between sexual abuse and sleep is needed, to guide future research and to raise clinicians’ awareness of early intervention and treatment of sleep disturbances among sexually abused clients. Early interventions aimed at improving sleep in sexually abused clients is important since sleep disturbances have been associated with an increased risk of using alcohol to cope with negative affects25 and increased risk of later revictimization15 in sexually abused samples. The aim of the present review was to: a) provide an overview of research on sleep disturbances in sexual abuse victims, b) determine whether it is possible to identify certain sleep symptoms as particularly predominant, and c) provide directions for future research.
Section snippets
Procedure
In the present review, we included studies which: a) reported empirical data, b) included sexually abused subjects, c) employed some form of sleep measure, d) were written in English, and e) were published in peer reviewed journals. Studies not meeting these criteria were excluded, such as theoretical papers, literature reviews, case studies, books and book chapters, non-published material (e.g., dissertation abstracts, conference presentations), and studies using samples of sexual abuse
Samples of sexual abuse victims
All ten studies comparing sexually abused with non-abused subjects*15, 26, 27, 28, 29, 30, 31, 32, 35, 36 found that sexually abused samples had more symptoms than the non-abused in at least one area of sleep functioning, including nightmares, restless sleep, and difficulties with sleep onset. Five studies did not specify the type of problem, but used general terms like “sleep disturbance”, “sleep problems”, and “sleeplessness”.*15, 29, 30, 31, 32 Three studies reported results for different
Discussion
This review of thirty-two empirical studies highlights that sleep disturbances are common in sexually abused samples. Sleep disturbances were found to be more prevalent in sexually abused as compared to non-abused samples by the majority of studies. Symptoms that were reported more frequently by sexually abused individuals as compared to by non-abused individuals included nightmare-related distress, sleep paralysis, nightly awakenings, restless sleep, and tiredness. Several studies did not
Conclusions
Sleep disturbances appear to be common among sexual abuse victims, and more prevalent in sexually abused than in non-abused samples. This has been established repeatedly and across highly varied samples (e.g., clinical, student, community, representative population samples), sample characteristics (e.g., age, gender, sample size), categories of abuse (e.g., rape, incest, child sexual abuse, in addition to abuse characteristics such as time since the abusive incident), and methods of sleep
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