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PubMed1996

Adult psychophysiologic insomnia and positive history of childhood insomnia.

Sixty-five adults diagnosed with "psychophysiologic chronic insomnia" following the criteria of the Association of Sleep Disorders Centers were investigated. They were subdivided into two groups based on whether onset of the insomnia had occurred in childhood or adulthood. Fifty similar-aged patients with obstructive sleep apnea syndrome (OSAS) were also investigated and served as a contrast group. All subjects were given polygraphic recordings and structured interviews, and all completed sleep questionnaires after reviewing the questions with an investigator. On many indices evaluating subjective daytime alertness and well-being, the psychophysiologic insomnia patients had scores similar to the OSAS patients. There were no significant differences between the childhood-onset and adult-onset psychophysiologic insomnia patients on most of the investigated items. However, the childhood-onset psychophysiologic insomniinacs had moderately but significantly higher reports of nightmares. This group also reported having had longer sleep latencies, significantly more "fear of the dark" and more frequent nightmares during childhood than the adult-onset group. These statistically significant findings reflected only a moderate increase in subjective scores, however, and in general the childhood-onset and adult-onset psychophysiologic insomnia patients were very similar.

Adult↗
PubMed2005

From psychophysiological insomnia to organic sleep disturbances: a continuum in late onset insomnia - with special concerns relating to its treatment.

The population suffering from insomnia in old age onset (LOI) is quite large. LOI might include a larger scale of syndromes ranging from typical psychophysiological insomnia to night delirium. The correlation between the biological, biochemical changes and the quantitative as well as the qualitative alterations of the sleep process through aging has not been fully explored. One can suppose that any cerebral lesion leading to a dysfunction in mental performance can also act on the sleep. The majority of LOI brain metabolic disturbances might therefore have some etiological role. The authors suggest the application of this concept in the clinical evaluation of LOI. The authors constructed a heuristic model for the pathophysiology and treatment of LOI. It is a bipolar axis containing the most typical symptoms of LOI. On the opposite margins psychophysiological insomnia and organic/metabolic insomnia (up to delirious states) are settled. The position on the axis (i.e., its distance from the "edge syndromes") gives information on the probability of its organic nature. Based on their clinical experiences and considering the data of the very few studies, they suppose that with the help of a detailed analysis of the symptoms of LOI and using some additional (electrophysiological and neuroimaging) laboratory methods most patients with LOI can get a strict diagnostic position on the LOI axis. Using the LOI axis not only a detailed evaluation of the symptomatology but also more sophisticated therapeutic interventions become possible. Symptoms on the "metabolic side" can be cured by a single evening application of any drugs improving the function of the brain (like nootropics, neuroprotective agents or even slight stimulants, e.g., caffeine) might show a "paradoxical hypnotic" effect, or in combination with sleeping pills they can cause an additive effect in LOI patients. The efficacy of this treatment can also have a diagnostic value: i.e., it helps to differentiate between the primary (organic) and psychophysiological (exogenous or emotional/psychic) forms of LOI.

Age of Onset↗
PubMed2004

Effect of cognitive behavioural therapy for insomnia on sleep architecture and sleep EEG power spectra in psychophysiological insomnia.

There is now an overwhelming preponderance of evidence that cognitive behavioural therapy for insomnia (CBT-I) is effective, as effective as sedative hypnotics during acute treatment (4-8 weeks), and is more effective in long term (following treatment). Although the efficacy of CBT-I in the treatment of chronic insomnia is well known, however there is little objective data on the effects of CBT-I on sleep architecture and sleep EEG power densities. The present study evaluated, first, subjective change in sleep quality and quantity, and secondly the modifications occurring in polysomnography and EEG power densities during sleep after 8 weeks of CBT-I. Nine free drug patients with psychophysiological insomnia, aged 33-62 years (mean age 47 +/- 9.7 years), seven female and two male participated in the study. Self-report questionnaires were administered 1 week before and 1 week after CBT-I, a sleep diary was completed each day 1 week before CBT-I, during CBT-I and 1 week after CBT-I. Subjects underwent two consecutive polysomnographic nights before and after CBT-I. Spectral analysis was performed the second night following 16 h of controlled wakefulness. After CBT-I, only scales assessing insomnia were significantly decreased, stages 2, REM sleep and SWS durations were significantly increased. Slow wave activity (SWA) was increased and the SWA decay shortened, beta and sigma activity were reduced. In conclusion CBT-I improves both subjective and objective sleep quality of sleep. CBT-I may enhance sleep pressure and improve homeostatic sleep regulation.

Adult↗
PubMed1983

Insomnia: II. Assessment and treatment of chronic insomnia.

Evidence for non-pharmacological effects of hypnotics on sleep is presented. This suggests that behavioural variables may be involved in the regulation of sleep onset in insomnia. Chronic 'true' insomnia is described in terms of precipitating events: fixed behavioural patterns which perpetuate it and the disordered timing of electrophysiological and hormonal events. Specific behavioural factors relevant to an individual patient's insomnia must be identified. The factors are: (i) the patient's expectations of the experience of going to sleep and his/her belief that he can or cannot control the onset of sleep, (ii) the patients' personal theory of the cause of the problem, (iii) what the patient says to himself privately about the problem, (iv) the presence of stimuli in the sleep setting which arouse the patients including objects, persons and behavioural rituals. Treatment requires that patients be taught special skills, individually tailored to the specific behavioural variables found to perpetuate their insomnia. Non specific 'placebo' effects are also involved as is the case with drug administration. Patients who fail to respond to treatment may have a masked disturbance of circadian rhythms. This recent observation requires the addition of new approaches to assessment and treatment.

Arousal↗
PubMed2000

Behavioral treatment of insomnia: the Wilford Hall Insomnia Program.

Persistent insomnia is one of the most common patient complaints reported in primary care settings. This paper reviews the behavioral assessment and treatment approaches for persistent insomnia and reports the results of 42 consecutively treated patients in the Wilford Hall Insomnia Program. Patients were treated in a six-session, multiple-component behavioral group treatment program consisting of sleep restriction, stimulus control, sleep hygiene, relaxation training, and cognitive therapy. In addition, patients were seen for two individual treatment sessions in conjunction with the program and for two individual post-group treatment sessions to assess treatment progress. The results indicated that sleep onset latency was improved by 53%, wake after sleep onset was decreased by 40%, and sleep efficiency was improved by 22%. A detailed description of the behavioral treatment program for insomnia is provided as well as recommendations for practitioners working in primary care settings.

Behavior Therapy↗
PubMed2000

Insomnia and the eye of the beholder: are there clinical markers of objective sleep disturbances among adults with and without insomnia complaints?

Previous findings suggest that some who report insomnia sleep well, whereas some noncomplaining individuals sleep rather poorly. This study was conducted to determine if mood, anxiety, and sleep-related beliefs might relate to perceived sleep disturbance. Thirty-two women and 32 men (aged 40-79 years) with primary insomnia and an aged-matched sample of 61 normal sleepers (31 women, 30 men) completed 6 nocturnal sleep recordings, as well as the Beck Depression Inventory (BDI), the Trait portion of the State-Trait Anxiety Inventory (STAI-2), and the Dysfunctional Beliefs and Attitudes About Sleep Questionnaire. Sleep and interview data were used to subdivide the majority of the sample (n = 108) into objective normal sleepers and subjective insomnia sufferers who seemingly slept well and subjective normal sleepers and objective insomnia sufferers who slept poorly. The 2 subjective subgroups showed the most marked differences on most of the psychometric measures. The findings suggest that the psychological factors scrutinized in this study may mediate sleep satisfaction and/or predict objective sleep difficulties.

Adult↗
PubMedDate not supplied

Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. NIH Technology Assessment Panel on Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia.

OBJECTIVE: To provide physicians with a responsible assessment of the integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. PARTICIPANTS: A nonfederal, nonadvocate, 12-member panel representing the fields of family medicine, social medicine, psychiatry, psychology, public health, nursing, and epidemiology. In addition, 23 experts in behavioral medicine, pain medicine, sleep medicine, psychiatry, nursing, psychology, neurology, and behavioral and neurosciences presented data to the panel and a conference audience of 528 during a 1 1/2-day public session. Questions and statements from conference attendees were considered during the open session. Closed deliberations by the panel occurred during the remainder of the second day and the morning of the third day. EVIDENCE: The literature was searched through MEDLINE, and an extensive bibliography of references was provided to the panel and the conference audience. Experts prepared abstracts with relevant citations from the literature. Scientific evidence was given precedence over clinical anecdotal experience. ASSESSMENT PROCESS: The panel, answering predefined questions, developed their conclusions based on the scientific evidence presented in open forum and the scientific literature. The panel composed a draft statement that was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. CONCLUSIONS: A number of well-defined behavioral and relaxation interventions now exist and are effective in the treatment of chronic pain and insomnia. The panel found strong evidence for the use of relaxation techniques in reducing chronic pain in a variety of medical conditions as well as strong evidence for the use of hypnosis in alleviating pain associated with cancer. The evidence was moderate for the effectiveness of cognitive-behavioral techniques and biofeedback in relieving chronic pain. Regarding insomnia, behavioral techniques, particularly relaxation and biofeedback, produce improvements in some aspects of sleep, but it is questionable whether the magnitude of the improvement in sleep onset and total sleep time are clinically significant.

Behavior Therapy↗
PubMed2001

Complex insomnia: insomnia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD.

BACKGROUND: Sleep disturbance in posttraumatic stress disorder is very common. However, no previous posttraumatic stress disorder studies systematically examined sleep breathing disturbances, which might influence nightmares, insomnia, and posttraumatic stress disorder symptoms. METHODS: Forty-four consecutive crime victims with nightmares and insomnia underwent standard polysomnography coupled with a nasal pressure transducer to measure airflow limitation diagnostic of obstructive sleep apnea and upper airway resistance syndrome. RESULTS: Forty of 44 participants tested positive on objective sleep studies based on conservative respiratory disturbance indices of more than 15 events per hour; 22 patients suffered from obstructive sleep apnea and 18 suffered from upper airway resistance syndrome. CONCLUSIONS: In an uncontrolled study, insomnia and sleep-disordered breathing were extremely prevalent in this small and select sample of crime victims. Research is needed to study 1) prevalence of sleep-disordered breathing in other posttraumatic stress disorder populations using appropriate controls and nasal pressure transducers and 2) effects of sleep treatment on posttraumatic stress symptoms in trauma survivors with comorbid obstructive sleep apnea or upper airway resistance syndrome. In the interim, some posttraumatic stress disorder patients may benefit from sleep medicine evaluations.

Adult↗
PubMed1999

The significance and management of persistent primary insomnia: the past, present and future of behavioral insomnia therapies.

Persistent primary insomnia (PPI) is a prevalent and potentially serious condition that compromises the functioning, health status, and quality of lives of millions of individuals around the world. This condition is typically perpetuated by a host of psychological and behavioral mechanisms that often require behavioral interventions. Nonetheless, all too commonly, practitioners underestimate the seriousness of this condition or rely too heavily on symptom focused sedative hypnotic therapy for its treatment. Herein we briefly review the epidemiology of PPI and consider the inadequacies of sedative hypnotics for treating this disorder. Subsequently, we provide rationale for the use of behavioral interventions with this condition and we describe the gradual evolution of the currently available behavioral insomnia treatments and consider promising recent developments such as the emergence of cognitive-behavioral and specially tailored, patient-specific approaches. In closing, we consider the potential usefulness of a combined pharmacological/behavioral intervention for PPI and present a number of important research questions to address in future studies of the behavioral insomnia therapies.

Journal Article↗
PubMed2003

Sleep microstructure around sleep onset differentiates major depressive insomnia from primary insomnia.

In the present study we investigate whether alterations of sleep propensity or of wake propensity are implicated in sleep initiation disturbances encountered in major depressive insomnia and in primary insomnia. For this purpose, the time course of electroencephalogram (EEG) power density during the period preceding sleep onset and during the first non-rapid eye movement (REM) period was examined in three age and gender matched groups of 10 women and 11 men (healthy controls, primary insomniacs and depressive insomniacs). In contrast to healthy controls and depressive insomniacs, patients with primary insomnia did not experience a gradual decrease of their alpha and beta1 power during the sleep onset period and had a lower delta activity in the 5 min preceding sleep onset. Compared with the two other groups, depressive patients exhibit less dynamic changes in slow wave activity during the first non-REM period. The present results suggest that hyperarousal (high 'Process W') may mainly be implicated in the sleep initiation difficulties of primary insomniacs whereas the homeostatic sleep regulation process seems to be partially maintained. In our major depressed patients, the sleep initiation disturbances appeared to relate to a lower sleep pressure (low 'Process S') rather than to hyperarousal. This study supports the idea that different mechanisms are implicated in sleep disturbances experienced by primary insomniacs and major depressive insomniacs.

Adult↗
PubMed1997

[Psychological, psychotherapeutic and other non-pharmacologic forms of therapy in treatment of insomnia. Position of the "Insomnia" Study Group of the German Society of Sleep Research and Sleep Medicine].

Psychological and psychotherapeutic techniques are an essential part of the treatment of insomnia. Mainly two facts stress the importance of psychological/psychotherapeutical strategies for insomnia: (1) Concepts for non-drug treatment aim at improvement of the symptoms and the underlying cause of the disease and (2) disadvantages of hypnotic therapy such as substance abuse or addiction are avoided. Effective treatment techniques such as patients education and counseling, sleep hygiene, stimulus control and relaxation techniques should be known to every therapist, especially general practitioners who treat the majority of patients haring difficulties in initiating or maintaining sleep. Several other effective behavioural techniques, e.g. sleep restriction, or cognitive therapy, and psychotherapy should be used only by skilled and trained experts. Insomniacs with chronic and severe complaints should be treated by therapists with experience in sleep medicine. Multimodal treatment strategies are provided for by sleep disorder centres and combine effective treatment elements in structured therapeutic concepts. There is absolute consensus of opinion that every hypnotic treatment of an insomniac patient should be combined with basal elements of non-drug treatment strategies.

Behavior Therapy↗
PubMed1999

Differential rates of psychopathology symptoms in periodic limb movement disorder, obstructive sleep apnea, psychophysiological insomnia, and insomnia with psychiatric disorder.

STUDY OBJECTIVE: To determine patterns and relative intensity of psychopathology, as measured by the Minnesota Multiphasic Personality Inventory (MMPI), in 108 patients with either psychophysiological insomnia (PI; n=20), insomnia with psychiatric disorder (IPD; n=30), periodic limb movement disorder (PLM; n=28), or obstructive sleep apnea (OSA; n=30). DESIGN: Cross-sectional. SETTING: University sleep disorders center. MEASUREMENTS AND RESULTS: Subjects completed the MMPI prior to overnight diagnostic polysomnographic assessment followed by Multiple Sleep Latency Test (MSLT). Seventy five percent of the entire sample had at least one MMPI elevation (T>70). Groups showed significant baseline differences in age, BMI, and MSLT latency (all ps<.05). Logistic regression indicated that even after statistically controlling for these three diagnostic covariates, MMPI elevation was more likely among PLM and IPD patients than OSA or PI patients (all ps<.05). Followup pairwise comparisons indicated that this same pattern of group differences occurred for the Depression, Psychasthenia, and Schizophrenia scales (all ps<.05). CONCLUSIONS: Irrespective of age, obesity, and daytime sleepiness, patients with untreated PLM or IPD are more likely to experience clinically significant psychological difficulties than those with either OSA or PI. These differences are most likely to be manifested in terms of depressive symptoms, anxiety symptoms (tension, worry, guilt), social alienation, and diminished mental concentration. Finally, PLM may be associated with greater MMPI elevations than previously suspected, and agree with earlier clinical reports of high rates of psychiatric treatment in PLM.

Adult↗
PubMed1998

Dreaming and insomnia: dream recall and dream content of patients with insomnia.

The present study investigated dream recall frequency and dream content of patients with insomnia in comparison to healthy controls. Patients' dream recall frequency was elevated, due mainly to their heightened frequency of nocturnal awakenings. Dream content seems to reflect waking life stressors found in these patients, i.e. dream emotions were more negative and dreams were characterized by themes of depression, 'negatives' in self-description and health themes. Patients taking antidepressants showed lower dream recall frequency than patients without any medication; benzodiazepine intake, however, did not affect dream recall frequency. Both drug groups reported more positively toned dreams than drug-free patients. It is suggested that future studies should use more dreams per subject in order to reduce error variance of the dream content measures and more detailed measures of waking life stress.

Adult↗