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PubMed2005

Treatment of residual insomnia after CBT for PTSD: case studies.

Insomnia is one of the most common symptoms of posttraumatic stress disorder (PTSD). Evidence suggests that insomnia may persist for many PTSD patients after other symptoms have responded to cognitive-behavioral therapy (CBT). The present article reports the effects of administering a five-session cognitive-behavioral insomnia treatment to 5 patients who responded to CBT for PTSD yet continued to report insomnia. Insomnia treatment was associated with improvements on subjective sleep measures (Pittsburgh Sleep Quality Index, Insomnia Severity Index, and Beliefs and Attitudes about Sleep Scale) and self-monitored sleep efficiency and related measures in 4 of 5 cases. Results highlight issues specific to treating insomnia in trauma populations and future directions for examining treatment of insomnia associated with PTSD.

Adult↗
PubMed2002

To breathe, perchance to sleep: sleep-disordered breathing and chronic insomnia among trauma survivors.

Standard psychiatric classification (DSM-IV-TR) traditionally attributes post-traumatic sleep disturbance to a secondary or symptomatic feature of a primary psychiatric disorder. The DSM-IV-TR paradigm, however, has not been validated with objective sleep assessment technology, incorporated nosological constructs from the field of sleep disorders medicine, or adequately addressed the potential for post-traumatic stress disorder (PTSD) sleep problems to manifest as primary, physical disorders, requiring independent medical assessments and therapies. This paradigm may limit understanding of sleep problems in PTSD by promulgating such terms as "insomnia related to another mental disorder," a.k.a. "psychiatric insomnia." Emerging evidence invites a broader comorbidity perspective, based on recent findings that post-traumatic sleep disturbance frequently manifests with the combination of insomnia and a higher-than-expected prevalence of sleep-disordered breathing (SDB). In this model of complex sleep disturbance, the underlying sleep pathophysiology interacts with PTSD and related psychiatric distress; and this relationship appears very important as demonstrated by improvement in insomnia, nightmares, and post-traumatic stress with successful SDB treatment, independent of psychiatric interventions. Continuous positive airway pressure treatment in PTSD patients with SDB reduced electroencephalographic arousals and sleep fragmentation, which are usually attributed to central nervous system or psychophysiological processes. Related findings and clinical experience suggest that other types of chronic insomnia may also be related to SDB. We hypothesize that an arousal-based mechanism, perhaps initiated by post-traumatic stress and/or chronic insomnia, may promote the development of SDB in a trauma survivor and perhaps other patients with chronic insomnia. We discuss potential neurohormonal pathways and neuroanatomatical sites that may be involved in this proposed interaction between insomnia and SDB.

Adult↗
PubMed2005

Insomnia.

Insomnia is a common problem that is chronic for many individuals. Multiple processes, including psychologic, physiologic, and environmental factors, can influence insomnia, and their effects can shift over time. Accordingly, the evaluation of patients who have insomnia should be broad in scope. Insomnia represents a clinical problem with significant daytime consequences, associations, and comorbidities. Several nosologies categorize insomnia into specific diagnoses. Useful minimal criteria for an insomnia disorder include persistent nighttime symptoms with daytime distress or impairment. Specific treatments, addressing particular underlying causes,and general pharmacologic and nonpharmacologic strategies may play valuable roles in the management of insomnia patients. The effective treatment of insomnia can have further benefits in decreasing the likelihood of future psychiatric symptoms.

Chronic Disease↗
PubMed2004

Studio Morfeo: insomnia in primary care, a survey conducted on the Italian population.

BACKGROUND AND PURPOSE: To carry out an observational epidemiological survey (Studio Morfeo), to determine: (1) the frequency of insomnia in a large Italian population presenting directly to the general physician (GP); (2) the impact of insomnia on the quality of life, on the use of health-care resources and on co-morbidity. PATIENTS AND METHODS: The study was accomplished by GPs, trained by sleep specialists accredited by the Italian Association of Sleep Medicine. Only patients spontaneously presenting to their GP for medical problems were surveyed. Each GP was asked to enroll at least five patients across a routine week of medical activity including both morning and afternoon clinics. The first patient of each weekday was recruited after obtaining written consent. According to the responses to the sleep-related questions, patients were classified into three categories: (1) no insomnia, (2) level 1 insomnia with absence of day-time dysfunction and (3) level 2 insomnia with presence of day-time dysfunction. RESULTS: A total of 3284 patients were enrolled by 738 GPs in this Italian survey. Insomnia was reported by 64% of all interviewed patients, with 20% classified as level 1 and 44% as level 2. Logistic analysis indicated that depression (odds ratio, 2.70), involvement of >1 organ systems (odds ratio, 1.24), female gender (odds ratio, 1.19), unemployment (odds ratio, 1.18), low education (odds ratio, 1.18) and increasing age (odds ratio, 1.02) were the major risk factors for insomnia. CONCLUSIONS: Our findings indicate that insomnia is a frequent disturbance in the Italian primary care population, is associated with high risk of co-morbid conditions, and results in increased use of health-care resources.

Catchment Area, Health↗
PubMed2004

Correlates of benzodiazepine use in individuals with insomnia.

BACKGROUND AND PURPOSE: Although benzodiazepines (BZDs) are commonly used in the treatment of insomnia, there is little information about psychological, health, and sociodemographic correlates associated with their use. OBJECTIVE: This study examined correlates of benzodiazepine use for sleep in a clinical sample of patients seeking treatment for insomnia at a sleep disorders clinic. PATIENTS AND METHODS: The sample consisted of 97 individuals evaluated at a sleep disorders clinic for a presenting complaint of insomnia. Two groups were formed, including one with 61 patients who had been using BZDs for sleep for an average of 56.6 months (SD=68.0), and another with 36 patients who had insomnia but were not using BZDs or any other sleep aid. Logistic regressions, adjusting for an age difference between the user and non-user groups, were performed to examine variables associated with BZD use. Independent variables included demographic, medical, insomnia-related and psychological parameters and subjective sleep-wake characteristics. Unadjusted regression analyses were performed to identify factors associated with a pattern of long-term use (>12 months) within the user group. RESULTS: Age was a significant predictor of BZD use (OR=1.84, P = 0.0002). Significant age-adjusted predictors of BZD use included perceived insomnia severity (OR=1.17, P = 0.038), depressive symptoms, (OR=1.108, P = 0.009) and state and trait anxiety symptoms (OR=1.062, P = 0.016; OR=1.084, P = 0.005, respectively). Significant predictors of long-term use (>12 months) were age of insomnia onset (OR=0.951, P = 0.0214), more frequent BZD use (OR=3.284, P = 0.0221), and higher state-anxiety (OR=1.106, P = 0.0471). CONCLUSIONS: Age, psychological variables and perceived sleep disturbances severity, are associated with BZD use in patients with insomnia.

Adult↗
PubMed2000

Relaxation therapy for insomnia: nighttime and day time effects.

We compared day time functioning in college students with and without insomnia and explored changes in day time functioning after progressive relaxation (PR) treatment for insomnia. Students with insomnia (SWI; n = 57) were compared to a control group of students not complaining of insomnia (SNI; n = 61) on self-reported sleep variables and five questionnaires: Insomnia Impact Scale (IIS), Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS), Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), and Penn State Worry Questionnaire (PSWQ). SWI demonstrated significant impairment on all day time functioning and sleep measures compared to SNI. To investigate treatment effects on day time functioning, 28 SWI were randomly assigned to PR. Treated SWI were compared to untreated SWI and SNI at posttreatment. Treated participants improved sleep in comparison to untreated SWI, but failed to show significant improvements in day time functioning. Insomnia treatments focused on improving sleep may not improve day time functioning, or day time gains may emerge more slowly than sleep gains. This study documents the wide range of day time functioning complaints in young adults with insomnia and suggests that the goal of insomnia treatment should be to not only improve sleep but also to improve the subjective experience of day time functioning.

Adolescent↗
PubMed2001

Insomnia and depressive symptoms in patients with Parkinson's disease. Relationship to health-related quality of life. An interview study of patients living at home.

The objectives of this study were to describe the prevalence of insomnia and depressive symptoms in patients with Parkinson's disease (PD) and to relate those symptoms to health-related quality of life. A total of 102 patients living at home, most of them moderately to severely disabled, were interviewed. Of them 43 patients were women with a mean age of 70 (range 58-79). The mean age for the men was 71 (range 56-80). Time since diagnosis was <2 years for 57%, 2-10 years for 31% and >10 years for 12%. The geriatric depression scale (GDS) and Livingston's insomnia scale were used. The results were related to quality of life as measured with the SF-36 health survey. The prevalence of insomnia was 80%. Moderate depressive symptoms were found in 47% and severe depressive symptoms in 5%. Patients with insomnia or with depressive symptoms had a significantly impaired quality of life on all eight scales of the SF-36. In a stepwise regression analysis the presence of pain and ache and depressive symptoms were significantly related to insomnia. The variables most related to depressive symptoms were Hoehn and Yahr group and insomnia. Hoehn and Yahr groups (more disability) were significantly related to insomnia and depressive symptoms. Thus, insomnia and depressive symptoms are prevalent in PD and influence quality of life and should, therefore, be considered when evaluating patients with PD.

Journal Article↗
PubMed2000

Diagnosis and management of insomnia.

Insomnia is a significant public health issue. Good sleep is essential for emotional and physical wellbeing. The importance of adequate sleep is evidenced by the fact that insomnia can adversely affect physical and mental health. The National Heart, Lung, and Blood Institute Working Group on Insomnia defines insomnia as an experience of inadequate or poor-quality sleep characterized by one or more of the following: difficulty falling asleep, difficulty maintaining sleep, waking up too early in the morning, or unrefreshing sleep. The symptoms of insomnia also include daytime consequences such as tiredness, lack of energy, difficulty concentrating, or irritability. Insomnia can be a symptom of an underlying medical, psychiatric, sleep, or circadian disorder or a disorder in itself (i.e., primary insomnia). This paper will present information about the prevalence, morbidity, causes, and diagnoses of insomnia, and the behavioral and pharmacologic management of this disorder.

Humans↗
PubMed2002

Prevalence of insomnia and associated socio-demographic factors in a Brazilian community: the Bambuí study.

BACKGROUND: Population-based studies of insomnia among adults residing in communities in developing countries are rare. The objectives of this population-based study were to determine the prevalence and factors associated with insomnia among adults (18 years and over) living in a Brazilian town with 15,000 inhabitants (Bambuí MG) and to determine how the use of different definitions of insomnia affect its prevalence. METHODS: A total of 87.3% of 1221 randomly selected individuals aged 18+ participated. Prevalences were estimated based on different definitions. To determine the associated characteristics, insomnia was defined as a complaint in the last month, occurring at least three times a week, causing distress. RESULTS: (1) Prevalence ranged from 12.0 to 76.3%; (2) prevalence of insomnia, as defined above, was 35.4%; (3) prevalence among women increased with age and was higher than that of men; (4) insomnia was independently associated with less education in both sexes, and among females it was associated with older age (60+ years). CONCLUSIONS: The prevalence of insomnia in Bambuí was high, similar to that of urban centers of developed countries; this investigation substantiated the importance of operational criteria in studies of insomnia.

Journal Article↗
PubMed2003

Effects of acupuncture therapy on insomnia.

BACKGROUND: Acupuncture therapy, commonly used in clinical practice in oriental cultures, has the potential to produce a positive effect with patients experiencing insomnia. AIM: The purposes of this systematic review were: (1) to assess the trends across intervention studies using acupuncture for insomnia from 1975 to 2002, (2) to examine dependent variables, and (3) to evaluate the effects of acupuncture therapy on insomnia in older people. METHOD: Data were collected from November 2001 to January 2003. A wide range of electronic databases was searched using the keywords 'insomnia', 'acupuncture' and 'experimental design'. Papers were included if they were published in the English language between 1975 and 2002 and described an experimental study using acupuncture therapy to treat insomnia. Eleven reports met these criteria. FINDINGS: Most of the studies had been conducted since 1990. The findings showed that the first author was usually a Chinese medical doctor (n = 9) employed in a traditional department of medicine. Most of the papers were published in two journals: International Journal of Clinical Acupuncture and Journal of Traditional Chinese Medicine. Data were limited because of the small number of studies available. Half the studies had small samples (50 subjects or fewer), which were composed mainly of older women who had a variable duration of insomnia from 3 days to 34 years. The main method used to assess outcomes was questionnaire. All the studies reported statistically significant positive results. CONCLUSION: The results of this review suggest that acupuncture may be an effective intervention for the relief of insomnia. Further research, using a randomized clinical trial design, are necessary to determine the effectiveness of acupuncture. More work is also needed to promote the long-term therapeutic effects of acupuncture and to compare it with other therapies for insomnia.

Acupuncture Therapy↗
PubMed2001

How age and daytime activities are related to insomnia in the general population: consequences for older people.

OBJECTIVES: To determine the role of activity status and social life satisfaction on the report of insomnia symptoms and sleeping habits. DESIGN: Cross-sectional telephone survey using the Sleep-EVAL knowledge base system. SETTING: Representative samples of three general populations (United Kingdom, Germany, and Italy). PARTICIPANTS: 13,057 subjects age 15 and older: 4,972 in the United Kingdom, 4,115 in Germany, and 3,970 in Italy. These subjects were representative of 160 million inhabitants. MEASUREMENTS: Clinical questionnaire on insomnia and investigation of associated pathologies (psychiatric and neurological disorders). RESULTS: Insomnia symptoms were reported by more than one-third of the population age 65 and older. Multivariate models showed that age was not a predictive factor of insomnia symptoms when controlling for activity status and social life satisfaction. The level of activity and social interactions had no influence on napping, but age was found to have a significant positive effect on napping. CONCLUSIONS: These results indicate that the aging process per se is not responsible for the increase of insomnia often reported in older people. Instead, inactivity, dissatisfaction with social life, and the presence of organic diseases and mental disorders were the best predictors of insomnia, age being insignificant. Healthy older people (i.e., without organic or mental pathologies) have a prevalence of insomnia symptoms similar to that observed in younger people. Moreover, being active and satisfied with social life are protective factors against insomnia at any age.

Adolescent↗
PubMed2003

Subtyping primary insomnia: is sleep state misperception a distinct clinical entity?

Among the range of primary insomnia subtypes, those assigned such labels as subjective insomnia or sleep state misperception historically have been among the most intriguing yet challenging to understand and manage clinically. Such patients who produce seemingly normal polysomnograms often present rather compelling and, at times, dramatic sleep complaints. Our earliest formal sleep nosology included a separate diagnostic category for such individuals, but little research has been devoted to this insomnia subtype in the 20 years since this classification scheme was proposed. As a result, use of diagnoses such as subjective insomnia or sleep state misperception have remained controversial. The current article reviews this controversy and highlights the major criticisms forged against subdividing primary insomnia into objective and subjective subtypes. Subsequently, the relative merits of these criticisms are considered in view of early and recent findings vis-à-vis the subjective/objective insomnia dichotomy. Although available data are not conclusive, there appears to be sufficient evidence to suggest subjective and objective insomnia subtypes may suffer from distinctive forms of sleep-related pathophysiology. We conclude by advocating continued study of the subjective insomnia phenomenon and by providing specific directions for relevant future research.

Diagnosis, Differential↗
PubMed1992

Fatal familial insomnia, a prion disease with a mutation at codon 178 of the prion protein gene.

BACKGROUND: We previously described two members of a family affected by an apparently genetically determined fatal disease characterized clinically by progressive insomnia, dysautonomia, and motor signs and characterized pathologically by severe atrophy of the anterior ventral and mediodorsal thalamic nuclei. Five other family members who died of this disease, which we termed "fatal familial insomnia," had broader neuropathologic changes suggesting that fatal familial insomnia could be a prion disease. METHODS: We used antibodies to prion protein (PrP) to perform dot and Western blot analyses, with and without proteinase K, on brain tissue obtained at autopsy from two patients with fatal familial insomnia, three patients with sporadic Creutzfeldt-Jakob disease, and six control subjects. The coding region of the PrP gene was amplified and sequenced in the samples from the two patients with fatal familial insomnia. Restriction-enzyme analysis was carried out with amplified PrP DNA from 33 members of the kindred. RESULTS: Protease-resistant PrP was found in both patients with fatal familial insomnia, but the size and number of protease-resistant fragments differed from those in Creutzfeldt-Jakob disease. In the family with fatal familial insomnia, all 4 affected members and 11 of the 29 unaffected members had a point mutation in PrP codon 178 that results in the substitution of asparagine for aspartic acid and elimination of the Tth111 I restriction site. Linkage analysis showed a close relation between the point mutation and the disease (maximal lod score, 3.4 when theta was zero). CONCLUSIONS: Fatal familial insomnia is a prion disease with a mutation in codon 178 of the PrP gene, but the disease phenotype seems to differ from that of previously described kindreds with the same point mutation.

Adolescent↗
PubMed2000

Factors associated with insomnia among post-acute traumatic brain injury survivors.

This study investigated the relationships between insomnia and select demographic, injury and psychosocial variables in post-acute, traumatic brain injury. Clinical assessment of sleep and mood was undertaken via objective measures and a diagnostic interview among 91 consecutive brain injury admissions to an outpatient neurorehabilitation clinic. No associations between insomnia and gender, education, age, and time since injury were found. A logistic regression model of insomnia prediction based upon the Beck Depression Inventory (BDI), self-reported pain disturbance, litigation and Glasgow Coma Score (GCS) correctly classified 87% of the sample with respect to the presence or absence of insomnia; however, depression and injury severity were the only variables that made a significant unique contribution to the prediction of insomnia. It is concluded that among post-acute traumatic brain injury patients, insomnia is linked with both the presence of depression and a history of milder brain injuries. This suggests that the determinants of insomnia may differ from the acute to the post-acute phase, with neurological factors playing a primary role early in the recovery process and psychosocial factors ascending later. Therefore, assessment and treatment of insomnia must give careful attention to the larger psychosocial context in which the sleep disorder emerges, particularly to role of emotional disturbance.

Adolescent↗
PubMed1994

Clinical diagnoses in 216 insomnia patients using the International Classification of Sleep Disorders (ICSD), DSM-IV and ICD-10 categories: a report from the APA/NIMH DSM-IV Field Trial.

Three diagnostic classifications for sleep disorders have been developed recently: the International Classification of Sleep Disorders (ICSD), the Diagnostic and Statistical Manual, 4th edition (DSM-IV), and the International Classification of Diseases, 10th edition (ICD-10). No data have yet been published regarding the frequency of specific diagnoses within these systems or how the diagnostic systems relate to each other. To address these issues, we examined clinical sleep disorder diagnoses (without polysomnography) in 257 patients (216 insomnia patients and 41 medical/psychiatric patients) evaluated at five sleep centers. A sleep specialist interviewed each patient and assigned clinical diagnoses using ICSD, DSM-IV and ICD-10 classifications. "Sleep disorder associated with mood disorder" was the most frequent ICSD primary diagnosis (32.3% of cases), followed by "Psychophysiological insomnia" (12.5% of cases). The most frequent DSM-IV primary diagnoses were "Insomnia related to another mental disorder" (44% of cases) and "Primary insomnia" (20.2% of cases), and the most frequent ICD-10 diagnoses were "Insomnia due to emotional causes" (61.9% of cases) and "Insomnia of organic origin" (8.9% of cases). When primary and secondary diagnoses were considered, insomnia related to psychiatric disorders was diagnosed in over 75% of patients. The more narrowly defined ICSD diagnoses nested logically within the broader DSM-IV and ICD-10 categories. We found substantial site-related differences in diagnostic patterns. These results confirm the importance of psychiatric and behavioral factors in clinicians' assessments of insomnia patients across all three diagnostic systems. ICSD and DSM-IV sleep disorder diagnoses have similar patterns of use by experienced clinicians.

Adolescent↗
PubMed2001

Beta/Gamma EEG activity in patients with primary and secondary insomnia and good sleeper controls.

STUDY OBJECTIVE: Several studies have shown that patients with insomnia exhibit elevated levels of Beta EEG activity (14-35 Hz) at or around sleep onset and during NREM sleep. In this study, we evaluated 1) the extent to which high frequency EEG activity is limited to the 14-32 Hz domain, 2) whether high frequency EEG activity (HFA) is associated with discrepancies between subjective and PSG measures of sleep continuity, and 3) the extent to which high frequency EEG activity occurs in patients with primary, as opposed to secondary, insomnia. DESIGN: Three groups (n=9 per group) were compared: Primary Insomnia, Insomnia secondary to Major Depression, and Good Sleeper Controls. Groups were matched for age, sex and body mass. Average spectral profiles were created for each NREM cycle after removing waking and movement epochs and epochs containing micro- or mini-arousals. SETTING: Sleep Research Laboratory PATIENTS OR PARTICIPANTS: Patients with primary and secondary insomnia INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Subjects with Primary Insomnia exhibited more average NREM activity for Beta-1 (14-20Hz), Beta-2 (20-35Hz) and Gamma activity (35-45Hz) than the other two groups (p.<.01). Group differences were also suggestive for Omega activity (45.0-125Hz) (p.<.10), with MDD subjects tending to exhibit more activity than the other groups. Correlational analyses revealed that average NREM Beta-1 and Beta-2 activity tended to be negatively correlated with subjective-objective discrepancy measures for total sleep time and sleep latency. CONCLUSIONS: Our results confirm that Beta activity is increased in Primary Insomnia. In addition, our data suggest that high frequency activity in patients with Primary Insomnia is limited to the Beta/Gamma range (14-45 Hz), and is negatively associated with the perception of sleep.

Adult↗
PubMed2001

Insomnia and health problems in Canadians.

STUDY OBJECTIVES: The objective of this study was to determine the prevalence of, and to identify the relative contribution of selected factors associated with insomnia in the Canadian population age 15 and older. DESIGN: Weighted analysis of cross-sectional data from the Canadian General Social Survey, Cycle 6, 1991. Prevalence estimates were calculated for the total and age-specific Canadian population age 15 and older. Multiple logistic regression techniques were employed to study the contribution of an array of sociodemographic, lifestyle, stress, and physical health factors to the experience of insomnia. SETTING: N/A. PARTICIPANTS: A representative sample of the Canadian household population age 15+ (n=11,924). INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Twenty-four percent of the Canadian population age 15+ report insomnia. The following factors were associated with insomnia in multivariate logistic regression: female gender, being widowed or single, low education, low income, not being in the labor force, ever having smoked, life stress, specific chronic physical health problems (circulatory, digestive and respiratory disease, migraine, allergy and rheumatic disorders), pain, activity limitation and health dissatisfaction. Age was not significantly associated with insomnia. CONCLUSIONS: Insomnia was highly prevalent among the non-institutionalized Canadian population age 15 and older. A very stressful life, severe pain and dissatisfaction with one's health demonstrated the highest odds ratios associated with insomnia. Increasing age per se and lifestyle factors were not significantly associated with insomnia.

Adolescent↗
PubMed2003

Sleep EEG power spectra, insomnia, and chronic use of benzodiazepines.

STUDY OBJECTIVES: The present study examined the sleep microstructure in relation to insomnia and chronic use of benzodiazepines in older adults. PARTICIPANTS: The participants were 46 older adults, aged 55 or older (mean age = 62.9), who were divided into three groups: insomnia sufferers using BZ chronically (n = 15), drug-free insomnia sufferers (n = 15), and self-defined good sleepers (n = 16). DESIGN: Participants completed 3 consecutive nights of polysomnography in the laboratory. Spectral analyses were carried on the second night of sleep recordings. Stages 2, 3, and 4 of the first 4 cycles of the second night were retained for the analysis. RESULTS: Results showed no significant differences between drug-free insomnia sufferers and good sleepers. However, benzodiazepine users exhibited significantly less delta and theta activity over the night than did good sleepers. When compared to drug-free insomnia sufferers, benzodiazepine users had less delta and theta activity within cycle 2 only. Regarding high-frequency bands, benzodiazepine users had more beta 1 activity within cycle 3 than did good sleepers and more than both drug-free insomnia sufferers and good sleepers within cycle 4. CONCLUSIONS: The findings show that spectral analysis is an efficient tool to detect and quantify the effects of benzodiazepine use on sleep structure, particularly with older adults, a group for whom macrostructure sleep alterations due to physiologic aging are hard to distinguish from sleep changes induced by insomnia and the use of hypnotic drugs. In addition, these results raise important questions about the effects and indications of prolonged use of benzodiazepine medications in older adults with insomnia complaints.

Aging↗