Cognitive anxiety in insomnia: An analogue test

Two theories on the cause of insomnia have emerged, the somatic and the cognitive. To test the cognitive theory, 15 insomniac and 15 normal sleepers were invited into the sleep laboratory. In the last of three sessions ostensibly designed to measure normal presleep physiological processes, a polygraph malfunction was staged raising the possibility of accidental shock. The major outcome was that insomniacs showed a significant increase of skin conductance level during this session while normals relaxed even further. This probably reflected the presence of anxious ruminations for insomniacs and the absence of such for normals in response to the third night threat. Insomniacs' tonic level of frontalis muscle tension surpassed normals but was non-reactive to the third night threat, suggesting a minor role for somatic arousal in insomnia. The present results support the primacy of cognitive arousal in insomnia and invite emphasis on cognitive control treatment strategies for this sleep disorder.     

Insomnia in maintenance haemodialysis patients.

BACKGROUND: Studies in the last 15 years have shown a high prevalence of sleep disorders in maintenance haemodialysis (HD) patients. METHODS: To investigate whether the new technical and therapeutic advances of the last decade have had a positive impact on sleep disturbances in HD patients: 694 patients (384 males, 310 females) were surveyed using a specific questionnaire; their clinical, lifestyle and dialysis data were also recorded. RESULTS: Forty-five per cent of patients (n=311; 156 males, 155 females) complained of insomnia, defined either by delayed sleep onset and/or night-time waking, and were included in the insomnia group; the remainder were used as controls (control group). There was a significantly higher risk of insomnia in patients with >12 months on dialysis, in patients dialysed in the morning (P<0.003), and in patients with higher parathyroid hormone (PTH) levels (P<0.05). Body mass index, body weight gain and blood pressure did not differ between the groups, and neither did the dialysis parameters. Creatinine and urea plasma levels were higher in the control group vs the insomnia group (P<0.001), but there was no difference in haemoglobin concentrations or use of erythropoietin, calcitriol and antihypertensive drugs. Cigarette smoking, caffeine or alcohol intake were comparable in the two groups. The most frequently recorded sleep disorders were night-time waking (92%), trouble falling asleep (67%) and early morning waking (62%). Restless leg symptoms were described in 52% of patients with insomnia. CONCLUSIONS: The prevalence of insomnia in HD patients is still very high; elderly patients, and those with longer time on dialysis and high levels of PTH are at major risk of insomnia, whereas type of dialysis, haemoglobin levels and behavioural factors do not seem to play a critical role in determining this sleep disorder.     

Daily sleep in relation to subjective and physiological stress in an occupational context: Daily vigour as a mediator

Studies on the stress-sleep relationship consistently demonstrate negative effects of stress on sleep. The reversed relation, however, has received less research attention. Also, field studies on physiological stress are scarce. The aim of this day-level diary study was to examine daily relationships between sleep quality and quantity, and subjective and physiological stress in an occupational context. Moreover, we examined daily vigour as an underlying mechanism of the sleep-stress relationship. Participants were 167 knowledge workers who filled in daily questionnaires measuring sleep quality and quantity, morning vigour and subjective afternoon stress on Tuesdays and Thursdays for 5 weeks. Physiological stress was assessed with cortisol decline from morning peak to evening, and with blood pressure in the afternoon. Multilevel path analysis results showed that better sleep quality and longer sleep hours predicted increased vigour the following morning, which in turn predicted lower subjective stress in the afternoon. Sleep quality and quantity were not related to physiological stress neither directly nor indirectly via morning vigour. On the basis of our results, sleep should be considered as a factor affecting vigour which in turn seems to lower stress.     

Basic psychological need experiences,fatigue, and sleep in individuals with unexplained chronic fatigue

Grounded in self‐determination theory, this study tested the hypothesis that the satisfaction and frustration of the psychological needs for autonomy, competence, and relatedness would relate to fatigue and subjective and objective sleep parameters, with stress and negative sleep cognitions playing an explanatory role in these associations. During a stay at a sleep laboratory in Belgium, individuals with unexplained chronic fatigue (N = 160; 78% female) underwent polysomnography and completed a questionnaire at 3 different points in time (i.e., after arrival in the sleep lab, before bedtime, and the following morning) that assessed their need‐based experiences and stress during the previous week, fatigue during the preceding day, and sleep‐related cognitions and sleep during the previous night. Results indicated that need frustration related to higher stress, which in turn, related to higher evening fatigue. Need frustration also related to poorer subjective sleep quality and shorter sleep duration, as indicated by both subjective and objective shorter total sleep time and subjective (but not objective) longer sleep latency. These associations were accounted for by stress and negative sleep cognitions. These findings suggest that health care professionals working with individuals with unexplained chronic fatigue may consider focusing on basic psychological needs within their therapeutic approach.     

Insomnia in a post-acute brain injury sample

OBJECTIVE: The purpose was to establish the frequency of insomnia within the post-acute TBI population and compare it with insomnia rates among other rehabilitation outpatients. DESIGN: A prospective study was undertaken of 50 consecutive post-acute TBI admissions and a comparison group of 50 rehabilitation outpatients evenly divided between spinal cord injury (SCI) and musculoskeletal (MSK) cases. SETTING: Subjects were recruited at various outpatient clinics of a major rehabilitation hospital. PATIENTS: Among the TBI subjects, the predominant cause of injury was motor vehicle accident; both mild and severe injuries were well represented in the sample; and, on average, patients were almost 4 months post-injury. The comparison and TBI groups did not differ significantly with respect to education or marital status. However, the MSK group was older and a higher proportion of the SCI group was female. MEASURES: The Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), and sleep diaries were administered to the TBI group. Only the PSQI and BDI were completed by the comparison group. RESULTS: Thirty per cent of the patients were found to suffer from insomnia. Sleep initiation was a problem almost twice as often as sleep duration. An additional 12% did not meet the DSM-IV criteria for insomnia but, nevertheless, experienced a degradation of sleep quality, as measured by the PSQI. Conversely, only slightly more than half (58%) of the TBI sample reported sleep to be relatively normal and satisfactory. Insomnia was also commonly reported by the patients in the rehabilitation comparison groups. They generated significantly higher mean PSQI Global Scores relative to the TBI group and the frequency of poor sleep quality was elevated significantly above the TBI rate. Relative to the TBI cases, twice as many comparison group patients were classified by the PSQI as insomniacs. CONCLUSION: Poor sleep quality and insomnia were definitely problems for the TBI group, although the magnitude of these problems was much greater for the rehabilitation comparison group. Degraded and disordered sleep may represent widespread challenges within the rehabilitation population in general.     

Insomnia may increase anesthetic requirement

Study ObjectiveGamma aminobutyric acid (GABA) is the primary inhibitory neurotransmitter in the central nervous system. It is a common target for general anesthetics, and it is strongly related to the etiology of chronic insomnia. In this study, we aimed to investigate whether insomnia has any effect on anesthetic requirement, and we also assessed pain to reveal a relationship with insomnia.DesignThis study designed as a prospective, observational study, registered ANZCTR (ACTRN12616000241437), with institutional review board approval and written informed consent.SettingPreoperative and postoperative areas of the training and research hospital.PatientsInpatients planning to undergo laparoscopic cholecystectomy as an elective surgery were enrolled in this study.InterventionsPatients were divided into 2 groups based on the results of the 4-item Jenkins Sleep Questionnaire which assesses the degree of sleep disturbance: those with or without insomnia. Anesthesia was standardized, and delivered sevoflurane concentration was adjusted according to bispectral index (BIS) value in both groups.MeasurementsParameters of the study were heart rate, noninvasive arterial blood pressure, arterial oxygen saturation, BIS, end-tidal carbon dioxide, and inspiratory and end-tidal concentrations of sevoflurane at 5-minute intervals during the operation. Pain was assessed for all participants; preoperatively using 2-sided blank body manikin (front and back) and postoperatively with numeric rating scale between 0 and 10.Main ResultsEnd-tidal concentration of sevoflurane found higher in insomnia group during the maintenance phase of anesthesia. Pain experience was higher in insomnia group. In addition, postoperative abdominal pain score was higher only at 18-hour interval in insomnia group. Although BIS values were similar in both groups during surgery, mean end-tidal sevoflurane concentrations were significantly higher in insomnia group (1.48 ± 0.20) than control group (1.23 ± 0.18) (P < .0001).ConclusionInsomnia may result in increased anesthetic requirement and pain experience. Further study is required to identify the relationship between insomnia and anesthetics.     

Nightmares, Insomnia, and Sleep-Disordered Breathing in Fire Evacuees Seeking Treatment for Posttraumatic Sleep Disturbance

Eight months after the Cerro Grande Fire, 78 evacuees seeking treatment for posttraumatic sleep disturbances were assessed for chronic nightmares, psychophysiological insomnia, and sleep-disordered breathing symptoms. Within this sample, 50% of participants were tested objectively for sleep-disordered breathing; 95% of those tested screened positive for sleep-disordered breathing. Multiple regression analyses demonstrated that these three sleep disorders accounted for 37% of the variance in posttraumatic stress symptoms, and each sleep disorder was significantly and independently associated with posttraumatic stress symptoms severity. The only systematic variable associated with posttraumatic stress symptoms of avoidance was sleep-disordered breathing. The findings suggest that three common sleep disorders relate to posttraumatic stress symptoms in a more complex manner than explained by the prevailing psychiatric paradigm, which conceptualizes sleep disturbances in PTSD merely as secondary symptoms of psychiatric distress.     

Diagnosis and management of insomnia in dialysis patients

Sleep-related complaints affect 50-80% of patients on dialysis. Sleep disorders impair quality of life significantly. Increasing evidence suggests that sleep disruption has a profound impact both on an individual and on a societal level. The etiology of sleep disorders is often multifactorial: biologic, social, and psychological factors play a role. This is especially true for insomnia, which is the most common sleep disorder in different populations, including patients on dialysis. Biochemical and metabolic changes, lifestyle factors, depression, anxiety, and other underlying sleep disorders can all have an effect on the development and persistence of sleep disruption, leading to chronic insomnia. Insomnia is defined as difficulty initiating or maintaining sleep, or having nonrestorative sleep. It is also associated with daytime consequences, such as sleepiness and fatigue, and impaired daytime functioning. In most cases, the diagnosis of insomnia is based on the patient's history, but in some patients objective assessment of sleep pattern may be necessary. Optimally the treatment of insomnia involves the combination of both pharmacologic and nonpharmacologic approaches. In some cases acute insomnia resolves spontaneously, but if left untreated, it may lead to chronic sleep problems. The treatment of chronic insomnia is often challenging. There are only a few studies specifically addressing the management of this sleep disorder in patients with chronic renal disease. Considering the polypharmacy and altered metabolism in this patient population, treatment trials are clearly needed. This article reviews the diagnosis of sleep disorders with a focus on insomnia in patients on dialysis.     

Insomnia in a displaced population is related to war-associated remembered stress

Although traumatic events are presumed to cause sleep disturbances, particularly insomnia, sleep in populations subjected to forced displacement has received little attention. The present study examined the prevalence of insomnia and associated factors in internally displaced persons (IDPs) from Abkhazia 15 years after displacement to Tbilisi. Detailed subjective information about sleep–wake habits, sleep‐related and stress‐related parameters were obtained from 87 IDPs categorized into good sleepers and insomniacs. The Insomnia Severity Index, Perceived Stress Scale and Beck Depression Inventory were administered. The incidence of insomnia was 41.4%. The majority of insomniacs strongly believed that war‐related stress accounted for the onset of their insomnia. Stepwise regression (95% confidence interval) revealed four variables significantly associated with insomnia status: self‐estimated influence of war related stress (odds ratio (OR) = 2.51), frequency of nightmares (OR = 1.6), Perceived Stress Scale score (OR = 1.14) and Beck Depression Inventory score (OR = 1.12). Insomnia in IDPs was strongly related to war‐associated remembered stress. ?Over thinking’ about major stress exposure enhanced IDPs' vulnerability to insomnia. These findings have implications for the management of insomnia and associated impairment of daytime functioning in IDPs. Copyright © 2011 John Wiley & Sons, Ltd.     

A comparative study of the efficacy and tolerance of dipotassium clorazepate and flunitrazepam for oral premedication]

The literature shows that benzodiazepines, in view of their anxiolytic, sedative, amnesic, muscle relaxant and anticonvulsive action, are the most important substances for premedication. Eminent workers regard anxiolysis as the most important aim of premedication. In the present clinical study, oral administration of the two different benzodiazepine derivatives, flunitrazepam (F) and chlorazepate dipotassium (CD) have been explored with a view to side effects, tolerance, quality of sleep during the night, anxiolytic effect and sedation. The study involved 108 women patients aged from 20 to 60 years (ASA class I or II), all scheduled to undergo gynecological surgery in general anesthesia. There were also 20 women who received no premedication. The three groups of patients were further divided into early (operation started before 10:30 a.m.) and late-operation (operation started after 10:30 a.m.) groups. The test drugs were administered as follows: 43 women received 50 mg CD p.o. on the evening before the operation, followed by 25 mg p.o. in the morning; 45 women received 2 mg F p.o. on the evening before the operation, followed by 1 mg p.o. in the morning. All patients took the preoperative premedication at 7 o'clock in the morning. Following this medication, the anxiolytic, sedative, and amnesic effects, side effects, vigilance and O2 saturation (SaO2) were determined at defined points during the day of the operation and the 1st postoperative day. Blood pressure and heart rate were recorded and interpreted as physiological stress parameters. Anxiolysis was determined using the Erlangen Anxiety Scale (EAS) of Galster and Sp?rl; the degree of sedation was assessed by the anesthesiologist; amnesia was determined by the patients' recognition of picture cards; vigilance and side-effects were assessed by standardized questionnaires. Both active drugs clearly improved the quality of sleep in the night before the operation over that experienced with no premedication. There were no significant differences among the three groups in the physiological stress parameters. The preoperative SaO2 saturation was decreased significantly by oral F, but it was always more than 95%. CD had little influence on the SaO2. Unwanted somatic symptoms were found a little more frequently in the group without any premedication. There were no signs of restricted tolerance for either of the test drugs. In the premedicated groups, pre- and postoperative anxiety decreased significantly.(ABSTRACT TRUNCATED AT 400 WORDS)     

Examining Insomnia During Intensive Treatment for Veterans with Posttraumatic Stress Disorder: Does it Improve and Does it Predict Treatment Outcomes?

Previous research has demonstrated that sleep disturbances show little improvement with evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, sleep improvements are associated with PTSD treatment outcomes. The goal of the current study was to evaluate changes in self-reported insomnia symptoms and the association between insomnia symptoms and treatment outcome during a 3-week intensive treatment program (ITP) for veterans with PTSD that integrated cognitive processing therapy (CPT), mindfulness, yoga, and other ancillary services. As part of standard clinical procedures, veterans (N = 165) completed self-report assessments of insomnia symptoms at pre- and posttreatment as well as self-report assessments of PTSD and depression symptoms approximately every other day during treatment. Most veterans reported at least moderate difficulties with insomnia at both pretreatment (83.0%–95.1%) and posttreatment (69.1–71.3%). Statistically significant reductions in self-reported insomnia severity occurred from pretreatment to posttreatment; however, the effect size was small, d = 0.33. Longitudinal mixed-effects models showed a significant interactive effect of Changes in Insomnia × Time in predicting PTSD and depression symptoms, indicating that patients with more improvements in insomnia had more positive treatment outcomes. These findings suggest that many veterans continued to struggle with sleep disruption after a 3-week ITP, and successful efforts to improve sleep could lead to better PTSD treatment outcomes. Further research is needed to establish how adjunctive sleep interventions can be used to maximize both sleep and PTSD outcomes.     

Stress system dysregulation in pediatric generalized anxiety disorder associated with comorbid depression

Because chronic stress is an important risk factor for anxiety states and depressive disorders, we studied hypothalamus–pituitary–adrenal (HPA) axis and sympathetic system activity via changes in cortisol and alpha amylase activity levels in pediatric generalized anxiety disorder (GAD) patients (n = 26) with comorbid depression and a healthy comparison group (n = 26). Morning plasma cortisol and diurnal profiles of salivary cortisol and salivary alpha amylase (sAA) activity were assessed, also reactivity of HPA‐axis, sAA activity, and heart rate following a psychosocial stressor (Trier Social Stress Test for children). GAD patients with comorbid depression showed increased morning plasma and salivary cortisol levels, ameliorating throughout in‐patient treatment, and higher sAA activity in their diurnal profile. Both HPA and sympathetic activity positively correlated with the severity of anxiety and depression. We also demonstrated a blunted HPA and sympathetic response to acute stress in patients. This pattern of neuroendocrine and sympathetic changes seems to be distinct from the one previously reported in pediatric patients with only social anxiety or depressive disorders. We propose morning plasma and saliva cortisol levels as potential physiological indicators for supporting the evaluation of symptoms' severity and treatment progress in children with GAD and comorbid depressive disorder.     

The functional anatomy of sleep-dependent visual skill learning

Learning of procedural skills develops gradually, with performance improving significantly with practice. But improvement on some tasks, including a visual texture discrimination task, continues in the absence of further practice, expressly during periods of sleep and not across equivalent waking episodes. Here we report that the brain activation revealed significantly different patterns of performance-related functional activity following a night of sleep relative to 1 h post-training without intervening sleep. When task activation patterns after a night of sleep were compared with activation patterns without intervening sleep (1 h post-training), significant regions of increased signal intensity were observed in the primary visual cortex, the occipital temporal junction, the medial temporal lobe and the inferior parietal lobe. In contrast, a region of decreased signal intensity was found in the right temporal pole. Corroborating these condition differences, correlations between behavioural performance and brain activation revealed significantly different patterns of performance-related functional activity following a night of sleep relative to those without intervening sleep. Together, these data provide evidence of overnight bi-directional changes in functional anatomy, differences that may form the neural basis of sleep-dependent learning expressed on this task.     

Nocturnal Autonomic Balance and Sleep in PTSD and Resilience

Posttraumatic stress disorder (PTSD) has been associated with heightened nocturnal autonomic nervous system (ANS) arousal and sleep disturbances. It has been suggested that relationships between sleep and nocturnal ANS activity are influenced by insomnia; however, investigation of this relationship has been limited in PTSD. This study examined nocturnal ANS activity and its relationship to sleep in PTSD and resilience. Physically healthy young adult African Americans with current PTSD (n = 20) or who had never had PTSD despite exposure to a high‐impact traumatic event (resilient, n = 18) were monitored with ambulatory electrocardiograms and actigraphy for 24‐hr periods. Frequency‐domain heart‐rate variability measures, that is, low‐frequency to high‐frequency ratios (LF/HF), which index sympathetic nervous system activity, and normalized HF (nHF), which indexes parasympathetic nervous system activity were examined. Normalized HF during the time‐in‐bed period was lower for those with PTSD than those with resilience (p = .041). Total sleep time was strongly correlated with time‐in‐bed LF/HF (r = ?.72) and nHF (r = .75) in the resilient group, but these were not correlated in the PTSD group. The results suggest elevated nocturnal ANS arousal and dissociation between ANS activity and total sleep time in PTSD.     

Acute and chronic stress in cardiothoracic anaesthetists

A distinction is made between acute and chronic stress in the workplace. The distinction leads on to two types of question: (1) How does the one relate to the other? (2) Is it possible to distinguish between acute and chronic stress physiologically? Preliminary attempts to tackle the latter question are reported. The subjects were anaesthetists on a cardiothoracic unit and the physiological measures taken were urinary cortisol and salivary flowrate. Perceived stress and arousal were monitored using self-report techniques. Among the results obtained were the following:

• 1 Self-reported arousal was higher in the morning than the afternoon.
• 2 The level of arousal was associated with salivary flow, flow being weaker when arousal was higher and vice versa.
• 3 Self-reports of stress were associated with higher than average urinary cortisol levels.
• 4 The mean level of urinary cortisol over 24 hours was significantly higher for the group than that found in the general population.

     

Sleep Variability in Military‐Related PTSD: A Comparison to Primary Insomnia and Healthy Controls

Sleep disturbances are prevalent in posttraumatic stress disorder (PTSD) and are associated with a number of adverse health consequences. Few studies have used comprehensive assessment methods to characterize sleep in Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OEF/OIF/OND) veterans with PTSD. OEF/OIF/OND veterans with PTSD and sleep disturbance (n = 45) were compared to patients with primary insomnia (n = 25) and healthy control subjects (n = 27). Participants were assessed using questionnaire‐based measures as well as daily subjective and objective measures of sleep. The 3 groups were compared with regard to (a) group means, (b) intraindividual (i.e., night‐to‐night) variability of sleep, and (c) interindividual (i.e., within‐group) variability of sleep. In terms of group means, only objective sleep efficiency was significantly worse with PTSD than with primary insomnia (d = 0.54). Those with PTSD differed from those with primary insomnia on measures of intraindividual as well as interindividual variability (d = 0.48–0.73). These results suggested sleep symptoms in OEF/OIF/OND veterans with PTSD are more variable across nights and less consistent across patients relative to sleep symptoms in insomnia patients without PTSD. These findings have implications for research, as well as for personalizing treatment for individuals with PTSD.     

Sleep disturbance in post-traumatic stress disorder: A comparison with non-PTSD insomnia

Sleep disturbances, including repetitive nightmares and insomnia, are central and long-lasting aspects of Post-Traumatic Stress Disorder (PTSD). This study utilized a questionnaire to compare sleep disturbance in Vietnam War combat veterans having PTSD with non-PTSD patients having insomnia without other PTSD symptoms. The PTSD group reported symptoms of anxiety, agitation and concurrent body movement which were associated with insomnia. Nightmares of this group were more repetitive and more disruptive of a return to sleep than the non-PTSD insomnia group. The PTSD group also reported more fatigue during daytime functioning and more anxiety during waking hours than the non-PTSD insomnia group.     

内科住院病人睡眠状况调查分析

目的 了解内科住院病人的睡眠状况及其影响因素,以便提供针对性的干预措施。方法 采用睡眠状况自评量表(SRSS)对300例内科住院病人进行问卷调查。结果 76.67％的内科住院病人存在不同程度的失眠,显著高于全国常模(P相似文献   

65例老年心血管疾病患者的失眠原因及护理干预措施研究

目的研究笔者所在医院老年心血管病患者的失眠原因和护理干预措施。方法回顾性分析笔者所在医院2009年6月～2010年12月65例有失眠症的老年心血管病患者的病例资料。结果失眠多数因环境改变和药物因素引起。干预后失眠发生率下降至52.3%,与干预前比较差异有统计学意义（x2=40.71,P〈0.01）。结论护理干预能够显著改善患者的睡眠质量。