Reliability of sleep log data versus actigraphy in veterans with sleep disturbance and PTSD

The goal of the study was to assess inter-rater reliability of the daily sleep log (a self-rating) with actigraphy (an objective measure of sleep based on activity) in veterans with Posttraumatic Stress Disorder (PTSD). This analysis focused on time asleep and number of awakenings during bedtime. Study participants consisted of 21 veterans with a lifetime diagnosis of Posttraumatic Stress Disorder and current sleep disturbance symptoms. Data collection included study participants' daily charting of sleep logs and actigraphy (utilizing study participants' activity level). Data analysis included the following: (1) interrater reliability for the tabulation of self-reported sleep logs by two trained raters using 99 nights of sleep from 10 cases; (2) comparison of sleep log data versus actigraphic findings for sleep time during 241 bedtimes; (3) comparison of sleep log data versus actigraphic findings for awakenings during 241 bedtimes. Findings showed that the two raters had intraclass correlation scores of .801 for time spent asleep and .602 for time spent in bed-acceptable scores for tabulation of the sleep logs. Comparison of patients' sleep logs versus actigraphy for 241 nights showed that 10 out of 21 study participants had acceptable intraclass correlations of 0.4 or above for duration of sleep. However, sleep logs and actigraphic data on number of sleep awakenings showed poor intraclass correlation, with only 1 subject having an intraclass correlation greater than .30. In conclusion, these data strongly suggest that sleep logs do not reproduce actigraphic records in patients with PTSD even though the sleep logs were reliably quantified. Sleep logs especially under-count awakenings in PTSD patients with sleep complaints.     

Actigraphic assessment of sleep in young adults with Asperger syndrome

A high prevalence of subjective insomnia in adults with Asperger syndrome has been reported. In the present study the sleep quality of these patients was studied using wrist actigraphy. Nineteen adults with Asperger syndrome and frequent feelings of insomnia were compared with 10 controls devoid of neuropsychiatric disorders and subjective sleep problems during six consecutive nights. The patients had similar actigraphic sleep profile to the controls. The subjective low sleep quality in patients was not reflected in actigraphic assessment of sleep. This finding suggests that pervasive anxiety inherent in persons with Asperger syndrome predisposes them to insomnia complaints.     

Factors associated with caregiver reports of sleep disturbances in persons with dementia.

OBJECTIVE: This investigation examined the relationship between caregivers' reports of sleep disturbances in persons with Alzheimer disease (AD) and actigraphic records of patients' sleep-wake activity, and explored the factors associated with discrepancies in this relationship. METHOD: Forty-six patients with AD living with their caregivers participated. Before study entry, all caregivers reported poor patient sleep quality using the Neuropsychiatric Inventory (NPI) Nighttime Behavior Scale. Patient sleep-wake activity was recorded for one week using an Actillume wrist-movement recorder. RESULTS: Although all patients were reported by caregivers to have multiple sleep disturbances, 41% of patients had actigraphic sleep efficiencies in the normal range and 43% averaged eight or more hours of sleep nightly. In bivariate analyses, greater patient percent nighttime sleep (indicative of more discrepancy between subjective reports and objective outcomes) was associated with less patient cognitive, physical and functional impairment, lower self-rated depression, higher self-rated quality of life, and less daytime sleepiness. No patient variable significantly predicted total patient nocturnal sleep time. In both bivariate and multivariate analyses, greater patient percent sleep and total sleep time were also associated with caregiver factors, particularly greater use of criticism as a behavior management strategy. CONCLUSION: The study suggests that both patient and caregiver factors contribute to reported sleep problems in community-dwelling patients with AD, and that caregiver reports and objective sleep assessments frequently may not agree. Treatments should consider these dyadic contributions rather than focusing on caregiver reports of patient symptoms alone.     

Subjective sleep complaints in pediatric depression: a controlled study and comparison with EEG measures of sleep and waking

OBJECTIVE: Children with major depressive disorder (MDD) often complain of sleep disturbances; however, polysomnographic studies have failed to find objective evidence of these disturbances. This article examines subjective sleep reports of children with MDD and healthy controls focusing on comparing subjective and objective sleep measures. METHOD: Fifty-one subjects with MDD and 42 healthy subjects, 8-17 years old, participated in a comprehensive psychobiologic study including three nights of EEG sleep recording. Each morning, subjects completed a post-sleep form subjectively rating their sleep, which was then compared with their polysomnographic studies. RESULTS: Depressed subjects reported significantly worse sleep on four scales: subjective sleep quality, perceived number of awakenings, estimated minutes awake, and perceived ease of waking. In contrast to these subjective complaints, objective EEG measures indicated no evidence of disturbed sleep in the depressed sample compared to controls. Furthermore, exploratory analyses focusing on the subset of depressed subjects with the greatest subjective sleep disturbance showed, paradoxically, significantly better sleep in terms of the number of EEG awakenings and objective disturbances. CONCLUSIONS: Despite clinical evidence of subjective sleep complaints in depressed children, our EEG measures showed little evidence to indicate an objective basis for these perceptions. These findings raise provocative questions regarding the nature of sleep complaints associated with early-onset depression.     

Sleep quality in children with attention deficit hyperactivity disorder: An actigraphic study

Abstract  The aim of the present study was to compare the sleep of 12 children with attention deficit hyperactivity disorder (ADHD) with that of 12 normal controls. The children were examined in their natural environment, using continuous actigraphic monitoring over several consecutive nights, as well as undergoing subjective parental reports. It was hypothesized that children diagnosed with ADHD would suffer from reduced sleep quality than children without ADHD. This hypothesis was supported by the actigraphic measures, but not supported by the subjective parental reports. It was also found that the sleep quality of the two groups differed over the course of the night, which suggests a difference in sleep architecture. Various possible explanations for these findings, their implications regarding the relationship between sleep and ADHD, and the resulting treatment ramifications are discussed, and suggestions for further research are provided.     

Comparison of actigraphic, polysomnographic, and subjective assessment of sleep parameters in sleep-disordered patients

OBJECTIVE: Comparison of polysomnography (PSG)-derived sleep parameters (total sleep time, sleep efficiency, and number of awakenings) to those derived from actigraphy and subjective questionnaires. BACKGROUND: Actigraphy is commonly used to assist sleep specialists in the diagnosis of various sleep and circadian-rhythm disorders. However, few validation studies incorporate large sample sizes, typical sleep clinic patients, or comparisons with subjective reports of sleep parameters. METHODS: Clinical series with 100 consecutive sleep-disordered patients (69 men, 31 women, mean age of 49+/-14.7 years) at a tertiary sleep disorders center. Sensitivity, specificity, and accuracy measures were obtained from epoch-by-epoch comparison of PSG and actigraphic data. Subjective sleep parameter data were derived from questionnaires given to subjects in the morning following their recording night. RESULTS: We found that total sleep time and sleep efficiency did not significantly differ between PSG data and the combined data obtained from actigraphy and subjective reports. Using a high-threshold (low-wake-sensitivity) actigraphic algorithm, the number of awakenings was not significantly different from those detected by PSG. CONCLUSIONS: We recommend the use of subjective data as an adjunct to actigraphic data in estimating total sleep time and sleep efficiency in sleep-disordered patients, especially those with disorders of excessive somnolence.     

The effect of nefazodone on subjective and objective sleep quality in posttraumatic stress disorder

BACKGROUND: This study assesses the efficacy of nefazodone treatment (target dose of 400-600 mg/day) on objective and subjective sleep quality in Vietnam combat veterans with chronic DSM-IV posttraumatic stress disorder (PTSD). METHOD: Medically healthy male Vietnam theater combat veterans with DSM-IV PTSD (N = 10) completed a 12-week open-label trial. Two nights of ambulatory polysomnography were obtained at baseline and at the end of the trial. PTSD and depressive symptoms and subjective sleep quality were assessed at baseline and after 12 weeks. Data were collected in 1999 and 2000. RESULTS: Nefazodone treatment led to a significant decrease in PTSD and depressive symptoms (p <.05), an improvement in global subjective sleep quality, and a reduction in nightmares. Nefazodone also resulted in a substantial improvement in objective measures of sleep quality, particularly increased total sleep time, sleep maintenance, and delta sleep as measured by period amplitude analysis. CONCLUSION: Nefazodone therapy results in an improvement of both subjective and objective sleep quality in subjects with combat-related PTSD.     

Post-traumatic stress disorder and sleep-what a nightmare!

According to DSM IV criteria, sleep disturbances are incorporated in the definition of post-traumatic stress disorder (PTSD). These include the re-experiencing symptoms (nightmares, criteria B) and a hyperarousal state (difficulty initiating and maintaining sleep, criteria D). PTSD patients commonly complain of sleep disturbances. Moreover, insomnia, restless sleep and trauma-related dreams might be the primary complaint of some patients. However, although subjective sleep disturbances are considered characteristic of PTSD, sleep laboratory studies have provided inconsistent evidence of objective sleep disorders. A variety of sleep architectures and sleep patterns has been reported in PTSD. However, only a few studies have controlled for comorbidities. Thus, uncertainty exists to what extent the sustained complaints of sleep disturbances in chronic PTSD are specifically related to the impact of exposure to traumatic stress, or rather are a consequence of comorbid disorders. Specific changes in REM sleep suggest a pathophysiologic role of REM sleep abnormality in PTSD (e.g. anxiety dreams, increased REM density, exaggerated startle response, decreased dream recall and elevated awakening thresholds from REM sleep). However, again, studies have failed to show consistent changes in percentage of REM sleep or in REM latency. There might be a coexistence of pressure to REM along with inhibitory forces of REM that result in high variability of REM parameters across patients. Alternatively, changes in REM sleep might reflect the effect of comorbid psychiatric disorders that results in inconsistent findings between patients. The current review tries to address these issues based on recent studies carried out in this field.     

Sleep in lifetime posttraumatic stress disorder: a community-based polysomnographic study

BACKGROUND: Sleep complaints are common in posttraumatic stress disorder (PTSD) and are included in the DSM criteria. Polysomnographic studies conducted on small samples of subjects with specific traumas have yielded conflicting results. We therefore evaluated polysomnographic sleep disturbances in PTSD. METHODS: A representative cohort of young-adult community residents followed-up for 10 years for exposure to trauma and PTSD was used to select a subset for sleep studies for 2 consecutive nights and the intermediate day. Subjects were selected from a large health maintenance organization and are representative of the geographic area except for the extremes of the socioeconomic status range. The subset for the sleep study was selected from the 10-year follow-up of the cohort (n = 913 [91% of the initial sample]). Eligibility criteria included (1) subjects exposed to trauma during the preceding 5 years; (2) others who met PTSD criteria; and (3) a randomly preselected subsample. Of 439 eligible subjects, 292 (66.5%) participated, including 71 with lifetime PTSD. Main outcomes included standard polysomnographic measures of sleep induction, maintenance, staging, and fragmentation; standard measures of apnea/hypopnea and periodic leg movement; and results of the multiple sleep latency test. RESULTS: On standard measures of sleep disturbance, no differences were detected between subjects with PTSD and control subjects, regardless of history of trauma or major depression in the controls. Persons with PTSD had higher rates of brief arousals from rapid eye movement (REM) sleep. Shifts to lighter sleep and wake were specific to REM and were significantly different between REM and non-REM sleep (F(1,278) = 5.92; P =.02). CONCLUSIONS: We found no objective evidence for clinically relevant sleep disturbances in PTSD. An increased number of brief arousals from REM sleep was detected in subjects with PTSD. Sleep complaints in PTSD might represent amplified perceptions of brief arousals from REM sleep.     

Sleep findings in young adult patients with posttraumatic stress disorder.

BACKGROUND: Laboratory sleep studies in posttraumatic stress disorder (PTSD) have not provided consistent evidence of sleep disturbance, despite apparent sleep complaints. Most of these studies have investigated middle-aged chronic PTSD subjects with a high prevalence of comorbidities such as substance dependence and/or personality disorder. METHODS: Ten young adult PTSD patients (aged 23.4 +/- 6.1 years) without comorbidities of substance dependence and/or personality disorder underwent 2-night polysomnographic recordings. These sleep measures were compared with those of normal control subjects and were correlated with PTSD symptoms. RESULTS: Posttraumatic stress disorder patients demonstrated significantly poorer sleep, reduced sleep efficiency caused by increased wake time after sleep onset, and increased awakening from rapid eye movement (REM) sleep (REM interruption). We found significant positive correlations between the severity of trauma-related nightmare complaints and the percentage of REM interruption, as well as wake time after sleep onset. CONCLUSIONS: The results indicate that trauma-related nightmares are an important factor resulting in increased REM interruptions and wake time after sleep onset in PTSD.     

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.     

The impact of disaster work on community volunteers: The role of peri-traumatic distress,level of personal affectedness,sleep quality and resource loss,on post-traumatic stress disorder symptoms and subjective health

Disaster work has shown to cause PTSD symptoms and subjective health complaints in professional emergency personnel. However, very little is known about how disaster work affects community volunteers.This first time longitudinal study examined factors contributing to post-traumatic stress disorder symptoms (PTSD) and subjective health complaints in volunteers working in an earthquake setting. At six and eighteen months post disaster, a sample of 506 Indonesian Red Cross volunteers were assessed using the Impact of Event Scale-Revised and the Subjective Health Complaints Inventory. Factors analyzed in relation to the outcomes included: peri-traumatic distress, level of personal affectedness by the disaster, sleep quality and loss of resources as a consequence of the disaster.At 18 months post-disaster the findings showed high levels of PTSD symptoms and subjective health complaints. Quality of sleep was related to both outcomes but resource loss only to PTSD symptoms. Neither peri-traumatic distress nor level of affectedness by the disaster (external versus directly affected volunteers), were predictive of symptoms. This study indicates that characteristics of disaster work e.g. low quality of sleep, may be an important contributor to PTSD symptoms and subjective health complaints in volunteers.     

睡眠障碍中的主观及客观评价方法

睡眠的主观及客观评价方法均能评估分析睡眠的结构形式和睡眠质量,在对睡眠障碍患者的诊断和治疗中有重要意义。但是很多研究表明,两种评价手段对睡眠障碍患者的评估结果并不完全一致,可能存在偏差,单凭主观评价或客观评价的个别参数不能确定睡眠质量的好坏,因此在临床上需根据两种评价方法的特点,结合使用。本文将对目前临床常用的几种主观评价和客观评价方法进行分析和比较。     

Screening for early dementia using memory complaints from patients and relatives

This study examined whether the subjective impression of memory function might differentiate healthy elderly subjects from patients with memory complaints, and whether memory complaints differed between patients with and without a dementing illness. Both self-assessment and relatives' responses on a new memory questionnaire differentiated patient groups from control subjects. The relatives' form measuring deterioration in memory function over time identified dementing individuals from those with non-dementing causes for their memory complaints. Factor analysis indicated that patients' memory complaints correlated with depression rather than objective memory performance, while relatives' ratings correlated with objective memory scores, not depression. Stepwise discriminant function analyses showed that objective memory testing greatly improved specificity but not sensitivity of the subjective memory questionnaire alone.     

Sleep in Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is often associated with sleep disturbances. In this review, we focus on the published literature on subjective and objective findings of sleep in patients with PTSD. Insomnia and nightmares are most commonly reported subjective sleep disturbances. Polysomnographic investigations have frequently reported rapid eye movement (REM) sleep abnormalities in PTSD. However, studies have not been consistent about the type of REM sleep dysfunction in PTSD patients. Antidepressants such as nefazodone, trazodone, fluvoxamine, and imagery rehearsal therapy are found to be beneficial in the treatment of PTSD associated sleep disturbances as well as core symptoms of this anxiety disorder. We propose use of such modalities of treatment in PTSD patients with predominant sleep disturbances. Further studies are required to clarify polysomnographic sleep changes especially role of REM sleep dysregulation and treatment of sleep disturbances in PTSD.     

Effects of comorbid diagnoses on sleep disturbance in PTSD

Objective: Patients with post-traumatic stress disorder (PTSD) are frequently diagnosed with other psychiatric comorbid conditions. This study tested the hypothesis that PTSD patients suffer a greater proportion of sleep problems according to comorbid diagnoses. Method: National Comorbidity Survey (NCS) data from 591 individuals diagnosed with PTSD were analyzed. Revised versions of the Diagnostic Interview Schedule and Composite International Diagnostic Interview were administered to a representative sample of males and females. Groups consisted of patients diagnosed with lifetime PTSD and with current comorbid panic disorder, major depressive disorder, generalized anxiety disorder, and alcohol dependence. Results: Patients diagnosed with PTSD/panic disorder reported a significantly greater proportion of nightmare complaints (96%) and insomnia (100%) compared with the other comorbid groups. Conclusions: A greater proportion of PTSD patients with comorbid panic disorder complain of sleep-related problems than other comorbid groups. This effect appears unique to panic, rather than other general anxiety disorder or depression. Prospective sleep studies are needed to differentiate the role of sleep in PTSD and PD, as well as to examine the role of psychiatric comorbidity in worsening sleep in PTSD patients.     

An open-label, 12-week clinical and sleep EEG study of nefazodone in chronic combat-related posttraumatic stress disorder

BACKGROUND: We examined the effects of nefazodone on polysomnographic sleep measures and subjective reports of sleep quality and nightmares. as well as other symptoms, in patients with chronic combat-related posttraumatic stress disorder (PTSD) during a 12-week, open-label clinical trial. To our knowledge, this is the first polysomnographic study of treatment in patients with PTSD. METHOD: The subjects were 12 male veterans (mean age = 54 years) who met DSM-IV diagnostic criteria for PTSD (mean duration = 30 years). All but I patient also met DSM-IV criteria for major depressive disorder. Patients were evaluated weekly with clinical ratings in an open-label clinical trial. Polysomnographic recordings for 2 consecutive nights were obtained before treatment and at 2, 4, 8, and 12 weeks. The dose of nefazodone was adjusted according to individual clinical needs. Final mean daily dose was 441 mg. RESULTS: The patients reported significantly fewer nightmares and sleep problems during treatment. Nevertheless, contrary to studies in depressed patients, nefazodone did not significantly affect polysomnographic sleep measures compared with baseline. In addition, the patients showed significant improvement in the Clinical Global Impressions of PTSD symptoms (global score, hyperarousals and intrusions subscales), the Clinician-Administered PTSD Scale (global, hyperarousal, and intrusions subscales), the Hamilton Rating Scale for Depression (HAM-D). and the Beck Depression Inventory (BDI). CONCLUSION: These patients with chronic, treatment-resistant, combat-related PTSD showed significant improvement of subjective symptoms of nightmares and sleep disturbance, as well as depression and PTSD symptoms. in this 12-week open-label clinical trial. Nevertheless, objective polysomnographic sleep measures did not change. Further studies, including double-blind. placebo-controlled trials, are needed to extend these findings and to understand the relationships between the physiology of sleep and symptoms of poor sleep and nightmares.     

Sleep disturbance in anxiety disorders

Many patients suffering from the majority of anxiety disorders complain about their sleep by reporting difficulties in initiating and maintaining it. Polysomnographic studies have shown that, in comparison to normal subjects, the sleep of patients with panic disorder is characterized by longer sleep latency, increased time awake and reduced sleep efficiency. Sleep architecture is normal and there are no significant changes in REM sleep measures. Nocturnal panic attacks are non-REM-related events and occur without an obvious trigger in 18-45% of panic disorder patients. Regarding generalized anxiety disorder, the patients complain of 'trouble sleeping' in 60-70%, while polysomnography has shown increased sleep latency and decreased sleep continuity measures. The findings in REM sleep and sleep architecture generally do not show any aberration to exist. In patients with obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD), results from the sleep laboratory do not seem to support the subjective complaints of poor sleep. The early reports of shortened REM latency in OCD could not be replicated by recent studies. A dysregulation of the REM sleep control system has been reported for patients with PTSD. Finally, no significant differences were found in all sleep parameters between social phobia patients and controls.     

Sleep in Parkinson's disease: A comparison of actigraphy and subjective measures

Sleep disturbances are common in Parkinson's disease (PD). Actigraphy has emerged as an alternative to polysomnography to measure sleep, raising the question of its ability to capture sleep quality in PD patients. Our aim was to compare self-report data with actigraphic data. Thirty non-demented individuals with PD and 14 normal control participants (NC) were included. Sleep was measured using 24-h wrist actigraphy over a seven day period, during which time participants kept a sleep diary. Subjective sleep and arousal questionnaires included the Parkinson's Disease Sleep Scale and Epworth Sleepiness Scale. Patients with PD presented with more sleep problems than NC. In NC, none of the actigraphic sleep variables were related to any of the self-report measures of sleep. In PD, scores on subjective sleep measures correlated with actigraphy-derived estimates of sleep quality. Our results suggest that actigraphy is an appropriate method of measuring sleep quality in PD.     

Sleep in post-traumatic stress disorder and panic: convergence and divergence

Disturbed sleep is a common clinical problem in anxiety disorders, particularly in patients with post-traumatic stress disorder (PTSD) and panic disorder (PD). Several studies have attempted to validate the subjective sleep complaints of these disorders using laboratory polysomnography. These attempts, typically focusing on PTSD or PD independently, have demonstrated inconsistent results. To our knowledge, no such studies have attempted to directly compare and contrast sleep disturbances in PTSD and PD together. Our review of the studies of subjective sleep disturbances, sleep architecture, and sleep-related biologic phenomena suggests that a comparative characterization of sleep disturbances in these two disorders is timely. Such an inference is based on our identification of several areas of convergence and divergence between PTSD and PD found in the published literature, as well as our own preliminary investigations. Specifically, PTSD and PD seem to converge on several sleep-related parameters, namely, sleep quality, presence of episodic parasomnias, and movement time. They also appear to diverge in other important sleep-related areas such as respiratory disturbances and the particular phenomenological nature of episodic parasomnias, namely nightmares or nocturnal panic attacks. Investigations focusing on such overlapping phenomena may provide groundwork for further elucidation of central fear systems underlying these two disorders. Additionally, such sleep studies have the potential to provide important insights into ongoing efforts to develop a cohesive conceptual framework into the patho-physiologies of these disorders.