Self‐administered acupressure for insomnia disorder: a pilot randomized controlled trial

Self‐administered acupressure has potential as a low‐cost alternative treatment for insomnia. To evaluate the short‐term effects of self‐administered acupressure for alleviating insomnia, a pilot randomized controlled trial was conducted. Thirty‐one subjects (mean age: 53.2 years; 77.4% female) with insomnia disorder were recruited from a community. The participants were randomized to receive two lessons on either self‐administered acupressure or sleep hygiene education. The subjects in the self‐administered acupressure group (n = 15) were taught to practise self‐administered acupressure daily for 4 weeks. The subjects in the comparison group (n = 16) were advised to follow sleep hygiene education. The primary outcome was the Insomnia Severity Index (ISI). Other measures included a sleep diary, Hospital Anxiety and Depression Scale and Short‐form Six‐Dimension. The subjects in the self‐administered acupressure group had a significantly lower ISI score than the subjects in the sleep hygiene education group at week 8 (effect size = 0.56, P = 0.03). However, this observed group difference did not reach a statistically significant level after Bonferroni correction. With regard to the secondary outcomes, moderate between‐group effect sizes were observed in sleep onset latency and wake after sleep onset based on the sleep diary, although the differences were not significant. The adherence to self‐administered acupressure practice was satisfactory, with 92.3% of the subjects who completed the lessons still practising acupressure at week 8. In conclusion, self‐administered acupressure taught in a short training course may be a feasible approach to improve insomnia. Further fully powered confirmatory trials are warranted.     

Symptom reports in severe chronic insomnia

STUDY OBJECTIVES: To describe patterns and severities of the daytime and nighttime symptoms of chronic insomnia patients. DESIGN: Exploratory chart review from clinicians' evaluation summaries, a self-report screening instrument, the Pittsburgh Sleep Quality Index, the Beck Depression Inventory, the Epworth Sleepiness Scale, and the Hopkins Symptom Checklist-90 (HSCL90). SETTING: A regional sleep disorders referral clinic. PATIENTS OR PARTICIPANTS: 94 patients with chronic insomnia (DSM-IV code 307.42), classified into the subgroups "Primary Insomnia," "Depression-Related," "Anxiety-Related," and "Other". INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Frequent symptoms occurred not only in nocturnal domains (e.g., sleep disturbances, environmental sensitivity), but also in daytime domains (e.g., cognitive difficulties, sleepiness). Compared to primary insomnia patients, those with depression-related insomnia endorsed more severe symptoms. All subgroups endorsed a generally similar symptom profile when single symptoms were considered in isolation. When considered conjointly, severe symptoms typical of depression and generalized social alienation had a high negative predictive value for primary insomnia. The number of severe symptoms on the HSCL90 was related to fewer sleep hours in the nonprimary insomnia subgroup but not in the primary insomnia subgroup. CONCLUSIONS: Patients with chronic insomnia report significant daytime as well as nighttime symptoms. Depression-related and primary insomnias were separable only by some highly characteristic symptoms of depression. Diagnostic subgroups of insomnia patients may vary in how their overall distress relates to diminished self-reported sleep. Nighttime and daytime symptoms need to be assessed together when measuring insomnia severity.     

Variability and predictability in sleep patterns of chronic insomniacs

Sleep of chronic insomniacs is often characterized by extensive night-to-night variability. To date, no study has examined this variability with long series of daily sleep data. The present study examined night-to-night variability with a sample of 106 participants meeting DSM-IV diagnostic criteria for persistent primary insomnia. Participants completed daily sleep diaries for an average of 31 days (range: 18-56). Sleep efficiency, sleep onset latency and wake after sleep onset were derived from this measure. Despite evidence of extensive night variability, results showed that sleep patterns could be classified in three clusters. The first one was characterized by a high probability of having poor sleep, the second one by a low and decreasing probability, and the third one by a constant median probability of having a poor sleep, which is an unpredictable sleep pattern. In the first cluster, poor sleep was expected each night for patients with a predominance mixed insomnia including the three insomnia subtypes. In the second cluster, patients presented moderate insomnia, sleep-onset latency below the threshold level and a predominance of sleep-maintenance insomnia. In the third pattern, poor nights seemed unpredictable for patients with moderate to severe insomnia associated with the lowest proportion of sleep-maintenance insomnia. Overall, sleep was predictable for about two-thirds of individuals, whereas it was unpredictable for about one-third. These findings confirm the presence of extensive variability in the sleep of chronic insomniacs and that poor sleep may be predictable for some of them. Additional research is needed to characterize those sleep patterns in terms of clinical features and temporal course.     

Interactions between evening and nocturnal cortisol secretion and sleep parameters in patients with severe chronic primary insomnia

Recent research provides evidence for an interaction between sleep and the activation of the hypothalamic-pituitary-adrenal (HPA)-axis, but detailed studies in patients are still missing. We investigated hourly evening and nocturnal plasma cortisol secretion and sleep in seven male patients with severe chronic primary insomnia and age- and gender-matched controls. Evening and nocturnal cortisol levels were significantly increased in patients. Evening cortisol correlated with the number of nocturnal awakenings in patients and controls. Additionally, patients showed significant correlations between sleep parameters and the first 4 h of nocturnal cortisol secretion. These results are indicative of changes in the HPA system in insomnia and may reflect a pathophysiological mechanism of chronic insomnia resulting in a vicious cycle of both disturbed HPA functions and chronic insomnia according to the arousal hypothesis of insomnia.     

Prolonged-release melatonin improves sleep quality and morning alertness in insomnia patients aged 55 years and older and has no withdrawal effects

Melatonin, secreted nocturnally by the pineal gland, is an endogenous sleep regulator. Impaired melatonin production and complaints on poor quality of sleep are common among the elderly. Non-restorative sleep (perceived poor quality of sleep) and subsequently poor daytime functioning are increasingly recognized as a leading syndrome in the diagnostic and therapeutic process of insomnia complaints. The effects of 3-weeks prolonged-release melatonin 2 mg (PR-melatonin) versus placebo treatment were assessed in a multi-center randomized placebo-controlled study in 170 primary insomnia outpatients aged > or =55 years. Improvements in quality of sleep (QOS) the night before and morning alertness (BFW) were assessed using the Leeds Sleep Evaluation Questionnaire and changes in sleep quality (QON) reported on five categorical unit scales. Rebound insomnia and withdrawal effects following discontinuation were also evaluated. PR-melatonin significantly improved QOS (-22.5 versus -16.5 mm, P = 0.047), QON (0.89 versus 0.46 units; P = 0.003) and BFW (-15.7 versus -6.8 mm; P = 0.002) compared with placebo. The improvements in QOS and BFW were strongly correlated (Rval = 0.77, P < 0.001) suggesting a beneficial treatment effect on the restorative value of sleep. These results were confirmed in a subgroup of patients with a greater symptom severity. There was no evidence of rebound insomnia or withdrawal effects following treatment discontinuation. The incidence of adverse events was low and most side-effects were judged to be of minor severity. PR-melatonin is the first drug shown to significantly improve quality of sleep and morning alertness in primary insomnia patients aged 55 years and older-suggesting more restorative sleep, and without withdrawal symptoms upon discontinuation.     

Impaired sleep-related memory consolidation in primary insomnia--a pilot study

STUDY OBJECTIVES: To compare sleep-related consolidation of procedural memory in patients with primary insomnia and healthy controls. DESIGN: Controlled comparison pilot study. SETTING: Sleep Laboratory of the Department of Psychiatry and Psychotherapy, University of Freiburg, Germany. PATIENTS OR PARTICIPANTS: Seven patients with primary insomnia and 7 sex-, age-, and IQ-matched healthy controls. INTERVENTIONS: Subjects spent 1 night in the sleep laboratory with polysomnographic monitoring. Performance on a mirror tracing task was measured before and after sleep. MEASUREMENTS AND RESULTS: Polysomnography revealed a trend toward disturbed sleep in the patients, compared with the control group, without reaching significance. Performance in the mirror tracing task before sleep did not differ between the groups. Both groups performed significantly better in the retest condition after sleep. Healthy controls showed an improvement of 42.8% +/- 5.8% in the mirror tracing draw time, whereas patients with insomnia showed an improvement of 20.4% +/- 14.8% (multivariate analyses of variance test session x group interaction: F(3,10) = 10.9, p = .002). CONCLUSIONS: These preliminary findings support the view that sleep-associated consolidation of procedural memories may be impaired in patients with primary insomnia.     

An open‐ended primary‐care group intervention for insomnia based on a self‐help book – A randomized controlled trial and 4‐year follow‐up

Chronic insomnia is a common and burdensome problem for patients seeking primary care. Cognitive behavioural therapy has been shown to be effective for insomnia, also when presented with co‐morbidities, but access to sleep therapists is limited. Group‐treatment and self‐administered treatment via self‐help books have both been shown to be efficacious treatment options, and the present study aimed to evaluate the effect of an open‐ended group intervention based on a self‐help book for insomnia, adapted to fit a primary‐care setting. Forty primary‐care patients with insomnia (mean age 55 years, 80% women) were randomized to the open‐ended group intervention based on a cognitive behavioural therapy for insomnia self‐help book or to a care as usual/wait‐list control condition. Results show high attendance to group sessions and high treatment satisfaction. Participants in the control group later received the self‐help book, but without the group intervention. The book‐based group treatment resulted in significantly improved insomnia severity, as well as shorter sleep‐onset latency, less wake time after sleep onset, and less use of sleep medication compared with treatment as usual. The improvements were sustained at a 4‐year follow‐up assessment. A secondary analysis found a significant advantage of the combination of the book and the open‐ended group intervention compared with when the initial control group later used only the self‐help book. An open‐ended treatment group based on a self‐help book for insomnia thus seems to be an effective and feasible intervention for chronic insomnia in primary‐care settings.     

Stress vulnerability and the effects of moderate daily stress on sleep polysomnography and subjective sleepiness

The purpose of this study was to investigate if and how sleep physiology is affected by naturally occurring high work stress and identify individual differences in the response of sleep to stress. Probable upcoming stress levels were estimated through weekly web questionnaire ratings. Based on the modified FIRST‐scale (Ford insomnia response to stress) participants were grouped into high (n = 9) or low (n = 19) sensitivity to stress related sleep disturbances (Drake et al., 2004). Sleep was recorded in 28 teachers with polysomnography, sleep diaries and actigraphs during one high stress and one low stress condition in the participants home. EEG showed a decrease in sleep efficiency during the high stress condition. Significant interactions between group and condition were seen for REM sleep, arousals and stage transitions. The sensitive group had an increase in arousals and stage transitions during the high stress condition and a decrease in REM, whereas the opposite was seen in the resilient group. Diary ratings during the high stress condition showed higher bedtime stress and lower ratings on the awakening index (insufficient sleep and difficulties awakening). Ratings also showed lower cognitive function and preoccupation with work thoughts in the evening. KSS ratings of sleepiness increased during stress for the sensitive group. Saliva samples of cortisol showed no effect of stress. It was concluded that moderate daily stress is associated with a moderate negative effect on sleep sleep efficiency and fragmentation. A slightly stronger effect was seen in the sensitive group.     

Sleep-related attentional bias in patients with primary insomnia compared with sleep experts and healthy controls

Sleep-related attentional bias has been proposed to be an important factor in the development and maintenance of primary insomnia. In this study, a newly introduced mixed modality (visual auditory) task and an emotional Stroop task were used to investigate attentional processes in patients with primary insomnia, sleep experts and healthy controls (n = 20 per group). The sleep expert group served as second control group to control for effects of frequency of concept usage (FOCU). The results of the emotional Stroop task showed a sleep-related attentional bias in the insomnia group in comparison with the expert group. However, no significant differences were detected in the other group comparisons and in the mixed modality task. The difference between insomnia patients and sleep experts in the emotional Stroop task indicates that FOCU is not the underlying process of sleep-related attentional bias. Insomnia patients seem to be more emotionally, cognitively or procedurally affected by sleep-related stimuli than sleep experts. The findings suggest that a desensitization of sleep-related stimuli might be used therapeutically, thus extending the current cognitive behavioral treatments for primary insomnia.     

Severe chronic insomnia is not associated with higher body mass index

Short sleep duration is widely considered to be a risk factor for weight gain, suggesting that patients suffering from sleep disorders are a risk group. Despite some positive preliminary data on patients with organic sleep disorders, empirical evidence for an increased body mass index in patients with insomnia is scarce. Two‐hundred and thirty‐three patients with a confirmed diagnosis of severe and chronic insomnia without co‐morbidity showing objectively impaired sleep quality were compared with respect to their body mass index with control data derived from a representative population survey matched in gender and age. As a result, patients with insomnia showed a lower body mass index (23.8 kg m^?2 versus 27.1 kg m^?2; P < 0.0005). Our findings suggest that patients with chronic insomnia do not exhibit overweight. These data are a valuable educational tool to calm patients’ fears about the consequences of insomnia, and contribute to the understanding of chronically disturbed sleep and weight regulation.     

Effects on sleep: a double-blind study comparing trimipramine to imipramine in depressed insomniac patients

Trimipramine, a sedating tricyclic antidepressant, and imipramine were compared on polysomnographic parameters during a 4-week double-blind trial in depressed patients with insomnia and anxiety. Trimipramine eliminated objective evidence of sleep disturbance. This was not the case with imipramine, although depression improved similarly in both groups. Subjects' sleep appeared unchanged or more disturbed at the end of the treatment with imipramine. For trimipramine, the major changes in sleep parameters occurred during the first week of drug administration and did not parallel the gradual changes seen in the measures of depression. Additionally, trimipramine did not suppress REM sleep even in a subgroup of six trimipramine patients who had short rapid-eye-movement (REM) sleep latencies during the placebo baseline period, even though their depression was alleviated. The data demonstrate that (a) antidepressants may vary in their effects on sleep, even though they have similar effects on depression; (b) REM sleep suppression does not necessarily accompany improvement in depression; and (c) reports of improved sleep by patients undergoing antidepressant therapy may not reflect improvement on objective measures of sleep. The different sleep effects suggest the possibility of different antidepressant pathways.     

Effect of short-term treatment with gaboxadol on sleep maintenance and initiation in patients with primary insomnia

STUDY OBJECTIVE: To perform an early evaluation of the efficacy and safety of gaboxadol in the treatment of primary insomnia. METHODS: 26 adults (18-65 years) with DSM-IV criteria for primary insomnia were randomly assigned gaboxadol (5 mg, 15 mg) or placebo in a double-blind, crossover study. After a 3-night polysomnographic (PSG) screen, treatment was administered 30 min before bedtime on 2 consecutive nights during 3 separate sessions including PSG. Efficacy analyses (n = 23) were based on the average of Nights 1 and 2, and compared gaboxadol versus placebo. Baseline was the average of Nights 2 and 3 of the screening session. Both gaboxadol doses significantly (P < 0.05) improved mean total sleep time (mean +/- SD: baseline = 368.0 +/- 51.1 min, 15 mg = 420.3 +/- 24.5 min, 5 mg = 419.8 +/- 20.4 min, placebo = 408.7 +/- 30.4 min). Both gaboxadol doses reduced mean wake after sleep onset, although statistical significance was only achieved with 5 mg (baseline = 61.6 +/- 35.4 min, 15 mg = 38.0 +/- 21.1 min, 5 mg = 34.6 +/- 14.3 min, placebo = 43.4 +/- 22.9 min). Gaboxadol 15 mg also significantly reduced mean latency to persistent sleep (baseline = 55.6 +/- 27.0 min, 15 mg = 23.6 +/- 15.1 min, placebo = 30.0 +/- 19.1 min) and enhanced slow wave duration (baseline = 72.4 +/- 20.8 min, 15 mg = 114.0 +/- 37.5 min, placebo = 93.9 +/- 31.3 min) with no significant effects on REM sleep duration. Patient reports (Leeds Sleep Evaluation Questionnaire) of reduced time to sleep and increased sleep quality showed significant improvement with gaboxadol 15 mg. No next-day residual effects were observed with either dose of gaboxadol (assessed 2 h and 9 h after lights on). All adverse events were mild or moderate. CONCLUSION: Gaboxadol 15 mg was effective and generally well tolerated in the short-term treatment of patients with primary insomnia. Gaboxadol also enhanced slow wave sleep duration and had no significant effects on REM sleep duration. These findings suggest that gaboxadol may be a useful treatment for insomnia.     

Cognitive and Behavioral Anomalies Among Insomnia Patients With Mixed Restless Legs and Periodic Limb Movement Disorder

This study examined whether patients who have periodic limb movement disorder (PLMD), with or without comorbid restless legs syndrome (RLS), display the sleep-disruptive cognitive and behavioral anomalies found among primary insomnia sufferers. Archival data from a Sleep History Questionnaire, home-based polysomnography, and a sleep log were obtained for matched RLS/PLMD, primary insomnia, and noncomplaining volunteer samples. Statistical comparisons showed that the RLS/PLMD and primary insomnia samples differed significantly from the normal sleepers in regard to their propensities for certain sleep disruptive habits, perceived difficulties controlling pre-sleep cognitive activity, and their subjective sleep appraisals. These findings suggest RLS/PLMD patients display many of the cognitive and behavioral anomalies thought to perpetuate primary insomnia. Hence, behavioral interventions may be warranted for RLS/PLMD patients.     

广东龙门县青少年失眠状况调查及相关因素分析

目的:了解广东省龙门县青少年失眠状况及其相关因素。方法:采用失眠严重指数量表(ISI)、焦虑自评量表(SAS)、贝克抑郁量表(BDI)等对4800名11～18岁青少年进行整群随机抽样调查。结果 :轻度失眠的总发生率为30.4%,中重度失眠为7.8%。单因素分析显示失眠发病率女性稍高于男性并随年龄增加而升高。此外,失眠与住校、抽烟、高学习压力、低学习兴趣、SAS和BDI得分有关。逻辑回归分析显示失眠发生率主要与年龄、住校、SAS和BDI得分有关。结论:失眠在青少年中非常普遍,随着年龄的增长患失眠的发生率增加。失眠与焦虑抑郁症状有关。     

Predictors of Interest in Psychological Treatment for Insomnia Among Older Primary Care Patients With Disturbed Sleep

In this study, we examined whether the common sense model of illness representation (CSMIR) could be successfully used to predict interest in cognitive-behavioral treatment for insomnia (CBT-I) among older primary care patients with disturbed sleep. The Sleep Impairment Index (C. M. Morin, 1993) was used to assess sleep disturbance and the constructs of the CSMIR in primary care patients ages 55 and older. Statistical analyses showed that the CSMIR constructs of consequences (perceived adverse consequences of sleep disturbance to functioning), causes (attributing one's insomnia to bad sleeping habits), and emotion (concern about one's sleep problem) predicted interest in CBT-I. These data provided encouraging support for the ability of the CSMIR to accurately predict patient interest in treatment for insomnia. Implications for assessment and treatment of insomnia in primary care are discussed.     

Cognitive and behavioral anomalies among insomnia patients with mixed restless legs and periodic limb movement disorder

This study examined whether patients who have periodic limb movement disorder (PLMD), with or without comorbid restless legs syndrome (RLS), display the sleep-disruptive cognitive and behavioral anomalies found among primary insomnia sufferers. Archival data from a Sleep History Questionnaire, home-based polysomnography, and a sleep log were obtained for matched RLS/PLMD, primary insomnia, and noncomplaining volunteer samples. Statistical comparisons showed that the RLS/PLMD and primary insomnia samples differed significantly from the normal sleepers in regard to their propensities for certain sleep disruptive habits, perceived difficulties controlling pre-sleep cognitive activity, and their subjective sleep appraisals. These findings suggest RLS/PLMD patients display many of the cognitive and behavioral anomalies thought to perpetuate primary insomnia. Hence, behavioral interventions may be warranted for RLS/PLMD patients.     

Predictors of interest in psychological treatment for insomnia among older primary care patients with disturbed sleep

In this study, we examined whether the common sense model of illness representation (CSMIR) could be successfully used to predict interest in cognitive-behavioral treatment for insomnia (CBT-I) among older primary care patients with disturbed sleep. The Sleep Impairment Index (C. M. Morin, 1993) was used to assess sleep disturbance and the constructs of the CSMIR in primary care patients ages 55 and older. Statistical analyses showed that the CSMIR constructs of consequences (perceived adverse consequences of sleep disturbance to functioning), causes (attributing one's insomnia to bad sleeping habits), and emotion (concern about one's sleep problem) predicted interest in CBT-I. These data provided encouraging support for the ability of the CSMIR to accurately predict patient interest in treatment for insomnia. Implications for assessment and treatment of insomnia in primary care are discussed.     

Manual‐guided cognitive–behavioural therapy for insomnia delivered by ordinary primary care personnel in general medical practice: a randomized controlled effectiveness trial

Chronic insomnia is a prevalent problem in primary health care and tends to be more serious than insomnia in the general population. These patients often obtain little benefit from hypnotics, and are frequently open to exploring various options for medical treatment. However, most general practitioners (GPs) are unable to provide such options. Several meta‐analyses have shown that cognitive–behavioural therapy (CBT) for insomnia results in solid improvements on sleep parameters, and a few studies have demonstrated promising results for nurse‐administered CBT in primary care. The aim of this randomized controlled study was to investigate the clinical effectiveness of manual‐guided CBT for insomnia delivered by ordinary primary care personnel in general medical practice with unselected patients. Sixty‐six primary care patients with insomnia were randomized to CBT or a waiting‐list control group. The CBT group improved significantly more than the control group using the Insomnia Severity Index as the outcome. The effect size was high. Sleep diaries showed a significant, medium‐sized treatment effect for sleep onset latency and wake time after sleep onset. However, for all measures there is a marked deterioration at follow‐up assessments. Almost half of the treated subjects (47%) reported a clinically relevant treatment effect directly after treatment. It is concluded that this way of delivering treatment may be cost‐effective.     

Stress exposure,psychological distress,and physiological stress activation in midlife women with insomnia

OBJECTIVE: The objective of this study was to describe perceived and polysomnograhic (PSG) sleep patterns and determine whether stress exposure, psychological distress, and physiological stress activation differed among midlife women with psychophysiologic-type (PP-type) or subjective only-type (SO-type) insomnia or no insomnia. METHODS: Women had their sleep monitored, collected urine samples, and completed questionnaires in a week-long field study, and 53 women met criteria for insomnia types or no insomnia based on reported sleep quality and PSG sleep efficiency. RESULTS: As expected, women with PP-type insomnia were found to have the lowest sleep efficiency, took longer to fall asleep, had more wakefulness after sleep onset, and had more fragmented sleep. Perceptions of stress exposure, either for major or minor events, did not differ among groups. Despite there being no differences in perceived stress exposure, women with both types of insomnia scored higher on psychological distress (SCL-90R), especially on the somatization subscale, than women with no insomnia. Of the physiological stress activation indicators tested, a morning-to-evening difference in urinary cortisol statistically differed across the groups (p <.005). Women in the PP-type insomnia group had the highest levels of urinary cortisol in an early morning urine sample. CONCLUSIONS: These data provide support for the hypothesis that, in midlife women, cognitive or emotional arousal with chronic stress neuroendocrine activation underlies chronic insomnia, particularly the PP-type.     

A randomized controlled trial of bedtime music for insomnia disorder

Music is often used as a self‐help tool to alleviate insomnia. To evaluate the effect of bedtime music listening as a strategy for improving insomnia, we conducted an assessor‐blinded randomized controlled trial. Fifty‐seven persons with insomnia disorder were included and randomized to music intervention (n = 19), audiobook control (n = 19) or a waitlist control group (n = 19). The primary outcome measure was the Insomnia Severity Index. In addition, we used polysomnography and actigraphy to evaluate objective measures of sleep, and assessed sleep quality and quality of life. The results showed no clear effect of music on insomnia symptoms as the group × time interaction only approached significance (effect size = 0.71, p = .06), though there was a significant improvement in insomnia severity within the music group. With regard to the secondary outcomes, we found a significant effect of the music intervention on perceived sleep improvement and quality of life, but no changes in the objective measures of sleep. In conclusion, music listening at bedtime appears to have a positive impact on sleep perception and quality of life, but no clear effect on insomnia severity. Music is safe and easy to administer, but further research is needed to assess the effect of music on different insomnia subtypes, and as an adjunctive or preventive intervention.