Behavioral treatment of disease-related chronic insomnia in a hemophiliac

Hemophilia represents a congenital chronic disorder characterized by recurrent unpredictable internal hemorrhages with accompanying acute bleeding pain. The medical management of a 38-year-old hemophiliac with severe classic hemophilia was further complicated by a high titer Factor VIII antibody, increasing the life-threatening status of a severe hemorrhage. The patient had a one-year history of less than 2 hours of sleep per night as a result of daily chronic tension and intrusive cognitions about the dangers of his illness. A treatment package consisting of progressive muscle relaxation, meditative breathing, cognitive refocusing, and stimulus control procedures resulted in an average of 6 hours per night of uninterrupted sleep; improvement was maintained over a 27-week follow-up period. The treatment is discussed within the context of the behavioral medicine approach in hemophilia comprehensive care.     

Psychotherapeutic treatment of chronic insomnia

Although psychotherapeutic treatment of patients with chronic insomnia can be difficult and frustrating, a psychotherapeutic approach in which the therapist actively explores and uncovers problem areas can be beneficial. Since chronic insomniac patients tend to internalize their feelings, which leads to increased psychologic arousal and insomnia, the therapist must consistently re-orient the patient toward awareness and expression of feeling. An active therapeutic approach also helps derail the chronic insomniac's tendency to focus on the daytime effects of insomnia rather than on the emotional factors that generate the symptoms. By utilizing the specific technical approaches described in this paper, gratifying therapeutic results may be achieved.     

Diagnosis and treatment of chronic insomnia

Insomnia is a disorder characterized by inability to sleep or a total lack of sleep, prevalence of which ranges from 10 to 15% among the general population with increased rates seen among older ages, female gender, White population and presence of medical or psychiatric illness. Yet this condition is still under-recognized, under-diagnosed, and under-treated. This article aims to review the operational definitions and management of chronic insomnia. A computerized search on PubMed carried from 1980 to January 2009 led to the summarization of the results. There are several strategies to manage chronic insomnia. To initiate treatment, it is necessary to define it and differentiate it from other co-morbid psychiatric disorders. Non-pharmacologic strategies such as stimulus control therapy and relaxation and cognitive therapies have the best effect sizes followed by sleep restriction, paradoxical intention and sleep hygiene education which have modest to less than modest effect sizes. Among pharmacotherapeutic agents, non-benzodiazepine hypnotics are the first line of management followed by benzodiazepines, amitryptiline and antihistaminics. However, adequate trials of combined behavior therapy and pharmacotherapy are the best course of management.     

Behavioral treatment of chronic aerophagia

Effects of various behavioral interventions on stereotyped aerophagic responding by a profoundly mentally retarded, 5-year-old girl were assessed. Aerophagic responding was defined as air swallowing with extreme stomach protrusion, followed by breath-holding. Observations of air swallowing, as well as physiologic measurements related to heart rate and respiratory patterns, were recorded across both baseline and treatment phases of the study. Multiple behavioral interventions were assessed within a laboratory setting using an alternating treatment design format, with the most effective treatment systematically extended to additional settings. Results indicated that a behavior modification treatment package was effective in suppressing the high frequency of this rare stereotyped act to near-zero rates.     

Predicting longer-term outcomes following psychological treatment for hypnotic-dependent chronic insomnia

OBJECTIVES: To identify predictors of treatment adherence, patient dropout, and treatment response among long-term hypnotic users recruited into a randomized controlled trial of psychological treatment for insomnia. METHODS: Of 108 treatment and 101 control patients initially recruited, 37 treatment group patients (34.3%) failed to complete all 6 sessions (i.e., were nonadherent), while across both groups 61 (29.2%) patients failed to return postal assessments at 3-month follow-up (i.e., dropped out). Relationships between baseline characteristics and adherence (adherent vs. nonadherent) and attrition (dropout vs. nondropout) were examined in discriminant models. Relationships between baseline characteristics and treatment response (sleep quality, sleep latency, sleep efficiency, and hypnotic drug use) were examined in a series of multiple regression models. RESULTS: Adherent patients showed a significantly greater severity of pretreatment sleep disturbance, as measured by the Pittsburgh Sleep Quality Index (PSQI). Dropout at 3 months was associated with significantly lower perceived health status at baseline. In the regression models, lower Cure/Control subscale scores from the Illness Perception Questionnaire (IPQ) predicted greater posttreatment improvements in sleep efficiency and PSQI scores, while lower baseline anxiety scores predicted a posttreatment increase in hypnotic-free nights/week. CONCLUSION: In routine clinical practice settings, higher anxiety and a less positive attitude towards symptom control were associated with poorer treatment response. Adherence and attrition show a different pattern of associations, with greater need (as indexed by insomnia severity) predicting higher levels of service uptake and poorer general health predicting a higher likelihood of dropout.     

氟西汀与阿普唑仑治疗慢性失眠症的对照研究

目的探索氟西汀对慢性失眠症的治疗是否有效,同时比较氟西汀与阿普仑对慢性失眠症的治疗效果。方法将84例符合慢性失眠症诊断标准的患者随机分为氟西汀治疗组和阿普唑仑治疗组。采用匹兹堡睡眠质量指数（PSQI）及睡眠日记对睡眠质量进行评定。结果治疗的第1天、第8天,阿普唑仑组患者睡眠状况显著改善,而氟西汀组则无明显变化;治疗的第15天,氟西汀组患者睡眠状况显著改善,睡眠各项指标与治疗前及阿普唑仑组相比,差异具有统计学意义,而阿普唑仑组患者的睡眠状况又恢复到治疗前水平;治疗结束时及治疗结束后3个月,氟西汀组患者的睡眠状况依然好于治疗前及阿普唑仑组,差异具有统计学意义。结论氟西汀可以有效治疗慢性失眠症,远期效果好于阿普唑仑。     

Diagnosis and treatment of chronic insomnia: a review

OBJECTIVE: Insomnia has high prevalence rates and is associated with significant personal and socioeconomic burden, yet it remains largely underrecognized and inadequately treated. METHODS: A PubMed search for English-language articles covering randomized controlled trials published between 1970 and 2004 was conducted. Search terms used were "insomnia," "behavioral therapy," and the generic names of agents commonly used to treat insomnia (the Food and Drug Administration-approved benzodiazepines and nonbenzodiazepines, trazodone, and over-the-counter agents). RESULTS: Evidence from epidemiologic studies, physician surveys, and clinical studies suggests that numerous patient and physician factors contribute to the fact that the needs of patients with insomnia remain unmet, including low reporting of insomnia by patients, limited physician training, and office-based time constraints, as well as misconceptions about the seriousness of insomnia, the advantages of treatment, and the risks associated with hypnotic use. Nonpharmacologic therapies produce long-lasting and reliable changes among people with chronic insomnia and have minimal side effects. Pharmacologic therapies have proven effective with improving wake time after sleep onset and sleep maintenance and reducing the number of nighttime awakenings. However, pharmacologic therapy has a greater chance of producing side effects. No conclusive evidence exists to favor either pharmacologic therapy or behavioral therapy. CONCLUSIONS: Insomnia is particularly challenging for clinicians because of the lack of guidelines and the small number of studies conducted in patient populations with behavioral and pharmacologic therapies. Current treatment options do not address the needs of difficult-to-treat patients with chronic insomnia, such as the elderly, and those with comorbid medical and psychiatric conditions. More research is necessary to determine the long-term effects of insomnia treatments.     

New potential stimulation targets for noninvasive brain stimulation treatment of chronic insomnia

BackgroundNoninvasive brain stimulation (NIBS) was recently used as a therapeutic application in patients with insomnia. Most of the previous NIBS treatments for insomnia directly selected the dorsolateral prefrontal cortex (DLPFC) as the stimulation site. As the NIBS target is an important factor in the efficacy of NIBS, it is necessary to detect more potential cortical sites for NIBS in insomnia.MethodsA neuroimaging study-based meta-analysis was used to examine sleep-related brain regions. A sleep-associated brain region-based functional connectivity (FC) map was constructed in 50 patients with chronic insomnia disorder (CID) without any comorbidity. We also combined the meta-analysis and FC results to examine the potential surface targets for NIBS for CID.ResultsThe results identified the bilateral supplementary motor area (SMA), left superior temporal gyrus (STG), bilateral DLPFC, precentral lobule, supramarginal gyrus, angular gyrus, superior frontal gyrus, middle temporal gyrus and middle occipital gyrus as potential brain stimulation targets for insomnia treatment. Notably, the bilateral SMA, right DLPFC and left STG were identified in the FC and meta-analyses. In addition, the SMA and DLPFC were positively and STG was negatively connected with other sleep related brain regions, which indicated inhibitory and excitatory stimulation for NIBS treatment for CID, respectively.ConclusionOur study suggests the SMA, DLPFC and STG as preferentially selected brain targets of NIBS for CID treatment. We recommend an inhibitory stimulation over SMA and DLPFC, and an excitatory stimulation over STG for NIBS treatment. Future studies should test these new targets using NIBS treatment for insomnia.     

失眠伴抑郁与单纯失眠患者失眠认知行为治疗的疗效分析

目的分析失眠认知行为疗法(cognitive behavioral therapy on insomnia,CBT-i)对失眠伴抑郁患者以及单纯失眠患者的疗效。方法71例符合失眠症诊断的患者,根据贝克抑郁量表(Beck Depression Inventory,BDI)得分分为单纯失眠组(<14分,33例)和失眠伴抑郁组(≥14分,38例)。2组患者每天填写睡眠日记,并给予8周标准的CBT-i治疗,在治疗前(基线)、治疗第4周、治疗第8周、治疗结束后4周(第3个月)、治疗结束后16周(第6个月)采用匹兹堡睡眠质量指数(Pittsburgh Sleep Quality Index,PSQI)、失眠严重程度指数(Insomnia Severity Index,ISI)、BDI、贝克焦虑量表(Beck Anxiety Inventory,BAI)、SF-36健康调查简表对2组患者睡眠质量、抑郁焦虑程度、个人健康状况等进行评估,采用独立样本t检验进行组间比较,采用重复测量方差分析进行各时间点组内比较。结果与基线时比较,单纯失眠组和失眠伴抑郁组第8周、第3个月和6个月随访时入睡潜伏期、睡眠效率、PSQI、ISI、BDI、BAI、SF-36组内比较差异均有统计学意义。失眠伴抑郁组较单纯失眠组在基线、第8周、第3个月和6个月随访时BAI(t=-6.340、-3.301、-3.511、-2.982)、SF-36(t=4.162、3.195、2.022、3.629)评分差异有统计学意义(P<0.01或0.05),2组ISI评分在第6个月随访时差异有统计学意义[(7.3±4.6)分与(4.7±3.4)分,t=-2.044,P=0.048]。2组入睡潜伏期和睡眠效率以及PSQI的评分在第8周、第3个月和6个月随访时与基线的变化量差异均无统计学意义;而2组BAI、BDI评分在第8周与第3个月和6个月随访时与基线的变化量差异有统计学意义。结论CBT-i对失眠伴抑郁患者和单纯失眠患者均有效,且可以缓解失眠伴抑郁患者的抑郁症状以及改善患者生活质量。     

Behavioral "insomnia" in the child

Most of the causes of sleeplessness in the young child after early infancy are behavioral in nature. These may be primary or they may complicate other disorders. Typical factors include inappropriate associations to the sleep transition process, absent and inconsistent limit setting by caretakers, and various scheduling abnormalities (including unnecessary nighttime feedings). Once proper diagnosis is made, rapid resolution can be expected through behavioral intervention. Even partial arousal symptomatology ("night terrors"), often misdiagnosed at this age, may reflect, and respond to correction of, inappropriate sleeping schedules.     

Behavioral covariation in the treatment of chronic pain

The successful use of operant procedures to alter behaviors associated with various medical conditions suggests that such behaviors may be learned and that the principles of learning may be applied not only to treatment but also to the study of the pathogenesis of illness behavior. The present study, conducted within an ongoing neuromuscular research project, assessed the covariation of behaviors associated with chronic pain within and across behavioral and drug approaches to treatment. Problems of screaming and five other behaviors (including self-reports of pain) were measured across conditions of varying behavioral contingencies (noncontingent reinforcement vs the removal of reinforcement contingent upon screaming) and varying administration (time since medication and dosage) of Parsidol during attempts to treat the muscle pain of a 24-year-old male with a severe, chronic neuromuscular disorder diagnosed as dystonia musculorum deformans (DMD). Results indicated that: (a) pain behaviors covaried during behavioral and drug conditions even though the behavioral intervention only targeted screaming; (b) effects were greater on nontargeted behaviors during periods that followed rather than preceded drug administration; (c) in contrast to behavioral observation data, physiological measures of neuromuscular activity (EMG) did not differ across conditions. These results suggest that functional response-response relationships exist in patients as the result of their illness experience.     

Insomnia: II. Assessment and treatment of chronic insomnia

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

Perfectionism and chronic insomnia

The relationship between chronic insomnia and perfectionism was investigated using a sample of 32 adults with chronic insomnia and 26 healthy controls. Different aspects of perfectionism were measured using two Multi-Dimensional Perfectionism Scales [Frost RO, Marten P, Lahart C, Rosenblate R. The dimensions of perfectionism. Cognit Ther Res 1990;14(5):449-468; Hewitt PL, Flett GL. The Multidimensional Perfectionism Scale: development and validation. Can Psychol 1989;30:339; Hewitt PL, Flett GL. Perfectionism in the self and social contexts: conceptualization, assessment, and association with psychopathology. J Pers Soc Psychol 1991;60:456-470.]. Using a univariate approach, results indicated that those with chronic insomnia were more likely to endorse features of "maladaptive" perfectionism relative to healthy controls. Further, those with chronic insomnia were more likely to report doubts about action, frequent parental criticism, and concern over mistakes. Although those with chronic insomnia were found to be more perfectionistic in these areas, only perception of heightened parental criticism was associated with the reporting of delayed sleep-onset latency. No other aspect of perfectionism was associated with sleep-onset latency, total sleep time, or sleep quality. Implications for theories of the development of insomnia are discussed.     

麻醉睡眠平衡术治疗慢性失眠症的疗效评估

目的 评价麻醉睡眠平衡术治疗慢性失眠症的疗效. 方法 选择第三军医大学大坪医院野战外科研究所脑三科收治的24例慢性失眠症患者,在患者自愿并征得书面同意后给予麻醉睡眠平衡术治疗.采用多导睡眠监测系统及里兹睡眠评估问卷(LSEQ)对患者治疗前后睡眠情况进行评估. 结果 患者经麻醉睡眠平衡术治疗后LSEQ得分增加100分以上患者22例,有效率为22/24(92%).患者在入睡情况、睡眠质量、警觉行为和总分等方面均较治疗前有明显改善,差异均有统计学意义(P<0.05).多导睡眠监测结果 表明:治疗后患者睡眠进程中的总睡眠时间有所延长,而觉醒次数明显减少,相应的觉醒时间也明显缩短,与治疗前比较,差异均有统计学意义(P<0.05),但睡眠潜伏期无明显变化;睡眠结构中的S1期睡眠较治疗前明显减少,S3期、S4期及REM期睡眠则明显增加,差异均有统计学意义(P<0.05),而S2期睡眠却未见明显变化. 结论 麻醉睡眠平衡术是短时间内纠正慢性失眠患者睡眠债务行之有效的方法 ,对部分难治性慢性失眠患者睡眠结构的改善亦有良好的效果.     

Non-benzodiazepines for the treatment of insomnia

Benzodiazepine hypnotics, the mainstay of pharmacological treatment for insomnia, have been associated with altered sleep architecture, psychomotor and memory impairment, rebound insomnia, withdrawal effects, tolerance, dependence, abuse potential and respiratory depression. Non-benzodiazepines, such as zolpidem, zopiclone and zaleplon, demonstrate hypnotic efficacy similar to that of benzodiazepines along with excellent safety profiles. Non-benzodiazepines generally cause less disruption of normal sleep architecture than benzodiazepines. Psychomotor and memory impairment may be less problematic with non-benzodiazepines, especially when compared to longer-acting benzodiazepines. Rebound insomnia and withdrawal symptoms occur infrequently upon discontinuation of non-benzodiazepines and may be less common and milder than those seen upon discontinuation of some benzodiazepines. For the long-term treatment of insomnia, which is generally not recommended, zolpidem and zopiclone are particularly good options because they do not develop tolerance rapidly and have a low abuse potential. Limited data indicate that zaleplon has low tolerance and abuse potential, although further experience is needed to determine its long-term efficacy and safety profile. Since non-benzodiazepines produce minimal respiratory depression, they may be safer than benzodiazepines in patients with respiratory disorders. The choice of which hypnotic to use should be based on the patient's primary sleep complaint, health history, adverse effects and cost.     

Acupuncture treatment for insomnia and acupuncture analgesia

Abstract Acupuncture is a simple and useful treatment for insomnia, with a success rate of around 90%. The acupuncture points applied vary depending on the doctor and on the case, but the usual points are Shenmen (HT7) and Anmien (extrapoint). The mechanism of this treatment has not been well elucidated. Acupuncture analgesia may be used as a great indicator, because in both practices needles are inserted in deep tissues as the common stimulation. The possible neuronal integration and transmitter effect in the acupuncture treatment for insomnia are discussed.     

Cognitive behavioral therapy for shift workers with chronic insomnia

ObjectiveShift work is a challenge in the screening and treatment of chronic insomnia. The aim of this study was to examine the implementation and effectiveness of a cognitive behavioral group intervention for insomnia (CBT-I) among shift workers with chronic insomnia. We also studied whether insomnia symptoms and intervention effects differed on work days and days off.MethodsThe study design was a non-randomized group intervention, including a waiting period prior to CBT-I as a control condition. A total of 19 media workers who worked irregular hours and had non-organic insomnia with features of psychological insomnia completed the study. We followed up with the results for a period of 6 months. Outcomes were assessed using a sleep diary, questionnaires, and actigraphy. The CBT-I groups were led by trained nurses of occupational health services (OHS).ResultsThe post-intervention results showed significant improvements in self-reported and actigraphic sleep onset latency, and in self-reported sleep efficiency, sleep quality, and restedness. In addition, the perceived severity of insomnia, sleep-related dysfunctional cognitions, psychiatric and somatic symptoms, and the mental component of health-related quality of life improved significantly. The improvements lasted and even strengthened over the follow-up period. The participants generally slept significantly better on days off than on work days, but the treatment improved sleep on both.ConclusionsThe study showed that non-pharmacological treatment of insomnia can be implemented among shift workers with chronic insomnia, and delivery of the treatment by trained OHS nurses yields promising results. Some caution, however, is needed when interpreting the results because of the non-randomized study design and small sample size.