The two-factor structure of sleep complaints and its relation to depression and anxiety.

Although sleep complaints are common in depression and anxiety, there is little agreement as to how they should be organized and assessed. It is also unclear whether sleep complaints show specificity with certain disorders or whether they are nonspecific symptoms. The authors examined the structure of sleep complaints and the relations of these complaints to depression and anxiety in 3 samples: college students, older adults, and psychiatric patients. Exploratory and confirmatory factor analyses indicated that sleep complaints consistently defined 2 distinct dimensions: Insomnia and Lassitude. The Insomnia factor included indicators of early, middle, and late insomnia, as well as poor sleep quality. The Lassitude factor included measures of hypersomnia, fatigue, and sleepiness. Both factors were significantly related to symptoms and diagnoses of depression and anxiety. However, Lassitude was more strongly related to symptoms of depression and anxiety than was Insomnia. In addition, Lassitude showed specificity to measures and diagnoses of depression compared with anxiety disorders. This specificity can be explained by Lassitude's relation with negative and positive emotionality, both of which are components of depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comorbidity of mental and insomnia disorders in the general population

The co-occurrence of insomnia and mental disorders constitutes the most prevalent diagnosis pattern found in sleep disorder clinics. Yet, there remains a paucity of epidemiological information regarding comorbidity of mental disorders and sleep disorder symptomatology in the general population. The present study showed results based on a large representative French cohort (n = 5,622; 80.7% of the contacted stratified sample). A total of 997 (17.7%) individuals with insomnia complaints were identified and divided into six diagnostic categories: (1) Insomnia related to a Depressive Disorder; (2) Insomnia related to an Anxiety Disorder; (3) Depressive Disorder accompanied by insomnia symptomatology; (4) Anxiety Disorder accompanied by insomnia symptomatology; (5) Primary Insomnia; and (6) isolated insomnia symptomatology. Telephone interviews were conducted using the Sleep-Eval System. Subjects with insomnia related to a Mental Disorder have a longer history of insomnia complaints and are usually younger than those with Depressive or Anxiety Disorders accompanied by insomnia symptoms. Subjects with Insomnia related to a Depressive Disorder experienced more repercussions than any other group. A surprisingly high percentage of individuals with depressive symptomatology had sought independent medical treatment specifically for their sleep problems, which raises the unsettling possibility that many cases of depression go undetected by the general medical community. The distinct predictability of commonly undiagnosed depression leading to chronic depression speaks directly to the imperative that physicians receive additional training in this area of community mental health.     

Two occult causes of insomnia and their therapeutic problems

Insomnia may be associated with a sleep-induced apnea syndrome in nonobese patients who snore. The "central" type of apnea appears to be predominant in this population, in opposition to Pickwickian and nonobese hypersomniacs. An abnormal "swallowing reflex syndrome," also induced by sleep, may be a differential diagnosis. Sleeping pills that are central nervous system depressants should be cautiously prescribed for patients with such syndromes.     

Sommeil, insomnie et psychopathologie.

Sleep plays a critical role in psychological well-being and adaptation. Not surprisingly, sleep disturbance is a frequent problem among individuals facing situational psychological difficulties as well as among those with more chronic psychopathology. This article examines the relationship among sleep, insomnia, and psychopathology. In the first section, we address the issue of comorbidity by examining prevalence rates of sleep disturbances in the general population and among subgroups of individuals with selected psychopathologies and, conversely, rates of psychological symptoms/syndromes among individuals with and without sleep disturbances. The data indicate high rates of psychological syndromes (40%) associated with insomnia among community-based samples, and even higher rates (80%) of sleep disturbances among selected samples of patients with psychopathology. Comorbidity is particularly high among patients with insomnia, major depression, and generalized anxiety disorder. Although insomnia is often a symptom of an underlying psychopathology, longitudinal studies show that it can also be an important risk factor for a new onset major depressive disorder. The second section of this article summarizes the main subjective and EEG sleep impairments in selected anxiety disorders, mood disorders, and schizophrenia. Insomnia is a common clinical feature or even a diagnostic criterion of several of those disorders. Other related symptoms such as fatigue, low energy and poor concentration are shared across insomnia, major depression, and generalized anxiety disorder, suggesting some common mechanisms among those conditions. In addition to subjective sleep complaints, there is also evidence of EEG sleep abnormalities, such as impairment of sleep continuity, reduced slow wave sleep, and altered REM sleep patterns, with the latter two features being more specific to mood disorders. The third section of this article examines the effects of insomnia treatment on co-existing psychological symptoms or disorders and, conversely, the effects of treatment of selected anxiety and mood disorders on sleep. These results indicate that treatments of depression and anxiety may produce some sleep improvements but, in many cases, residual sleep disturbances persist and may actually increase the risk of subsequent relapse. The main implication is that treatment should directly target both co-existing conditions. Additional implications for the treatment and prevention of comorbid sleep disturbances and psychopathology and for future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychotherapeutic agents in older adults. Sedative hypnotics and sleep

Complaints about sleep are prominent among geriatric patients. Insomnia is a prominent feature of many psychiatric and general medical conditions. The physiologic effects of aging and primary sleep disorders also contribute to insomnia, sleep pattern changes, daytime sleepiness, and dozing. The clinical approach to insomnia requires a thorough diagnostic assessment as well as study of sleep habits and hygiene. Hypnotic agents may be useful in providing short-term relief. Pharmacologic intervention is best combined with nonpharmacologic approaches that improve the efficiency of sleep.     

Treatment of insomnia. Getting to the root of sleeping problems

Insomnia may be periodic and transient, as caused by situational stress, or persistent, as caused by a chronic sleep disorder. Physicians can gain much information concerning the type, probable cause, onset, and duration of insomnia through history taking. A sleep diary may reveal helpful information, and input from the patient's sleeping partner can also be valuable. Complicating disorders, such as heart failure, prostatism, or depression, should be sought and specific treatment prescribed. Chemical dependency, too, requires appropriate treatment. These measures, institution of good sleep-hygiene practices, and behavior modification may resolve sleeplessness. The primary indication for use of hypnotic agents is transient sleep disruption caused by acute stress. When an agent is chosen, onset of action, metabolism, and side effects should be considered, especially in elderly patients. Addictive agents should not be given to patients with substance abuse problems. If insomnia persists, evaluation at a sleep-disorder center is recommended to facilitate design of an appropriate therapeutic regimen.     

A behavioural basis for distinguishing wakefulness from sleep in insomniac and good sleepers.

Distinguished between the sleep of normal Ss and insomniacs, using the behaviorally-based sleep/wake monitor. 18 Ss with insomnia (aged 26–65 yrs) and 11 controls (aged 30–44 yrs) underwent a hearing test, and completed the Brock Sleep and Insomnia Questionnaire (K. A. Cote and R. D. Ogilvie, 1993). They used the behavioral response sleep/wake monitors for 3 consecutive nights, to assess behavioral sleep data. Results indicate group differences for wakefulness, sleep onset latency, total percent sleep, and percent wakefulness prior to sleep onset. Significant night effects were present in a number of measures. Group by Night interactions were found for total percent sleep, and after sleep onset, total percent wakefulness and after sleep onset. These findings support differences between normal and insomniac sleep. (French abstract) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nursing management of sleep disorders: Part 1--Assessment

Insomnia and hypersomnia are the two most frequent sleep complaints. This article will focus on the assessment of these two symptoms. A thorough assessment, which includes a sleep history, information about the person's habits, a family history, a social history, a health history and a physical examination is necessary to determine the cause of patients' symptoms.     

Idiopathic hypersomnia

Idiopathic hypersomnia is not as well delineated as narcolepsy and its history is much more recent. There are at least two forms of the disorder: (1) a polysymptomatic form, characterized by excessive daytime sleepiness, nocturnal sleep of abnormally long duration, and signs of sleep drunkenness on awakening, and (2) a monosymptomatic form that manifests only by excessive daytime sleepiness. The most widely used laboratory procedures are nocturnal polysomnographic recording following by an MSLT demonstrating a mean sleep latency of less than 10 minutes. At least in the polysymptomatic form, however, continuous polysomnography on an ad lib protocol deserves to be performed to catch the abnormally long major sleep episode and the long unrefreshing naps. Idiopathic hypersomnia is probably one of the most overdiagnosed sleep disorders. Several other disorders must be excluded before the diagnosis can be considered conclusive. Treatment of idiopathic hypersomnia relies on stimulants, which are frequently less effective and less well tolerated than in narcolepsy.     

Reliability and validity of Women's Health Initiative Insomnia Rating Scale.

The reliability and construct validity of the 5-item Women's Health Initiative Insomnia Rating Scale (WHIIRS) were evaluated in 2 studies. In Study 1, using a sample of 66,269 postmenopausal women, validity of the WHIIRS was assessed by examining its relationship to other measures known to be related to sleep quality. Reliability of the WHIIRS was estimated using a resampling approach; the mean alpha coefficient was .78. Test-retest reliability coefficients were .96 for same-day administration and .66 after a year or more. Correlations of the WHIIRS with the other measures were in the predicted directions. Study 2 used a sample of 459 women and compared the WHIIRS with objective indicators of sleep quality. Results showed that differences in the objective indicators could be detected by the WHIIRS. Findings suggest that a between-group mean difference of approximately 0.50 of a standard deviation on the WHIIRS may be clinically meaningful. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Disorders of excessive daytime sleepiness--an update

Disorders of excessive daytime sleepiness (EDS) constitute a major health hazard, since impaired alertness may lead to accidents and poor quality of life, and some of them are associated with increased cardiovascular morbidity and mortality. Many disorders of EDS are neurological diseases (e.g. narcolepsy and periodic limb movements in sleep, PLMS). The largest group of disorders causing EDS consists of sleep-related disturbances of breathing, where neuroregulatory mechanisms play a major role in pathophysiology. Many patients with neurodegenerative and neuromuscular diseases suffer from sleep disturbances associated with EDS. Therefore, neurologists must be acquainted with the differential diagnosis of EDS and the major categories of sleep disorders causing it. The present update focuses on major sleep disorders causing EDS, and approaches the topic from the neurologist's perspective. Rather than being an extensive review, this update includes recent data on epidemiology, pathophysiology, diagnosis and treatment of obstructive sleep apnea and related conditions (increased upper airway resistance syndrome, central sleep apnea), as well as of narcolepsy and PLMS. Also included are recent data concerning EDS in neurodegenerative (Alzheimer's disease, Parkinson's disease, multiple system atrophy) and neuromuscular disorders.     

Characteristics of apneas and hypopneas during sleep and relation to excessive daytime sleepiness

STUDY OBJECTIVES: One of the most important symptoms in patients evaluated for possible obstructive sleep apnea syndrome is excessive daytime sleepiness, but the measures of apnea severity and of sleepiness used most commonly have not generally shown strong associations. We explored whether information recorded during standard polysomnography, other than the overall rate of apneas and hypopneas per hour of sleep (AHI), might help explain the measured severity of sleepiness. DESIGN: Observational SETTING: A clinical sleep laboratory in a university hospital PATIENTS: N = 1,146 patients evaluated for suspected sleep-disordered breathing with nocturnal polysomnograms and multiple sleep latency tests. RESULTS: The AHI during supine sleep (recorded in a subgroup of n = 169 subjects), the rate of apneas (n = 1,146), and the rate of obstructive apneas (n = 1,146) were particularly useful in explaining variation in measured levels sleepiness; rates of hypopneas and central apneas were less useful (n = 1,146). In addition, the minimum recorded oxygen saturation (n = 1,097) was as important as the AHI to the level of sleepiness. CONCLUSIONS: In an attempt to explain excessive daytime sleepiness among patients evaluated for sleep-disordered breathing, additional insight is provided by observation of supine sleep during polysomnography, by emphasis on apneas rather than hypopneas, by emphasis on obstructive rather than central events, and by consideration of the minimum oxygen saturation.     

Parent and child reports of sleep problems associated with early-onset bipolar spectrum disorders.

Despite sleep problems being part of the diagnostic criteria for mood disorders, research on sleep difficulties related to early-onset bipolar spectrum disorders (EBSDs) is sparse. The authors examined the parent and child agreement, frequency, and severity of EBSD-related manic, depressive, and comorbid sleep problems. A sample of one hundred thirty-three 8- to 11-year-olds with EBSDs was assessed with parental and self-report measures of EBSD-related sleep problems. Dimensional and categorical measures indicated low agreement and high discrepancy between parent and child reports of EBSD sleep problems. Subsequent combination of parent-child data revealed the majority (96.2%) of children had moderate-to-severe sleep problems related to manic, depressive, or comorbid symptoms, either currently or during their worst mood period. More depression-related sleep problems than mania-related sleep problems were reported, especially initial insomnia. Over half the sample had sleep problems associated with current comorbidity, particularly separation anxiety disorder. These findings, their implications, and study limitations are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical aspects of sleep disorders--experiences with 817 patients of an ambulatory sleep clinic; comment

Between 1992, the year in which the Sleep Out-Patient Clinic at the Department of Psychiatry, University of Vienna, Allgemeines Krankenhaus (General Hospital) Vienna, was established, and 1996, 817 patients (58% females, average age 52 years; 42% males, average age 48 years) were treated for sleep disorder. According to the International Statistical Classification of Diseases and Related Health Problems (ICD-10) of the World Health Organization (WHO), 70% of the patients presented with a non-organic sleep disorder and 30% with an organic sleep disorder as main diagnosis. Non-organic insomnia was by far the most frequently diagnosed sleep disorder (48%), while within the organic sleep disorders sleep apnea was dominant (12%). In regard to the additional non-organic (mental disorder) diagnoses rounding off the clinical picture, neurotic, stress related, and somatoform disorders were the most common (41%), followed by affective disorders (31%) and mental and behavioural disorders due to intake of psychoactive substances, e.g. alcohol, drugs (15%). Additional organic diagnoses related to sleep disorders involved primarily endocrine disorders such as adipositas (23%), followed by cardiovascular disorders (19%), and primary snoring (17%). The sleep out-patient clinic has at its disposal a supportive diagnostic armamentarium such as all-night sleep polysomnography, 24-hour polysomnography, the Multiple Sleep Latency Test, EEG and EEG-mapping in the affiliated sleep laboratory, the evaluation of event-related potentials (P300) and actometry in the psychophysiological laboratory, as well as psychological and psychophysiological tests in the clinical psychodiagnostic laboratory, in order to determine the right treatment or preventive measures for the individual patients.     

Sleep apnea

Regular and unobstructed breathing during the night is the prerequisite for an undisturbed and restful sleep. The most prevalent nocturnal breathing disturbance with morbid consequences is the obstructive sleep apnea syndrome. Forms severe enough to need therapy and, therefore, a thorough work-up, can be usually detected by a detailed history. Pathophysiology, clinical findings, differential diagnosis as well as work-up and therapy of the sleep apnea syndrome are discussed.     

Assessment of intervention for infant night waking: Parental reports and activity-based home monitoring.

Sleep patterns of 50 infants (aged 9–24 mo) with sleep disturbances were studied by using an activity monitor (actigraph) and parental reports during the baseline and intervention periods. Two behavioral intervention methods were used to treat the multiple or prolonged night-waking problems. Infant sleep significantly improved during the period of intervention as measured by both actigraphic and parental monitoring. The discrepancy between parental and actigraphic measures increased over time, as did the number of omitted items from the parental daily logs. The results highlight some of the advantages as well as some of the limitations of actigraphic and parental monitoring of infant sleep, and they suggest that the 2 methods may have complementary roles in assessing intervention efficacy in this field. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Obstructive sleep apnea during pregnancy resulting in pulmonary hypertension

Obesity is known to increase maternal morbidity and mortality. We describe a case of obstructive sleep apnea due to obesity and discuss our treatment of the resulting pulmonary hypertension. A patient was transferred to our hospital at 29 weeks' gestation with severe anasarca and more than a 100-pound weight gain during pregnancy. Pulmonary hypertension due to obstructive sleep apnea was diagnosed. The patient was treated with nasal continuous positive airway pressure (CPAP) during sleep and remained in the hospital the remainder of her pregnancy. She had a massive spontaneous diuresis during her hospital stay and lost more than 100 pounds. She was delivered at term via cesarean section because of transverse lie. Preoperative hemodynamic monitoring confirmed the diagnosis of pulmonary hypertension. This represents the first case in the literature of obstructive sleep apnea leading to pulmonary hypertension in pregnancy. This patient responded well to nasal CPAP as evident by the massive diuresis and good maternal outcome.     

Insomnia and the eye of the beholder: Are there clinical markers of objective sleep disturbances among adults with and without insomnia complaints?

Previous findings suggest that some who report insomnia sleep well, whereas some noncomplaining individuals sleep rather poorly. This study was conducted to determine if mood, anxiety, and sleep-related beliefs might relate to perceived sleep disturbance. Thirty-two women and 32 men (aged 40–79 years) with primary insomnia and an aged-matched sample of 61 normal sleepers (31 women, 30 men) completed 6 nocturnal sleep recordings, as well as the Beck Depression Inventory (BDI), the Trait portion of the State-Trait Anxiety Inventory (STAI-2), and the Dysfunctional Beliefs and Attitudes About Sleep Questionnaire. Sleep and interview data were used to subdivide the majority of the sample (n?=?108) into objective normal sleepers and subjective insomnia sufferers who seemingly slept well and subjective normal sleepers and objective insomnia sufferers who slept poorly. The 2 subjective subgroups showed the most marked differences on most of the psychometric measures. The findings suggest that the psychological factors scrutinized in this study may mediate sleep satisfaction and/or predict objective sleep difficulties. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Fatigue following traumatic brain injury: Frequency, characteristics, and associated factors.

Objectives: To document the frequency, characteristics, and factors associated with fatigue following traumatic brain injury (TBI). Design: Survey methodology and multivariate statistical design. Setting: Rehabilitation center and community. Participants: 452 participants aged 16 years and over with minor to severe TBI who answered a questionnaire measuring diverse aspects of fatigue as well as different dimensions of psychological distress, pain, and sleep quality. Measures: Proportion of participants reporting being significantly fatigued. Validated measures of fatigue, sleep quality, and psychological distress. Results of a logistic regression analysis. Results: Significant fatigue was reported by 68.5% of participants. Mental fatigue was the most prominent type of fatigue, followed by physical fatigue. Fatigue was present even several years following the accident and had many perceived impacts on day-to-day function. Factors associated with fatigue were a shorter time since injury; being on long-term disability leave; and higher levels of sleep problems, cognitive disturbances, and anxiety. Conclusion: Fatigue is a prevalent problem after TBI that requires more clinical and scientific attention because it probably has important repercussions on the quality of rehabilitation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Countercontrol treatment of sleep-maintenance insomnia in relation to age.

Administered countercontrol behavioral therapy for sleep-maintenance insomnia to 34 insomniacs (aged 35–78 yrs) in small groups. 22 Ss received immediate and 12 received delayed treatment. Three self-report measures of sleep disruption were collected on daily sleep diaries at baseline, termination of treatment, 1-mo follow-up, and 12-mo follow-up. Although amount of time awake at night was correlated with age, response to treatment was not. Even though older Ss experienced more time awake after sleep onset prior to treatment, they were able to profit from therapy as well as the younger insomniacs. Countercontrol therapy reduced the sleep complaint for the total group by about 30% at the end of treatment, with gradual improvement continuing through a 4-wk follow-up. It is suggested, however, that sleep-maintenance insomnia may be more difficult to treat than sleep-onset problems. (21 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)