Perfect Enough to Sleep? Perfectionism and Actigraphy-Determined Markers of Insomnia.

OBJECTIVES: Perfectionism is an important factor in insomnia development and maintenance. Previous studies exploring the relationship between perfectionism and insomnia have predominantly relied on self-reported sleep measures. Therefore, this study sought to assess whether actigraphy-measured sleep parameters were associated with perfectionism. METHODS: Sixty adults (85% females, mean age 30.18 ± 11.01 years) were sampled from the Australian general population. Actigraphy-derived objective sleep measures, subjective sleep diary measures, the Frost Multidimensional Perfectionism Scale (FMPS), Hewitt-Flett Multidimensional Perfectionism Scale (HFMPS) and Depression, Anxiety and Stress Scale 21 (DASS-21) were collected. RESULTS: High perfectionism levels were associated with poor sleep, but these relationships differed between objective and subjective measures. Perfectionism via FMPS total score and subscales of Concern over Mistakes, Doubts about Actions, Personal Standards and Self-oriented Perfectionism correlated with subjective sleep onset latency and sleep efficiency with moderate effects (r = .26 to .88). In contrast, perfectionism via HFMPS total score and subscales of Socially Prescribed Perfectionism and Parental Expectations predicted objective sleep onset latency and sleep efficiency. Additionally, stress mediated the relationships between objective sleep efficiency and Concern over Mistakes and Doubts about Actions. CONCLUSIONS: Perfectionism demonstrated stronger associations with subjective than objective sleep measures. Higher Parental Expectations and Socially Prescribed Perfectionism may increase one's vulnerability to objectively measured poor sleep. Therefore, perfectionism may be important in preventing and treating insomnia.

Narcolepsy: Comorbidities, complexities and future directions.

Patients with narcolepsy live with a lifelong sleep-wake disorder, impairing their quality of life, productivity, educational and employment outcomes. Clinicians are becoming aware that a significant aspect of the burden of this disease relates to frequent comorbid conditions, including aspects of the patient's emotional, metabolic, sleep and immune health. This review explores the literature describing the comorbidities seen in patients with narcolepsy, to enhance understanding of these often complex presentations. It hopes to encourage a multidisciplinary approach, to collaborate with patients and a broad clinical team, and to maximise clinical and quality of life outcomes, for those living with narcolepsy.

Prospective cohort study to evaluate the accuracy of sleep measurement by consumer-grade smart devices compared with polysomnography in a sleep disorders population.

OBJECTIVES: Consumer-grade smart devices are now commonly used by the public to measure waking activity and sleep. However, the ability of these devices to accurately measure sleep in clinical populations warrants more examination. The aim of the present study was to assess the accuracy of three consumer-grade sleep monitors compared with gold standard polysomnography (PSG). DESIGN: A prospective cohort study was performed. SETTING: Adults undergoing PSG for investigation of a suspected sleep disorder. PARTICIPANTS: 54 sleep-clinic patients were assessed using three consumer-grade sleep monitors (Jawbone UP3, ResMed S+ and Beddit) in addition to PSG. OUTCOMES: Jawbone UP3, ResMed S+ and Beddit were compared with gold standard in-laboratory PSG on four major sleep parameters-total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO) and sleep efficiency (SE). RESULTS: The accelerometer Jawbone UP3 was found to overestimate TST by 28 min (limits of agreement, LOA=-100.23 to 157.37), with reasonable agreement compared with gold standard for TST, WASO and SE. The doppler radar ResMed S+ device underestimated TST by 34 min (LOA=-257.06 to 188.34) and had poor absolute agreement compared with PSG for TST, SOL and SE. The mattress device, Beddit underestimated TST by 53 min (LOA=-238.79 to 132) on average and poor reliability compared with PSG for all measures except TST. High device synchronisation failure occurred, with 20% of recordings incomplete due to Bluetooth drop out and recording loss. CONCLUSION: Poor to moderate agreement was found between PSG and each of the tested devices, however, Jawbone UP3 had relatively better absolute agreement than other devices in sleep measurements compared with PSG. Consumer grade devices assessed do not have strong enough agreement with gold standard measurement to replace clinical evaluation and PSG sleep testing. The models tested here have been superseded and newer models may have increase accuracy and thus potentially powerful patient engagement tools for long-term sleep measurement.

Management of insomnia in primary care.

Insomnia can have significant health and economic impacts. In contrast, sleep disturbance is common but does not usually affect daytime activity Short-term approaches for acute insomnia are often appropriate. These include dealing with precipitating factors such as stress Chronic insomnia has a high relapse and recurrence rate. It is best managed with cognitive behavioural therapy which includes sleep hygiene, stimulus control and sleep restriction In primary care, brief behavioural therapy for insomnia is an accessible and effective management strategy. If there is no response, referral should be considered Adjuvant use of drugs in insomnia may be appropriate in some cases. Prescription should be for a limited duration.

The DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure identifies high levels of coexistent psychiatric symptomatology in patients referred for insomnia treatment.

PURPOSE: Referrals to sleep psychology services, even for a perceived single problem such as insomnia, can present with complex, coexistent psychiatric symptoms and comorbid disorders. This study aimed to assess the feasibility of implementing the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure (CCSM) into a sleep psychology clinic to identify coexistent psychiatric symptomatology in insomnia referrals. PATIENTS AND METHODS: Patients were 50 consecutive referrals to a private sleep psychology service within a sleep disorders center in Melbourne, Australia. Patients who attended sleep psychology services between June 2015 and January 2017 had their clinical records reviewed. Basic demographic information, comorbidities, and responses to the Insomnia Severity Index were gathered. The Diagnostic and Statistical Manual of Mental Disorders Ed. 5 Task Force and Work Groups created the CCSM in 2013 to deal with the issue of coexistent psychiatric symptomatology across mental health conditions, and this measure was included into the sleep psychology intake procedure and patient responses were reviewed. RESULTS: The CCSM was simple and quick to administer and score and revealed high levels of psychiatric symptomatology in sleep psychology referrals. Sleep problems were the most common domain of psychiatric symptomatology reported (86%). Anxiety (66%), depression (64%), anger (64%), and somatic symptoms (50%) were also very common. Suicidal ideation was acknowledged by 26% of patients. In addition, 82% of patients had at least one diagnosed comorbidity upon referral (eg, psychiatric, physical health, or other sleep disorder). CONCLUSION: The findings support the CCSM as a feasible measure for identifying the high levels of coexistent psychiatric symptomatology in patients presenting for insomnia treatment at sleep psychology services.

User Compliance and Behavioral Adaptation Associated With Supine Avoidance Therapy.

This study investigates behavioral adaptation to vibrotactile position-avoidance therapy during sleep in patients with obstructive sleep apnea (n =135) across 15 to 52 weeks. The overall compliance, based on nights used ≥ 4 hr, was 71%. Overall regular use, that is, ≥ 4 hr/night over 70% of nights, was 88%. Poor early compliance strongly predicted poor long-term treatment adherence, with 92% of those noncompliant across the first 12 weeks of therapy remaining noncompliant. Conversely, 21% of those with compliant utilization in the short term became noncompliant in the long term. It appears that patients do not habituate to the stimulus during sleep, nor was there a training effect associated with long-term use.

Australasian Sleep Association position statement regarding the use of psychological/behavioral treatments in the management of insomnia in adults.

Insomnia disorder is a high prevalence condition with a high disease burden, which, left untreated, can increase risk of poorer health outcomes. Due to Insomnia's tendency towards having a chronic course, long-term treatment approaches are required to reduce the impact of Insomnia over time. After reviewing the available literature, The Australasian Sleep Association (ASA) recommends Cognitive Behavior Therapy for Insomnia (CBT-I) as a first line treatment in the management of Insomnia. The ASA notes that in addition to CBT-I, there is emerging evidence for the use of Mindfulness Based Therapy for Insomnia when used in combination with behavioural techniques (MBT-I). CBT-I should be used whenever possible, and medications should be limited to the lowest necessary dose and shortest necessary duration. CBT-I, whilst the most effective long-term treatment, does not work for everybody across all circumstances, so there will be circumstances in which other treatments are required (e.g., pharmacotherapy). Improving access to CBT-I is an important issue which will involve raising awareness of the effectiveness of CBT-I, increasing the number of trained practitioners, and the development of effective low intensity treatments that can be offered in the first instance.

Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis.

BACKGROUND: Because psychological approaches are likely to produce sustained benefits without the risk for tolerance or adverse effects associated with pharmacologic approaches, cognitive behavioral therapy for insomnia (CBT-i) is now commonly recommended as first-line treatment for chronic insomnia. PURPOSE: To determine the efficacy of CBT-i on diary measures of overnight sleep in adults with chronic insomnia. DATA SOURCES: Searches of MEDLINE, EMBASE, PsycINFO, CINAHL, the Cochrane Library, and PubMed Clinical Queries from inception to 31 March 2015, supplemented with manual screening. STUDY SELECTION: Randomized, controlled trials assessing the efficacy of face-to-face, multimodal CBT-i compared with inactive comparators on overnight sleep in adults with chronic insomnia. Studies of insomnia comorbid with medical, sleep, or psychiatric disorders were excluded. DATA EXTRACTION: Study characteristics, quality, and data were assessed independently by 2 reviewers. Main outcome measures were sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency (SE%). DATA SYNTHESIS: Among 292 citations and 91 full-text articles reviewed, 20 studies (1162 participants [64% female; mean age, 56 years]) were included. Approaches to CBT-i incorporated at least 3 of the following: cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation. At the posttreatment time point, SOL improved by 19.03 (95% CI, 14.12 to 23.93) minutes, WASO improved by 26.00 (CI, 15.48 to 36.52) minutes, TST improved by 7.61 (CI, -0.51 to 15.74) minutes, and SE% improved by 9.91% (CI, 8.09% to 11.73%). Changes seemed to be sustained at later time points. No adverse outcomes were reported. LIMITATION: Narrow inclusion criteria limited applicability to patients with comorbid insomnia and other sleep problems, and accuracy of estimates at later time points was less clear. CONCLUSION: CBT-i is an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes. PRIMARY FUNDING SOURCE: None. (PROSPERO registration number: CRD42012002863).

A randomized controlled trial of cognitive behavioral therapy for insomnia: an effective treatment for comorbid insomnia and depression.

UNLABELLED: Insomnia and depression are highly comorbid conditions that show a complex, bidirectional relationship. This study examined whether cognitive-behavioral therapy for insomnia (CBT-I) delivered by a therapist compared with self-help CBT-I (written materials only) reduces insomnia and depression severity in individuals with comorbid insomnia and depression. A total of 41 participants (18-64 years; 25 females) with comorbid depression and insomnia, treated with antidepressants for at least 6 weeks, were randomized to receive 4 sessions of either CBT-I or self-help CBT-I over 8 weeks. Insomnia (Insomnia Severity Index [ISI]) and depression (Beck Depression Inventory-II [BDI-II]) were assessed at baseline, following each session, and at 3-month follow-up. Secondary outcomes were sleep quality and duration (actigraphy and diaries), anxiety, fatigue, and daytime sleepiness. Compared with self-help CBT-I, BDI-II scores in the CBT-I group dropped by 11.93 (95% confidence interval [CI] [6.60, 17.27], p < .001) more points, and ISI scores dropped by 6.59 (95% CI [3.04, 10.15], p = .001) more points across treatment. At 3-month follow-up, 61.1% of CBT-I participants were in clinical remission from their insomnia and depression, compared with 5.6% of the self-help group. CONCLUSIONS: CBT-I administered by a therapist produced significant reductions in both insomnia and depression severity posttreatment and at follow-up, compared with a control condition in which participants received only written CBT-I material. Targeting insomnia through CBT-I is efficacious for treating comorbid insomnia and depression, and should be considered an important adjunct therapy for patients with depression whose symptoms have not remitted through antidepressant treatment.

Insomnia: prevalence, consequences and effective treatment.

Insomnia is common and can have serious consequences, such as increased risk of depression and hypertension. Acute and chronic insomnia require different management approaches. >Chronic insomnia is unlikely to spontaneously remit, and over time will be characterised by cycles of relapse and remission or persistent symptoms. Chronic insomnia is best managed using non-drug strategies such as cognitive behaviour therapy. For patients with ongoing symptoms, there may be a role for adjunctive use of medications such as hypnotics.

The emergence of devastating impulse control disorders during dopamine agonist therapy of the restless legs syndrome.

INTRODUCTION: The Restless Legs Syndrome is a common sensorimotor disorder, typically amenable to treatment with dopamine agonist therapy. Dopamine agonists have been associated with emergent impulse control disorders (ICDs) when used in patients with Parkinson disease, and ICDs have now been reported in individuals with RLS on dopamine agonist therapy. Our aim was to characterize cases of emergent ICDs in Australian patients with focus on the dopamine agonists implicated and the social significance of ICDs. METHOD: A series of RLS patients on dopamine agonist therapy were identified with ICDs over a 2-year period. Additional cases of ICDs were found using a mailout questionnaire designed to capture those with high impulsivity. These patients were assessed using the Barratt Impulsiveness Scale, Version 11, and a modified Minnesota Impulse Disorders Interview. Case records and medication schedules were evaluated. RESULTS: Twelve cases of patients with de novo ICDs were found with a range of impulsive behaviors including pathological gambling, kleptomania, compulsive shopping, and hypersexuality. Criminality, suicidality, and marital discord also were featured. These occurred over a wide range of latencies and l-dopa exposures. DISCUSSION: This group of Australian RLS patients with ICDs display high levels of impulsivity and is the first to use the BIS-11 questionnaire in this setting. Impulse control disorders can occur over a wide range of dopamine agonist therapy types and dose exposures. Impulse control disorder tendencies may persist, despite withdrawal of dopamine agonists. The emergence of ICDs needs careful consideration in light of their potentially devastating financial, social, and marital consequences.

Excessive daytime somnolence in spinocerebellar ataxia type 1.

Autosomal dominant spinocerebellar ataxias (SCAs) are progressive neurodegenerative disorders which result in dysfunction of the neuronal systems of the spinal cord, brainstem, and cerebellum. The manifestations of daytime somnolence and abnormal sleep behavior have been described in SCA type 3 (SCA3) and SCA type 6 (SCA6), but as yet have not been described in SCA type 1 (SCA1). We report two cases of sleep disturbance, fatigue and excessive daytime somnolence in individuals with SCA1 and their progress through several therapies. These case studies are unique as they describe excessive daytime somnolence and sleep abnormalities in SCA1.

Prevalence of sleep disordered breathing in paroxysmal and persistent atrial fibrillation patients with normal left ventricular function.

AIMS: Recent studies have suggested an emerging link between sleep apnoea and atrial fibrillation (AF). These studies included patients with reduced left ventricular (LV) function which may cause both AF and sleep disordered breathing (SDB). We examined the prevalence of SDB in a population of patients with AF and normal LV function. METHODS AND RESULTS: Ninety patients with paroxysmal or persistent AF and 45 controls were prospectively enrolled and matched 2:1 for age (AF 56 +/- 12 years; controls 54 +/- 11years) and sex. All patients had normal LV function. SDB was diagnosed using all-night portable polysomnography. Apnoea-hypopnoea index (AHI) in AF patients was higher than in controls (23.19 +/- 19.26 vs. 14.66 +/- 12.43, P = 0.01). The proportion with significant SDB (AHI > 15) was also greater in AF patients (62 vs. 38%, P = 0.01). After adjustment for relevant covariates, the odds ratio for the association between AF and SDB (AHI > 15) was 3.04 (95% CI 1.24-7.46, P = 0.02). The paroxysmal AF group was classified as either 'low-frequency AF' (< or =6) or 'high-frequency AF' (>6) episodes in the past year. High-frequency AF was associated with a higher prevalence (75 vs. 43%, P = 0.012) and severity (mean AHI 28.08 +/- 22.94 vs. 16.69 +/- 15.06, P = 0.028) of SDB when compared with those with low-frequency AF. CONCLUSION: A high prevalence of SDB is found in relatively young patients with both paroxysmal and persistent AF with normal LV function. This AF population warrants careful consideration for the presence of SDB.