Daytime sleepiness in insomnia: Are we focusing on what truly matters?

Insomnia, the most prevalent sleep disorder, is commonly associated with other mental and somatic disorders, making it a significant health concern. It is characterized by nighttime symptoms and daytime dysfunction, with sleepiness being a potential criterion for the latter. Sleepiness is a normal physiological state that is typically experienced near usual bedtime, in normal circumstances. In insomnia, it seems somewhat logical the idea that there is significant daytime sleepiness. However, the topic has been the subject of various discussions in sleep medicine, with studies yielding contradictory and inconsistent results. In this article, we aim to critically examine daytime sleepiness in individuals with insomnia disorder and propose an alternative approach to addressing it, both in clinical practice and research settings. It is crucial to further investigate the role of daytime sleepiness in insomnia, particularly by focusing on sleepiness perception as a more relevant dimension to explore in majority of patients. It is plausible that certain insomnia phenotypes are objectively sleepy during the day, but more studies are necessary, particularly with well-defined clinical samples. The implications of assessing sleepiness perception in insomnia for clinical practice are discussed, and new avenues for research are suggested.

Sleep effort and its measurement: A scoping review.

Insomnia disorder is characterized by disruption in sleep continuity and an overall dissatisfaction with sleep. A relevant feature of insomnia is sleep effort, which refers to both cognitive and behavioural conscious attempts to initiate sleep. The Glasgow Sleep Effort Scale is a self-report tool developed to assess this construct. The objective of the current scoping review was to map how sleep effort has been discussed in the literature and operationalized through its respective measure. Medline/PubMed, Scopus, Web of Science and PsycInfo databases were used to search for potential studies. The search query used in databases was the specific name of the self-reported tool itself (Glasgow Sleep Effort Scale) and "sleep effort" term. This scoping review followed JBI guidelines. To be included, records pertaining to any type of study that mentioned the Glasgow Sleep Effort Scale were considered. No language constraint was used. At the end, 166 initial records were retrieved. From those, 46 records met eligibility criteria and were analysed. Among the main findings, it was observed that the Glasgow Sleep Effort Scale has been increasingly used in recent years, with a notable observed upward trend, especially in the last 2 years. In addition to the original measure, only three published adapted versions of the instrument were identified. This suggests that there is limited research on adapting the scale for different populations or contexts. Sleep effort has been increasingly studied in the last few years. Nonetheless, more research on the Glasgow Sleep Effort Scale tool is recommended, including cross-cultural adaptations.

Does valerian work for insomnia? An umbrella review of the evidence.

Valerian is one of the most used herbal agents (phytotherapeutics) to manage sleep disturbances, in particular, sleep-onset difficulties in young adults. However, the evidence based on primary studies and systematic reviews that supports its use in this domain is weak or inconclusive. In the current study, an umbrella review was performed on the efficacy of valerian for sleep disturbances with a focus on insomnia. As such, only systematic reviews (with or without meta-analysis) were considered for this study. Systematic searches in PubMed, Web of Science, Scopus, Cochrane Database of Systematic Reviews, PROSPERO and CNKI databases retrieved 70 records. Only 8 articles were considered eligible for qualitative analysis. Overall, data suggested that valerian has a good safety profile, however, the results showed no evidence of efficacy for the treatment of insomnia. Moreover, valerian appears to be effective concerning subjective improvement of sleep quality, although its effectiveness has not been demonstrated with quantitative or objective measurements. Despite its widespread use and prescription by general practitioners, psychiatrists and other professionals, valerian does not have empirical support for insomnia. Further studies, in particular high quality randomized controlled trials, are highly recommended since there are scarce studies and the existing ones are quite heterogeneous and with low methodological quality. The implications of our findings for clinical practice are critically discussed.

The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023.

Progress in the field of insomnia since 2017 necessitated this update of the European Insomnia Guideline. Recommendations for the diagnostic procedure for insomnia and its comorbidities are: clinical interview (encompassing sleep and medical history); the use of sleep questionnaires and diaries (and physical examination and additional measures where indicated) (A). Actigraphy is not recommended for the routine evaluation of insomnia (C), but may be useful for differential-diagnostic purposes (A). Polysomnography should be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders, etc.), treatment-resistant insomnia (A) and for other indications (B). Cognitive-behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (including patients with comorbidities), either applied in-person or digitally (A). When cognitive-behavioural therapy for insomnia is not sufficiently effective, a pharmacological intervention can be offered (A). Benzodiazepines (A), benzodiazepine receptor agonists (A), daridorexant (A) and low-dose sedating antidepressants (B) can be used for the short-term treatment of insomnia (≤ 4 weeks). Longer-term treatment with these substances may be initiated in some cases, considering advantages and disadvantages (B). Orexin receptor antagonists can be used for periods of up to 3 months or longer in some cases (A). Prolonged-release melatonin can be used for up to 3 months in patients ≥ 55 years (B). Antihistaminergic drugs, antipsychotics, fast-release melatonin, ramelteon and phytotherapeutics are not recommended for insomnia treatment (A). Light therapy and exercise interventions may be useful as adjunct therapies to cognitive-behavioural therapy for insomnia (B).

Epworth sleepiness scale: A meta-analytic study on the internal consistency.

OBJECTIVE/BACKGROUND: The Epworth Sleepiness Scale (ESS) is one of the most used self-reported instruments to assess sleepiness. Thus, several adaptations into different Languages have been performed worldwide over the years. The scale has produced disparate psychometric properties when applied in different settings. In the current study, our aim was to perform a Reliability Generalization meta-analysis of the Cronbachá¾½s alphas of all published studies on ESS, specifically with a psychometric focus. PATIENTS/METHODS: Three reference databases (Scopus, PubMed and Web of Science) were searched since 1991 to October 2022 and all the records on psychometric or validation studies that reported Cronbach's alphas, from clinical and nonclinical groups, were included. In total, data from 46 publications (63 estimates) were extracted, comprising 92,503 participants. RESULTS: Using a Random-Effects Model, the cumulative Cronbach's alpha for the 63 estimates was about 0.82 (CI: 0.798, 0.832) which can be considered as a good measure. However, and as expected, it was observed a high level of heterogeneity (I2 = 98.96%). Moderation analyses considering setting, date, continent, risk of bias, sex, age and language were performed in order to account for the heterogeneity. Even so, only the variables study setting and continent were significant, and had little importance in explaining the heterogeneity. CONCLUSIONS: The ESS is a reliable tool to measure sleepiness; however, further studies are needed to investigate what variables might explain the observed variability. Moreover, it will be important to include empirical studies beyond psychometric ones.

The Dysfunctional Beliefs and Attitudes about Sleep scale: Dimensions of the European Portuguese DBAS-30 and development of a new short version (DBAS-SF-16).

OBJECTIVES: The Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) is the most widely validated instrument for assessing sleep-related cognitions. This study aimed to examine the reliability of the DBAS-30 European Portuguese version, explore its dimensionality, and develop a new short version suitable for differentiating the presence/absence of insomnia. METHODS: From 824 participants aged 18-85 years, the Insomnia Group (IG, n = 355, 261 females and 94 males) and Normal Sleepers Group (NSG, n = 292, 237 females, 54 males and 1 with no response) were constituted. Thirty-one patients with Obstructive Sleep Apnea Syndrome were also recruited. For the DBAS 16-items version, the ability to differentiate dysfunctional beliefs between people with and without insomnia was used as the main criterion for item retention. RESULTS: DBAS-30 PT demonstrated good internal consistency and significantly discriminated IG from NSG. Based on a robust EFA (RDWLS), a three-dimensional structure was determined for IG (Ageing and Hopelessness, Sleep Expectations, and Consequences and Helplessness). DBAS-SF-16 presented as an internally-consistent measure with a reliable two-factor structure (Consequences and Helplessness, Medication and Hopelessness) and showed construct and known groups validity. ROC analysis demonstrated DBAS-SF-16's relevant clinical accuracy, and 4.3 provides the best cut-off score in detecting the level of dysfunctional beliefs associated with clinical insomnia. CONCLUSIONS: A new and meaningful dimensionality of the DBAS-30 was found. DBAS-SF-16 showed to be a reliable, valid, and robust tool for evaluating dysfunctional beliefs about insomnia in clinical and non-clinical populations.

Insomnia Severity Index: A reliability generalisation meta-analysis.

The aim of the current study was to conduct a reliability generalisation (RG) meta-analysis of Cronbach's alpha for the Insomnia Severity Index (ISI). A systematic search of three databases (PubMed, Scopus, and Web of Science) from inception to 12 March 2021 was performed. Publications that reported Cronbach's alpha for the total ISI score were included. Only psychometric-focussed studies were considered. Meta-analysis was carried out using a random-effects model to derive a pooled estimate of Cronbach's alphas. The number of participants in the included publications ranged from 25 to 12,056, with 33 studies (42 estimates) comprising internal consistency coefficients, and a combined sample size of N = 29,688. The age range of the included publications was from 13.4 to 74.3 years. Data extraction implied 33 publications out of 706 found through the database search. Cronbach's alphas ranged from 0.65 to 0.92. The majority of the reported coefficients were ≥0.7 and presented a low risk of bias (n = 32). The pooled alpha coefficient was 0.83 (IC [0.81-0.85]; SE = 0.009) with high heterogeneity among the included publications (I2  = 97%). Subgroup analyses including moderators such as continent, setting, risk of bias, and age did not affect significantly the overall result. In general, the cumulative estimate of Cronbach's alpha for the ISI is good. However, this finding should be interpreted with caution since there is a high heterogeneity level and some of the studies might not have checked the assumptions underlying Cronbach's alphas.

Psychometric Properties of the Sleep Locus of Control (SLOC) Scale in a Portuguese Sample.

Over the past few decades, research has suggested that cognitive variables play a key role in sleep disorders, particularly, in insomnia. The SLOC (Sleep Locus of Control Scale) evaluates the sleep locus of control, which is associated with the degree to which an individual attributes her/his experiences of sleep to chance or internal causes. The aim of this study was to develop the first translation and adaptation of the SLOC into the European Portuguese, as well as to analyze its psychometric properties. In this study, it was recruited a sample of 2029 Portuguese Higher Education students, aged ≥ 18 years, where approximately 75% of the sample were women and 25% men. The results showed that the SLOC had acceptable internal consistency value (α = .64), considering that it is a measure with a reduced number of items. As in the original study, a principal component analysis with varimax rotation identified two components. A parallel analysis was also conducted, identifying two factors. The correlation between the two subscales "internal sleep locus of control" and "chance sleep locus of control" was positive albeit of low magnitude (r = .15). Through the analysis carried out, it was also observed that individuals with "insomnia", relative to those without, had a more chance sleep locus of control. Overall, these findings show similarities with the original study. The SLOC seems to be a useful psychological assessment measure to be used in clinical and research settings.

Sleep Quality and Insomnia Severity among Italian University Students: A Latent Profile Analysis.

Insomnia is a widespread sleep disorder associated with physical and mental health conditions. Although the heterogeneity of insomnia presentations has been acknowledged, research investigating clinically meaningful insomnia subtypes is still ongoing. This study aimed at exploring insomnia subtypes according to widely-used measures of symptoms severity and sleep quality among Italian university students using a latent profile analysis. Data were collected from 490 students reporting relevant insomnia symptoms through an online cross-sectional survey comprising the Insomnia Severity Index, the Pittsburgh Sleep Quality Index, the 21-item Depression Anxiety Stress Scale, and the Short Form-12. Latent profile analysis identified five insomnia subtypes. The severe insomnia (8.8%) group showed the highest insomnia severity, with diverse complaints concerning sleep quality and daytime functioning. Moderate insomnia with sleep duration complaints (8.4%) and moderate insomnia with medication use (15.9%) subgroups were characterized by middle range insomnia severity, with problems of sleep continuity and sleep medication use, respectively. Subthreshold insomnia with sleep latency complaints (20.4%) and subthreshold insomnia (46.5%) groups showed attenuated insomnia symptoms. Higher psychological complaints and worse quality of life were associated with greater sleep complaints. Overall, these findings highlight the relevance of sleep quality domains in identifying insomnia subtypes and might help optimize insomnia treatments.

Profiles of Subjective Daytime Sleepiness through Cluster Analysis.

Sleepiness propensity and sleepiness perception are two relevant dimensions of the general multidimensional sleepiness construct. In the current study, the aim was to identify eventual homogeneous subgroups when sleepiness propensity and sleepiness perception measures are combined. Data from 678 undergraduate students (aged 17 to 24 years) from a medical school were analyzed. A Two-Step Cluster Analysis was performed taken into consideration sleepiness propensity and sleepiness perception measures as clustering variables. Four different clusters were identified. Additionally, the two groups comprising higher levels of sleepiness perception (i.e., "high perception, low propensity" and "high subjective daytime sleepiness" clusters) had the most compromised results in some of the sleep-related variables examined - sleep needs, sleep latency, sleep quality, sleep sufficiency, self-reported insomnia, sleep reactivity to stress, and cognitive arousal - and in some of non-sleep related variables, such as neuroticism and affect. As to non-sleep variables, those groups reported higher scores in neuroticism, arousability, self-reported mental health and affective states. The identification of distinct groups concerning self-reported sleepiness may bring new avenues for research and understanding of the specific and differential role of sleepiness and its dimensions in sleep health and sleep disturbances, in particular, insomnia disorder.

Differences in Early Maladaptive Schemas between Young Adults Displaying Poor Versus Good Sleep Quality.

Research on the connection between sleep-related problems and Early Maladaptive Schemas (EMS) is scarce. The aim of the current study was to investigate a potential link between EMSs and poor sleep quality. Participants (n = 249) were selected from a larger sample of 1253 European Portuguese college students who completed the BaSIQS and the YSQ-S3. The major inclusion criteria for the selected participants were high versus low scores on the BaSIQS (poor versus good sleep quality). Students with poor sleep quality had significantly higher levels of Abandonment/ Instability, Mistrust/Abuse, Social Isolation/Alienation, Vulnerability to Harm or Illness, Entitlement/Grandiosity, Self-Sacrifice, and Negativity/Pessimism. These data suggest that EMSs are associated with poor sleep quality. However, additional studies are necessary to better understand this relationship.

Mindfulness and self-compassion along the chronotype: a cross-sectional study.

It is well established in the literature that morning-type individuals present better health indicators than evening-types. Mindfulness is considered an adaptive self-regulation skill associated with well-being and physical and mental health. However, there is scarce studies that relate chronotype and mindfulness. Thus, in this research, our aim was to study the relationship between chronotype and mindfulness-related variables. For this purpose, a sample composed of 483 participants from the community was recruited through an online survey and invited to fill out the Five Facet Mindfulness Questionnaire, the Self-Compassion Scale, and the Composite Morningness Scale. Regarding mindfulness measure, the results indicated that morning-types presented higher levels of "acting with awareness" than intermediate and evening-types. Additionally, as to self-compassion measure, morning-types presented higher levels of "mindfulness" and "overall self-compassion" than intermediate and evening-types. The remaining associations examined were not statistically significant. In sum, the morning-types showed higher scores in some of the mindfulness and self-compassion scales which seem to suggest that this morningness tendency may function as protective factor concerning eventual disorders´ development. Nonetheless, more systematic studies are needed to better understand this association and subsequently foster changes for psychological intervention.

Insomnia Disorder and Brain's Default-Mode Network.

PURPOSE OF REVIEW: Insomnia disorder (ID) is a prevalent sleep disorder that significantly compromises the physical and mental health of individuals. This article reviews novel approaches in the study of brain networks and impaired function in ID through the application of modern neuroimaging techniques such as functional magnetic resonance imaging (fMRI). RECENT FINDINGS: The default-mode network (DMN) is presumed to be correlated with self-referential information processing, and it appears to be altered or unbalanced in insomnia. A growing body of evidence suggests the lack of deactivation of brain regions comprising the DMN when insomnia patients are at rest. Moreover, core areas of the DMN demonstrate greater activation in insomnia patients when compared to healthy controls in self-referential related tasks. Despite the few studies on the topic, underpinning the correlation between abnormal DMN activity and ID deserves further attention in the future. Implications for therapeutics are briefly outlined.

Assessing Stress-Induced Sleep Reactivity in College Students: The European Portuguese Version of the Ford Insomnia Response to Stress Test (FIRST).

OBJECTIVE AND BACKGROUND: Over the past few years, the comprehensive models of insomnia have exhibited impressive developments. However, there is scarce knowledge on predisposing or vulnerability factors for insomnia. One of the most promising constructs to aid in filling this gap is stress-induced sleep reactivity assessed through self-report. Our aim was to study the psychometric properties of the European Portuguese version of the Ford Insomnia Response to Stress Test (FIRST). PARTICIPANTS: We recruited a large sample of students attending medical school (N = 699). METHODS: Several analyses were carried out such as internal consistency, construct validity, and discriminant groups' analysis. RESULTS: It was observed that FIRST-PT shows good internal consistency (Cronbach´s alpha = .81) and validity indicators. Interestingly, and contrary to what was observed in the previously published studies on psychometric properties of the FIRST, it was observed that a two-factor solution (Factor I = rumination, Factor II = worry) was the most adequate one to explain the correlation matrix, accounting for approximately 44% of the total variance. CONCLUSIONS: The FIRST-PT proved to be a useful and reliable tool to measure stress-induced sleep reactivity. However, these results should be replicated in other groups, particularly clinical samples, in order to verify the stability of its factorial dimension.