The Hierarchy of Coupled Sleep Oscillations Reverses with Aging in Humans.

A well orchestrated coupling hierarchy of slow waves and spindles during slow-wave sleep supports memory consolidation. In old age, the duration of slow-wave sleep and the number of coupling events decrease. The coupling hierarchy deteriorates, predicting memory loss and brain atrophy. Here, we investigate the dynamics of this physiological change in slow wave-spindle coupling in a frontocentral electroencephalography position in a large sample (N = 340; 237 females, 103 males) spanning most of the human life span (age range, 15-83 years). We find that, instead of changing abruptly, spindles gradually shift from being driven by slow waves to driving slow waves with age, reversing the coupling hierarchy typically seen in younger brains. Reversal was stronger the lower the slow-wave frequency, and starts around midlife (age range, ∼40-48 years), with an established reversed hierarchy between 56 and 83 years of age. Notably, coupling strength remains unaffected by age. In older adults, deteriorating slow wave-spindle coupling, measured using the phase slope index (PSI) and the number of coupling events, is associated with blood plasma glial fibrillary acidic protein levels, a marker for astrocyte activation. Data-driven models suggest that decreased sleep time and higher age lead to fewer coupling events, paralleled by increased astrocyte activation. Counterintuitively, astrocyte activation is associated with a backshift of the coupling hierarchy (PSI) toward a "younger" status along with increased coupling occurrence and strength, potentially suggesting compensatory processes. As the changes in coupling hierarchy occur gradually starting at midlife, we suggest there exists a sizable window of opportunity for early interventions to counteract undesirable trajectories associated with neurodegeneration.SIGNIFICANCE STATEMENT Evidence accumulates that sleep disturbances and cognitive decline are bidirectionally and causally linked, forming a vicious cycle. Improving sleep quality could break this cycle. One marker for sleep quality is a clear hierarchical structure of sleep oscillations. Previous studies showed that sleep oscillations decouple in old age. Here, we show that, rather, the hierarchical structure gradually shifts across the human life span and reverses in old age, while coupling strength remains unchanged. This shift is associated with markers for astrocyte activation in old age. The shifting hierarchy resembles brain maturation, plateau, and wear processes. This study furthers our comprehension of this important neurophysiological process and its dynamic evolution across the human life span.

Chronic insomnia, REM sleep instability and emotional dysregulation: A pathway to anxiety and depression?

The world-wide prevalence of insomnia disorder reaches up to 10% of the adult population. Women are more often afflicted than men, and insomnia disorder is a risk factor for somatic and mental illness, especially depression and anxiety disorders. Persistent hyperarousals at the cognitive, emotional, cortical and/or physiological levels are central to most theories regarding the pathophysiology of insomnia. Of the defining features of insomnia disorder, the discrepancy between minor objective polysomnographic alterations of sleep continuity and substantive subjective impairment in insomnia disorder remains enigmatic. Microstructural alterations, especially in rapid eye movement sleep ("rapid eye movement sleep instability"), might explain this mismatch between subjective and objective findings. As rapid eye movement sleep represents the most highly aroused brain state during sleep, it might be particularly prone to fragmentation in individuals with persistent hyperarousal. In consequence, mentation during rapid eye movement sleep may be toned more as conscious-like wake experience, reflecting pre-sleep concerns. It is suggested that this instability of rapid eye movement sleep is involved in the mismatch between subjective and objective measures of sleep in insomnia disorder. Furthermore, as rapid eye movement sleep has been linked in previous works to emotional processing, rapid eye movement sleep instability could play a central role in the close association between insomnia and depressive and anxiety disorders.

Acceptance and Commitment Therapy, Combined with Bedtime Restriction, versus Cognitive Behavioral Therapy for Insomnia: A Randomized Controlled Pilot Trial.

INTRODUCTION: Cognitive behavioral therapy for insomnia (CBT-I) is the current first-line treatment for insomnia. However, rates of nonresponse and nonremission are high and effects on quality of life are only small to moderate, indicating a need for novel treatment developments. We propose that Acceptance and Commitment Therapy (ACT) addresses core pathophysiological pathways of insomnia. ACT therefore has the potential to improve treatment efficacy when combined with bedtime restriction, the most effective component of CBT-I. The aim of this study was to compare the efficacy of ACT for insomnia combined with bedtime restriction (ACT-I) and CBT-I in improving insomnia severity and sleep-related quality of life. METHODS: Sixty-three patients with insomnia disorder (mean age 52 years, 65% female, 35% male) were randomly assigned to receive either ACT-I or CBT-I in a group format. The primary outcomes were insomnia severity (Insomnia Severity Index) and sleep-related quality of life (Glasgow Sleep Impact Index). Outcomes were assessed before randomization (T0), directly after treatment (T1), and at 6-month follow-up (T2). RESULTS: The results indicated significant, large pre-to-post improvements in both groups, for both primary and secondary outcomes. Improvements were maintained at the 6-month follow-up. However, there was no significant group by time interactions in linear mixed models, indicating an absence of differential efficacy. On a subjective treatment satisfaction scale, patients in the ACT-I group indicated significantly greater satisfaction with their improvement of several aspects of health including their energy level and work productivity. CONCLUSIONS: The results suggest that ACT-I is feasible and effective, but not more effective than CBT-I for the improvement of insomnia severity and sleep-related quality of life. Future studies are needed to assess whether ACT-I is noninferior to CBT-I and to shed light on mechanisms of change in both treatments.

Insomnia symptoms as risk factor for somatic disorders: An umbrella review of systematic reviews and meta-analyses.

The objective of this umbrella review is to present a comprehensive summary of systematic reviews and meta-analyses on the longitudinal association between insomnia and the risk of developing somatic disorders. Pubmed, Medline, CINAHL, PsycInfo and PsycArticles were searched until 16 December 2022. Fourteen systematic reviews and meta-analyses met the inclusion criteria. Results suggest that insomnia symptoms (i.e. aspects of disturbed sleep continuity as a single symptom) convey a risk factor for cardiovascular diseases, hypertension and thyroid cancer. The presence of insomnia symptoms may also enhance the risk for obesity, cognitive decline and dementia-however, results are contradictory and not conclusive here. Results do not suggest an association between insomnia symptoms and mortality. No conclusions can be drawn regarding insomnia disorder because the reviews did not ensure a valid diagnosis. It remains unclear what proportion of participants with insomnia symptoms fulfil diagnostic criteria for insomnia disorder and/or suffer from an organic sleep disorder such as sleep-related breathing disorder. Moreover, most of the included reviews were assessed to have critically low confidence according to the AMSTAR-2 tool. Inconsistent definitions of insomnia and methodological unclarities further underline that results should be interpreted with caution. There is a need for future longitudinal studies that focus on a careful definition and differential diagnosis of both insomnia and the outcome.

Cognitive behavioural therapy for insomnia in inpatient psychiatric care: a systematic review.

Insomnia is highly prevalent among patients with psychiatric disorders. According to current guidelines, cognitive behavioural therapy for insomnia (CBT-I) represents the first-line treatment for chronic insomnia, also for patients with psychiatric comorbidity. While recent studies have demonstrated that CBT-I not only improves insomnia but also other health outcomes in patients with psychiatric disorders and comorbid insomnia in outpatient settings, the level of implementation and treatment potential of CBT-I in inpatient psychiatry is less clear. The objective of this systematic review is to present and discuss studies that have adapted CBT-I for inpatient psychiatric care. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO, were searched until June 2023. A total of 10 studies were identified, with the majority being non-randomised trials without comparison groups and small sample sizes. With preliminary character, studies report feasibility and potential efficacy in inpatient settings. Together, this review identifies a paucity of studies on CBT-I or derivates in inpatient psychiatry. Despite challenging in this setting, studies adapting CBT-I to the needs of severely ill patients and hospital settings might have the potential to improve mental health care.

Insomnia-A risk factor for mental disorders.

Longitudinal studies observed that individuals suffering from insomnia disorder have a higher vulnerability to develop symptoms of psychopathology compared with good sleepers. Particularly, insomnia disorder has been associated with an increased risk for depression. Previous studies indicate relatively stable effects; however, replication is needed as the last meta-analysis on the topic has been published 4 years ago. We conducted a replication of a previous systematic review and meta-analysis evaluating the longitudinal association between insomnia disorder and psychopathology, including original works published between 2018 and 2022. Literature search was conducted from April 2018 to August 2022 using key words identifying longitudinal studies that evaluate individuals with insomnia disorder compared with good sleepers at baseline, and the onset of all possible mental disorders at long-term follow-up. Only one work was added to the previous sample of studies published in 2019 looking at the longitudinal association between insomnia disorder and depression. Meta-analytic results confirmed the previous observation, with an even higher observed effect for the link between insomnia and depression. This again recognizes insomnia disorder as a possible transdiagnostic process in psychopathology, with consequent important clinical implications. Nevertheless, more longitudinal studies are needed evaluating the link between insomnia disorder and mental disorders.

Feasibility, efficacy, and functional relevance of automated auditory closed-loop suppression of slow-wave sleep in humans.

Slow-wave sleep (SWS) is a fundamental physiological process, and its modulation is of interest for basic science and clinical applications. However, automatised protocols for the suppression of SWS are lacking. We describe the development of a novel protocol for the automated detection (based on the whole head topography of frontal slow waves) and suppression of SWS (through closed-loop modulated randomised pulsed noise), and assessed the feasibility, efficacy and functional relevance compared to sham stimulation in 15 healthy young adults in a repeated-measure sleep laboratory study. Auditory compared to sham stimulation resulted in a highly significant reduction of SWS by 30% without affecting total sleep time. The reduction of SWS was associated with an increase in lighter non-rapid eye movement sleep and a shift of slow-wave activity towards the end of the night, indicative of a homeostatic response and functional relevance. Still, cumulative slow-wave activity across the night was significantly reduced by 23%. Undisturbed sleep led to an evening to morning reduction of wake electroencephalographic theta activity, thought to reflect synaptic downscaling during SWS, while suppression of SWS inhibited this dissipation. We provide evidence for the feasibility, efficacy, and functional relevance of a novel fully automated protocol for SWS suppression based on auditory closed-loop stimulation. Future work is needed to further test for functional relevance and potential clinical applications.

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).

[Insomnia in psychiatry and psychotherapy]. / Insomnie en psychiatrie et psychothérapie.

Insomnia disorder is characterized by disturbed sleep continuity and associated daytime impairment. Insomnia is frequent in patients with psychiatric disorders ; 30-40% fulfill the criteria for insomnia disorder as a comorbidity. According to current guidelines, cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment, comprising sleep education, bedtime restriction, relaxation and cognitive restructuring. Despite guideline recommendations, CBT-I is insufficiently implemented, and insomnia is frequently over-treated with hypnotics. 'Become your own SLEEPexpert' is a behavioral treatment program based on CBT-I with the aim of empowering patients to take care of their own sleep health.

L'insomnie est un trouble de la continuité du sommeil et des troubles diurnes associés. Les symptômes sont fréquents chez les patients souffrant de troubles psychiatriques ; 30 à 40 % d'entre eux remplissant les critères du trouble de l'insomnie en tant que comorbidité. Selon les directives internationales, la thérapie cognitivo-comportementale de l'insomnie (TCC-I) est le traitement de première intention, comprenant l'éducation, la restriction du temps passé au lit, la relaxation et la restructuration cognitive. Malgré les recommandations, la TCC-I n'est pas suffisamment mise en œuvre et l'insomnie est souvent surtraitée avec des hypnotiques. « Become your own SLEEPexpert ¼ est un programme comportemental basé sur la TCC-I, dont l'objectif est de permettre aux patients de prendre en charge leur propre santé du sommeil.

Sleep, insomnia and mental health.

While sleep serves important regulatory functions for mental health, sleep disturbances, in particular insomnia, may favour a state of allostatic overload impairing brain neuroplasticity and stress immune pathways, hence contributing to mental disorders. In this framework, the aim of this work was to link current understanding about insomnia mechanisms with current knowledge about mental health dysregulatory mechanisms. The focus of the present work was on mood, anxiety, and psychotic disorders, which represent important challenges in clinical practice. Literature searches were conducted on clinical, neurobiological, and therapeutic implications for insomnia comorbid with these mental disorders. Given the complexity and heterogeneity of the existing literature, we ended up with a narrative review. Insomnia may play an important role as a risk factor, a comorbid condition and transdiagnostic symptom for many mental disorders including mood/anxiety disorders and schizophrenia. Insomnia may also play a role as a marker of disrupted neuroplasticity contributing to dysregulation of different neurobiological mechanisms involved in these different mental conditions. In this framework, insomnia treatment may not only foster normal sleep processes but also the stress system, neuroinflammation and brain plasticity. Insomnia treatment may play an important preventive and neuroprotective role with cognitive behavioural therapy for insomnia being the treatment with important new evidence of efficacy for insomnia, psychopathology, and indices of disrupted neuroplasticity. On the other hand, pharmacological pathways for insomnia treatment in these mental conditions are still not well defined. Therapeutic options acting on melatonergic systems and new therapeutic options acting on orexinergic systems may represents interesting pathways of interventions that may open new windows on insomnia treatment in mental disorders.

Co-ordination of brain and heart oscillations during non-rapid eye movement sleep.

Oscillatory activities of the brain and heart show a strong variation across wakefulness and sleep. Separate lines of research indicate that non-rapid eye movement (NREM) sleep is characterised by electroencephalographic slow oscillations (SO), sleep spindles, and phase-amplitude coupling of these oscillations (SO-spindle coupling), as well as an increase in high-frequency heart rate variability (HF-HRV), reflecting enhanced parasympathetic activity. The present study aimed to investigate further the potential coordination between brain and heart oscillations during NREM sleep. Data were derived from one sleep laboratory night with polysomnographic monitoring in 45 healthy participants (22 male, 23 female; mean age 37 years). The associations between the strength (modulation index [MI]) and phase direction of SO-spindle coupling (circular measure) and HF-HRV during NREM sleep were investigated using linear modelling. First, a significant SO-spindle coupling (MI) was observed for all participants during NREM sleep, with spindle peaks preferentially occurring during the SO upstate (phase direction). Second, linear model analyses of NREM sleep showed a significant relationship between the MI and HF-HRV (F = 20.1, r2  = 0.30, p < 0.001) and a tentative circular-linear correlation between phase direction and HF-HRV (F = 3.07, r2  = 0.12, p = 0.056). We demonstrated a co-ordination between SO-spindle phase-amplitude coupling and HF-HRV during NREM sleep, presumably related to parallel central nervous and peripheral vegetative arousal systems regulation. Further investigating the fine-graded co-ordination of brain and heart oscillations might improve our understanding of the links between sleep and cardiovascular health.

Augmentation of Psychotherapy with Neurobiological Methods: Current State and Future Directions.

BACKGROUND: Psychotherapy and pharmacotherapy are first-line treatments for mental disorders. Despite recent improvements, only approximately 50% of the patients reach sustained remission, indicating a need for novel developments. The main concept put forward in this systematic review and hypothesis article is the targeted co-administration of defined neurobiological interventions and specific psychotherapeutic techniques. METHODS: We conducted a systematic literature search for randomized controlled trials comparing the efficacy of augmented psychotherapy to psychotherapy alone. RESULTS: Thirty-five trials fulfilled the inclusion criteria. The majority (29 trials) used augmentation strategies such as D-cycloserine, yohimbine, or sleep to enhance the effects of exposure therapy for anxiety disorders. Fewer studies investigated noninvasive brain stimulation with the aim of improving cognitive control, psychedelic compounds with the aim of enhancing existentially oriented psychotherapy, and oxytocin to improve social communication during psychotherapy. Results demonstrate small augmentation effects for the enhancement of exposure therapy - however, some of the studies found negative results. Other methods are less thoroughly researched, and results are mixed. CONCLUSIONS: This approach provides an open matrix for further research and has the potential to systematically guide future studies.

Cognitive behavioural therapy for insomnia does not appear to have a substantial impact on early markers of cardiovascular disease: A preliminary randomized controlled trial.

According to the World Health Organization, cardiovascular diseases are the leading cause of death in the world. Therefore, early prevention of these diseases is a public health priority. Epidemiological data suggest that insomnia may be a modifiable risk factor for cardiovascular diseases. A randomized controlled trial in a sample of insomnia patients without cardiovascular disease was conducted to investigate the effects of insomnia treatment on early markers of cardiovascular diseases assessed by 24-hr ambulatory blood pressure, heart rate and heart rate variability monitoring, and morning fasting blood samples. Forty-six patients with insomnia disorder were randomized to cognitive behavioural therapy for insomnia (CBT-I; n = 23) or a waitlist control condition (n = 23). Contrary to the hypothesis, intention-to-treat analyses did not show any significant treatment effects on early markers of cardiovascular disease (d = 0.0-0.6) despite successful insomnia treatment (d = 1.3). Potential methodological and conceptual reasons for these negative findings are discussed. Future studies might include larger sample sizes that are at risk of cardiovascular diseases and focus on other cardiovascular markers.

Targeting Arousal and Sleep through Noninvasive Brain Stimulation to Improve Mental Health.

Arousal and sleep represent fundamental physiological domains, and alterations in the form of insomnia (difficulty falling or staying asleep) or hypersomnia (increased propensity for falling asleep or increased sleep duration) are prevalent clinical problems. Current first-line treatments include psychotherapy and pharmacotherapy. Despite significant success, a number of patients do not benefit sufficiently. Progress is limited by an incomplete understanding of the -neurobiology of insomnia and hypersomnia. This work summarizes current concepts of the regulation of arousal and sleep and its modulation through noninvasive brain stimulation (NIBS), including transcranial magnetic, current, and auditory stimulation. Particularly, we suggest: (1) characterization of patients with sleep problems - across diagnostic entities of mental disorders - based on specific alterations of sleep, including alterations of sleep slow waves, sleep spindles, cross-frequency coupling of brain oscillations, local sleep-wake regulation, and REM sleep and (2) targeting these with specific NIBS techniques. While evidence is accumulating that the modulation of specific alterations of sleep through NIBS is feasible, it remains to be tested whether this translates to clinically relevant effects and new treatment developments.

Can spectral power predict subjective sleep quality in healthy individuals?

The aim of this study was to assess the relationship between electroencephalogram (EEG) power spectral density and subjective sleep quality in healthy individuals. The sample was selected from the archival database of the Sleep Center at the Department for Psychiatry and Psychotherapy, Medical Center - University of Freiburg, and consisted of 206 healthy adults aged 19-73 years (85 male, 121 female) who underwent a polysomnographic examination for two consecutive nights. A multivariate analysis of variance (MANOVA) with spectral power variables of different frequency bands as dependent variables and subjective sleep quality, night number, age and gender as independent variables was statistically significant for subjective sleep quality, age and gender, but not for night number. In subsequent separate ANOVAs, higher subjective sleep quality was significantly related to decreased non-rapid eye movement (NREM) stage 2 sigma 2 and rapid eye movement (REM) delta 1; however, the relation between REM delta 1 and sleep quality did not remain significant when REM duration was accounted for. The effect sizes of the correlations between sleep quality and spectral power were small (r = -0.1). In contrast to common assumptions, the amount of variance in subjective sleep quality that can be explained through EEG power spectral density variables is small. This finding indicates that subjective and objective sleep are different constructs, the interrelations of which are not yet well understood.

Phase-amplitude coupling of sleep slow oscillatory and spindle activity correlates with overnight memory consolidation.

Initially independent lines of research suggest that sleep-specific brain activity patterns, observed as electroencephalographic slow oscillatory and sleep spindle activity, promote memory consolidation and underlying synaptic refinements. Here, we further tested the emerging concept that specifically the coordinated interplay of slow oscillations and spindle activity (phase-amplitude coupling) support memory consolidation. Particularly, we associated indices of the interplay between slow oscillatory (0.16-1.25 Hz) and spindle activity (12-16 Hz) during non-rapid eye movement sleep (strength [modulation index] and phase degree of coupling) in 20 healthy adults with parameters of overnight declarative (word-list task) and procedural (mirror-tracing task) memory consolidation. The pattern of results supports the notion that the interplay between oscillations facilitates memory consolidation. The coincidence of the spindle amplitude maximum with the up-state of the slow oscillation (phase degree) was significantly associated with declarative memory consolidation (r = .65, p = .013), whereas the overall strength of coupling (modulation index) correlated with procedural memory consolidation (r = .45, p = .04). Future studies are needed to test for potential causal effects of the observed association between neural oscillations during sleep and memory consolidation, and to elucidate ways of modulating these processes, for instance through non-invasive brain-stimulation techniques.

Declarative virtual water maze learning and emotional fear conditioning in primary insomnia.

Healthy sleep restores the brain's ability to adapt to novel input through memory formation based on activity-dependent refinements of the strength of neural transmission across synapses (synaptic plasticity). In line with this framework, patients with primary insomnia often report subjective memory impairment. However, investigations of memory performance did not produce conclusive results. The aim of this study was to further investigate memory performance in patients with primary insomnia in comparison to healthy controls, using two well-characterized learning tasks, a declarative virtual water maze task and emotional fear conditioning. Twenty patients with primary insomnia according to DSM-IV criteria (17 females, three males, 43.5 ± 13.0 years) and 20 good sleeper controls (17 females, three males, 41.7 ± 12.8 years) were investigated in a parallel-group study. All participants completed a hippocampus-dependent virtual Morris water maze task and amygdala-dependent classical fear conditioning. Patients with insomnia showed significantly delayed memory acquisition in the virtual water maze task, but no significant difference in fear acquisition compared with controls. These findings are consistent with the notion that memory processes that emerge from synaptic refinements in a hippocampal-neocortical network are particularly sensitive to chronic disruptions of sleep, while those in a basic emotional amygdala-dependent network may be more resilient.

European guideline for the diagnosis and treatment of insomnia.

This European guideline for the diagnosis and treatment of insomnia was developed by a task force of the European Sleep Research Society, with the aim of providing clinical recommendations for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta-analyses published till June 2016. The target audience for this guideline includes all clinicians involved in the management of insomnia, and the target patient population includes adults with chronic insomnia disorder. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations. The diagnostic procedure for insomnia, and its co-morbidities, should include a clinical interview consisting of a sleep history (sleep habits, sleep environment, work schedules, circadian factors), the use of sleep questionnaires and sleep diaries, questions about somatic and mental health, a physical examination and additional measures if indicated (i.e. blood tests, electrocardiogram, electroencephalogram; strong recommendation, moderate- to high-quality evidence). Polysomnography can be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders), in treatment-resistant insomnia, for professional at-risk populations and when substantial sleep state misperception is suspected (strong recommendation, high-quality evidence). Cognitive behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short-term treatment of insomnia (≤4 weeks; weak recommendation, moderate-quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low- to very-low-quality evidence). Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low-quality evidence). Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very-low-quality evidence).

The exploratory power of sleep effort, dysfunctional beliefs and arousal for insomnia severity and polysomnography-determined sleep.

Differences between subjective sleep perception and sleep determined by polysomnography (PSG) are prevalent, particularly in patients with primary insomnia, indicating that the two measures are partially independent. To identify individualized treatment strategies, it is important to understand the potentially different mechanisms influencing subjective and PSG-determined sleep. The aim of this study was to investigate to what extent three major components of insomnia models, i.e., sleep effort, dysfunctional beliefs and attitudes about sleep, and presleep arousal, are associated with subjective insomnia severity and PSG-determined sleep. A sample of 47 patients with primary insomnia according to DSM-IV criteria and 52 good sleeper controls underwent 2 nights of PSG and completed the Glasgow Sleep Effort Scale, the Dysfunctional Beliefs and Attitudes about Sleep Scale, the Pre-Sleep Arousal Scale and the Insomnia Severity Index. Regression analyses were conducted to investigate the impact of the three predictors on subjective insomnia severity and PSG- determined total sleep time. All analyses were adjusted for age, gender, depressive symptoms and group status. The results showed that subjective insomnia severity was associated positively with sleep effort. PSG-determined total sleep time was associated negatively with somatic presleep arousal and dysfunctional beliefs and attitudes about sleep. This pattern of results provides testable hypotheses for prospective studies on the impact of distinct cognitive and somatic variables on subjective insomnia severity and PSG-determined total sleep time.

Perfectionistic Tendencies in Insomnia Patients' Behavior During Psychometric Testing.

According to self-report questionnaire studies, insomnia patients differ from healthy controls with respect to several personality traits. The current study aimed at exploring how these personality traits may translate into behavior. Insomnia patients' behavior during psychometric testing (n = 163) was investigated in comparison to healthy controls (n = 81), patients with other sleep disorders (n = 80), and patients with obsessive-compulsive disorder (n = 36). In line with our hypotheses, insomnia patients made more additional comments than healthy controls and more corrections than patients with other sleep disorders during sleep-related questionnaire completion. Furthermore, insomnia patients calculated the sum score of a depression questionnaire more frequently than both healthy controls and patients with other sleep disorders. These findings further support the assumption of an altered personality profile in patients with primary insomnia. Future work should aim to elucidate what personality factors these novel behavioral markers may reflect.