Sleep Health Analysis Through Sleep Symptoms in 35,808 Individuals Across Age and Sex Differences: Comparative Symptom Network Study.

BACKGROUND: Sleep health is a multidimensional construct that includes objective and subjective parameters and is influenced by individual sleep-related behaviors and sleep disorders. Symptom network analysis allows modeling of the interactions between variables, enabling both the visualization of relationships between different factors and the identification of the strength of those relationships. Given the known influence of sex and age on sleep health, network analysis can help explore sets of mutually interacting symptoms relative to these demographic variables. OBJECTIVE: This study aimed to study the centrality of symptoms and compare age and sex differences regarding sleep health using a symptom network approach in a large French population that feels concerned about their sleep. METHODS: Data were extracted from a questionnaire provided by the Réseau Morphée health network. A network analysis was conducted on 39 clinical variables related to sleep disorders and sleep health. After network estimation, statistical analyses consisted of calculating inferences of centrality, robustness (ie, testifying to a sufficient effect size), predictability, and network comparison. Sleep clinical variable centralities within the networks were analyzed by both sex and age using 4 age groups (18-30, 31-45, 46-55, and >55 years), and local symptom-by-symptom correlations determined. RESULTS: Data of 35,808 participants were obtained. The mean age was 42.7 (SD 15.7) years, and 24,964 (69.7%) were women. Overall, there were no significant differences in the structure of the symptom networks between sexes or age groups. The most central symptoms across all groups were nonrestorative sleep and excessive daytime sleepiness. In the youngest group, additional central symptoms were chronic circadian misalignment and chronic sleep deprivation (related to sleep behaviors), particularly among women. In the oldest group, leg sensory discomfort and breath abnormality complaint were among the top 4 central symptoms. Symptoms of sleep disorders thus became more central with age than sleep behaviors. The high predictability of central nodes in one of the networks underlined its importance in influencing other nodes. CONCLUSIONS: The absence of structural difference between networks is an important finding, given the known differences in sleep between sexes and across age groups. These similarities suggest comparable interactions between clinical sleep variables across sexes and age groups and highlight the implication of common sleep and wake neural circuits and circadian rhythms in understanding sleep health. More precisely, nonrestorative sleep and excessive daytime sleepiness are central symptoms in all groups. The behavioral component is particularly central in young people and women. Sleep-related respiratory and motor symptoms are prominent in older people. These results underscore the importance of comprehensive sleep promotion and screening strategies tailored to sex and age to impact sleep health.

Eco-anxiety: An adaptive behavior or a mental disorder? Results of a psychometric study.

OBJECTIVE: Eco-anxiety is a complex construct that has been created to grasp the psychological impact of the consequences of global warming. The concept needs a reliably valid questionnaire to better evaluate its impact on the risk of anxiety and depressive disorders. The Eco-Anxiety Questionnaire (EAQ-22) evaluates two dimensions: 'habitual ecological anxiety' and 'distress related to eco-anxiety'. However, a version in French, one of the world's widely spoken languages, was until now lacking. We aimed to translate and validate the French EAQ-22 and to evaluate the prevalence of the level of the two dimensions of eco-anxiety and the relationship with anxiety and depressive symptoms in a representative adult sample of the French general population. METHODS: This study was performed under the auspices of the Institut national du sommeil et de la vigilance (INSV). Participants (18-65 years) were recruited by an institute specialized in conducting online surveys of representative population samples (quota sampling). Two native French speakers and two native English speakers performed a forward-backward translation of the questionnaire. The Hospital Anxiety and Depression scale (HAD) was administered to assess anxiety (HAD-A) and depressive (HAD-D) symptoms and for external validity. Internal structural validity and external validity were analysed. RESULTS: Evaluation was performed on 1004 participants: mean age 43.47 years (SD=13.41, range: [19-66]); 54.1% (n=543) women. Using the HAD, 312 (31.1%) patients had current clinically significant anxiety symptoms (HAD-A>10) and 150 (14.9%) had current clinically significant depressive symptoms (HAD-D>10). Cronbach's alpha coefficient was 0.934, indicating very good internal consistency. Correlation between EAQ-22 and HAD scores was low (r[1004]=0.209, P<0.001), 'habitual ecological anxiety' was correlated less with HAD-A and HAD-D than 'distress related to eco-anxiety', indicating good external validity. CONCLUSION: This study validates the French EAQ-22 and paves the way for using the EAQ-22 as a global tool for assessing eco-anxiety. Further prospective studies are now required to better evaluate the impact of eco-anxiety on the occurrence of anxiety and depressive disorder.

[Behavioral management of insomnia]. / Prise en charge comportementale de l'insomnie.

BEHAVIORAL MANAGEMENT OF INSOMNIA. Behavioral management of insomnia aims to bring about lasting changes in the habits of insomniacs, in terms of sleep schedules, regularity, and organization of the day (naps). Eating and exercise habits also need to be restructured and regularized. The two most effective techniques for improving insomniac sleep are time restriction and stimulus control. Reducing the time spent in bed to 6 or 6.5 hours rapidly leads to an improvement in falling asleep and sleep continuity. For the first few weeks, however, this technique may lead to drowsiness, which the patient should be warned about. Stimulus control try to re-establish the bed=sleep signal, by eliminating time spent in bed without sleeping. Relaxation, meditation, and rhythm synchronization are natural complements of these techniques.

PRISE EN CHARGE COMPORTEMENTALE DE L'INSOMNIE. La prise en charge comportementale de l'insomnie vise à modifier durablement les habitudes des insomniaques à la fois sur les horaires de sommeil, leur régularité et sur l'organisation de la journée (sieste). Les habitudes alimentaires et sportives sont également à restructurer et à régulariser. Les deux techniques les plus efficaces pour améliorer le sommeil de l'insomniaque sont les techniques de restriction du temps passé au lit ou de contrôle du stimulus. Réduire le temps passé au lit à six heures ou six heures trente permet une amélioration rapide de l'endormissement et de la continuité du sommeil. Cette technique peut, les premières semaines, entraîner une somnolence dont il faut prévenir le patient. Le contrôle du stimulus essaye de rétablir le signal « lit = sommeil ¼, en faisant la chasse au temps passé au lit sans dormir. La relaxation, la méditation et la synchronisation des rythmes sont les compléments naturels de ces techniques.

[Sleep in a performance artist: Eight days and seven nights sitting inside a metal sculpture]. / Le sommeil d'un performeur de l'extrême. Dormir huit jours et sept nuits, assis, sans bouger, enfermé dans une sculpture.

Sleep in extreme situations has been little studied. The artist Abraham Poincheval (AP) is known for his performances in confined spaces. For his show at the Perrotin Gallery in Paris, he was enclosed for 8days and 7nights in a metal sculpture of his body in a seated position, with his head facing a work by Hans Hartung at the end of a cone system placed in front of his eyes which occluded all other visual stimuli. The interior of the metal structure was not padded and there was no head support. His sleep and internal temperature were continuously recorded using polysomnography (Grael, Compumedics) and an orally swallowed temperature sensitive capsule (Bodycap) with temperature sampling every 2min. AP slept an average of 355.1min/24h, composed of light slow-wave sleep (N1: 47.1min, N2: 192.2min), deep slow-wave sleep (N3: 100.4min), and REM sleep 4,3 % (15.4min). Sleep, although mostly nocturnal, was split into periods of no more than 20min. Deep sleep was therefore remarkably resistant to the uncomfortable experimental conditions, while REM sleep was markedly impaired, lasting only a few short minutes and followed by rapid awakening. This is probably due to the head position within the sculpture which was unsupported, so REM sleep with its inherent muscle atonia led to involuntary head flexion and was impossible to sustain for long. The thermal minimum was between 5:17 a.m. and 6:35 a.m. The amplitude of the core temperature decreased by more than 30 % between the beginning and the end of the protocol. Despite the immobility induced by the confined experimental conditions, there was no desynchronization of circadian rhythms. The sleep time was surprisingly long given the conditions, and slow-wave sleep was relatively preserved with an amount typically found in normal subjects while REM sleep was markedly impaired. Slow-wave sleep is clearly preserved underlying its central role in physical and mental homeostasis. REM sleep is clearly more fragile. The reduction in REM sleep linked to position has been found in a study of sleep in the sitting position in airplanes where loss of muscle tonus in the neck fragments REM sleep. Techniques for selective REM sleep deprivation also use muscle atonia: one of the initial techniques of selective REM sleep deprivation relied on muscle atonia in REM causing a cat to fall from a small perch into water. In man, the lack of head support is clearly a source of REM fragmentation. However in the case of this study, we cannot exclude an effect of other factors, notably the meditative techniques used by the performer to maintain attention on the painting, described as a dream state punctuated by visual hallucinations. Surprisingly, despite physical isolation within the sculpture, AP's biological rhythms remained stable. However, the conditions were not those of complete isolation: noise, the presence of the public in the gallery who occasionally talked to AP through the sculpture, and variations in light during the day were all temporal cues. In addition, a heatwave during the performance raised the temperature in the room with reduced total sleep time on the hottest night. Although the phase of the circadian rhythm measured by the internal temperature did not change, the amplitude fell which is compatible with reduced physical activity. In conclusion, under physically constraining and uncomfortable sleep conditions, deep sleep is maintained while REM sleep is starkly reduced. From a homeostatic point of view, this means that over a short period of time, in a survival situation, energy recovery through deep slow-wave sleep takes priority over REM sleep.

Better characterizing sleep beliefs for personalized sleep health promotion: the French sleep beliefs scale validation study.

Background: The Sleep Beliefs Scale (SBS) is a well-known tool to design and monitor personalized sleep health promotion at an individual and population level. The lack of an established French version limits the development of effective interventions targeting these populations. Thus, the aim of this study was to validate the French version of the SBS in a representative sample of the general population. Methods: Quota sampling was used to recruit 1,004 participants (18-65 years, mean age: 43 years, 54% of female) who underwent an online survey to complete the SBS, and to assess sleep schedules, sleep quality and disorders, and mental health. Cronbach's α coefficient, confirmatory factor analysis, item-internal consistency (IIC), and item discriminant validity (IDV) of the SBS were computed to assess internal validity while bivariate associations with sleep schedules, sleep quality and disorders, and mental health were used to assess external convergent and discriminant validity. Results: The mean score on the SBS was 12.3 ± 4.9. Item 19 ("Quiet & Dark") showed the highest rate of correct answers (n = 801, 79.8%), while item 20 ("Recovering sleep") showed the lowest rate of correct answers (n = 246, 24.5%). Overall, the SBS showed satisfactory internal consistency (α = 0.87) and confirmed the three-factor structure proposed by the original study. All items were found consistent (IIC > 0.4) and discriminant (IIC > IDV) except for item 20 ("recovering lost sleep by sleeping for a long time"). Females, older participants, and subjects with short time-in-bed, poor sleep quality, insomnia, and circadian rhythm disorder had higher SBS scores while participants with depressive symptoms had lower SBS scores. Conclusion: We successfully translated and validated the French version of the SBS in a representative sample, making it a reliable instrument for researchers and clinicians to assess and target sleep beliefs. Correct answers vary from 25 to 80% which underlines the importance of continuing sleep health promotion campaigns by targeting poorly understood behaviors. Our findings also shed light on the fickleness of beliefs that are prone to vary within individuals across time, in step with societal changes. Several associated factors were identified, thus contributing to our understanding of sleep beliefs and offering insights for personalized approaches to enhance sleep health and overall well-being.

Do both timing and duration of screen use affect sleep patterns in adolescents?

BACKGROUND: Sleep duration has declined in adolescents over the last 30 years and screen use has been identified as a risk factor. Studies have examined the duration of screen use and screen-based activities but have not differentiated between evening and night-time use. METHODS: Cross sectional questionnaire survey of adolescents recruited in schools. Sleep habits on school nights and weekends, symptoms of insomnia and daytime repercussions were recorded using an online questionnaire administered in the classroom setting. Sleep deprivation (<7 hours in bed /night), school night sleep restriction (≥2 hours difference in sleep duration on school nights vs weekends), excessive sleepiness (score >6 on a visual analogue scale), duration of screen use and timing of screen use (evening vs after bedtime) were determined. RESULTS: 2513 students (53.4% female, median age 15 years) were included. 20% were sleep deprived and 41% sleep restricted. A clear dose effect relationship in a model controlling for age, sex, school level and sociodemographic class was seen with all levels of night-time screen use on sleep deprivation and sleep restriction (>2 hours use sleep deprivation OR 5.23[3.03-9.00]. sleep restriction OR 2.05[1.23-3.42]) and > 2 hours evening use (>2 hours use sleep deprivation OR 2.72[2.15-3.44] sleep restriction OR 1.69[1.36-2.11]) but not moderate evening use. All night-time use and > 2 hours evening use increased the risk of insomnia, non refreshing sleep, and affected daytime function (daytime sleepiness, lack of energy and irritability). CONCLUSIONS: Both duration of screen use and timing are associated with adverse effects on sleep and daytime functioning in adolescents. More than 2 hours evening use and all night-time use should be avoided.

Differential effects of COVID-related lockdown on sleep-wake rhythms in adults with autism spectrum disorder compared to the general population.

COVID-related lockdown led to a radical modification of daily activities and routines which are known to affect sleep. Compared to the general population, participants with autism may be particularly vulnerable to the repercussions of lockdown on sleep, given their intrinsic inflexible adherence to routines and the high overall prevalence of sleep disturbances in this population. The study is a French nation-wide online survey assessing sleep-wake rhythms and behaviors known to affect sleep (daily screen time, daylight exposure, and physical activity), before and during COVID-related lockdown. Respondents were 207 adults with autism (56% female) and 1652 adults of the general population (77% female), with a mean age 35.3 years (SD 11.3). Before lockdown, the adults with autism displayed on average later bedtime and waking hours, lower sleep quality, more evening screen time, less exposure to daylight, and less exercise (all p < 0.01). Lockdown affected all studied measures of sleep and related exposures in a similar way in both groups: poorer self-rated sleep quality as well as a less regular and delayed sleep-wake rhythm, longer screen time in the evening and less exposure to daylight (all p < 0.001). Adults with autism displayed significantly higher levels of sleep and circadian rhythm disturbances and less favorable daily routines known to regulate sleep. While the effect of confinement on sleep and sleep related behaviors was similar in both groups, the results highlight that the pre-existing shift in circadian rhythms and lifestyles in adults with ASD further deteriorated during lockdown. LAY ABSTRACT: COVID-related lockdown led to a radical modification of daily activities and routines known to affect sleep. In a sample of 1800 adults, we observed that, before lockdown, participants with autism displayed significantly higher levels of sleep disturbances and less favorable daily routines known to regulate sleep, compared to the general population. While the deleterious effect of lockdown on sleep was similar in both groups, pre-existing difficulties in adults with autism reached worrying levels during lockdown.

International Expert Opinions and Recommendations on the Use of Melatonin in the Treatment of Insomnia and Circadian Sleep Disturbances in Adult Neuropsychiatric Disorders.

Introduction: Insomnia and circadian rhythm disorders, such as the delayed sleep phase syndrome, are frequent in psychiatric disorders and their evaluation and management in early stages should be a priority. The aim of this paper was to express recommendations on the use of exogenous melatonin, which exhibits both chronobiotic and sleep-promoting actions, for the treatment of these sleep disturbances in psychiatric disorders. Methods: To this aim, we conducted a systematic review according to PRISMA on the use of melatonin for the treatment of insomnia and circadian sleep disorders in neuropsychiatry. We expressed recommendations for the use of melatonin in psychiatric clinical practice for each disorder using the RAND/UCLA appropriateness method. Results: We selected 41 studies, which included mood disorders, schizophrenia, substance use disorders, attention deficit hyperactivity disorders, autism spectrum disorders, neurocognitive disorders, and delirium; no studies were found for both anxiety and eating disorders. Conclusion: The administration of prolonged release melatonin at 2-10 mg, 1-2 h before bedtime, might be used in the treatment of insomnia symptoms or comorbid insomnia in mood disorders, schizophrenia, in adults with autism spectrum disorders, neurocognitive disorders and during sedative-hypnotics discontinuation. Immediate release melatonin at <1 mg might be useful in the treatment of circadian sleep disturbances of neuropsychiatric disorders.

Do hypnotics increase the risk of driving accidents or near miss accidents due to hypovigilance? The effects of sex, chronic sleepiness, sleep habits and sleep pathology.

Driving accidents due to hypovigilance are common but the role of hypnotics is unclear in patients suffering from sleep disorders. Our study examined factors influencing accidents and near miss accidents attributed to sleepiness at the wheel (ANMAS). Using data from an online questionnaire aimed at patients with sleep disorders, we analysed the associations between ANMAS, sociodemographic data, symptoms of sleep disorders, severity of insomnia (Insomnia Severity Index (ISI)) symptoms of anxiety and depression (Hospital Anxiety and Depression scale with depression (HADD) and anxiety (HADA) subscales), chronic sleepiness (Epworth sleepiness scale ESS), hypnotic use and information about sleep habits. Hypnotics were hierarchically grouped into Z-drugs, sedative medication, melatonin and over the counter (OTC) alternative treatments. Of 10802 participants; 9.1% reported ANMAS (Men 11.1% women 8.3%) and 24.4% took hypnotics (Z-drugs 8.5%, sedative medication 8%, melatonin 5.6% and alternative treatments 2.5%). Logistic regression analysis identified the following risk factors for ANMAS: moderate (OR 2.4; CI: 2.10-2.79) and severe sleepiness (ESS OR 5.66; CI: 4.74-6.77), depression (HADD OR 1.2; CI: 1.03-1.47), anxiety (HADA OR 1.2;CI: 1.01-1.47), and insufficient sleep (OR1.4; CI: 1.2-1.7). Hypnotics were not associated with an increased risk of ANMAS in patients suffering from insomnia. Risk factors varied according to sex: in females, sex (OR 0.; CI: 0.55-0.74), mild insomnia (OR 0.5; CI: 0.3-0.8) and use of alternative treatments (OR 0.455, CI:0.23-0.89) were protective factors and risk was increased by sleepiness, sleep debt, social jetlag, caffeine use, anxiety and depression. In men no protective factors were identified: sleepiness, sleep debt, and severe insomnia were associated with an increased risk of ANMAS. In clinical practice, all patients with daytime sleepiness and men with severe insomnia should be counselled concerning driving risk and encouraged to avoid sleep debt.

Initial consultation, analysis of complaint, causal investigation of insomnia / Consultation initiale, analyse de la plainte, enquête causale devant une insomnie

Initial consultation, analysis of complaint, causal investigation of insomnia Insomnia requires an initial clinical check-up with a full examination that explores both the complaint of sleep (difficulties in falling sleep, awakening in the night, early awakening) and the repercussion on the day. Lifestyle and behaviors are assessed (meals, sporting activity, type of activity before and at bedtime, regularity of schedules, working hours). Comorbidities are evaluated : depression, anxiety, restless legs syndrome, sleep apnea, somatic diseases, medication. Simple tools are used to complete this assessment : questionnaire of sleep assessment and its disorders, sleep schedule, possibly actimetry.

Consultation initiale, analyse de la plainte, enquête causale devant une insomnie L'insomnie nécessite un bilan initial clinique avec un interrogatoire complet qui explore à la fois la plainte concernant le sommeil (difficultés d'endormissement, réveils dans la nuit, réveil précoce) et son retentissement sur la journée. Le mode de vie et les comportements du patient sont évalués (repas, activité sportive, type d'activité avant et au moment du coucher, régularité des horaires, horaires de travail). Les comorbidités sont recherchées : dépression, anxiété, syndrome des jambes sans repos, apnées du sommeil, maladies somatiques, prise de médicaments. Des outils simples sont utilisés pour compléter ce bilan : questionnaire d'évaluation du sommeil et de ses troubles, agenda du sommeil, éventuellement actimétrie.

Short sleep duration and increased risk of hypertension: a primary care medicine investigation.

OBJECTIVES: Compelling evidence from laboratory-based and population-based studies link sleep loss to negative cardiovascular health outcomes. However, little is known about the association between sleep duration and hypertension in primary care health settings, independently of other well controlled clinical and biochemical characteristics. We investigated the association between sleep duration and the prevalence of hypertension adjusting for 21 potential confounding factors in a noncontrolled primary care sample. METHODS: The sample included 1046 French adults older than 40 years (mean age, 55.5 years), who visited any of the general practitioners of primary care centers in the Paris area. Blood pressure (BP) readings, blood samples and standardized health and sleep questionnaires were performed on each participant. Hypertension inclusion criteria were either high BP measurements (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg) or the use of antihypertensive medications. Sleep duration was recorded as the self-reported average number of hours of sleep per night during the week. Logistic regressions were performed to test the association between hypertension and sleep duration adjusted for sociodemographic, clinical, biochemical, lifestyle, psychological and sleep disorder covariates. RESULTS: Compared to the group sleeping 7 h, individuals sleeping 5 h or less had an increased odds ratio (OR) for the prevalence of hypertension [OR = 1.80, 95% confidence interval (1.06-3.05)], after adjusting for 21 potential confounders which did not markedly attenuate this association. CONCLUSION: Our data provide further epidemiologic evidence that with no specific selection in primary care medicine, usual short-sleep duration increases the risk of hypertension prevalence in adults over 40 years.

Ambulatory sleep recording in a healthcare network: a feasibility study.

Sleep disorders have a high prevalence: around 20% of insomniacs, 10% hypersomnolent including 2 to 4% of sleep disordered breathing in the general adult population. The low availability of sleep centres implies the research of alternative recording techniques in the natural setting of the patient. The objective was to evaluate an ambulatory recorder and its integration in a managed healthcare network. Fifteen patients had a full set-up at home and ten patients were hooked-up in the hospital but recorded at home. Technical failures occurred in 2/15 with full polysomnographic recordings. Integration within an experimental sleep network is in progress. This managed care network will include training of general practitioners, teletransmissions between GP and sleep specialists for a graded use of available resources including ambulatory monitoring.