Daytime sleepiness in insomnia: behavioral, biological and subjective indices.

We compared three measures of daytime sleepiness, sleep behavior (as measured by the multiple sleep latency test), a biological index of sleepiness (pupillometry) and subjective sleepiness (as measured by the Stanford Sleepiness Scale), in evaluating middle-aged individuals with psychophysiological insomnia (n = 20) or no sleep problem (n = 20). Subjects underwent polysomnography (PSG) and four multiple sleep latency test/pupillometry trials the following day. The results determined that neither behavioral, biological nor subjective indices distinguished these two groups. Differentiating the insomniacs into true insomniac (n = 14) and normal sleeping insomniac (insomniacs with sleep efficiency greater than 90%, n = 6) subgroups based upon PSG did not improve daytime discriminations. Furthermore, nighttime sleep experience, measured by either PSG or self-report, was not a strong predictor of these daytime indices among either insomniacs or noninsomniacs. The results of this study support the conclusions that insomniacs do not exhibit heightened levels of daytime sleepiness and that routine fluctuations in sleep exert minimal influence on daytime sleepiness among insomniacs and noninsomniacs. The former finding is likely due either to insomniacs satisfying their biological sleep need despite poor sleep or chronic physiological hyperarousal preventing both sleep and sleepiness.

Intensity pattern of snoring sounds as a predictor for sleep-disordered breathing.

The relationship between a new operational definition of sleep sounds and apnea was examined in a population of 69 patients referred for overnight evaluations in a sleep disorders center. The sample contained 18 women (mean age 53.6 years) and 51 men (mean age 48.4 years). Subjects underwent polysomnography (PSG) with concurrent graphical recording of sleep sound intensities throughout the night. An acoustical signature event (ASE) was defined as a loud sound preceded by at least 10 but no more than 90 seconds of silence. Multiple regression was performed using known correlates of apnea and ASE to predict PSG levels of respiratory disturbance. Of the commonly known correlates, only self-reported estimate of snoring and apnea severity explained significant variance to the respiratory disturbance index (RDI; R2 = 0.24, p < 0.0001). ASE was entered into the equation as the last step, significantly improving explained variance (R2delta = 0.54, p < 0.0001). The final equation R2 was 78% (p < 0.0001). An alternative analysis compared ASE findings to polysomnographic findings in each matched 30-second interval (60,231 observations) in an analysis of receiver's operating characteristics. This analysis resulted in d' = 2.67, indicating acceptable accuracy for screening.

Occult sleep apnea in a recruited sample of older adults with insomnia.

Although costly polysomnography (PSG) is not routinely performed with people with insomnia, it may be more necessary with recruited older adults with insomnia because this population may pose a greater risk of veiled sleep disorders compared with younger age groups and with referred samples. The present PSG screening of a recruited sample of older adults with insomnia found a 29%-43% rate of undiagnosed sleep apnea (SA), depending on whether an apnea-hypopnea index of 15 or 5 was used, after interviews had already screened out obvious cases of SA. Also, PSGs revealed a 4% rate of occult periodic limb movements. A discriminant analysis identified overweight men reporting dry mouth at highest risk for occult SA, with an apnea-versus-insomnia classification success rate of 78%. Using PSG evaluations in research on insomnia in recruited older adults is requisite to preclude substantial representation of occult SA.

Relaxation and sleep compression for late-life insomnia: a placebo-controlled trial.

Older adults with insomnia were recruited from the community and randomized to treatments: relaxation, sleep compression, and placebo desensitization. Questionnaire data collected at baseline, posttreatment, and 1-year follow-up and polysomnography data collected at baseline and follow-up yielded the following conclusions: All treatments improved self-reported sleep, but objective sleep was unchanged. Clinical significance analyses yielded the strongest findings supporting the active treatments and suggested that sleep compression was most effective. Results partially supported the conclusion that individuals with high daytime impairment (i.e., fatigue) respond best to treatments that extend sleep, as in relaxation, and individuals with low daytime impairment respond best to treatments that consolidate sleep, as in sleep compression. Strong methodological features including a placebo condition and a treatment implementation scheme elevate the confidence due these findings.

Objective sleep measures and subjective sleep satisfaction: how do older adults with insomnia define a good night's sleep?

The relationship between objective sleep measures and subjective sleep satisfaction was explored in a sample of 47 older adults (59 years and older; 35 women, 12 men) with primary insomnia. Participants submitted to all-night sleep evaluations (polysomnography) for 2 nights. After each night, participants provided subjective sleep-satisfaction ratings. Depth of sleep (decreased Stage 1 sleep and increased Stages 3 and 4 sleep) and sleep latency were the best predictors of subjective sleep satisfaction. For other sleep variables such as sleep efficiency and wake time after sleep onset, no value predicted satisfaction on a particular night. However, for these sleep variables, relative improvement from Night 1 to Night 2 predicted greater subjective satisfaction.

Relaxation for insomnia and hypnotic medication use in older women.

Relaxation therapy was given to 3 groups of older women (N = 57): (a) hypnotically medicated insomniacs, (b) nonhypnotically medicated insomniacs, and (c) noninsomniacs. Groups b and c were receiving antihypertensives. Self-reported sleep and medication data were collected for 1 week at pretreatment (except relaxation), posttreatment, and 6-weeks follow-up. Three relaxation sessions, a nondemanding, hybrid method, were administered with the rationale of helping insomnia or high blood pressure. Substantial sleep improvement occurred only for nonhypnotically medicated insomniacs. Substantial sleep medication reduction (47%) occurred only for hypnotically medicated insomniacs. This relaxation approach proved valuable, but the nature of the treatment effect was dependent on the medication status of the insomniac.

Sleep compression and sleep education for older insomniacs: self-help versus therapist guidance.

A treatment package consisting of a bed-time restriction strategy and education was administered to 50 insomniacs and 50 noninsomniacs 60 years or older. Half of the insomniacs and noninsomniacs received treatment through a self-help video only, whereas the remaining treated participants received therapist guidance to supplement the video. A waiting-list control group of 25 senior insomniacs was also included. Sleep knowledge was equivalent for senior insomniacs and noninsomniacs. The self-help insomniac group exhibited improvement on multiple sleep variables, but the addition of therapist guidance appeared to enhance treatment outcome for sleep latency, wake time after sleep onset, and sleep satisfaction. Control participants also improved across time but were generally outperformed by treated insomniacs.

Psychological treatment of secondary insomnia.

Psychological treatment of insomnia has focused on primary insomnia (i.e., having a psychological origin). Secondary insomnia, sleep disturbance caused by a psychiatric or medical disorder, although it is more common than primary insomnia, has received very little attention as a result of the belief that it would be refractory to treatment. The present study randomly assigned older adults with secondary insomnia to a treatment group, 4 sessions composed of relaxation and stimulus control, or a no-treatment control group. Self-report assessments conducted at pretreatment, posttreatment, and a 3-month follow-up revealed that treated participants showed significantly greater improvement on wake time during the night, sleep efficiency percentage, and sleep quality rating. The authors hypothesize that treatment success was probably due in part to difficulty in diagnostic discrimination between primary and secondary insomnia.

Primary versus secondary insomnia in older adults: subjective sleep and daytime functioning.

Most psychological research on insomnia has centered on primary insomnia (PI). Secondary insomnia (SI), though more common than PI, has received little attention because of its presumed unresponsiveness to treatment. The present study recruited older adults with PI, SI, and a comparison group of older adults with no insomnia (NI). Self-report assessments of sleep revealed no significant difference between the 2 insomnia groups. Daytime functioning measures found significant differences in impairment between the 3 groups with SI having the worst daytime functioning, followed by PI, which was worse than NI. Further analyses found substantial independence between sleep and daytime functioning. Implications of these findings for the clinical management of SI are discussed.

A general index of self-reported sleep: the sleep quotient.

Utilizing multiple sleep measures, a practice common to virtually all sleep assessments, poses problems both for statistical analyses in the form of inflated Type I error rate and for interpretation by the inability to specify general sleep change. A sleep quotient (SQ) is proposed that appears to overcome these problems. The paper presents archival norms for self-report sleep data, demonstrates the use of these norms in transforming novel data to standardized units, and casts the standardized score in the form of an intelligence quotient, now called a SQ, with a mean of 100 and a standard deviation of 15. Previously published data are reanalyzed by use of SQ scores, methods of interpreting SQ data are demonstrated, and advantages of SQ analyses are described. The SQ appears to be a valid, useful composite sleep index permitting the measurement of general sleep.

Pupillometric discrimination of insomniacs.

Unlike the multiple sleep latency test, pupillometry does not require sleep to test sleepiness, which may be an advantage in assessing insomniacs. Pupillometry was employed to study possible differences in daytime sleepiness between insomniacs and noninsomniacs. Thirty self-defined insomniacs and an equal number of noninsomniacs, age 30-50 yr, submitted to four 10-min pupillometry sessions distributed from early morning to bedtime. The sessions consisted of infrared television monitoring of the pupil in a totally dark, nonstimulating environment. Insomniacs exhibited significantly smaller pupil diameters than noninsomniacs, and this effect persisted in all sessions. However, the size of effect averaged about 0.5 mm, and this was judged to be a small magnitude. Heightened subjective sleepiness discriminated the insomniacs in only the midday session. The absence of polysomnography was a methodologically limiting factor. Theoretical and clinical implications of these data were discussed.

Biofeedback to enhance psychophysiological effects of imagery.

Unlike most applications of biofeedback, the outcome goal and the aim of the present investigation was to increase arousal by the provision of feedback. The ability to generate psychophysiological arousal during noxious imagery may be therapeutically beneficial to individuals receiving emotive imagery therapies, and in the present study we evaluated biofeedback as a means of correcting psychophysiological deficits in imagery. Thirty psychophysiologically unreactive undergraduates were randomly assigned to skin-resistance-level biofeedback, false-feedback, or no-feedback conditions for six sessions of assessment and treatment. The methodology controlled for placebo, practice, and initial value effects. Significant increases in skin resistance level, heart rate, and frontalis electromyography accrued to the biofeedback group but not the control groups, and these gains persisted when biofeedback was withdrawn. Subjective measures showed no changes. The results support the usefulness of biofeedback as a remedy for imagery underarousal.

Strategies for evaluating adherence to sleep restriction treatment for insomnia.

The methodology of assessing adherence to sleep restriction therapy for insomnia has received little attention in the empirical literature. The present study proposes and evaluates several approaches to assessing adherence to sleep restriction. We investigated multiple methods of measuring adherence and tested their utility by determining the strength of their association with treatment outcome in a sample of 22 older adults with insomnia (16 women, six men). As a group, the measures indicated reasonably good adherence to treatment recommendations. Time spent in bed was significantly reduced at post-treatment, and the night to night consistency of time spent in bed and arising time was significantly greater at post-treatment. However, time spent in bed per night at post-treatment still exceeded therapist recommendations by a mean of 27.89 min (SD=31.72). Greater consistency of time spent in bed per night and a more consistent arising time predicted a better treatment outcome. Measures of degree of bedtime reduction did not predict treatment outcome.

Leisure interest patterns and subjective stress in college students.

A first study of the Leisure Interests Checklist (LIC) is reported based on a large (N = 670) normative sample of college students. Acceptable reliability was found on the total interest scores, and on both rationally- and factorially-derived LIC subscales. The BAROMAS stress scales were also studied concurrently with the same college students, and normative data are provided from that sample. Interest in very active diversions and Sports on the LIC did correlate with confidence in doing sports on the BAROMAS. Otherwise, the two instruments showed little overlap. Comparisons between ethnic and gender groupings mainly agreed with advance expectations by disclosing culturally conventional differences in response patterns. The LIC appears promising for future use in both applied and research contexts.

Are insomniacs sleepy during the day? A pupillometric assessment.

A biodevelopmental model of insomnia is articulated specifying coordinated nighttime (disturbed sleep pattern) and daytime (no excessive daytime sleepiness) characteristics defining an insomnoid classification in at-risk groups: short sleepers and older adults. Pupillometry is proposed as a useful means of discriminating degree of daytime sleepiness to aid in the differential diagnosis of insomnia and insomnoid states, and the present study tested the discriminative validity of this approach. Noninsomniac (n = 34) and insomniac (n = 29) college students submitted to four 10 min pupillometry sessions tracking daytime sleepiness from morning arising to bedtime. Pupil diameter proved to be an able discriminator of these two groups though substantial overlap of the two distributions was also noted. The results supported the sensitivity of pupillometry in detecting daytime sleepiness, but yielded alternative interpretations. We observed statistical differentiation in insomniac and noninsomniac daytime sleepiness, but substantial, functional overlap between these groups. Assessment and treatment implications arising from the biodevelopmental model were hypothesized.

Quantitative criteria for insomnia.

Formal diagnostic systems (DSM-IV, ICSD, and ICD-10) do not provide adequate quantitative criteria to diagnose insomnia. This may not present a serious problem in clinical settings where extensive interviews determine the need for clinical management. However, lack of standard criteria introduce disruptive variability into the insomnia research domain. The present study reviewed two decades of psychology clinical trials for insomnia to determine common practice with regard to frequency, severity, and duration criteria for insomnia. Modal patterns established frequency (> or =3 nights a week) and duration (> or =6 months) standard criteria. We then applied four versions of severity criteria to a random sample and used sensitivity-specificity analyses to identify the most valid criterion. We found that severity of sleep onset latency or wake time after sleep onset of: (a) > or =31 min; (b) occurring > or =3 nights a week; (c) for > or =6 months are the most defensible quantitative criteria for insomnia.

Fatigue and sleep disorders.

Fatigue has often been confused with sleepiness and has received little study as an independent symptom of sleep disturbance. To investigate if fatigue is a common and severe symptom in sleep disordered individuals, the Fatigue Severity Scale (FSS) was administered to 206 patients over a 12-month period at a sleep disorder center. Our sample averaged 4.8 on the 7-point FSS, which is in the severe fatigue range. High fatigue was present in a broad range of sleep disorders, but was particularly high among individuals diagnosed with psychophysiological insomnia. A number of variables predicted fatigue (being female, being a smoker, high BMI, low sleep efficiency percent, and high MMPI average clinical scale score), but surprisingly daytime sleepiness (as measured by the multiple sleep latency test) did not. Apparently, daytime sleepiness and perceived fatigue are independent phenomena. We discussed the importance of attributing credence to the complaint of fatigue and suggested some areas for future study including further study of fatigue in insomnia, expanded consideration of sleep variables causing fatigue, and testing objective measures of fatigue.

Relaxation therapy for insomnia: nighttime and day time effects.

We compared day time functioning in college students with and without insomnia and explored changes in day time functioning after progressive relaxation (PR) treatment for insomnia. Students with insomnia (SWI; n = 57) were compared to a control group of students not complaining of insomnia (SNI; n = 61) on self-reported sleep variables and five questionnaires: Insomnia Impact Scale (IIS), Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS), Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), and Penn State Worry Questionnaire (PSWQ). SWI demonstrated significant impairment on all day time functioning and sleep measures compared to SNI. To investigate treatment effects on day time functioning, 28 SWI were randomly assigned to PR. Treated SWI were compared to untreated SWI and SNI at posttreatment. Treated participants improved sleep in comparison to untreated SWI, but failed to show significant improvements in day time functioning. Insomnia treatments focused on improving sleep may not improve day time functioning, or day time gains may emerge more slowly than sleep gains. This study documents the wide range of day time functioning complaints in young adults with insomnia and suggests that the goal of insomnia treatment should be to not only improve sleep but also to improve the subjective experience of day time functioning.

Judging outcomes in psychosocial interventions for dementia caregivers: the problem of treatment implementation.

PURPOSE: In published dementia caregiver intervention research, there is widespread failure to measure the level at which treatment was implemented as intended, thereby introducing threats to internal and external validity. The purpose of this article is to discuss the importance of inducing and assessing treatment implementation (TI) strategies in caregiving trials and to propose Lichstein's TI model as a potential guide. DESIGN AND METHODS: The efforts of a large cooperative research study of caregiving interventions, Resources for Enhancing Alzheimer's Caregiver Health (REACH), illustrates induction and assessment of the three components of TI: delivery, receipt, and enactment. RESULTS: The approaches taken in REACH vary with the intervention protocols and include using treatment manuals, training and certification of interventionists, and continuous monitoring of actual implementation. IMPLICATIONS: Investigation and description of treatment process variables allows researchers to understand which aspects of the intervention are responsible for therapeutic change, potentially resulting in development of more efficacious and efficient interventions.

The ecological assessment of an autistic child.

The behavior of an autistic child was observed in his natural environment. Observations were made in three settings, over approximately 6 months. Sixteen behaviors of the child and six behaviors of adults and peers were recorded. A cluster analysis was performed to identify response classes within the behavioral structure of the child and to see if correlations existed between response and stimulus events. To examine intra- and intersetting changes, Spearman rank correlations and t tests were also computed. The autistic child exhibited a diversity of behavior over time in a given setting and across settings. He persistently ignored other nonautistic children, although he was responsive to adults. Response classes reflected an inverse correlation between the child's self-stimulatory behaviors and his attentiveness to the environment. Elevated levels of adult attention were consistently related to reduced levels in most self-stimulatory behaviors. Two response classes showed inverse relationships between self-stimulatory behaviors. Reducing the frequency of some self-stimulatory behaviors might cause increases in others.