Arthur J. Spielman

Assessment of insomnia

Abstract The conceptual and practical aspects of the assessment of insomnia are described. A rationale is presented for the categorization of case material into a schema of predisposing conditions, precipitating circumstances and perpetuating factors. The application of this method is illustrated with an ‘expectable’ case. Following the discussion of the case, the features of a patients history most likely to result in the greatest diagnostic yield are described and indications for specialized polysomnographic recording are reviewed. Finally, the common insomnia disorders are described employing the Association of Sleep Disorders Centers Nosology.

THE ACTIGRAPH DATA ANALYSIS SOFTWARE: II. A NOVEL APPROACH TO SCORING AND INTERPRETING SLEEP-WAKE ACTIVITY

Decades of empirical observations have established the validity of actigraphy primarily in individuals without sleep disorders. Methodological problems encountered thus far coupled with the widespread use of actigraphy signal the need for concentrated efforts to establish a consensus regarding scoring procedures. Currently available scoring methods show less reliability in clinical populations. To address these issues two validation studies were conducted: one for individuals without sleep disorders and the other for patients diagnosed with insomnia. The results of these two studies using the Actigraph Data Analysis Software as the scoring method have shown that the described system is fairly precise. It can be used for actigraphs with different features and mode of operation and is applicable to individuals with insomnia. These findings corroborate previous research showing that actigraphy is a valid instrument for assessment of sleep and wakefulness.

theoretical and Technical Problems in the Measurement of Nocturnal Penile Tumescence for the Differential Diagnosis of Impotence1

&NA; Theoretical and technical problems in using Nocturnal Penile Tumescence (NPT) measurements for the differential diagnosis of impotence are discussed and possible solutions are offered: 1) The basic assumption that NPT measurements can distinguish psychogenic from organic impotence has never been demonstrated in patients shown to be psychogenically and organically impotent independent of the NPT measurements themselves. Studies attempting to do this are necessary to determine definitively the limits of the clinical applicability of this important diagnostic tool. 2) Evidence is presented showing that though a direct observation of one of the patients fullest erections is required for an adequate NPT evaluation, this is not always done. The danger of misdiagnosis if this step is omitted is illustrated with a case report. 3) Disagreements in the literature about NPT criteria for diagnosing psychogenic impotence are discussed and criteria are suggested that are based on demonstrating the intactness of the physiological mechanisms required for erection rather than on values recorded in normal subjects.

Non-pharmacological treatments for insomnia

Insomnia is a common disorder effecting millions of people worldwide. Currently most individuals suffering from insomnia take medications to help them sleep. However, there are a variety of behavioral treatments, which have been shown to be effective in empirical studies that offer many advantages over medications. In addition, behavioral treatments have been shown to be more effective long-term than medication. This paper reviews the principles and practice of these behavioral treatments. At the end of the paper there is also a brief discussion of circadian rhythm disorders that can mimic insomnia.

Sleep Restriction Therapy

Drawing on clinical experience in sleep disorder centers and laboratory-based investigations, we are continuing to develop conceptual models as well as behavioral treatment strategies for insomnia. The technique reported on here, sleep restriction therapy, has had its effectiveness confirmed in laboratory and clinical studies and is now widely used in sleep disorders centers (Spielman, Saskin, & Thorpy, 1987; Friedman, Bliwise, Yesavage, & Salom, 1991; Morin, Kowatch, & Wade, 1989; Morin, Kowatch, & O’Shanick, 1990; Rubinstein, Rothenberg, Maheswaran, Tsai, Zozula, & Spielman, 1990).

Intracerebral hemodynamics probed by near infrared spectroscopy in the transition between wakefulness and sleep

Previous imaging studies have shown that cerebral metabolism is gradually reduced at the beginning of sleep. Few studies have examined the sleep state transition periods from wakefulness to sleep and sleep to wakefulness. The current study used the Near Infrared Spectroscopy (NIRS) technique to describe the intracerebral hemodynamics at the frontal pole in the circumscribed period between wakefulness and sleep. Nine healthy young adults were studied during afternoon naps. Optical probes were placed on the forehead and EEG electrodes on the scalp. At sleep onset oxygenated hemoglobin (oxy-Hb) was reduced (P<0.01) and deoxygenated hemoglobin (deoxy-Hb) showed a near significant reduction (P<0.063). At sleep offset there were increases in oxy-Hb (P<0.005) and deoxy-Hb (P<0.05). In 18 of 26 transitions to sleep there was a coordinated fall in both NIRS parameters, we call the Switch Point, that lasted a mean of 3.6 s. In 32 of 36 transitions to wakefulness there was an analogous Switch Point that lasted a mean of 3.4 s. Before and after the Switch Point, changes were small and the relationship between oxy-Hb and deoxy-Hb was a combination of parallel and reciprocal fluctuations. A synchronized, parallel and short-lived change in oxy-Hb and deoxy-Hb is a discrete event in the transition period between wakefulness and sleep. The concentration of these light absorbing molecules is abruptly set to a new level at sleep-wake transitions and probably reflects the different perfusion demands of these states.

Effects of otolithic vestibular stimulation on sleep.

This study evaluated the effects of otolithic vestibular stimulation in the form of a linearly accelerated parallel swing on nighttime sleep parameters and daytime sleep tendency in eight normal subjects. The protocol consisted of one adaptation night following by two motion nights, one adaptation night followed by two stationary nights, and two Multiple Sleep Latency Tests (MSLT), one motion and one stationary. On the motion nights, there was a decrease in stage 2 percentage as well as a facilitative effect on sleep latency on the last night. In addition, an increase in the number of rapid eye movements (REMs) per night was found without a significant alteration of REM sleep amount or latency. No significant differences were found between the motion and stationary MSLT days.

Effects of pyridoxine on dreaming: a preliminary study.

The effect of pyridoxine (Vitamin B-6) on dreaming was investigated in a placebo, double-blind study to examine various claims that Vitamin B-6 increases dream vividness or the ability to recall dreams. 12 college students participated in all three treatment conditions, each of which involved ingesting either 100 mg B-6, 250 mg B-6, or a placebo prior to bedtime for a period of five consecutive days. The treatment conditions were completely counterbalanced and a two-day wash-out period occurred between the three five-day treatment blocks. Morning self-reports indicated a significant difference in dream-salience scores (this is a composite score containing measures on vividness, bizarreness, emotionality, and color) between the 250-mg condition and placebo over the first three days of each treatment. The data for dream salience suggests that Vitamin B-6 may act by increasing cortical arousal during periods of rapid eye movement (REM) sleep. An hypothesis is presented involving the role of B-6 in the conversion of tryptophan to serotonin. However, this first study needs to be replicated using the same procedures and also demonstrated in a sleep laboratory before the results can be considered certain.

Impaired nocturnal erections and impotence following transurethral prostatectomy.

A case of impotence with significantly impaired nocturnal penile tumescence (NPT) following transurethral resection of the prostate (TURP) is described. The patient was studied with polysomnographic recording including measurements of NPT for three consecutive nights at nine months after surgery and showed a total absence of full erections. Possible causes of his impotence are discussed. It is concluded that the total clinical picture strongly suggests that the erectile dysfunction was a result of physiologic complications of the surgery. Methodologic problems in past work are discussed, and the need for detailed diagnostic studies is stressed. The sleep studies that should be a part of this comprehensive evaluation are described.

The Role of Behavioural Treatment in the Management of Insomnia

Insomnia is a highly prevalent complaint among the general public that can affect an individual’s health, performance and quality of life. Despite its broad effects, patients’ help-seeking rate is very low. One possible reason for this is the patients’ lack of knowledge about treatment options for insomnia.In order to facilitate understanding and appreciation of the behavioural treatments of insomnia, this article offers an overview of clinical indications, procedures, and expected short term and long term effects of various effective behavioural treatments for insomnia.Treatments discussed include: (i) stimulus control instructions that eliminate the maladaptive association between bedtime cues and anxiety; (ii) sleep restriction therapy that enhances central sleep mechanisms by systematically curtailing the amount of time in bed; (iii) relaxation techniques that promote sleep by reducing physiological tension and cognitive arousal; (iv) biofeedback protocols that produce relaxation or enhance sleep regulation through the feedback of physiological measures; (v) cognitive therapies that facilitate sleep onset by alleviating pre-sleep cognitive arousal; (vi) sleep hygiene that improves sleep by avoiding habits and activities interfering with sleep; and (vii) chronotherapy and light therapy that facilitate sleep regulation based on the principles of circadian rhythmicity.