Kenneth L. Lichstein

The Consensus Sleep Diary: Standardizing Prospective Sleep Self-Monitoring

STUDY OBJECTIVES To present an expert consensus, standardized, patient-informed sleep diary. METHODS AND RESULTS Sleep diaries from the original expert panel of 25 attendees of the Pittsburgh Assessment Conference(1) were collected and reviewed. A smaller subset of experts formed a committee and reviewed the compiled diaries. Items deemed essential were included in a Core sleep diary, and those deemed optional were retained for an expanded diary. Secondly, optional items would be available in other versions. A draft of the Core and optional versions along with a feedback questionnaire were sent to members of the Pittsburgh Assessment Conference. The feedback from the group was integrated and the diary drafts were subjected to 6 focus groups composed of good sleepers, people with insomnia, and people with sleep apnea. The data were summarized into themes and changes to the drafts were made in response to the focus groups. The resultant draft was evaluated by another focus group and subjected to lexile analyses. The lexile analyses suggested that the Core diary instructions are at a sixth-grade reading level and the Core diary was written at a third-grade reading level. CONCLUSIONS The Consensus Sleep Diary was the result of collaborations with insomnia experts and potential users. The adoption of a standard sleep diary for insomnia will facilitate comparisons across studies and advance the field. The proposed diary is intended as a living document which still needs to be tested, refined, and validated.

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.

Insomnia as a health risk factor

This article reviewed insomnia epidemiological research, identifying areas where insomnia was a risk factor and isolating areas deserving of further investigation. Insomnia was consistently predictive of depression, anxiety disorders, other psychological disorders, alcohol abuse or dependence, drug abuse or dependence, and suicide, indicating insomnia is a risk factor for these difficulties. Additionally, insomnia was related to decreased immune functioning. The data were inconclusive regarding insomnia as a risk factor for cardiovascular disease and mortality, but sleep medication use was predictive of mortality. These results must be tempered with the knowledge that significant weaknesses existed in the studies reviewed. The main weaknesses were inadequate definition of insomnia and inadequate control for alternative explanations. Despite these limitations, this review suggests that insomnia is a risk factor for poor mental and physical health.

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.

Fair tests of clinical trials: A treatment implementation model

Abstract We propose a psychotherapy treatment implementation model whereby adequate levels of independent treatment components (delivery, receipt, and enactment) are prerequisite to asserting whether a valid clinical trial has been conducted. The delivery component refers to the accuracy of treatment presentation, receipt refers to the accuracy of the clients comprehension of treatment, and enactment refers to the extent of out of session application initiated by the client. Clinical scientists regularly address one or two of these components, but rarely all three, according to a survey we report. Sources and effects of model deficits, i.e., inadequate levels of treatment components, as well as methods of component assessment and induction, are discussed. We conclude that faults in any one of the components drain validity proportional to the degree of deficit, and that clinical trials have often incorrectly been considered fair tests, resulting in biased efficacy judgments.

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.

Treatment of late-life insomnia

PART ONE: OVERVIEW Sleep and Aging - Kevin Morgan Characteristics of Older Adults with Insomnia - Catherine S Fichten et al Assessment and Differential Diagnosis - Colin A Espie PART TWO: INTERVENTION STRATEGIES Treatment Overview - Kenneth L Lichstein and Charles M Morin Sleep Hygiene - Brant W Riedel Sleep Restriction Therapy - William K Wohlgemuth and Jack D Edinger Stimulus Control - Richard R Bootzin and Dana R Epstein Relaxation - Kenneth L Lichstein Cognitive Therapy - Charles M Morin, Josee Savard and France Blais Pharmacologic Treatment - Daniel J Buysse and Charles F Reynolds III PART THREE: SPECIAL TREATMENT TOPICS Discontinuation of Sleep Medications - Charles M Morin, Lucie Baillargeon and Celyne Bastien Secondary Insomnia - Kenneth L Lichstein Insomnia in Dementia and in Residential Care - Donald L Bliwise and Michael J Breus

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.

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.

Insomnia and Complicated Grief Symptoms in Bereaved College Students

In this study, we extended previous research by concentrating on sleep- and grief-related symptoms in a cohort of bereaved college students, in view of the potential for each of these problems to exacerbate the other. A sample of 815 college students completed the Inventory of Complicated Grief (H. G. Prigerson & S. C. Jacobs, 2001), along with an assessment of diagnostic criteria for insomnia and associated sleep behaviors. As predicted, the rate of insomnia was significantly higher (22%) in the bereaved sample than in a nonbereaved comparison group (17%), a difference that was particularly pronounced in terms of middle insomnia. Also as hypothesized, bereaved insomniacs reported higher complicated grief scores than bereaved noninsomniacs, and several specific sleep variables (including sleep-onset insomnia related to nighttime rumination about the loss and sleep-maintenance insomnia associated with dreaming of the deceased) were significantly related to complicated grief symptomatology.