Cerebral Asymmetry in Insomnia Sufferers

Cerebral asymmetry is used to describe the differences in electroencephalographic activity between regions of the brain. The objective of this study was to document frontal, central, and parietal asymmetry in psychophysiological (Psy-I) and paradoxical (Para-I) insomnia sufferers as well as good sleeper (GS) controls, and to compare their patterns of asymmetry to others already found in anxiety and depression. Additionally, asymmetry variations between nights were assessed. Participants were 17 Psy-I, 14 Para-I, and 19 GS (mean age = 40 years, SD = 9.4). They completed three nights of polysomnography (PSG) recordings following a clinical evaluation in a sleep laboratory. All sleep cycles of Nights 2 and 3 were retained for power spectral analysis. The absolute activity in frequency bands (0.00–125.00 Hz) was computed at multiple frontal, central, and parietal sites in rapid eye movement and non-rapid eye movement sleep to provide cerebral asymmetry measures. Mixed model ANOVAs were computed to assess differences between groups and nights. Correlations were performed with asymmetry and symptoms of depression and anxiety from self-reported questionnaires. Over the course of the two nights, Para-I tended to present hypoactivation of their left frontal region but hyperactivation of their right one compared with GS. As for Psy-I, they presented increased activation of their right parietal region compared with Para-I. Asymmetry at frontal, central, and parietal region differed between nights. On a more disrupted night of sleep, Psy-I had increased activity in their right parietal region while Para-I presented a decrease in cerebral activity in the right central region on their less disrupted night of sleep. Anxious and depressive symptoms did not correlate with asymmetry at any region. Therefore, Psy-I and Para-I present unique patterns of cerebral asymmetry that do not relate to depression or anxiety, and asymmetry varies between nights, maybe as a consequence of variability in objective sleep quality from night to night

Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia : a randomized controlled trial

Context: Cognitive behavioral therapy (CBT) and hypnotic medications are efficacious for short-term treatment of insomnia, but few patients achieve complete remission with any single treatment. It is unclear whether combined or maintenance therapies would enhance outcome. Objectives: To evaluate the added value of medication over CBT alone for acute treatment of insomnia and the effects of maintenance therapies on long-term outcome. Design, Setting, and Patients: Prospective, randomized controlled trial involving 2-stage therapy for 160 adults with persistent insomnia treated at a university hospital sleep center in Canada between January 2002 and April 2005. Interventions: Participants received CBT alone or CBT plus 10 mg/d (taken at bedtime) ofzolpidemforaninitial6-weektherapy,followedbyextended6-monththerapy.Patients initially treated with CBT attended monthly maintenance CBT for 6 months or received no additional treatment and those initially treated with combined therapy (CBT plus 10 mg/d of zolpidem) continued with CBT plus intermittent use of zolpidem or CBT only. Main Outcome Measures: Sleep onset latency, time awake after sleep onset, total sleep time, and sleep efficiency derived from daily diaries (primary outcomes); treatment response and remission rates derived from the Insomnia Severity Index (secondary outcomes). Results: Cognitive behavioral therapy used singly or in combination with zolpidem produced significant improvements in sleep latency, time awake after sleep onset, and sleep efficiency during initial therapy (all P .001); a larger increase of sleep time was obtained with the combined approach (P=.04). Both CBT alone and CBT plus zolpidem produced similar rates of treatment responders (60% [45/75] vs 61% [45/74], respectively; P=.84) and treatment remissions (39% [29/75] vs 44% [33/74], respectively; P=.52) with the 6-week acute treatment, but combined therapy produced a higher remission rate compared with CBT alone during the 6-month extended therapy phase and the 6-month follow-up period (56% [43/74 and 32/59] vs 43% [34/75 and 28/68]; P=.05). The best long-term outcome was obtained with patients treated with combined therapy initially, followed by CBT alone, as evidenced by higher remission rates at the 6-month follow-up compared with patients who continued to take zolpidem during extended therapy (68% [20/30] vs 42% [12/29]; P=.04). Conclusion: In patients with persistent insomnia, the addition of medication to CBT produced added benefits during acute therapy, but long-term outcome was optimized when medication is discontinued during maintenance CBT

Research process and sleep app design lessons learned from the reflective examination of a sleep study

Introduction   Mobile sleep apps are promising accessible treatment for insomnia. Using them as data collection tools akin to sleep diaries has also been proposed. Most of these apps, however, have not been developed using evidence-based principles; limited research exists on their design as research tools (Bhat et al. 2015) (Yu et al., 2019). In the present study, we explored the opportunities and challenges experienced when using a mobile app for research with our own team’s research study as the unit of analysis. This is an intrinsic case study (Stake, 1995), which can inform other researchers as they use sleep apps in research as an intervention (treatment) or research tool (data collection).  Materials and methods: Data were collected during a larger study, designed to test the effects of serial diverse imagining (Beaudoin et al., 2016), using SomnoTest, on insomnia. Data of 19 controls and 15 insomniacs, aged between 18 and 30 years, were analysed. Participants were assigned to one of two app conditions. Group 1 participants heard a countdown from 99 to 1 and Group 2 were prompted to visualise randomly selected brief scenes read by the app at eight-second intervals. Participants completed a one-week sleep diary while using SomnoTest, during the second week.             This was the first study to analyze SomnoTest data using a qualitative approach involving direct interpretation of participants’ patterns of mobile app usage based on actions recorded (i.e., press start, end, pause, resume, or cancel; time stamp; count of played items), reorganization of usage patterns into tables (visualisation; tabulation), reflection of researchers on their respective experiences in analyzing the data, and the derivation of themes and selection of exemplars based on participants’ usage and researchers’ experiences. Results Our exploration revealed four themes: 1) unreliability of sleep diaries when triangulated against SomnoTest data, given that 9 participants had not used the app as claimed; 2) complex, intensive qualitative analysis is needed to identify valid data in an unstructured data set; 3) importance of visualisation when examining data to uncover patterns; 4) identification of “fans” who continue to use the app after their participation in the study. Our findings reveal that data cleaning involves intensive case-by-case analysis of participant data, which proved challenging with 34 participants and would prove prohibitive for larger scale studies. However, these insights can inform how future sleep studies involving mobile app.  Conclusion The development of an algorithm that can efficiently filter valid data usage patterns would facilitate data analysis and researchers’ experience. This would increase sleep app usability as a treatment and research tool. Developing a process for increasing efficiency in data analysis is necessary to exploit the advantages of large-scale data collection that a sleep app makes possible. Further, informing participants that app data would be triangulated against sleep diary during data collection and analysis might increase the accuracy of the data that participants provide in sleep diaries. Acknowledgements Conflict of Interest  Dr. Beaudoin is president of CogSci Apps (develops SomnoTest, mySleepButton and Hook propductivity apps) and owner of CogZest. References: Beaudoin, L. P., Digdon, N., O’Neill, K. & Racour, G. (2016). Serial diverse imagining task: A new remedy for bedtime complaints of worrying and other sleep-disruptive mental activity.Poster presented at SLEEP 2016 (A joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society). Denver, CO. Morin, C. M., Drake, C. L., Harvey, A. G., Krystal, A. D., Manber, R., Riemann, D., & Spiegelhalder, K. (2015). Insomnia disorder. Nature Reviews Disease Primers, 1, 15026. Allocca, G., Ma, S., Martelli, D., Cerri, M., Del Vecchio, F., Bastianini, S., ... & Blackburn, S. (2019). Validation of\u27 Somnivore\u27, a Machine Learning Algorithm for Automated Scoring and Analysis of Polysomnography Data. Frontiers in Neuroscience, 13, 207

Acute and Chronic Insomnia: What Has Time and/or Hyperarousal Got to Do with It?

Nearly one-third of the population reports new onset or acute insomnia in a given year. Similarly, it is estimated that approximately 10% of the population endorses sleep initiation and maintenance problems consistent with diagnostic criteria for chronic insomnia. For decades, acute and chronic insomnia have been considered variations of the same condition or disorder, only really differentiated in terms of chronicity of symptoms (days/weeks versus months). Whether or not acute and chronic insomnia are part of the same phenomena is an important question, one that has yet to be empirically evaluated. The goal of the present theoretical review was to summarize the definitions of acute and chronic insomnia and discuss the role that hyperarousal may have in explaining how the pathophysiology of acute and chronic insomnia is likely different (i.e., what biopsychological factors precipitate and/or perpetuate acute insomnia, chronic insomnia, or both?)

Pre-Sleep Cognitive Arousal Is Negatively Associated with Sleep Misperception in Healthy Sleepers during Habitual Environmental Noise Exposure: An Actigraphy Study

Specific noises (e.g., traffic or wind turbines) can disrupt sleep and potentially cause a mismatch between subjective sleep and objective sleep (i.e., “sleep misperception”). Some individuals are likely to be more vulnerable than others to noise-related sleep disturbances, potentially as a result of increased pre-sleep cognitive arousal. The aim of the present study was to examine the relationships between pre-sleep cognitive arousal and sleep misperception. Sixteen healthy sleepers participated in this naturalistic, observational study. Three nights of sleep were measured using actigraphy, and each 15-s epoch was classified as sleep or wake. Bedside noise was recorded, and each 15-s segment was classified as containing noise or no noise and matched to actigraphy. Participants completed measures of habitual pre-sleep cognitive and somatic arousal and noise sensitivity. Pre-sleep cognitive and somatic arousal levels were negatively associated with subjective–objective total sleep time discrepancy (p < 0.01). There was an association between sleep/wake and noise presence/absence in the first and last 90 min of sleep (p < 0.001). These results indicate that higher levels of habitual pre-sleep arousal are associated with a greater degree of sleep misperception, and even in healthy sleepers, objective sleep is vulnerable to habitual bedside noise

Pre-Sleep Cognitive Arousal Is Unrelated to Sleep Misperception in Healthy Sleepers When Unexpected Sounds Are Played during Non-Rapid Eye Movement Sleep: A Polysomnography Study

Background: It is well-established that environmental noise can disrupt sleep, and cause a mismatch between subjective and objective sleep, which is known as “sleep misperception”. Naturalistic studies indicate that pre-sleep cognitive arousal and sleep misperception are associated in the context of noise. However, it is not known if this is the case when ecologically valid noises are specifically played during non-rapid eye movement (NREM) sleep, which is susceptible to noise-related disruption. The present study evaluated if pre-sleep cognitive arousal was associated with sleep misperception in healthy normal sleepers, when unexpected ecologically valid common nocturnal noises were played during NREM sleep. Methods: Eighteen healthy sleepers (Mage = 23.37 years, SDage = 3.21 years) participated. Sleep was measured objectively on three consecutive nights using polysomnography, in a sleep laboratory environment, and subjectively, through participant estimates of total sleep time (TST). Night 1 was a baseline night where no noises were played. On Night 2, noises, which were chosen to be representative of habitual nocturnal noises heard in home environments, were played to participants via in-ear headphones after 5 min of objective sleep. Results: Unexpectedly, habitual pre-sleep cognitive arousal was not associated with subjective–objective TST discrepancy on Night 2. Conclusions: These results suggest that in healthy sleepers, when ecologically valid noises are played unexpectedly during NREM sleep in an unfamiliar sleep laboratory environment the subjective experience of sleep is not associated with pre-sleep cognitive arousal, or negatively impacted by noise exposure

We know CBT-I works, now what?

Cognitive behavioral therapy for insomnia (CBT-I) has been shown to be efficacious and now is considered the first-line treatment for insomnia for both uncomplicated insomnia and insomnia that occurs comorbidly with other chronic disorders (comorbid insomnia). The purposes of this review are to provide a comprehensive summary of the efficacy data (for example, efficacy overall and by clinical and demographic considerations and by CBT-I formulation) and to discuss the future of CBT-I (for example, what next steps should be taken in terms of research, dissemination, implementation, and practice)

The Natural History of Insomnia: Predisposing, precipitating, coping and perpetuating factors over the early developmental course of insomnia

While there is an extensive literature on predisposing, precipitating, coping, and perpetuating factors in those with chronic insomnia, very little work has been undertaken to evaluate these factors over the early developmental course of insomnia. The present aim was to determine whether several hypothesized factors in each domain (predisposing, precipitating, coping, and perpetuating), assessed during an episode of acute insomnia (AI), are related to its persistence or remission to normal sleep. Participants comprised n = 140 people with AI and n = 737 normal sleepers (NS) recruited from the general public. Participants completed measures assessing predisposing characteristics (personality traits, arousal predisposition, and insomnia vulnerability), precipitating events and outcomes (life events, perceived stress, anxiety, and depression), coping styles (thought control strategies and coping styles), and perpetuating factors (sleep preoccupation, pre-sleep arousal, dysfunctional beliefs, and fatigue). Additionally, insomnia status (from AI at baseline to its persistence or natural remission [NR]) was assessed 1 month later (n = 129). Baseline differences between NS and individuals with AI were observed in each domain with increasing age, lower openness to experience and conscientiousness, higher insomnia severity, levels of anxiety, and affective sleep preoccupation significantly predicting AI status. Further, a previous episode of insomnia, higher depression scores, and affective sleep preoccupation scores significantly predicted its persistence, as opposed to its NR. Results are discussed with reference to the conceptualization of insomnia and how the findings may influence the design of preventative interventions to circumvent the transition from acute to chronic insomnia

Co-Morbid Insomnia and Sleep Apnea (COMISA): Prevalence, Consequences, Methodological Considerations, and Recent Randomized Controlled Trials

Co-morbid insomnia and sleep apnea (COMISA) is a highly prevalent and debilitating disorder, which results in additive impairments to patients&rsquo; sleep, daytime functioning, and quality of life, and complex diagnostic and treatment decisions for clinicians. Although the presence of COMISA was first recognized by Christian Guilleminault and colleagues in 1973, it received very little research attention for almost three decades, until the publication of two articles in 1999 and 2001 which collectively reported a 30%&ndash;50% co-morbid prevalence rate, and re-ignited research interest in the field. Since 1999, there has been an exponential increase in research documenting the high prevalence, common characteristics, treatment complexities, and bi-directional relationships of COMISA. Recent trials indicate that co-morbid insomnia symptoms may be treated with cognitive and behavioral therapy for insomnia, to increase acceptance and use of continuous positive airway pressure therapy. Hence, the treatment of COMISA appears to require nuanced diagnostic considerations, and multi-faceted treatment approaches provided by multi-disciplinary teams of psychologists and physicians. In this narrative review, we present a brief overview of the history of COMISA research, describe the importance of measuring and managing insomnia symptoms in the presence of sleep apnea, discuss important methodological and diagnostic considerations for COMISA, and review several recent randomized controlled trials investigating the combination of CBTi and CPAP therapy. We aim to provide clinicians with pragmatic suggestions and tools to identify, and manage this prevalent COMISA disorder in clinical settings, and discuss future avenues of research to progress the field